NHS Safety and Lord Sugar's new Apprentice

Prof Don Berwick

Today Professor Don Berwick published his review into patient safety in the NHS in England following the recent Stafford Hospital enquiry. He is an international expert in improving patient safety and was formerly President and Chief Executive Officer for the Institute of Healthcare Improvement (IHI). He was also former health advisor to Barack Obama. After the enquiry into deaths in Staffordshire, the NHS in England asked for his analysis and recommendations for improving the NHS. Most of his recommendations don't come as much of a surprise to doctors who are already be familiar with the work of the IHI but here are some of the most important points:

• The NHS remains an international gem and could be the safest system in the world.
• Cultural changes are needed, criminal sanctions are only required in extreme cases of wilful or reckless neglect.
• The NHS should be compelled to inform patients if serious errors are made in their care. 
• Trusts should be keeping a close eye on staffing levels to make sure patient care is not suffering.
• Staff must be given good support and training to help make sure they take pride and joy in their work.
• Patient harm shouldn't be accepted as being inevitable.

A BBC news article summary of the report can be found here: http://www.bbc.co.uk/news/health-23572696

The winner of BBC's The Apprentice this year had a controversial plan to start up skin aesthetics clinics which offer topical cosmetic procedures such as Botox in the UK. The doctor who won the Apprentice, Dr Leah Totton, did well to beat off the candidates and showed her quality as an investable candidate during the tasks but her business plan does seem poorly contrived. Her claims to be 'an expert' in the field who can teach her s

Dr Leah Totton

taff to run the clinic are hard to believe. It has to be born in mind that although she is a qualified doctor (at exactly the same stage in her career as I am today), she has only two years of experience as a post-graduate (and given that she must have taken a few months out to film The Apprentice I doubt she has met the requirements to complete FY2) and cannot possibly have learnt the skills required to carry out the techniques she wants to offer in such a short period of time. She has done well to win the process and I did want her to win the final, but I have to doubt the ethical grounding of her decision to leave NHS practice to start a chain of clinics offering private cosmetic dermatological procedures.

One thing which is certain is that the professional organisations who represent the kind of work she is looking to become involved in have unanimously rebuked her proposals and will definitely not be supporting her clinics. The British Association of Dermatologists (BAD) and other organisations released the following press statement a couple of weeks ago:

The main professional bodies for plastic surgery and dermatology today jointly and unequivocally condemn BBC Apprentice winner Dr Leah Totton’s capacity to set up and run a chain of outlets offering injectable facial treatments such as Botox and fillers. Not only the British Association of Dermatologists (www.bad.org.uk), the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (www.bapras.org.uk) but a whole host of high-profile clinicians have taken to social media in a Twitter storm denouncing the junior doctor’s dangerously inadequate credentials for the project.

The extensive independent Review of Regulation on Cosmetic Interventions led by Sir Bruce Keogh (which issued its report earlier this year) highlighted problems within the non-surgical cosmetic sector and called for urgent development of an accredited training framework by Health Education England. The recommendations of the Review were welcomed by specialist professional groups who emphasise patient and public safety must be put ahead of commercial interests. They continue to urge rapid Parliamentary approval in order to take the recommendations forward and ensure that proficient implementation and improved patient care is in place – but in the meantime, the public remain at risk.

Mr Graeme Perks, President of the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) says “At a time when all professionals are collaborating with Sir Bruce Keogh to improve cosmetic surgery practice and protect the vulnerable, it is a concern that a very junior doctor can make claims to be an authority in this field and provide the direction and clinical judgement that only comes with experience. The results of BBC Apprentice provide yet another demonstration of why Parliament must act fast.

Prof Chris Bunker, President of the British Association of Dermatologists states  “We are seeing more and more complications at the hands of inadequately trained practitioners and counterfeit products. These adverse events can be permanent and life-ruining, and there are even reports of blindness being caused by inappropriate injection of fillers. Many patients require continued treatment and support on the NHS.

