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Underactive thyroid disease – a modern approach

9 Jun


The Problem

A patient comes to the doctor concerned about longstanding fatigue symptoms. She knows of a family history of underactive thyroid disease and is worried her thyroid is not working properly

Introduction and some basic concepts

[from Basic endocrinology : for students of pharmacy and allied health sciences, edited by Constanti et al (1998; ISBN 9780203301739) ]

The thyroid gland lies in front of the trachea below the larynx. The hypothalamus and pituitary control normal secretion of thyroid hormones. The thyroid hormones in turn control the body’s metabolism. The two active hormones are iodinated derivatives of the amino acid tyrosine. Nearly 90% of the output is thyroxine (T4) containing four iodine atoms while nearly 10% of the output is triiodothyronine (T3) containing three iodine atoms. In health < 1% “reverse” T3 (rT3) is released; this increases in presence of severe illness or starvation. In the bloodstream the thyroid hormones are extensively bound to plasma proteins, principally thyroxine binding globulin (TBG).

Note that in patients on T4 replacement all T3 is produced by peripheral conversion, and so circulating T4 levels may need to be maintained slightly above the “normal” reference range to generate adequate tissue T3 concentrations.

So far so good that is what medical students and other healthcare professionals have been taught to decades. The thyroid stimulating hormone from the pituitary goes up when/if thyroid hormone levels too low, and vice versa.

However this is not the whole story. A more detailed appreciation of the nuances of thyroid hormone metabolism are required to appreciate why so many people with underactive thyroid disease continue to struggle to regain normal health. For example, the story of Coralie Phillips and Donna Roach gives pause for thought about one of the most neglected conditions in general medicine http://www.thyroidbooks.co.uk/ .

Underactive thyroid disease (UAT) is considered simple to diagnose and simple to treat. Luckily this is the case most of the time. Unfortunately when the approach does not seem to be working effectively patients are labelled as difficult or dismissed as mentally ill instead. The medical establishment generally has failed to treat people with UAT scientifically by looking at factors which may conspire to prevent the neat outcome which is expected.

The purpose of this brief essay is to highlight these pitfalls in the hope that fewer people with UAT will suffer in future.

Modern thyroid hormone biochemistry

Role of vitamin D

It seems that adequate levels of vitamin D are necessary to maintain thyroid health.

For example (http://www.endocrine-abstracts.org/ea/0032/ea0032p1008.htm): In this study of 100 patients with autoimmune hypothyroidism compared to 100 subjects as control group, the higher vitamin D deficiency rates besides lower vitamin D levels in the Hashimoto group together with the inverse correlation between vitamin D and anti-TPO suggest that vitamin D deficiency may have a role in the autoimmune process in Hashimoto’s thyroiditis.

Conversely, some evidence emerging that high levels of T3 may suppress vitamin D levels (e.g. http://endo.endojournals.org/content/154/2/609.short) This may be one mechanism for bone losing state of untreated hyperthyroidism (or over-treatment of UAT)

Role of vitamin B12

A new abstract summarises the impact of low vitamin B12 on thyroid disease (and other [geriatric] conditions http://www.bioline.org.br/abstract?rc13008):

Vitamin B12 deficiency is a common condition in the elderly. It is repeatedly overlooked due to multiple clinical manifestations that can affect the blood, neurological, gastrointestinal, and cardiovascular systems, skin and mucous membranes. The various presentations of vitamin B12 deficiency are related to the development of geriatric syndromes like frailty, falls, cognitive impairment, and geriatric nutritional syndromes like protein-energy malnutrition and failure to thrive, in addition to enhancing aging anorexia and cachexia. Therefore, interventions must be developed to include their screening and diagnosis to make early and appropriate treatment to prevent its complications before they become irreversible.

Role of trace minerals

A detailed overview of heavy metals by a nanotechnology team illustrates how important optimising the levels can be for cellular health and ascorbic acid/Krebs cycle [http://www.ijsrp.org/research-paper-0413/ijsrp-p16110.pdf]

Iron (Fe) Contained in hemoglobin and myoglobin which are required for oxygen transport in the body. Part of the cytochrome p450 family of enzymes. Anemia is the primary consequence of iron deficiency. Excess iron levels can enlarge the liver, may provoke diabetes and cardiac falurer. The genetic disease hemochromatosis results from excess iron absorption. Similar symptoms can be produced through excessive transfusions required for the treatment of other diseases.

