Tuesday, September 11, 2007

Risk Management?

A couple of weeks ago Pat had some chest pain. It was unclear if her pain was indigestion, heartburn, or, perhaps, something more serious. But that’s o.k. In these enlightened times we have “pathways of care” to enable us to sift such problems.

So Pat found herself shunted off down the Yellow Brick Road to Oz… er, the Rapid Access Chest Pain clinic. They did a battery of tests, including and exercise EKG*. All were inconclusive.

In case you were wondering, that means that the RACPC has not been able to show that Pat has heart disease. But, in these enlightened times, this does not mean Pat is out of the woods. You see, the way the pathway works, if you have conclusive tests, i.e. proven heart disease, then to get whisked straight from clinic to Cardiology Out Patients to having a stent put in (where possible) before you can say “myocardial ischaemia”. And you get put on lots of drugs to “save” your life.

But if, as with Pat, the tests do not prove you have heart disease, well you still might have it anyhow, so instead of all the tedious mucking about actually making sure one way or the other, you just get put on lots of drugs anyway, “just in case”. Pat has been told she must come and see us to start her meds A.S.A.P. These are to include a beta blocker (recent headlines reporting these drugs are less good at preventing heart disease and so should not be used without a compelling reason) and a statin (to lower cholesterol- can lead to deranged liver function and rarely to muscle wasting).

Now, call me old fashioned, but before I start a patient on long term medication with a significant side effect profile, I would at least like a clear indication, and in the case of the statin a baseline blood test to monitor her liver function BEFORE she starts, so that when her liver function is abnormal on the statin (as it will inevitably be) I can be sure it was in fact normal before the treatment began. The only problem is, poor Pat is now scared she may drop down dead of a heart attack before she gets to start her treatment.

Unfortunately, the RACPC neglected to tell her that though we feel statins are an important part of the preventive treatment for patients with established heart disease risk, even where this is the case (which we as yet have no reason to suspect is so for her) we have to treat eighty patients to prevent one cardiac death.

Somehow we seem to have lost all sense of proportion in managing medical risk. Intriguingly this is happening as we see the drug companies more and more involved in training the Nurse Practitioners who run a lot of the “Rapid Access” diagnostic facilities.

* yes you read it right. I’m actually with the Americans on his one (actually of course it ought to be “epsilon kappa gamma” but EKG has to suffice to save all the mucking about with fonts etc.).

15 comments:

BenefitScroungingScum said...

I had thought the inability to manage risk was to do with fear of litigation or complaint? It's interesting to hear the drug companies and np involvement. I've found it worse in Social Care/OT world though, I was refused a bath lift because my hips were so bad I might hurt myself on it (therefore leaving them liable) You have to laugh really! BG

Shinga said...

There is a distressing tendency to emphasise reliance upon tests rather than the clinical history as interpreted by a person with sufficient training/experience to interpret them in context. Possibly, there is a creep whereby guidelines are inexorably transformed into recommendations.

I'm not sure why this has happened.

Claire said...

"There is a distressing tendency to emphasise reliance upon tests rather than the clinical history as interpreted by a person with sufficient training/experience to interpret them in context. Possibly, there is a creep whereby guidelines are inexorably transformed into recommendations.

I'm not sure why this has happened."
Shinga

Let me guess...insufficient numbers of persons with sufficient training/experience, aka our old friend, 'dumbing down'?

Doctor Jest said...

bendy girl-- Gaah! that sort of petty minded wilful misapplication of so called "health and safety" advice really gets on my nerves. I know it is effectivelt a social care issue but have you thought about trying to get you PCTs PALS officer on the case to knock some sense into them. (PALS short for Patients Advocacy and Liaison service. They can be a great help when the NHS monolith needs a kicking. Not so sure how it applies to the more paramedical arena though.... Good luck and keep us posted!).

Shinga-- In essence it is in part our own fault. For some years we have known that to get a protocol run properly the very last person to give it to is a Doc. Doc's tend to be dangerous free thinkers you see. Our butterfly minds take us off on all sorts of tangents. If you want boxes ticking a nurse is yer man, (or woman obviously). You see their training is geared to encouraging them to follow protocols and pathways of care and so forth, and quite right too. But, when you get a nice big drug company coming o your cash strapped provider unit and offering free "badge" nursie time to run a diagnostic facility like a RACPC you end up missing the actual "diagnosis" step and fall straight in to the management part. Sadly this is now so endemic that Juniour Docs are falling into the trap too, largely because the only people they tend to come into regular contact with these days are the "badge" nurses perhaps?

Claire-- perhaps it's not so much insufficient training as "too specific" training. Our "badge" nurses are a tremendous resource when properly deployed, but this requires more thought and planning than our local trusts seem capable of.

The Shrink said...

You've lost me on the whole EKG thingy.

Isn't it an ElectroCardioGram and thus ECG?

PALS

Doc's tend to be dangerous free thinkers you see.
- true, there is a tendency to apply common sense and the patient's best interests in to the equation rather than slavishly adhere to protocol.

Some see this as most lamentable.

Claire said...

