Is perfect too good?

22 Oct

A recent study in the prestigious British Medical Journal raised the question – should there be an acceptable level of mistakes that doctors can make?
Counter-intuitively, striving less hard to always be right may be safer for the patients in the long run. Every test and every treatment has a cost – and not just financially. Tests are unpleasant and time consuming, medications have side effects and surgery often painful and debilitating.
Yet often all these tests and treatments are for no purpose other than “to be sure”. If we accepted that sometimes we will miss conditions in the early stages, it may be possible to significantly decrease the number of tests and treatments we perform.
To be sure that may result in some things being missed. But it will also significantly decrease the number of problems that we cause.
Getting the balance right is the great challenge of modern medicine.

Ebola fear and facts

20 Oct

In a world where the media seems incapable of reporting fact without adding hype, it’s hard to tell the difference between issues which should cause panic and those which are just a curiosity. Where then does Ebola fit?
It’s certainly true that Ebola is a horrific disease. About three weeks after exposure, patients develop headache, fever, abdominal pain, vomiting and diarrhoea and then internal bleeding and shock. There is no specific treatment – just what the medical profession calls supportive care, which means fluids and drugs to keep up blood pressure and circulation.
In Africa, with less advanced medical support, over 70% of patients die. In Western countries, the death rate is still about 50%. By any standard, Ebola is a serious condition.
But currently the risk of Ebola is still pretty remote. There hasn’t yet been a confirmed case in Australia and only a handful in the Western world. Travellers from West Africa are now being screened; understanding of the need for case management and isolation has grown and awareness of the condition is high. The chances of Australia’s first case arising in Rowville or Lysterfield isn’t just low….it’s tiny.
Our advice is stay calm! Have a long talk to us if you are planning a trip to Africa. If you are in close contact with someone who has been to West Africa and you have concerns, please call us to discuss over the phone. In almost all cases, we will be happy to see you. If there is any significant reason for concern, we will arrange for the appropriate hospital to assess you.

When a cancer’s not a cancer

12 Dec

A fascinating article on the website The Conversation discusses whether we should abandon the word “cancer”. Why? Because so many cancers these days are so minor that they won’t ever cause any harm to the patient. But the very act of using the word cancer can frighten people well out of proportion to the danger they face.

This is particularly so for cancers which are found by screening tests. The theory is that finding a cancer in the early stages improves the odds of survival. The best known examples are prostate and breast cancer.

Yet interestingly, after 30 years of screening for breast cancer in the USA, the number of minor cancers detected has doubled … but the number of advanced cancers detected has dropped by less than 10%. In other words, lots of new cancers are being found, but they were unlikely to ever cause any problems even if not discovered. The same applies – perhaps more so – to prostate cancer.

These extra “cancers” also make the figures for treatment look much better. If you “treat” all cancers – including those that aren’t nasty – your survival figures will dramatically improve.

The discussion around renaming these early or minor cancers is part of a movement in medicine against over-diagnosis and over-treatment. Doctors and patients both have a role to play – doctors need to think more clearly about the implications of conditions, and patients need to understand that medicine is not perfect, that we are always learning and re-evaluating our knowledge; and that doing more can be worse than doing less.

The best investment

30 Nov

Best reason to quit smoking #1
Because it’s the single best thing you can do for your health. The life expectancy of a smoker in the year 2000 is the same as the life expectancy of a non-smoker in the year 1900. That is – smoking eliminates all the benefits of antibiotics, anaesthetics, surgery, ambulances, Intensive Care Units etc. There is NOTHING you can do for your health – exercise, lose weight, take cholesterol tablets – that is as effective as stopping smoking.

Best reason to quit smoking #2
Cigarette prices are going up by 12.5% on December 1st due to increased tax and that will continue each year till 2016 (at least).
Assuming a pack costs about $20, a pack-a-day smoker is spending $7300 a year on cigarettes. (How many weeks work does that equate to in your job?)
A 40 year old will spend $182,500 on cigarettes by the time s/he retires. (Of course with the increased tax rises in coming years, that will rise significantly). An 18 year old smoker will spend over $343,000.

Actually both figures are wrong. If a 40 year old were to take their cigarette money and invest in their retirement savings (assuming 9% compound per year), they will retire better off by over $600,000.

And an 18 year old who invests their 30/day cigarette money will retire with an extra …. $4.3million!! (That’s the benefit of compound interest!)

If you want help to stop, we would be delighted to spend time with you talking about the addiction, the habit and the many ways we can help you quit.