Copper (Cu) Contained in enzymes of the ferroxidase (ceruloplasmin?) system which regulates iron transport and facilitates release from storage. A structural element in the enzymes tyrosinase, cytochrome c oxidase, ascorbic acid oxidase, amine oxidases, and the antioxidant enzyme copper zinc superoxide dismutase. A copper deficiency can result in anemia from reduced ferroxidase function. Excess copper levels cause liver malfunction and are associated with genetic disorder Wilson’s Disease

Manganese (Mn) Major component of the mitochondrial antioxidant enzyme manganese superoxide dismutase. A manganese deficiency can lead to improper bone formation and reproductive disorders. An excess of manganese can lead to poor iron absorption.

Iodine (I) Required for production of thyroxine which plays an important role in metabolic rate. Deficient or excessive iodine intake can cause goiter (an enlarged thyroid gland).

Zinc (Zn) Important for reproductive function due to its use in FSH (follicle stimulating hormone) and LH (leutinizing hormone). Required for DNA binding of zinc finger proteins which regulate a variety of activities. A component of the enzymes alcohol dehydrogenase, lactic dehydrogenase carbonic anhydrase, ribonuclease, DNA Polymerase and the antioxidant copper zinc superoxide dismutase. An excess of zinc may cause anemia or reduced bone formation.

Selenium (Se) Contained in the antioxidant enzyme glutathione peroxidase and heme oxidase. Deficiency results in oxidative membrane damage with different effects in different species. Human deficiency causes cardiomyopathy (heart damage) and is known as Keshan’s disease.

Fluorine (Fl) Constituent of bones and teeth. Important for tooth development and prevention of dental caries. Derives from water, tea, and fish.

Cobolt (Co) Contained in vitamin B12. An excess may cause cardiac failure.

Molybdenum (Mo) Contained in the enzyme xanthine oxidase. Required for the excretion of nitrogen in uric acid in birds. An excess can cause diarrhea and growth reduction.

Chromium (Cr) A cofactor in the regulation of sugar levels. Chromium deficiency may cause hyperglycemia (elevated blood sugar) and glucosuria (glucose in the urine).

A recent Turkish paper indicates low zinc levels in saliva (and so plasma) in people with UAT [http://www.turkjem.org/sayilar/79/buyuk/1-4.pdf]. It is not known if this is a cause or effect of UAT but suggests that people with UAT should ensure zinc levels are optimised.

Role of reverse T3?

A recent study highlights the dangers of subclinical hyperthyroidism considering healthy aging associated with decline in T3, unchanged levels of T4, with rise in TSH and rT3 [http://goo.gl/WCUk8]

The process of normal aging affects the hypothalamic-pituitary-thyroid axis in a number of ways, resetting of the set point being the most important of them. Contrary to the earlier belief, longevity has been reported to be associated with high serum TSH. Most recent studies have demonstrated an age dependent decline in serum free T3 levels, whereas FT4 levels remains relatively unchanged and TSH & rT3 levels increase with age. Two recent meta-analyses have shown increased risk of adverse cardiovascular outcomes in patients younger than 65 years of age, but not in those more than 65 year old. There is a good number of evidence documenting increased mortality in elderly individual with sub- clinical hyperthyroidism, which should be kept in mind while treating mildly elevated TSH in these patients. It is also important to remember that thyroid functions in the elderly closely mimics that found in sick euthyroid syndrome.

People with UAT recognise that rT3 levels can rise while they are ill. They make a good argument that rT3 levels ought to be checked in cases of poor response to standard treatment. If rT3 is raised then clearly the the patient is ill and efforts need to be made to restore her/him to biochemical euthyroid state.

Thyroid stimulating hormone response is not predictable

A recent paper by JEM Midgley highlights the problem with depending on TSH to determine whether or not a person with thyroid disease is adequately treated [http://jcp.bmj.com/content/66/4/335.abstract and http://www.hindawi.com/journals/jtr/2012/438037/]

Our data suggest that the states of hypothyroidism, euthyroidism and hyperthyroidism can be regarded as differently regulated entities. The apparent complexity could be replicated by mathematical modelling suggesting a hierarchical type of feedback regulation involving patterns of operative mechanisms unique to each condition. For clinical purposes and assay evaluation, neither the standard model relating logTSH with FT4, nor an alternative model based on non-competitive inhibition can be reliably represented by a single correlation comparing all samples for both hormones in one all-inclusive group.

