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Archive for April, 2014

Confidence, the demise of the SHO, and lung cancer screening.

20 Apr, 14 | by tomfardon

I have been on call this weekend. Recently in an RCPE survey the consultant body was asked specifically “Do you frequently carry out duties previous carried out by more junior roles”, or words to that effect. Many a time do I hear my colleagues saying “I do the same job today as I did xx years ago as a house officer”. I certainly saw plenty of patients today, rewrote a number of treatment charts, prescribed analgesia, night sedation, and the like, looked up blood results, and requested radiology tests. So perhaps not much has changed since 2000.

One of the tasks today was the removal of a chest drain that was not working, mainly because it wasn’t actually in the thoracic cavity any more. I asked the house officer to do it, which seemed reasonable enough to me (and the registrar trudging around after me). 2 hours later I got a call from the FY1 telling me that they didn’t feel confident to pull the drain; could I come and do it?

We used to have a sea of SHOs in hospitals – I remember being one. The SHOs ran the show – they knew the patients, they did the ward rounds, they did the jobs, saw the relatives, and kept the hospital running. We don’t seem to have SHOs any more. FY2 – ST2 should be the group of Doctors who run everything. But there’s been a change. I’m not sure when registrars started doing all the work, no that’s not right, I don’t think FY2 – ST2 doctors don’t do any work, they do seem very busy, but they don’t seem to make decisions any more, that’s what the registrars and consultants do. Perhaps our hospital is different from everywhere else, but I suspect not. Consultants do what the registrars did, registrars do what the SHOs did, so perhaps the SHOs are doing what the house officers used to do? House officers seem to have an awful lot of paperwork to do these days.

I’m sure everyone across the land has had similar conversations. Our juniors seem to lack the confidence to make decisions – perhaps that’s appropriate, perhaps the every increasing senior cover is the correct way to go, but I do worry about how the future consultant body will get to the point of making decisions, or at least being confident in the decisions they make.

The most recent edition of Thorax runs an editorial on being confident about our diagnosis of ‘meaningful’ lung cancer in screening programs. Overdiagnosis is reported as common most screening programs, lung cancer included. But we ‘know’ that some patients have a lung cancer that doesn’t progress, at least not dramatically, so they die “with” lung cancer, not “from” lung cancer. But identification of these patients is difficult. Dr Frank C Detterbeck, Division of Thoracic Surgery, Yale, muses that overdiagnosis can only be defined in retrospect, looking back in a population after a long period, yet the clinician has to make decisions prospectively about an individual patient, not a population. He concludes that the article by Patz in JAMA doesn’t help to determine the benefits of screening, but does suggest how to minimise harm, stating that intervention in non-Broncho-Alveolar-Carcinoma NSCLC is very rately unnecessary, but for BAC we should be more circumspect, and wait for the right time to intervene. Of course our biggest dilemmas come for patients who have isolated lung cancers, early stage, with no pathological confirmation of malignancy, never mind a sub-type. Perhaps these cases are more straightforward – excision biopsy is indicated. But how confident can we be that these lesions are malignant? How much functional loss will occur due to the lobectomies carried out to find out? I don’t think we’re looking at the same situation found in breast and prostate cancer screening, with many unnecessary procedures, but with more widespread use of CT screening, we might get close.

The ECLS lung cancer screening study is underway in East and West Scotland – too early to see what the screening will lead to, in terms of surgical procedures, but we’ve already seen a lot of people with advanced disease who only presented as they answered the call for volunteers for the study: same patients, a bit earlier, but not early enough. Time will tell if lung cancer screening does save lives.

COPD, Me and the GMC

12 Apr, 14 | by tomfardon

This blog has been fallow for some time, for which I can only apologise, and push on. The main reason behind the paucity of musing has been that I’ve been investigated by the GMC.

That may cause a slight intake of breath from you, but it caused a lot more when I found out 5 months ago. The letter from the GMC came on a Friday evening. I’d had a particularly good Friday: bronch list with an EBUS and a couple of tran-bronchials, and an entertainingly enthusiastic trainee; an educational meeting with some actual education in it; an afternoon of paperwork, but a satisfyingly empty in-tray at 5pm. A weekend of parkrun, bike riding, and family fun lay ahead, and lest we forget that Friday night is Pizza night. When a letter comes from the GMC it’s usually a pamphlet about the duties of a doctor, or an invoice for the annual fee, but the tell-tale markings on the envelope raise the heart rate a little. This letter caused more sympathetic drive than a direct debit notification.

The GMC, the austere body we pay hundreds of pounds to each year and hope to never hear from. The letter was a pretty stock thing: someone has made a complaint about you, and we need to investigate it; the investigation will take 6 months; we’ll be investigation all of your practice, not just the issues surrounding the complaint. This focuses the mind somewhat. The recent GMC guidance on digital professionalism, likewise. So on advice from my chums at the MPS, I’ve been digitally silent.

Last month I was cleared of all wrong-doings, and declared to have practiced in the manner of a “reasonably competent doctor”. I’ve not framed the letter for hanging in my study, but I can now get back to the business of musing on the world of respiratory medicine.

The new issue of Thorax is about to hit your doormat. Paul Enright (Arizona) writes in his editorial on the COPDGene Study: “There is no evidence that the cost/benefit ratio of daily COPD inhalers is favourable for patients with CAO unless their FEV1 is below 60% predicted. No inhaler will help those with HRCT-defined emphysema and mild CAO. Therefore, the only imperative that I see to detect COPD early is to ‘sell sickness’ and thus enhance the billion dollar (pound or Euro) annual profits of companies that sell COPD inhalers”. Perhaps this explains why our patients with large bullae secondary to coannabis abuse seem to be so symptom free.

All this does leave an important question – what do you do with a patient who has significant symptoms, but doesn’t reach these criteria for an inhaler? It’s very difficult to do nothing. Patients will ask about ‘those inhalers that my friend has’. Patients do tend to feel better on a bronchodilator – I completely accept the ICS argument, and I’m sure all my colleagues around the country are in the process of stopping ICS in a large proportion of their COPD patients this week. Enright also highlights the importance of COPD phenotyping – a subject I think is key to our understanding of how to treat our COPD patients in the future.

It’s nearly conference time – I’m heading to the ATS this year, my first visit to the ‘big’ American meeting since 2006. The ERS attracted over 22,000 visitors in 2013, the ATS fewer than 10,000. Does this mean the meeting is no longer relevant? No longer worth the huge trip across a continent and an ocean to reach? I’ll admit that the meeting being in San Diego is an attraction: the sun is usually out in May; I can take my cycling shoes and pedals out there and hire a bike to ride the PCH for an afternoon; it has a lovely zoo; and I can’t remember having a bad meal in any part of California. My real motivation for going is to see what has become of the meeting – is it still relevant in 2014?

I’ll be going to the Summer BTS too. Again, it being in York is an attraction: the county of my youth; the chance to spend a few days cycling before the conference; and the Grand Depart of the Tour De France is the day after! (I’ve been selected as a ‘Tour Maker’) But the real reason for the trip to Yorkshire is to meet up with colleagues, and attend what I think is a greatly under-appreciated meeting.

I’ll be Tweeting and updating Facebook from both venues, so keep a lookout for the new from California, and Yorkshire.

Tomorrow is the London Marathon. A number of virtual friends and FIRL are running; some for charity, some for personal bests, and some for fun. Good luck to them all – remember than water is all you need, despite what the manufacturers of Lucozade might tell you – it’s GSK, and we’re back to inhaler cost effectiveness again.

More digital musings should follow, now I’m “reasonably competent” again.

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