"Too specific" training is better, and the point about the pharmas influencing the rush to pharmacotherapy is well made. I worry that all the box ticking in this sort of context might create the illusion that this kind of approach is underpinned by solid statistics.
Evidence based policy or policy based evidence - or is that too cynical?

Claire said...

Perhaps not directly relevant but this occurs to me in connection with the recent Archives of Disease in Childhood paper which expressed concern about the increase in numbers of inhalers containing LABAs to children in the UK (full text available here: http://press.psprings.co.uk/adc/september/ac119834.pdf )

Is it possible that a proportion of these were prescribed by 'badge nurses' rather than GPs or would they have needed the GP's sanction?

BenefitScroungingScum said...

Dr J thank you for your kind advice :) I'm also not sure whether the PCT PAL's officer could intervene in a social care arena when they are completely separate services (thus causing a number of the problems I suspect)

I'm not sure if you have the equivalent in your area but in mine we have an independent direct payments forum of which I am currently a trustee, set up to challenge such issues. However it is a sad indictment of our current social 'care' services that on balance I personally feel safer without social work involvement in my life.

Both your and Shrink's point about doctors being free thinkers is I think even more important with the current moves towards protocols in the welfare area. It is I suspect supposed to eradicate fraud, but I suspect is likely to do far more harm than good as of course no condition or person can fit a check box and most muddle along quite happily free thinking their way through daily challenges rather than procuring a referral or piece of equipment for every new problem that crops up. That I would guess is most likely to apply to those who are 'trying it on' thus creating additional work for doctors. Again. BG

Doctor Jest said...

First sorry to all for the slight hiatus. Three hours with the accontants yesterday did little for my humour and robbed any time for comments :-(

Shrink-- or can I call you "The". It's just a pesonal quirk of mine, but I like the look of EKG better. It looks more like it comes from the greek taht the bastardized latinizaion, but that ;'s probbaly just me....

As for the free thinking, I fear it being ground out of the upcoming generation of juniours and try to do everything in my power to encourage it. Still there are days when I do feel rather like poor old Cnut trying in vain to turn back the tides.

Claire--

"Evidence based policy or policy based evidence - or is that too cynical?"

Sometimes I worry that as a profession we aren't cynical, or at least questioning, enough.

"Is it possible that a proportion of these were prescribed by 'badge nurses' rather than GPs or would they have needed the GP's sanction?"

In reality, certainly locally, all such scripts would be initiated by docs. This is one we can't blame on the NP tendency. In truth the increase in LABA use across the board is fuelld by two or three trends. First it is likely to give a quicker fix than stepping up inhaled steroid doses, so better symptom control (though perhaps not disease control). Next there is a disenchantment with the perhaps more age appropriate LTRAs, which promised much, but in my admittedly limited experience, only work in about half the people wou would hope. Finally there is still a significant amount of steroid resistance in parents who view even modest doses of inhaled steroids as little better than strychnine for their little darlings.

(Apologies if this is a bit technical. Let me know if you need translation, but from the tone and content of your previous posts I imagine you have more than a little clinical knowledge.)

Bendy Girl--

"It is I suspect supposed to eradicate fraud, but I suspect is likely to do far more harm than good as of course no condition or person can fit a check box..."

One of the things that really gets my goat is all the PC nonsense we keep hearing about social eclusion in relation to the urban poor / youth / migrant populations, with not a word about disability. This makes me sound horibly Daily Mailish, which is very far removed from the truth. I'm all for including everybody, but this increasing trend to beureuacratize simple things like aids to daily living cannot but be exclusive in outcome, whatever the intentions behind it.

Fight the Power!

Dr Grumble said...

Our rapid access chest pain clinic regularly comes up with the diagnosis of non-cardiac chest pain - which is no diagnosis at all. And sometimes it doesn't stop them giving the patient a bucket load of medicines which are 'bound to do the patient good'. This bad medicine does seem to have stemmed from protocolisation and the removal of thinking from the management of patients.

We all know this but saying it openly is difficult.

Doctor Jest said...

Dr Grumble-- welcome. You are of course quite right. It's as though the meds themselves will avert "the evil eye" like a modern day charm. Perhaps we should all join hands and sing "Ring-a-ring a Rosie" as well just for good measure. ;-)

orchidea said...

I'm glad the shrink didn't get the EKG thing - I feel a little less stupid now. Of course in these parts it's called an Elektrokardiogramm, hence EKG.

But I'm not telling you 'owt you don't already know.

I'm sorry for being an absentee commenter; my first proper job in yonks is fun but draining. Still reading, just so you know...

orchidea xxx

Doctor Jest said...

orchidea-- To be honest I'm stagered (but quietly pleased) that anybody stops by to read this nonsense at all, let alone leave a comment, but you are always most welcome. Look forward to hearing about the new job if and when you feel able to reveal all, and thanks again for stopping by.

xxx

Claire said...

very late in the day but have recently come across this by Dr Paul Enright, touching on the (possible) overuse of LABAs: http://blogs.webmd.com/allergies-and-asthma/2007/09/managing-mild-asthma.html

One day I'll grow up and learn how to do the jazzy blue writing link thing!

Doctor Jest said...

claire-- thanks for the url. And don't worry. There's nothing wrong with good old fashioned cut-and-paste-ing.