Conclusion and approach to the patient

UAT is a common condition though there is still a lot to learn how to accurately diagnose it in all patients. Even if the diagnosis is not elusive the patient’s response to treatment is occasionally not what is expected.

To ensure improved diagnostic accuracy free T3 ought to be checked for all patient suspected of suffering UAT.

Thus it is my practice to check the following in a person who presents with a longstanding history of fatigue with no obvious abnormality on physical examination:

  • Full blood count with vitamin B12, folic acid and transferrin saturation index for iron status
  • Thyroid function test, including free T3 as well as free T4 and TSH
  • C-reactive protein
  • Vitamin D level and calcium profile

If patient is proved to have UAT, treatment is started at 25 mcg daily of thyroxine. The patient will be reviewed approximately 2 months later when thyroid function is rechecked with fT3, as well as checking thyroid peroxidase autoantibody (for autoimmune thyroid disease). If there has been a poor response to treatment, copper, zinc and 9am cortisol level should also be checked. rT3 should be checked in all poor responders to treatment too; this is recommended by Thyroid UK.

For details about signs and symptoms of UAT see for example: patient.co.uk
http://www.hormone.org/diseases-and-conditions/thyroid

Some patient resources

UK

Thyroid UK – http://thyroiduk.healthunlocked.com/ http://www.thyroiduk.org.uk/tuk/index.html

International

American Thyroid Association – http://www.thyroid.org/

Association Française des Malades de la Thyroïde – http://www.asso-malades-thyroide.org/

Petition – Better Endocrinological Service and Treatment for Thyroid Patients in United Kingdom

If you agree that more should be done for people with thyroid disease, then please sign the petition here

David Lewis
Hertfordshire
June 2013

Vitamin B12 deficiency – time for a rethink?

2 Mar

Traditional view

NHS Choices offers a traditional view of vitamin B12 metabolism and diagnosis and management of vitamin B12 deficiency anaemia.

An up to date review was published recently link

Vitamin B12 deficiency anaemia or folate deficiency anaemia develops when a lack of vitamin B12 or folate causes the body to produce abnormally large red blood cells that cannot function properly.

The main symptoms of vitamin B12 deficiency or folate deficiency anaemia are:

  • tiredness
  • lethargy (lack of energy)

View from special interest group(s)

Conversations with members from Pernicious Anaemia Society and B12 deficiency support group indicate there is more to the cobalamin metabolism story than the traditional view describes.

Recent articles and abstracts scattered through the scientific literature point to a more sinister effect on human biology when there is functional deficiency of B12.

Adenosylcobalamine, the adenosyl form of Vitamin B12, is needed to keep the TCA cycle running smoothly, and many people with B12 deficiency suffer a “dreadful fatigue”. But it’s a complicated process getting B12 into mitochondria, and an awful lot of things can go wrong.

A key to better understanding is awareness of biochemical reactions in which vitamin B12 is a crucial. These include [link]:

  • conversion of odd chain fatty acids (specifically propionate) into succinate
  • conversion of homocysteine into methionine via methyl group donation

Medically Unexplained Symptoms – is this a B12 deficiency syndrome?

This week it was proposed that any patient with medically unexplained symptoms should be referred for CBT. It was estimated this may save the NHS £3 million per year. No mention by the authors of the report to explicitly exclude functional deficiency of vitamin B12 [Advances in Psychiatric Treatment (2009)15: 146-151doi:10.1192/apt.bp.107.004606]

Do not forget magnesium deficiency – it is important to ensure magnesium levels are normal in any patient who is taking high dose proton pump inhibitor especially if also prescribed a diuretic agent.

The neuropsychiatric changes caused by functional B12 deficiency may predate the typical changes seen in the blood by months (perhaps years). These are detailed by MacDonald Holmes [JMD Holmes – British Medical Journal, 1956].

McAlpine (1929) said, ” Mental changes occur not uncommonly in pernicious anaemia. They range from states of depression accompanied by loss of mental energy to definite psychoses…” [McAlpine, D. (1929). Lancet, 2. 643]

When there is doubt about the status of vitamin B12 rather than repeat the test in 6 weeks in “borderline cases” as is the present practice, serum methylmalonic acid levels and serum homocysteine levels should be measured.

