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The Art of Medicine

Adrenaline, Information Provision and the Benefits of a Non-Randomised Methodology

17 Aug, 14 | by Iain Brassington

Guest Post by Ruth Stirton and Lindsay Stirton, University of Sheffield

One of us - Ruth – was on Newsnight on Wednesday the 13th August talking about the PARAMEDIC2 trial.  The trial is a double blind, individually randomised, placebo controlled trial of adrenaline v. normal saline injections in cardiac arrest patients treated outside hospital.  In simpler terms, if a person were to have a cardiac arrest and was treated by paramedics, they would usually get an injection of adrenaline prior to shocks to start the heart.  If that same person was enrolled in this study they would still receive an injection but neither the person nor the paramedic giving the injection would know whether it was adrenaline or normal saline.  The research team is proposing to consent only the survivors for the collection of additional information after recovery from the cardiac arrest.  This study is responding to evidence coming from other jurisdictions that indicates that there might be some significant long term damage caused by adrenaline – specifically that adrenaline saves the heart at the expense of the brain.  It is seeking to challenge the accepted practice of giving adrenaline to cardiac arrest patients.

Our starting position is that we do not disagree with the research team.  These sorts of questions need to be asked and investigated.  The development of healthcare depends on building an evidence base for accepted interventions, and where that evidence base is not forthcoming from the research, the treatment protocols need changing.  This going to be tricky in the context of emergency healthcare, but that must not be a barrier to research.

There are two major ethical concerns that could bring this project to a grinding halt.  One is the opt-out consent arrangements, and the other is the choice of methodology.

Consent, then. more…

Paternalism up a Mountain

12 Aug, 14 | by Iain Brassington

“Paternalism” is one of those words that has a hell of a lot of power.  On several occasions, I’ve seen it used as a trump to shut down an argument: saying “But that’s paternalism” is, at least sometimes, treated as a way of showing that anyone arguing in favour of the allegedly paternalistic action is an imbecile, and has therefore lost the argument by default.  I suspect that this is due to a bastardisation of the (already iffy) “Georgetown Mantra”; but it does seem to be a position horribly common in medical schools.  It’s also very unsophisticated.  Whether or not something is paternalistic seems to me to be less important than whether it’s justified.  Something might be unjustified, and the reason for that might be because it’s paternalistic; but it doesn’t follow from that that no paternalism could be justified.  In just the same way, too much bleach or bleach in the wrong place is something you’d want to avoid; but it doesn’t follow that you should avoid bleach at all times and at all costs.

I want here to tell you a story based on something that happened just over a week ago. more…

Athletic Sex

11 May, 14 | by Iain Brassington

There was an interesting article published in the BMJ a few days ago on the subject of athletes and their sex.  Here’s the opening gambit:

The International Olympic Committee (IOC) and international sports federations have recently introduced policies requiring medical investigation of women athletes known or suspected to have hyperandrogenism. Women who are found to have naturally high testosterone levels and tissue sensitivity are banned from competition unless they have surgical or pharmaceutical interventions to lower their testosterone levels.

The primary justification offered seems to be one of reducing unfair advantage, with a secondary justification that investigations of this sort might be to the medical advantage of the athletes themselves. Rebecca Jordan-Young and her colleagues aren’t impressed, and think that the policy is ethically suspect: not the least of their worries is that the policy effectively medicalises an unusual but benign characteristic of some people.  This could lead to medically useless surgery.  However, the potential problems are wider than that:

When pharmacological intervention or gonadectomy is a precondition for eligibility to compete, an athlete has to make a profound life and health altering decision for non-medical reasons. These are not merely individual decisions: athletes are embedded in families, teams, organisations, and even nations that depend on them to compete. Athletes can be “regarded as vulnerable to undue, even extreme situational pressures arising from the decision-making environment,” especially when a competitive career is also a path to economic mobility and stability.

I have to admit that I’m fairly relaxed about surgical interventions being undergone for non-medical reasons; more…

Resurrectionism at Easter

23 Apr, 14 | by Iain Brassington

There’s a provocative piece in a recent New Scientist about what happens to unclaimed bodies after death – about, specifically, the practice of coopting them for research purposes.

Gareth Jones, who wrote it, points out that the practice has been going on for centuries – but that a consequence of the way it’s done is that it tends to be the poor and disenfranchised whose corpses are used:

[T]he probably unintended and unforeseen result [of most policies] was to make poverty the sole criterion for dissection. [... U]nclaimed bodies are still used in countries including South Africa, Nigeria, Bangladesh, Brazil and India. While their use is far less in North America, they continue to constitute the source of cadavers in around 20 per cent of medical schools in the US and Canada. In some states in the US, unclaimed bodies are passed to state anatomy boards.

