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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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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

eLearning Needs in NHS Sept 2012 #mobimooc

13 Sep

Mobimooc 2012 is up and running.  2 webinars have been well attended.  Regrettably the timing is not great for me – but the team has recorded the lectures 

By coincidence two new systems are due to launch in my region of UK.  An electronic prescribing system (EPS) and new telephone triage service (NHS 111)

NHS 111

http://goo.gl/ra2IE points to introduction to the system.  The NHS has also provided online introduction with accompanying slideshow here with direct link to the video Introduction to NHS 111

Here is a great example of mLearning in action but the local NHS managers insisted on practice teams send delegates to a meeting somewhere in my town.  Clearly this was a poor use of time for my practice manager.  With such a good presentation created, it is clear to me that the time taken for many people to get to the meeting would be better spent watching the slide show.  How patronising of our service managers!  There is apparently good evidence that the new system will be good for patients and reduce some of the demand on emergency services from (trivial) emergencies.

It does look like no-one locally is aware of mobile learning project management.  Here is  an excellent opportunity which has passed us by!  Notice there is no system on the website to help visitors assess their learning after reading the transcript while watching the slide show.  Why is the slide show an embedded video rather than posted on Slideshare, Brainshark, or other public cloud service?  How hard would it be to have a feedback form?

Whether the UK really needs another emergency number is a moot point now.  As a GP, this system looks to me a threat for the future primacy of General Practice as the first point of contact for health care questions by UK citizens.  This is sad.  In the not too distant future UK may come to regret the demise of the family doctor as an independent gatekeeper to healthcare services.  That is a discussion for a future post.

Electronic Prescribing System

I wish to share the following from my local medical committee concerning the roll out of the new electronic prescribing service because the rational behind it is described and the questions from my representatives focus us on another opportunity for eLearning.

NHS Bedfordshire and NHS Luton are working for Electronic Prescription Service (EPS) Release 2.  This will mean that the PCTs would then be enabled to allow practices and pharmacies to take part in EPS, if the practices and pharmacies want to.  This is part of a national programme.  We were told that EPS has been available in Hertfordshire for some time and that just under 30 practices are taking part in EPS there.  
We’ve seen documentation from Bedfordshire and Luton about what EPS is; what practices would have to do under EPS; what the criteria would be for selecting patients who could use EPS and what participating practices would need to do to support patients in making their choice; how patients would nominate which pharmacy they want to use for EPS and what the participating practice would need to do to facilitate this.

Beds LMC members recognised the positive objectives of the scheme, e.g.
It is supposed to reduce GP work load ultimately
It may be more convenient to the patient
It may reduce waste
It is understood that EPS will be optional for practices.
But Beds LMC members did have some concerns:
To what extent is it a whole new area of unfunded work in general practice?
Beds LMC members thought that EPS would create the following work:
1. GPs will be expected to identify suitable patients.
2. The GP has to look at all applications for it and make sure they do not have any of the exclusions (large groups of patients such as those on controlled drugs, anticoagulants and some others).
3. The GP or GP staff will be expected to promote and explain the process and follow this up in writing and collect a signature 
4. The practice will be expected to telephone suitable patients and offer it to them.
5. Time will be need to train GP staff.  Nothing about backfill for this.
6. All prescribers will have to use smartcards and be wary of prescribing some formulations or brands of medication which do not have a suitable barcode.  Not all practices use their “smartcards” when consulting because they cause their system to run slow and time out.  So clinicians log in and work offline.
Patients with regular repeat prescriptions tend to be patients on chronic disease registers.
On the rare occasions when patients such as this come in “just for a repeat prescription” it gives the GP an opportunity to pick up on preventative care, QoF items and other aspects of the health and wellbeing agenda.  In other words, the aspects GPs do not always have time for when dealing with acute illness in a 10 minute consultation.  Could the use of EPS actually reduce the level of care available for some patients?
Concerns that the EPS will not be a simple scheme, as some items cannot be included in EPS, so there would have to be two prescribing systems for EPS patients: one for EPS-included medications and one for EPS-excluded medications
Is there any evidence that EPS has saved time for GPs or staff in primary care?
If any Hertfordshire practices who are using EPS would be willing to share any of their experiences or would be able to answer any of the specific concerns listed, it would be very interesting to hear from you?

Here is my response:

Wow! How can such a simple idea as electronic repeat prescribing become so complex?

FIrst thoughts: I want nothing to do with a system with more bureacracy to set up. We have enough to deal with without this additional burden.