Measurement of methylmalonic acid, total homocysteine, or both is useful in making the diagnosis of vitamin B12 deficiency in patients who have not received treatment. The levels of both methylmalonic acid and total homocysteine are markedly elevated in the vast majority (>98%) of patients with clinical B12 deficiency including those who have only neurologic manifestations of deficiency (i.e., no anemia). [Stabler, S NEJM 2013]

Implications for general practice

Clearly there is a need to review how we view vitamin B12 metabolism. Recognition in primary care of functional deficiency of vitamin B12 will require medical curricula to pay better attention to this. Haematology does not have a monopoly on clinical features of vitamin B12. There are too few haematologists and neurologists, at least in the UK to provide clinical opinions when vitamin B12 deficiency is suspected. This leaves it to general practice and family doctors to learn more about the protean manifestations of altered vitamin B12 metabolism.

With performance managed healthcare becoming the norm around the world, it may be time to press for explicit scrutiny of vitamin B12 levels in patients with long term conditions including many in the following systems: gastrointestinal, hepatic, psychiatric, neurological, endocrine, renal, and non-malignant anaemias. Only then might we be certain that a scourge of (modern) society will be beaten.

David Lewis

GP UK

Acknowledgement

I would like to thank @b12unme for educating me about this issue. Any errors and omissions are mine.

Nothing to see here – General Practice serves our children well

20 Feb


February 19, 2013 UK readers awoke to the headline that NHS is failing the children. Why?

  • Kids with meningococcal disease are turned away rather than sent to hospital to be cured;
  • Children with asthma are not given adequate treatment;
  • Too many children are admitted to paediatric wards with minor illnesses
  • Doctors prescribe too many drugs which have not been tested on children
  • General practitioners do not have proper postgraduate training in child health

At face value such accusations are depressing. The accusations sully the credibility of GPs who are constantly berated for some failing or other every week in the Britain.

Here I hope to show that the accusations are baseless. General practitioners are fantastic physicians who can manage any patient in first contact doctor setting from cradle to grave.

Meningococcal disease in children

This myth perpetuated in the article that children are turned away is based on an article published in 2006 [http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)67932-4/abstract, accessed Feb 20, 2013]


Much has changed since that article was published. In any event the study makes no mention of the fate of the fatalities many of whom, one may argue, would have died anyway. Be that as it may, meningococcal disease is less common now Haemophilus influenzae type B (HiB) immunisation is universally available in UK.


Screen clipping taken: 20/02/2013 22:22

Nearly 70% reduction in cases since 2006 is attributable to the immunisation program. Given that millions of GP visits are children, the fact is the chance of any one GP diagnosing a case of meningococcal disease is vanishingly small today. Thus the hazard referred to is scaremongering. The British public deserve better information to make decisions about their kids who develop fevers and blanching rashes. Sadly a reputable charity, The Meningococcal Foundation perpetuates the hazard speculating there are nearly 3,500 cases of meningococcal disease annually in Britain. The figure for 2012 is 443 recorded cases, and many are adults.

Childhood Asthma

Asthma in children is a common condition. General practitioners diagnose the condition regularly. It is a core competency of MRCGP curriculum to diagnose, treat, and manage asthma.

What we cannot do is make parents give the treatment as often as may be needed. We cannot make children and teens take their inhalers regularly. Important risk factor for poor asthma control in youngsters include: parents/carers who smoke, overcrowding, damp, dusty environment. Prematurity is an independent risk factor for bronchial hyperreactivity/asthma. This is important with the upsurge in assisted conception and attendant increase in multiple births which often end in premature delivery of the babies.

Asthma UK does a good job helping people with asthma understand their condition and manage it properly, including an excellent section on inhaler usage.


Screen clipping taken: 20/02/2013 22:36

It is not doctors’ fault that many children have poorly controlled asthma and asthma-like conditions. People with asthma must take more responsibility for the correct management of this long term condition. Wringing of hands that doctors are not treating people with asthma properly perpetuates a State-controlled solution for every ill affecting individuals. This requires better reading comprehension, better education of children to take responsibility for their actions/conditions, and better access to online resources for everyone to improve information flow.

The story about asthma can apply to every long-term condition. There is not space here to enumerate many of the places to look for advice, though NHS Choices and BBC Health deserve wider readership at least in UK.

Minor illness admissions of children

It is a truism that all serious illness begins as minor illness. The trick is to spot which cases may progress. Doctors receive many years of training to learn how to spot the the worrying case. It is an art not a science in this. Suffice to say, like many of my colleagues, I will refer a child to hospital when I fear that worry will stop me sleeping at night about a particular case. This is, I know, not scientific, but when the hairs on the back of my neck stand on end, the child in front of me at that moment will be referred to see a colleague in paediatrics.