Privacy and the Private Sector

27 Nov

A disturbing article in todays The Age http://www.theage.com.au/digital-life/digital-life-news/medical-examinations-used-to-access-your-private-information-20131126-2y7t9.html suggests that some private companies that provide workplace and pre-employment medicals then forward the information to a private business which stores the information for the longer term.
Apart from this activity being illegal under the National Privacy Principles, it’s a gross violation of the basic principle of medical confidentiality.
In general patients have a right to expect their personal medical information will remain private unless they specifically allow that information to be shared. That’s why we are not able to pass on a husband’s test results to their wife or discuss a teenage child’s health issues with their parents – unless we have previously obtained specific consent.
There are a few exceptions to the privacy rules. There are legal circumstances when we are obliged to reveal information – such as a court subpoena or a demand by the coroner’s court.
It is also generally accepted that doctors can share clinical information with others involved in your care – for example referrals to medical specialists, or discussing treatment options with allied health practitioners. Even then, the information being shared needs to be relevant to the issues being discussed.
But the idea that a company not involved in ongoing care can store your health information long term, when it was provided only as a step in applying for a job is beyond any limit of what is acceptable.
Unfortunately many patients don’t read the fine print of the consent forms they are signing. That applies not just to medicals but also applications for health, life, income and travel insurance; employment applications and many other forms. Be aware that if we are completing a form that you have signed we are obliged to provide all the information that is asked for provided that you have consented.
We encourage you to read and think carefully about what you are consenting to release and to discuss with us any issues that you are uncomfortable about us releasing. There may be ways of phrasing information in a manner that is honest but less compromising.

Safety in (correct) numbers

25 Nov

We would like to draw your attention to a recall of Children’s Panadol Baby Drops which has been declared by the TGA (Therepeutic Goods Administration – the government body which regulates drugs in Australia).

Children’s Panadol Baby Drops are given by a syringe which comes with the medicine bottle. Some batches of the Panadol have been supplied with a faulty syringe. Note that the Panadol itself is perfectly safe. However the syringe markings are in the wrong spot and therefore you may accidentally give a bigger dose of medication than intended.

The CORRECT syringes have the markings of millilitres starting right at the tip of the syringe.

The FAULTY syringes have the measuring label markings start further up the syringe.

It is very unlikely that a child will come to harm even if you have used a faulty syringe, but it is best to be sure. If you aren’t clear on whether your syringe is correct or not, please take it in to your pharmacy or drop in to the clinic and ask one of the nurses or doctors to take a quick look.

For more info see the TGA announcement: http://www.tga.gov.au/safety/alerts-medicines-childrens-panadol-baby-drops-syringe-131122.htm which includes pictures of the faulty and correct syringes.

Statins, Statistics and Stations

5 Nov

TV shows love a good controversy and where there isn’t one available it’s always handy to be able to generate one.

So ABC-TV show Catalyst did an excellent job last week running a two part episode on how statins – a family of tablets used to treat high cholesterol – are overprescribed, not very useful and that doctors don’t adequately think about (or warn patients about) their side effects.

There is enough truth in those claims that they can’t be rejected out of hand. But there is enough about the claims which bends, distorts or maims the truth that they have to be refuted in clear terms. Our depth of feeling can be gauged by the fact that it has drawn us back into blogging!

So what’s true and what’s not. Well …..it’s complicated.

Nobody ever died of high cholesterol.  People die of heart attacks and strokes. The controversy is whether cholesterol is a cause of those fatal conditions, and whether lowering cholesterol with tablets is worthwhile.

We know FOR CERTAIN that high cholesterol is associated with heart attacks.

We know ALMOST CERTAINLY that cholesterol is a risk factor.

We know FOR CERTAIN that statins lower cholesterol in most people.

We know FOR CERTAIN that people who have already had a heart attack, on average live longer if they are put on statins.

We are REASONABLY CERTAIN that people who have not had a heart attack but have high cholesterol are, on average, less likely to have one if they take statins.

We are REASONABLY CERTAIN how likely it is that statins will reduce the risk.

We are REASONABLY CERTAIN that in most individual people, taking a statin will not help – because most people will not have a heart attack, and statins don’t always work in people who do.

We have NO IDEA in a large group of people, which ones will be helped by the statins and who won’t.

We know FOR CERTAIN that a small number of people will get major side effects from statins and a moderate number of people will get mild side effects.

We have NO IDEA in a large group of people who will get the side effects till they’ve had them.

 

So ….should you take (or keep taking) statins?