Second: The system is doomed unless bandwith of broadband connections is increased to cope with the demand from our desktops (and mobile devices). Currently broadband speed is around 10megabits per second down and 0.5 mb/s up, at least in Watford. Divide this by 8 prescription terminals and you can see the speed drop makes the system inoperable.

Third: Barcodes are not immune from corruption; at least several times a week a popup warns there has been a problem and the barcode should be scratched out. How do you do that with an electronic script?

Fourth: The main benefit of EPS is prescribing from mobile devices. With 4G/LTE imminent this seems practical so long as all prescribers have feature phones with the necessary hardware. I fear the powers that be are focussing on the wrong systems. We need secure login systems for iPhones/iPads and android devices to make EPS useful (e.g. prescribing urgent scripts on home visits, or residential facilities)

FIfth: How are pharmacists supposed to be persuaded to adopt this?

Sixth: Prescribing2U is already available. How does this differ from EPS 2?

Seventh: All HCPs who access clinical system must log in with NHS Smartcard. If there are hardware problems managing this, the IM&T teams across our area must fix these before rolling out EPS.

This system is being imposed on us on the background of a longterm agenda to cut the printed script costs.  There is also an agenda to improve security of prescribing.  Since proposed several years ago, IM&T systems and devices have evolved.  Mobile devices are so much more capable than before.  For example, my smartphone (HTC One X) is more powerful computer than my desktop system 10 years ago!

There is nothing in my local medical committee concerns nor in the NHS EPS background documents to indicate any desire to develop a mLearning project to aid in the implementation of this system.

Conclusion

Two new systems are being implemented shortly with the intention of improving patient care in an NHS region.  Two sophisticated organisations are responsible for the roll out of NHS 111 and EPS.  Neither seems to embrace education technology which, in my opinion, would ease the pain involved in changing behaviour of health care professionals and the public.

There is clearly a very long way to go to embed eLearning into the NHS.  This is a terrible state of affairs for a developed society.  It is ironic that some countries with large health care burdens (e.g. sub-Sahara Africa countries; South America countries) may be receiving superb instruction in mLearning systems.

I would love to see some discussion about the particular systems described above – your experiences of similar systems in your country, ideas on how to improve implementation, or anything else you think would be interesting.

Thank you in advance…

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.

Quote

What doctors do | Abetternhs’s Blog

18 Jun

http://abetternhs.wordpress.com/2011/07/24/what-doctors-do-2/

GPs are Fantastic Resource

17 Jun

Matthew Parris has managed to stir up debate about UK General Practice. Was this the intention? Was he being deliberately ironic? The timing of his opinion piece on the weekend before the first doctors’ strike since 1975 cannot be a coincidence.

The article can be found here, behind The Times paywall However, in the interest of openness, I have made a copy for you here

If family doctors had not existed, would we today have found it necessary to invent them?

The second question by Mr Parris is arguably the crux of his essay. The short answer is a resounding “Yes!” I will set aside the false premise that the doctors strike, in Mr Parris’ eyes is solely a GP strike. Perhaps because the bulk of the UK public who seek healthcare on a given day normally see GPs one can excuse this falsehood. All doctors (well, > 70%) will not be doing routine tasks on Thursday 21st June.

So back to the invention of family doctors. Family doctors are the descendents of “apothecaries” and “ship’s suregeons”. The health care professional who was available to the masses for many centuries. The idea that specialists should be available to all is a modern concept, especially in the UK where health care delivered by the National Health Service since 1948 is free at the point of delivery.

You do not need to go too far back in time to see that specialist medical advice was only available to the rich – the ruling classes and merchant class. The medical workforce was concentrated in cities, especially London and Edinburgh (and Dublin). Oxford and Cambridge Universities were for a long time the only recognised centres for training physicians in the UK.

The Public needs medical women and men who are trained in the nuances of first contact healthcare. There is far more to the intitial consultation than simply making a diagnosis of a somatic process. Mr Parris is lucky to need a doctor so rarely. His experience does not, in my opinion, give him the right to pass judgement on what doctors like me do!

Barbara Starfield (1932-2011) wrote some of the best essays on the merits of general practitioners and primary health care. An important conclusion is that mature health care systems must have robust primary health care systems to withstand the constant pressures of medical advances in order to protect citizens from the worst excesses of health seeking behaviour. Economies with strong primary healthcare also spent less on health without compromising outcomes. A selected bibliography in support of this statement is here

Are we investing too much in the citizen’s first port of call, to the detriment of investment in the specialist attention to which, to an increasing degree, surgeries are likely to end up referring the patient?