If one admits too few patients to hospital, too many unwell children will be taken to Emergency Department out of hours. If one admits too many children, there will be no space for the truly ill child referred by a colleague. All GPs know this. Yes some of us are high referrers while others are not. No-one has discovered what is the ideal referral rate. This is well known to the profession and health economists.

Therefore the accusation in the article is baseless.

Prescribing untested drugs to children

This is a specious argument. With the widespread availability of the British National Formulary for Children, there is a sound basis for prescribing for children in UK (and elsewhere). Yet another baseless accusation threatening to undermine the professionalism of the medical profession in its management of children.

Too few GPs have postgraduate child health training

This is baseless accusation too. General practice curriculum described by RCGP includes core competency in child health. Further, nearly 80% GPs have some postgraduate training in paediatrics before they complete general practice training (at least in UK) [personal communication from Doctors.net website].

Conclusion

The British public has a fantastic primary healthcare service which serves our children well. With a little bit of research it is obvious the article which prompted me to write this is full of inaccuracies and unfounded accusations.

Samuel Shem, 34 Years After ‘The House of God’ – Atlantic Mobile

28 Nov

http://goo.gl/TZ3fx A fabulous essay celebrating humanity in healthcare which must be preserved for all our sakes

Shame

16 Nov

A superb essay on addressing “Shame” in order to help people recover from depression and health care professionals develop better emotional resilience.

A Better NHS

Masaccio: The Expulsion of Adam and Eve from Eden 1425

Through the concrete physicality of the two figures and the arid landscape around them, Masaccio makes believable the first dolorous steps of human beings on earth, in the solitude of the shame of sin and the dramatic experience of pain. Quoted from ‘Medicine in Art’ Getty Publications. p.292

One of my patients, June, was standing near the entrance of the surgery when I came back from a home visit. June and I had been through a lot together in the two years since she came to see me with a breast lump, her subsequent mastectomy and chemotherapy, her husband’s dementia and death, and her depression and redundancy, but in recent months she had been steadily recovering and rebuilding her life and her health. The last few times we met she had been really well and we had time to talk…

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Dying with dignity – Liverpool Care Pathway and Palliative Care 2012

11 Nov

With the furore over Liverpool Care Pathway showing little sign of going away it may be a good time to pull together some of the threads. Margaret McCartney has written about the issue in this week’s BMJ (http://goo.gl/VeqY1)

We need to go back to Dame Cicely Saunders who established the groundwork for the specialty of Palliative Care to understand how we arrived at the stage now:

She founded St. Christopher’s Hospice in 1967 as the first research and teaching hospice linked with clinical care, pioneering the field of palliative medicine.

I was a medical student in the 80’s at Monash University, Melbourne. An element of the curriculum included palliative care, especially pain management. We even has a pocketbook to help with prescription of analgesia. Even so, people were still suffering with pain, sometimes horrible pain, right up to death on the wards. The interns and other doctors in training feared giving too much morphine to our patients. The nurses hovered like hawks to ensure we never over-stepped the mark with pain relief. Patient-controlled analgesia was introduced onto surgical and medical wards to improve pain management with variable success (e.g. Macintyre, 2001).

So fast forward to the Liverpool Care Pathway or LCP

The LCP affirms the vision of transferring the model of excellence for care of the dying from hospice care into other healthcare settings.  We have demonstrated a process that inspires, motivates and truly empowers the generic workforce in caring for the patient and their family in the last hours or days of life.”
Deborah Murphy, National Lead Nurse-LCP, Associate Director MCPCIL

A detail of the process is here

So we get to the recent storm.

Daily Mail 13th Oct 2012

Did NHS kill my mother to free bed? The profoundly disturbing story by son of patient at controversial terminal illness care home
Peter Tulloch believes doctors sought to hasten his mother’s death

He was informed that mother Jean Tulloch had just weeks to live

Without his knowledge, doctors removed her drip but Mr Tulloch believes she was still aware of her surroundings

Daily Mail 14th Oct 2012

Care? No, this is a pathway to killing people that doctors deem worthless

But, as Margaret McCartney discovered, the Daily Mail was a fan only last year of end of live care that worked:

Daily Mail 30 Aug 2011

I’ll always be grateful to the GP who eased Mum’s pain – even if it hastened her death

This was after an example of poor nursing care at end of life was reported in 2009 in the same paper

Daily Mail 28 Aug 2009

Many NHS nurses are still the finest in the world. But they let my poor father die in agony like a dog

We were treated to a celebration of the care UK citizens receive at the end of life in 2010.