For Jones, the practice of cooption ought to be stopped.  His main bone of contention is the lack of consent – it’s a problem that’s made more acute by the fact that the bodies of the disenfranchised are more likely to be unclaimed, but I take it that the basic concern would be there for all.

One question that we might want to ask right from the off is why informed consent is important. more…

Who’s the SilLIer?

30 Mar, 14 | by Iain Brassington

It’s funny how things come together sometimes.  A few months ago, I mentioned a slightly strange JAMA paper that suggested that non-compliance with treatment regimes should be treated as a treatable condition in its own right.  The subtext there was fairly clear: that there’s potential scope for what we might term “psychiatric mission-creep”, whereby behaviour gets seen as pathological just if it’s undesirable and can be changed with drugs.  I was reminded of this by a couple of things I found last weekend.

I was avoiding work by pootling away on the internet, and stumbled across a couple of things.  This - an article about American politics that notes the use of psychiatry as a means of social control – was one of them:

[In 1980] an increasingly authoritarian American Psychiatric Association added to their diagnostic bible (then the DSM-III) disruptive mental disorders for children and teenagers such as the increasingly popular “oppositional defiant disorder” (ODD). The official symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules,” “often argues with adults,” and “often deliberately does things to annoy other people.”

Many of America’s greatest activists including Saul Alinsky [...] would today certainly be diagnosed with ODD and other disruptive disorders. Recalling his childhood, Alinsky said, “I never thought of walking on the grass until I saw a sign saying ‘Keep off the grass.’ Then I would stomp all over it.” Heavily tranquilizing antipsychotic drugs (e.g. Zyprexa and Risperdal) are now the highest grossing class of medication in the United States ($16 billion in 2010); a major reason for this, according to the Journal of the American Medical Association in 2010, is that many children receiving antipsychotic drugs have nonpsychotic diagnoses such as ODD or some other disruptive disorder (this especially true of Medicaid-covered pediatric patients).

For some reason, I had foxes on my mind as well, and so I entered the word “Fox” into google; and I should have known that it’d provide lots of hits for the US TV conglomerate.  One story that came up on the search had to do with a twitter account called @LIPartyStories.  This was apparently a feed that would repost pictures sent from its teenage followers of themselves in various states of intoxication and déshabillé.  So far, so straightforward: the day that teenagers stop getting drunk and doing stupid things at parties is the day that the world will stop turning.  Granted, when I was young, we didn’t post stuff online – but if the internet had been around, we probably would have.  Kids do daft stuff; they sometimes regret it; then they grow up, and do daft stuff less.

Keith Albow, a Fox pundit, doesn’t see it quite like that: more…

Under-Treatment, Treated.

29 Aug, 13 | by Iain Brassington

Right: file this paper from the JAMA under “Properly Odd”.  It’s a proposal that nonadherence to a treatment regime be classed as a treatable medical condition in its own right.

No, really.  Look at the title: “Medication Nonadherence: A Diagnosable and Treatable Medical Condition”.

Starting from the fairly straightforward premise that non-adherence to treatment regimes is “a common and costly problem”, Marcum et al move at the end of their opening paragraph to have medication nonadherence recognised “as a diagnosable and treatable medical condition”.  The authors allow that, as a precursor to treatment, there must be an accurate diagnosis.  However,

for undetected and under-treated conditions such as medication nonadherence, one way to identify the population of interest is to conduct screening. The 1968 World Health Organization principles on screening tests have clear application to medication non-adherence. For example, the condition is an important problem, there are suitable tests available, and there are acceptable treatments for those with this problem.

Well, OK; but it hasn’t yet been shown that nonadherence is a condition, and so it’s too early to say that it’s a condition for which tests and treatments are available.  It shouldn’t be hard to see what’s gone wrong here: the fact that treatable medical conditions are serious problems that are (or could in principle be) reversible doesn’t entitle us to say that any serious problem that is (or could be) reversible is a treatable medical condition.  The authors appear to have got things – to use the vernacular – arse about tit.

So is there any evidence offered in the paper for non-adherence being a medical condition in its own right?  The paper is short, but even so, it’s not something I want to reproduce here; all the same, there’s nothing that leaps out.  The main planks of the argument are simply that it’s a problem, that it’s a problem that has something to do with health, and that it’s therefore a health problem properly understood.