According to Rajiv Grover, consultant plastic surgeon and BAAPS President“What this debate needs is a strong injection of common sense – if Dr Leah Totton were training to be a GP she would not be able to work unsupervised for another four years after qualifying. Yet in the private sector she is setting herself up to train others. Having a stab at running a business shouldn’t be taken literally.

According to Dr Tamara Griffiths, dermatology representative on the European Committee for Standardisation (CEN) which has been developing EU-wide standards for cosmetic surgery “Dr Totton is a very junior doctor and her claim to be an expert in the field of cosmetic procedures may not measure up to the review by the European Committee for Standardisation, where international consensus has been reached regarding the imperative of adequate and accredited training.”

New Research into Atopic Eczema

Viewpoint at Glenashdale Falls

Sannox Bay

Atopic Eczema - What's New? A review of the condition was published in the July edition of CED (Clinical and Experimental Dermatology) by Dr Donna Torley from the department of dermatology at the Southern General in Glasgow (my local hospital). A systematic review of the key findings from 24 summaries published between August 2010 and December 2011. Here are some of the key findings:

Epidemiology: antibiotic use in early life may increase risk of atopic eczema whereas exposure to dogs and consumption of unpasteurised milk may reduce risk. There is no strong evidence that exclusive breastfeeding, hydrolysed protein formulas, soy formulas or fatty-acid supplements help to prevent atopic eczema.

Treatment: In patients with moderate to severe disease, pro-active treatment with topical corticosteroids and calcineurin inhibitors can be used to prevent flares. An example of this which has been tried is 'weekend therapy' which consists of preventative topical therapy being applied on two consecutive days each week (such as the weekend) to prevent flares.

Patient education about the condition produced mixed results with no high quality randomised trials to compare effectiveness and make reliable conclusions. Also in treatment, tacrolimus was shown to have a comparable efficacy to mild to moderate topical corticosteroids. There was little evidence found to support the use of coal tar in the management of the condition. Again, the lack of large and well designed randomised controlled trials led the authors to conclude that there was no clear evidence for the efficacy of homeopathy, botanical extracts or Chinese herbal medicines in the treatment of atopic eczema.

Also, a couple of photos from last weekend in Arran - great weather, food and company meaning a fantastic weekend away!

What an amazing few weeks!

It's been a busy few weeks and lots going on: Glastonbury festival at the end of June, then Liverpool for the British Association of Dermatologist's (BAD) annual conference in July and Amy and I are off to Arran this weekend. 

A moment of praise for Andy Murray on winning Wimbledon. He's an inspirational character to me and I admire him for his drive and determination to succeed, particularly in the face of previous disappointments such as the Wimbledon final which he lost in 2012. While several of the top tennis players such as Nadal and Federer started winning Grand Slams when they were younger (Nadal age 19, Federer age 21, Djokovic age 20), Murray has pushed ahead when many had written him off and his constant desire to improve has seen him finally deliver the success which he so rightly deserves. 

Improving patient safety and delivering better standards of care for patients in NHS Scotland is something which I am passionate about. I believe that there are two aspects to this for everyone who works in healthcare. One is personal improvement - looking at how we can get better at what we do as individuals. This helps to set example and is a good way to develop leadership. One of the speakers at the BAD last week was Professor Wendy Reid, who is Medical Director of HEE (Health Education England). She spoke about the importance of doctors acting as clinical leaders in hospital and how we are in a position where can initiate change. The other is looking at the wider picture, and how we change the cultures and systems that exist to create a safer environment. I feel that as junior doctors who regularly move between hospitals and departments, we have a unique opportunity to share our ideas and experiences. I hope to share some of the ideas I have and experiences (both good and bad ones) when I move to my next hospital job in August.