Daily Mail 15 Jul 2010

The country tops the Quality of Death Index, which ranked 40 countries according to the care offered to dying people. In second place was Australia, followed by New Zealand, Ireland, Belgium and Austria.

It cannot be emphasised enough that the model of care exemplified by LCP helps reduce, if not eliminate, the disasters highlighted in the 2009 article. The knowledge, skills and attitudes which the LCP training gives healthcare professionals has virtually eliminated the scenes I witnessed as a medical student in the 80’s.

Now we come to the present again. The Association of Palliative Medicine will review end of life procedures

Daily Mail 24 Oct 2012 and here

the Association of Palliative Medicine has ordered a review of the concerns expressed by countless bereaved relatives, with a promise to explore ways of improving practice.

And the new Health Minister, Jeremy Hunt, has chipped in. (Surely not to gain political points)

Huffington Post UK 3 Nov 2012

NHS Constitution: Families To Get Consultation On ‘Death Pathway’ Decision, Says Jeremy Hunt

But wait! Is there anything actually wrong with the LCP?

Christian Medical Comment 16 Oct 2012

Consensus Statement: Liverpool Care Pathway for the Dying Patient (LCP) 

Published misconceptions and often inaccurate information about the Liverpool Care 
Pathway risk detracting from the substantial benefits it can bring to people who are dying and to their families. In response to this we are publishing this consensus statement to provide clarity about what the Liverpool Care Pathway is – and what it is not. 

Read full statement

The Catholic press also expresses view that nothing is wrong with the system two years ago.

Catholic Herald 23 Apr 2010

A dependable pathway to the life beyond

It is important that death and dying in our community is being debated. With the erosion of spirituality in our lives, our mortality is denied. However, it is so sad that some of the most vulnerable amongst us are being used to sell newspapers and gain political points.
Death and dying is part and parcel of excellent healthcare. The healthcare professionals who work in the NHS (and in private sector) understand this. It is a sign of the times that the authority of healthcare professionals (and priests) at the end of life are being called into question. We are the people who witness more death and dying in civilian populations not at war than any other group in our society. General practitioners with their teams are the midwives to dying process and the grief which follows for those left behind.

To give you an idea of the scope of knowledge and skills involved a selection books has been added.

Helpful Palliative Care resources for healthcare professionals

Paediatrics

Oxford Textbook of Palliative Care for Children

Paediatric Palliative Medicine (Oxford Specialist Handbooks in Paediatrics)

Adults

Oxford Textbook of Palliative Medicine

Oxford Handbook of Palliative Care (Oxford Medical Handbooks)

Palliative Care Nursing, Third Edition: Quality Care to the End of Life

Geriatric Palliative Care

Journals & websites

American Journal of Hospice and Palliative Medicine

Journal of Palliative Care & Medicine

International Association for Hospice & Palliative Care

General and popular books

A selection of books at Goodreads.com

TASME #ukmeded Chat

31 Oct

An excellent opportunity to share ideas with #meded enthusiasts

Med Ed Connect

On Thursday 1st November at 9pm TASME will be hosting #UKmeded chat on twitter.

For those that don’t know, TASME (Trainees in the Association for the Study of Medical Education) is a Special Interest Group of ASME (Association for the Study of Medical Education) that aims to support trainee involvement in teaching. More information can be found on the website here.

The broad topic for discussion will be ‘the role of trainees in medical education’ but as well as trainees, we welcome input from a range of healthcare professionals at all levels. Are you a medical student who struggles to get teaching from trainees that are often too busy? Perhaps you are a trainee who is keen to get involved in med ed but doesn’t know to start? Maybe you’re a consultant that thinks trainees lack the experience required to teach effectively.

Some of the questions we’d like to answer…

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WHO | Patient safety: the rising star of clinical care

22 Oct

WHO | Patient safety: the rising star of clinical care.

Patient safety: the rising star of clinical care

Dr Margaret Chan
Director-General of the World Health Organization

Keynote address at the 29th International Conference of the International Society for Quality in Health Care
Geneva, Switzerland
 

22 October 2012

Distinguished delegates, colleagues in public health, ladies and gentlemen,

It is a great pleasure to address an audience committed to advancing safe, high-quality clinical care for all patients, rich and poor, now and in the future.