Perhaps the most important concept to help understand whether statins are useful for you is an idea called Number Needed to Treat (NNT for short).   This tells us how likely it is that a statin will help.  And then YOU need to decide what degree of risk you are willing to accept.

In the following examples it’s not important to understand the individual risk factor numbers – it’s the overall risks that matter:

Imagine a 50 year old male, non-smoker, non-diabetic, with a blood pressure of 140/85 and a cholesterol ratio (Total cholesterol/HDL) of 6.  

His chance of a heart attack in the next 5 years is 5-10%. A statin might reduce that risk by about a quarter. Whether the patient thinks the statin is helpful depends on how his doctor presents the figures:

Doctor 1:   If you take a statin, we can reduce your risk of a heart attack by 25%  (ie from say 7.5% to 5.7%)

Patient 1: Wow Doc, that’s great …gimme a script

OR

Doctor 2: If you take a statin we can reduce your risk of heart attack by 1 or maybe 2%  (ie from say 7.5% to 5.7%)

Patient 2: And run the risk of side effects? Your kidding – why would I bother?

OR

Doctor 3: If we cloned 100 of you and we gave none of you statins, about 93 of you would not have a heart attack in the next 5 years, 7 of you would.  If we gave you all statins – 95 would not have heart attacks, 5 would.  So we can prevent one heart attack for every fifty people who take the tablet.  For the other 49 – about 46 WON”T have a heart attack whether or not they take a tablet. Three WILL have a heart attack whether or not they take a tablet and about 1 of you will prevent a heart attack by taking a statin tablet for five years.

Patient 3:  Well….I don’t want to take a tablet that’s useless, but the idea of a heart attack is pretty scary and I’d want to do whatever is reasonable to reduce the risk. Let me think about it……

 

Another example – a 60 year old diabetic woman who smokes and has a blood pressure of 160/100 and Cholesterol Ratio of 6. Now the NNT to prevent a heart attack is about 13 …ie 12 women out of 13 will get no benefit from the tablet but the 13th will avoid a heart attack.

For some patients, that screams “take the tablet”.  For others, that’s still not enough of a sure thing for them to want to take medication.

The problem with shows like the Catalyst program is that they suffer from the same deficiency as medical research – they deal with statistics, not the individual concerns of each patient and their own views on what they want for their health.

For that you need to see your GP.

We strongly urge patients already on statins NOT to stop taking them till they have had a proper discussion with their family doctor. We know FOR CERTAIN that is a worthwhile exercise!

 

PS … we cheerfully note that losing weight, controlling blood pressure and especially stopping smoking are usually more important than controlling cholesterol. Those issues are subjects for another day!

 

 

 

2 is worse than 1

24 Aug

Medical students (and by extension doctors and then their patients) are taught that Type 1 Diabetes is worse than Type 2. Turns out, at least some of the time, that’s wrong.

Type 1 diabetes – also called Insulin Dependant diabetes or “juvenile onset diabetes” – is what young kids get. They develop antibodies which attach their own pancreas, the insulin-producing cells stop working, they produce no insulin and they get very sick. Before the discovery of insulin in 1921, Type 1 diabetes was an early death sentence. Now, it commits the patient to a lifetime of sugar testing and insulin injections.

Type 2 diabetes – Non-Insulin Dependant diabetes or “adult onset diabetes” – is classically associated with overweight, inactive middle-aged patients. In fact we see a wide variety of people with Type 2 diabetes and not all fit that mould, but it is true that lack of exercise and excess weight do make the likelihood of developing diabetes much greater. However there is probably also a gene which makes the condition more likely, though not inevitable, in many patients.

With the progressive increase in obesity in society we are seeing increasing numbers of diabetics, and in particular Type 2 diabetes at younger and younger ages. Whereas even a generation ago, we never saw Type 2 diabetes in teenagers or children, now about 1/3 of kids who develop diabetes have type 2.

Frighteningly – and against traditional teachings – it turns out Type 2 is much more dangerous in kids than Type 1. Research at Royal Prince Alfred Hospital in Sydney shows the death rate for teens with adult-type diabetes is double that of those with juvenile-onset diabetes. They also develop more severe complications, develop them sooner and do so even if their sugar control after diagnosis is the same as the Type 1 patients.

There are lots of theories as to why that might be – perhaps the genetic predisposition that allowed Type 2 diabetes to develop might be the cause of the complications, or perhaps the lifestyle issues which triggered the diabetes are the cause.