The authors continue:

Using previously established methods and instruments, screening to diagnose medication nonadherence among adults across care settings should be routine. A number of screening tools or instruments are currently available to determine the underlying behavior(s) of interest.  This approach illustrates how clinicians and researchers can begin conceptualizing the diagnosis and treatment of medication nonadherence.  [...] Also, given the proposal to routinely screen for medication non-adherence in adults, the next step is to match the identified barriers to a proven treatment for the condition.

Well – if I can interrupt for a moment – they can begin diagnosis and treatment of the condition so long as the condition is actually a thing.  Which it isn’t.

I have a horrible feeling that I know what’s going on here; there’s a couple of telltale signs:

Inclusion of medication adherence data in the electronic health record will allow for sharing among health care professionals and insurers, establishing trends over time as well as benchmarking for quality improvement purposes. Moreover, it is paramount that patient-reported medication adherence information (eg, medication beliefs and values) is incorporated into such documentation.

And this makes me think that it’s got something to do with the role of private insurance in the US medical system.  If you can get non-aherence accepted as a condition, then it’s something that insurers’d have to cover, which would mean…

Eh?

… Actually, no.  I’ve no idea.  I mean, it wouldn’t actually make it a condition.  You can’t just define a condition into existence because it’d suit some purpose.

In the current health care climate, there is a strong demand for improving the quality of care delivered, including medication adherence.

Hmm.  That’s not really helping.

 

Winston Churchill and the Spirochaetes

29 May, 13 | by Iain Brassington

Did you hear the programme about syphilis on Radio 3 on Sunday?  If not, you can catch up on it here – and I’d thoroughly recommend doing so: it was superb.

One bit in particular caught my attention; it had to do with the use of penicillin to treat the illness during World War II.  (It’s from about 38:40 on the iplayer version.)  Astonishingly, in 1942, more men were out of action in North Africa because of syphilis than because of battlefield wounds.  Obviously, penicillin would be of immense help to both groups; but the problem was that there was not enough of the drug to meet both demands.  Giving it to the wounded obviously had some moral gravity… but so did giving it to the syphilitic: after all, they’d be cured and battle-ready very quickly, whereas the wounded might never be battle-ready again.

You can doubtless see why this might be problematic: more…

Is the NIMH Turning its Back on DSM-V?

9 May, 13 | by Iain Brassington

Thanks to Brian Earp for bringing this release from the US’ National Institute of Mental Health to my attention; it concerns the Institute’s decision to move away from DSM as its diagnostic tool.  DSM has been enormously successful – in terms of having established itself at the centre of psychiatry – but it has been enormously controversial, as well; the NIMH moving away from it is very big news indeed.  Whether the new model that they’re going to be working on will be any better, of course, remains to be seen.

The important bit seems to be this:

NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.

One or two things about the statement leap out at me. more…

Conference: Compassion Fatigue: Changing Culture in the NHS

18 Apr, 13 | by Iain Brassington

26-28 June, Woodbrooke Quaker Study Centre, Birmingham

(via Andrew Edgar)

Can the language of compassion capture the moral problems confronted by the NHS, or might it obfuscate and distract us from more subtle and demanding issues?

Through a series of plenary addresses, workshops, panels and shared opportunities for discussion, “Compassion Fatigue” will provide an opportunity to explore the language of compassion, and the impact that it has on the practice of health care provision.

More details below the fold. more…

Gay Conversion “Therapy”: Might the CMF have a point?

5 Feb, 13 | by Iain Brassington

Spoiler alert: Almost certainly not.  But hear me out for a bit.

The Christian Medical Fellowship blog had an article posted yesterday about what it praised as a balanced documentary concerning “sexual orientation change efforts” – gay conversion therapy to you and me – on Radio 4 on Sunday.  Actually, it wasn’t a documentary – it was a short article on Sunday, the station’s religious-affairs-quota-filling hour (go to about 30:50 here), and it’s no more a documentary than is the sports bulletin - and the balance is “BBC balance”, which means giving equal airtime to the fireman and the fire.  But anyway, that’s not what struck me.

Neither am I particularly bothered for the sake of this post about whether or not psychotherapy can make any difference to sexual orientation.  I’ll simply allow, for the sake of the argument, that it can at the very least make a difference to sexual behaviour, and maybe to orientation tout court.

What struck me was a couple of things that Peter Saunders says on his CMF blog post about the use of such “therapies”.  One of the striking things was this: more…

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