I thank ISQua, its officers, its programme and planning committee, and the support provided by the Canton of Geneva and the Geneva University Hospitals, for making this event possible.

The conference is timely for WHO. For many reasons, concern about the quality and safety of patient care is reaching new heights. Patient safety is on the agenda for next year’s Executive Board and World Health Assembly.

Patient safety is a complex multifaceted objective that demands a multi-pronged approach. The diversity of factors contributing to the safety and quality of care is well-reflected in the nine track programme for this conference.

Like WHO, you will be looking at top-down and bottom-up approaches. You will be looking at the role of provider education in reducing errors, and the importance of patients’ expectations, perceptions, and engagement.

Of course, hospitals are not hotels to be rated by their comfort or the quality of their food. But patient experiences yield important clues when things go wrong, and important insights into how to make things better.

You are moving beyond the hospital to consider other settings, including self-medication in homes. You are exploring innovative technologies and what they promise for the future.

Above all, you will be discussing ways to standardize and institutionalize protective and preventive measures, whether through policies, accreditation, and regulation, or practices in hospitals, doctors’ offices, pharmacies, and homes.

Patient safety is a comparatively new discipline that has rapidly risen to star status. This rise began in the late 1990s, with eye-opening reports documenting the scale of harm caused by medical errors.

These reports had media appeal, which gave them popular and political traction. And understandably so. Medical errors cause deep indignation. Health care should heal, not hurt, injure, or kill.

Documenting the costs has also helped quantify the magnitude of the problem. These are the costs of distress on the part of patients and providers, long-term if not life-time disabilities, and needlessly lost lives.

These are the economic costs of direct and indirect medical expenses, the recall of faulty equipment or contaminated medical products, and the settlement of clinical negligence claims.

I need only mention the current meningitis outbreak, in multiple states of the USA, linked to tainted steroid drugs, with as many as 14,000 patients thought to be at risk.

Let me illustrate the consequences of medical mishaps with just a few statistics. Worldwide, unsafe injections alone are thought to cause around 1.3 million deaths, with economic losses of around $535 million in direct medical costs. That figure represents an astronomical loss of around 26 million years of life.

The prospect of reducing such costs has further increased the appeal of patient safety, especially at a time of rising public expectations, soaring medical costs, and shrinking budgets.

Such conditions place a premium on strategies that tackle waste and inefficiency. When safety becomes part of the culture of clinical care, health systems see a reduction in unnecessary, costly, and often dangerous care.

As just one measure of this appeal, patient safety Global Challenges have been the fastest growing campaigns ever launched by WHO

WHO is proud to be part of this movement. Together, we are turning clearly defined needs into concrete, practical, and highly effective tools that make the people, the patients, the winners.

Ladies and gentlemen,

Like any other young discipline, patient safety faces challenges. These include the need to change human behaviours, and the reluctance of medical professionals to acknowledge errors, on their own part or that of others.

To err is human, especially in today’s complex world of medical care with its increasingly sophisticated interventions and equipment. Errors can never be entirely eliminated, but their numbers and severity can be reduced.

Some medical mishaps are egregious and unforgiveable, like wrong-site surgery or releasing an infant to the wrong parents. These are the errors that make the headlines and blacken the image of health care. Fortunately, they are rare.

Other errors are less sensational, far more common, and greater in their cumulative impact, such as adverse drug reactions in the elderly and faulty prescribing practices that contribute to the emergence of drug-resistant pathogens.

What is disconcerting is that the same mistakes keep happening over and over again. This says much about the pressing need to make patient safety a top priority for any well-functioning health system.

This sentiment was well captured in a resolution adopted by the World Health Assembly in 2002. That resolution elevated patient safety to the level of a global priority for improving the quality of clinical care and strengthening the performance of health systems. That resolution recognized patient safety as a fundamental principle of all health systems.

As a young discipline, patient safety also needs a scientific framework rooted in multiple lines of evidence, a shared vocabulary, an accepted system of measuring and classifying adverse events, and a culture of transparent reporting.

I am pleased to note that efforts to address all these problems are being undertaken by national initiatives, international societies, like ISQua, and WHO.

But patient safety also has a number of advantages and unique opportunities, and these fuel the energy and excitement of events like this conference.