The next question deserves an explicit answer: “No, Mr Parris, we are not investing too much in the citizen’s first port of call”. If anything, there is too little investment in first contact doctoring because politicians are seduced by the gleaming hospital in their constituency. It is not sexy to spend money on often small and out of the way health centres which are often owned by the doctors. There is no political mileage in giving more money to the hardworking GPs and their staff. We do not spend enough money for your campaign funds. Profits are ploughed back into the practice to maintain services. Unglamourous activities like cervical smears and blood pressure monitoring. There is no obvious soundbite for enhancing the environment 95% citizens visit in any year. Greedy doctors must not be encouraged. On the other hand hospital doctors are gagged – prevented from speaking out because of their contracts. GPs remain independent contractors which is an anathema to the Ruling Class.

Is the work of these expensive and expensively trained men and women best directed to the point at which they’re doing it?

“Yes, Mr Parris”. We are the cheapest healthcare professional available to determine whether the first sneeze is the beginnings of a serious illness or just a virus. Making that decision requires confidence, high level of training, and a feel for pattern failure that almost any other healthcare professional cannot do. Nurses are generally hopeless at detecting pattern failure. Secondary care doctors are trained to investigate; general practitioners are trained to reassure. Certainly, we would love to investigate more given the chance (witness the explosion of near patient testing), but there is little evidence that such behaviour improves outcomes. It may reduce the doctor’s stress levels, but that is not a good reason to inflict tests on patients “just because it seems a good idea”.

 

“Referral rates” — the proportion of GP consultations that lead to a consultation with a specialist — are rising fast

Whose fault is this, Mr Parris? Media campaigns pandering to the worried well concerning the latest medical scare do not help manage demand for secondary care opinions. Two week rules for suspected cancer, demands for early diagnosis of dementia, advances in cardiovascular and respiratory medicine, better endoscopy techniques, imaging techniques denied to GP access by NHS rules, barriers for experienced GPs which prevent in house treatment, and a culture of defensive medicine engendered by people like Mr Parris who insist on certainty in an uncertain world all conspire to increase referrals. This is not of our doing. This protocol driven medicine is the undoing of decades of responsible use of scarce resources.

Perhaps, if the Royal Family could be persuaded to employ a Royal general practictioner, there would be a sea-change in the respect GPs should receive.

Nurse-led primary care, too, is plainly on its way and expanding fast, with (the research is clear) excellent results. 

Mr Parris should do better research. Nurse-led primary care does not work! 30 minute appointments, protocol-driven working, limited formulary, lack of experience, deference to a GP when things go awry, and catastrophic errors do not support this blithe assertion. Rhona Knight (2008) points out that it would be backward step. If you cannot read the whole article, you will find it here. Nurses are anxious not to fight GPs for primary care; we must collaborate and play to each other’s strengths. Nurse-led clinics can improve health, for example in secondary prevention of heart disease (see Campbell et al 1998) but this is not the same as nurse led general practice.

Decades ago, at the bookshop Foyles, you had to get a little chitty from a person in a booth before you could get your purchase. One day we’ll remember the GP surgery in the same way, with the same amusement that the archaic practice lingered so long.

The day this arrives, Mr Parris, will be a very sad day indeed for the healthcare of this once proud Nation. At the one and the same time you express such strident opinion, countries around the globe are struggling to implement primary health care modelled on the very system you seem so intent on dismantling: Quatar, India, Poland, Slovenia, USA to name a few. How can such an erudite fellow as Mr Parris get it so wrong?

Finally

It feels good to make this effort to dismantle Mr Parris’ thesis. I do hope it is now clear why General Practice and the GP are a fantastic resource for the UK. By the way, the Royal College of General Practitioners is the guardian of the high standards of practice expected in the UK. Its new building in Euston which opens later in 2012 is a testament to the endurance of primary health care and GPs. GPs are here to stay and we will fight hard to protect the most vulnerable in our society from the excesses of the Ruling Classes who share Mr Parris’ views.

Focus on Stroke: Infographic – Risk factors

29 May

Excellent resource! This particular article very good overview of stroke.

Wellcome Trust Blog

Focus on Stroke infographic - risk factors

This article is part of the Wellcome Trust’s Focus on stroke, a series of articles, interviews and videos running throughout May 2012, which is the Stroke Association’s Action on Stroke Month.
For more information on stroke, visit the Stroke Association’s site or call its helpline on 0303 303 3100. If you or someone with you is suspected of having a stroke, call the emergency services immediately.

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Illusions of Autonomy

Where medical ethics and human behaviour meet, by Dr Philip Berry

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