I was sent round an email for induction for the new job last week and the consultant who sent the email sent a link to the following video on youtube. It's a good one to watch - because it accurately depicts a realistic hospital scenario where a patient is identified as having sepsis. The sepsis 6 bundle is just one of the initiatives which has been worked on by healthcare improvement scotland (the project which I worked on in Ninewells on venous thrombo-embolism prevention was with them also). They have a youtube channel and there are several other videos there which explain who they are and what they aim to achieve and I would recommend that anyone interested have a watch.

http://www.youtube.com/watch?v=CrUHnYIZbpM

Hypocalcaemia Investigation

Glasgow in the Sun

No more Part 1 revision - found out this week that I passed! Part 2 next sitting isn't until December so a chance to take to foot off the gas a bit for a couple of months before CMT starts up.

It's June, the sun is shining and summer is here. Lots of good things going on right now. Finalising my poster presentation at the moment for the British Association of Dermatologists' annual meeting in Liverpool and putting together an audit presentation for the West of Scotland Dermatology regional audit meeting later this month

Investigating Hypocalcaemia: This topic of discussion occurs in an educational article in this week's BMJ and covers an area which often causes me confusion as calcium metabolism is a complex process. It is not uncommon for a patient admitted acutely to hospital to be calcium depleted and a 'bone profile' investigation is a useful blood investigation to carry out on any unwell acute medical admission. Adjusted calcium levels (that is, serum albumin adjusted calcium concentrations) are the most informative. Common causes of hypocalcaemia include drug related causes, chronic kidney disease and post-operative hypoparathyroidism. In a patient with a low serum adjusted calcium level, a serum parathyroid hormone level is informative. Low serum calcium frequently occurs alongside low phosphate and magnesium levels and these should be checked. A cause of hypocalcaemia which seems to be coming increasingly frequent is due to inadequate sunlight exposure leading to lack of vitamin D. Vitamin D levels can be checked in patients believed to be at risk, although Vitamin D deficiency would not cause acute hypocalcaemia. 

Here is an example of how the serum phosphate and PTH levels can help in investigating the cause of hypocalcaemia:

Low phosphate + High PTH: ?Acute pancreatitis or drug induced eg. secondary to bisphosphonates

High phosphate + Low PTH: ?Hypomagnesaemia, hypoparathyroidism

High phosphate + High PTH: ?CKD or rhabdomyolysis

Patients with severe hypocalcaemia may become symptomatic with neuromuscular irritability and paraesthesia (think Chovstek & Trousseau's signs!). There may also be prolonging of the QT interval and therefore an ECG is indicated. Treatment may involve oral calcium supplementation if hypocalcaemia is mild, or IV calcium gluconate in the treatment of severe hypocalcaemia.

CT Radiation, Weekend Safety, COPD and Acute Leg Ischaemia

Anonymous clinical image
courtesy of (Aaron G. Filler MD PhD FRCS)

Dangers of CT Radiation

CT scans are now widely available and accessible. In my experience, a relatively large proportion of patients admitted under medicine / surgery in our hospitals undergo CT scanning as part of their investigation - eg. Head CT to diagnose a stroke, CT Pulmonary Angiogram to diagnose a PE, CT KUB to diagnose stones or CT Chest/Abdo/Pelvis to investigate weight loss and search for malignancy. The risk of radiation posed by CT scans have long been known about and a new study published in the New England Journal of Medicine this week offers compelling evidence linking risk of cancer with radiation exposure. The study followed up young patients who had been scanned and looked at subsequent risk of cancer. The RELATIVE increased risk of malignancy was in the region of 24%. It is important to note though that the ABSOLUTE risk of malignancy was only marginally increased. This is because the baseline rate of childhood cancers is very low to start with. There was roughly one excess cancer per 1800 CT head scans performed. Although the benefits of CT scanning at the time are often likely to far outweigh the later increased risk of cancer, this piece of research can serve as a reminder (particularly in young people) that scans should only be requested where there is a clear indication and where the results will affect clinical decision making or treatment.