First, as I mentioned, patient safety has political appeal and popular traction, and this encourages accountability. I am thinking about the numerous chat rooms and blogs where patients share their experiences, good, bad, and sometimes horrific, holding individual facilities accountable for the quality of their services.

Second, solutions don’t need to break the bank. Measures for improving patient safety are often simple and comparatively inexpensive to introduce. For example, measures such as hand hygiene and safety checklists can be rapidly introduced. They also bring rapid results.

I can think of no other dimension of clinical care that responds so well to simple, common-sense interventions.

Approaches aimed at quality improvement leverage better results. They do so through changes in the way health care is delivered, not through a large influx of funds.

Third, solutions travel well. Many medical mishaps have common causes and common solutions that work well in rich and poor countries alike. The WHO Safe Childbirth Checklist is a good example of the kind of intervention that can make a night-and-day, life-and-death difference in clinical outcomes in the developing world.

What good does it do to offer free maternal care and have a high proportion of babies delivered in health facilities if the quality of care is substandard or even dangerous?

Fourth, patient safety resonates well with many of today’s burning issues in public health. All around the world, health is being shaped by the same powerful forces, like population ageing, rapid urbanization, and the globalization of unhealthy lifestyles.

Chronic noncommunicable diseases are on the rise everywhere, with the greatest burden now concentrated in the developing world. This means more and more people needing long-term if not life-long care. This means more and more people needing sophisticated hospital treatment for acute events.

The need for care is increasing in a world where health care is crippled by a shortage of 4 million doctors, nurses, and other health care staff, with the shortage greatest in areas most in need of care.

Taken together, these trends mean more opportunities for errors and unsafe practices to occur, everywhere. They mean increased pressure to find solutions that work well, everywhere.

Patients, in rich and poor countries alike, need and expect quality clinical care. Don’t disappoint them.

Finally, patient safety has passionate and articulate champions. I am pleased to share this podium with Sir Liam Donaldson. I am pleased that platforms established by WHO have given a voice to more than 250 patients groups and other champions in more than 50 countries.

As I said, I am proud that WHO is part of this movement.

Ladies and gentlemen,

In clinical care, things will go wrong. To err is human. Some medical errors are unforgiveable. Others are more understandable. All can be addressed.

Health care will never be risk-free. But we can make these risks extremely rare rather that so disconcertingly common.

The best way to make progress is to learn from each other, with our eyes clearly on the patients as the ultimate winners. We want to heal, not harm.

I warmly welcome this conference, and wish you a most successful meeting.

Thank you.

 

The Things We Carried, Then and Now – NYTimes.com

10 Oct

http://goo.gl/bJa7W Fabulous short essay on what the new doctor of 21st century should carry in their bag

Old age care as frail as it’s users?

9 Jul

Care of frail elderly

The weekend newspapers included reports here in UK that older people with £35,000 to £50,000 saved for a rainy day would be out of luck if they needed residential care later. The prize for being honest savers was the State would rob you of the hard earned money to pay for care and when the money ran out the State would continue to pay. For the hard living spenders, they will get residential care, if required, for free from the start.

Is this fair? In my opinion this makes a mockery of saving ethos.

To add insult to injury, care at home is failing our older citizens. It is scandalous that contracts for home care budget for 15-20 minutes per client for washing, toileting and dressing then a meal. These people are often frail, usually vulnerable. Our pets are often looked after better!

Part of the problem is the zeal people have destroyed residential institutions. With the rising elderly population of whom nearly 10% will need support there are not enough residential places. So Local Authorities are purchasing care at home packages. These packages are ridiculously designed in many cases. Failing to budget for the travelling time of carers is negligent. All the travel time would be caring time if the carers were based in large institutions. In days gone by these institutions were community hospitals and care homes.

Our vulnerable elderly are not helped by well meaning people who trumpet end of life choices for all. It is soul destroying to see people convinced they have a right to die at the place of their choosing. It can cause terrible upset for relatives who are left behind. Failure to fund adequate home care is part of the problem. In the current climate vulnerable elderly are stuck between Scylla of doing right thing and preserving some if not all of hard earned money for the next generation and Charybdis of getting properly cared for while exhausting all the hard earned savings.

Illusions of Autonomy

Where medical ethics and human behaviour meet

Enjoying every second

Cada lugar, cada rincón, cada momento compartido arreglando el mundo entre imprescindibles

The Commonplace Book

Jim McManus blogs on public health, ethics, books, theology and more

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