In any event, the study (care.diabetesjournals.org/content/early/2013/07/09/dc12-2455.abstract) noted that most treatment offered to adults with diabetes (particular types of cholesterol and blood pressure medications) are not normally given to kids because most research excludes children from drug trials. But something needs to be done to help these kids. And foremost, is trying to prevent diabetes in the first place.

Whilst we can’t do anything about the genetic factors, it’s critical for parents, doctors and society at large to look at the lifestyle choices and behaviours that may cause diabetes and that can be altered to improve our kids overall health.

Regular reaps rewards

19 Aug

One of the great frustrations of general practice is the paperwork. Forms for everything!

And one of the greatest contributors to paperwork is a little tool called “care plans”.

Care plans were a cute idea introduced about 10 years ago. The theory was that doctors who were doing hours of unpaid work coordinating care and mapping out treatment plans for patients with multiple complex conditions would be rewarded by paying them additional sums for completing paperwork. The idea was that by just filling in a form in addition to usual care for the patient, the doctors could then claim (significant) sums for the work they were already doing. The advantage for the patient was that they would be given a clear, written outline of their health needs and goals and a formal plan of how to get there. There was also the carrot of Medicare subsidising up to 5 visits per year with various allied health providers who would help manage the conditions identified in the plan.

Whenever there is money to be made, someone will abuse the system. There are certainly some doctors and practices that see care plans as their major revenue stream and generate dozens of the things daily. Those practices do very well financially though we wonder whether either the patients or the taxpayer is getting any value for the dollars being spent.

And many doctors have queried the value of care plans at all. The care plan is often just paperwork – does it actually change the patients treatment or the outcomes?

Turns out … it does. This weeks Medical Journal of Australia has an article that shows patients with diabetes who have a care plan – and have it reviewed at least twice a year – have small but significant improvements in their sugar levels, weight and cholesterol. Patients without care plans and those with care plans that were not reviewed regularly did not benefit as much.

Care plans can be annoying – they involve reams of printing and often several visits to the doctor. But there is the benefit of the visits to allied health practitioners that Medicare will subsidise or fund; the reassurance of a formal up-to-date summary of your condition being prepared; the knowledge that having a care plan does result in better health outcomes … and the satisfaction of knowing that your doctor will be well rewarded for having worked hard!

We’re from the government …. we have no idea how to help you

18 Aug

The promise of a personal medical record accessible to everyone involved in a patient’s health care sounds like a wonderful idea. And if the system actually worked – it would be! Tests wouldn’t be duplicated, hospitals would know the full list of diseases that the GP was treating and GPs would know all the medication changes that hospitals and specialists instigated.

Of course the more complex a system, the bigger the chances that something will go wrong. So the development of the PCEHR (Personally Controlled Electronic Health Record) was always going to be difficult. Medical groups were worried whether the information on the file would be accurate; IT experts were worried about whether the security levels would be robust enough; consumer groups wanted patients to be able to control who could and couldn’t have access to any aspect of the record.

The danger with a asking a committee to design a horse is that you end up with something that looks like a camel. Although the government invested close to a billion dollars developing the PCEHR system, nobody involved has been really happy with the outcome. Several hundred-thousand people have registered to enrol in the system but in fact less than 5000 GP-written health care summaries have been created across Australia.

Simply put most GPs don’t trust the system. We are worried about the security, we are worried about the implications of relying on the information in the record when there is no certainty as to who is able to amend notes, and we are worried about the time involved in creating a health summary when Medicare will not fund it as an exercise other than letting us count the time towards a consultation.

A few of our patients have asked our thoughts on PCEHRs and the answer our doctors give is pretty consistent – a good idea that we think has a long way to go before it’s useful and therefore we won’t get involved just yet.

Earlier this week our view was justified when the entire group of clinical leads at NEHTA resigned. NEHTA is the National Electronic Health Transition Authority – a government body that is overseeing the development of electronic, internet and computerised medical records and information. The clinical leads are the doctors who are both providing advice to the Authority on how practitioners want the system to work to best benefit patients and those treating them; and they are the representatives of the Authority whose job is to spread and sell the benefits of the system to doctors throughout the country.

That not just the lead clinician – the highly-respected Dr Mukash Haikerwal – but the ENTIRE group of clinical leads have all resigned because they feel that the concerns of doctors about the usefulness of the system is being completely ignored, endorses our view that the system simply isn’t fit for its intended purpose.

Our practice has always been forward-thinking in the use of technology for medical care. Dr Peter Tribe was one of the first doctors in Victoria to write electronic scripts, and we converted to electronic medical records years before most practices. But we will never adopt a technology just because it’s new.

There is nothing quite as dangerous as “a good idea”.