Safety at the Weekend

A big story in the news this week came with the publication of a retrospective study in England which has shown that patients who undergo elective surgery on a Friday or at the weekend have a greater risk of complications and death. So why might this be? The patients operated on at the end of the week had a lower index of comorbidity but still had worse outcomes. One of the most dangerous times following an operation comes in the days immediately after the operation as opposed to the time of the operation itself. Early identification of complications is essential and perhaps due to reduced staffing levels at the weekends it is the management of the patient in the peri-operative period which is most likely to contribute to adverse outcomes.

Treating an Acute Exacerbation of COPD

According to research published in JAMA this week, five days of high dose prednisolone is enough to treat most acute exacerbations of COPD. In this head to head trial in Switzerland there wasn't a statistically significant difference in outcomes between patients treated with five or fourteen day courses. The study shows that a five day course works just as well as fourteen and limits patient exposure to systemic steroids which can cause side effects and toxic accumulation.

A Diagnosis not to be Missed: Acute Leg Ischaemia

There are many conditions which could present with acute leg pain however this is one not to be missed. It results from thrombotic, embolic or traumatic arterial occlusion of the vessels of the leg.

Presentation can be remembered by "The 6 Ps":Pain, Pallor, Perishing with cold, Pulselessness (always present), Paraesthesia and Paralysis. It may be missed because it can be mistaken a lumbar disc prolapse or a Bakers' cyst and risk factors for vascular disease may not always be present. Immediate referral to a vascular surgeon is necessary as urgent limb-saving surgery may be required. 

Whole Genome Sequencing - Yes or No?

One of the most significant scientific developments over the past decade has been the ability to rapidly sequence the entire human genome. The success of this technology has led to a rapid increase in the detection and diagnosis of genetically inherited diseases. One use has been to identify specific disease causing mutations, while another use has been to identify susceptibility loci and polymorphisms which combine to increase a patient's risk of developing a disease which may be caused by not one, but many genes. It can also help to predict how a patient will respond to certain types of medications (pharmacogenomics). 

So should we sequence every person's genome? There are obvious arguments for: personalised medication, screening for disease etc. However the counter-arguments are also significant ie. screening for diseases which cannot be treated. There is risk of harm by screening a person's entire genome. For example, it may suggest that a patient has a predisposition to certain conditions and may lack clinical significance. Would it be useful to know that you carried a gene for an inherited condition? This could lead to a world of 'genetic compatibility' testing between partners before having a child. It would be useful for doctors to know if patients are going to respond / not respond to certain drugs eg. warfarin or chemotherapy before they are prescribed. 

A number of ethical implications need to be considered: for example how will implications for relatives be handled - who owns the genetic information? How can we ensure that the information obtained is kept private and not shared with research or pharmaceutical organisations? The discovery that a patient may be at a slightly increased risk of coronary heart disease could lead to a rise in un-necessary investigations (particularly in the private sector) eg. unnecessary imaging, while a result showing low risk could also be harmful, leading to a person becoming too relaxed about their health and abandoning healthy diet and exercise as it is felt un-necessary due to low genetic risk. At the moment, in my opinion there is too much risk of harm to be caused by screening everyone's human genome. However once our knowledge expands and our ability to handle the information improves, I honestly believe that in my lifetime it will become routine medical practice (ie. genome sequencing at 18th birthday or on registering with a new GP practice).

One of the big medical news stories last week was the revelation by Hollywood actress Angelina Jolie that she had undergone a double mastectomy to prevent her risk of developing breast cancer, caused by her carrying the BRCA1 gene. I think it is highly commendable that she went public with this - helping to increase awareness of the risk of breast cancer. The question this raises and which is the title of the article in the BMJ this week which I am referring to is the 'who owns our genes?' question. Unbelievably, in the US it costs about $3000 to undergo testing for BRCA1 and BRCA2 because one biotechnology company owns the patent and hence has a monopoly over the testing (the company's share prices jumped 3% after Jolie's announcement). These patents are set to expire in 2014 as it has now been argued in the US Supreme court that human genes are 'natural' and therefore cannot be patented.