Monday 13 September 2010

Losing our Doctors

In my day being a junior doctor sucked. I had a miserable time, was bullied by an evil female surgeon with a chip on her shoulder and permanently felt like a zombie due to a ridiculous work rota. I’m not sure I actually learned anything for the first year or so other than the fact that this really wasn’t the working life that I wanted or hoped for. I got out and sought an alternative. Essentially we were slaves, used as 24-hour phlebotomists, secretaries, and robot-like IV cannulators by consultants who were completely disinterested in training us. We looked for any opportunity to rise as quickly as we could through the archaic feudal system or get out altogether. Unfortunately those opportunities were few and far between.
Very little attempt was made to rectify this until the EU working time directive, which was introduced into the NHS last summer, forced hands. Designed to improve the work-life balance of junior doctors it limits the working week to 48 hours. Understandably many rejoiced until the realities set in: the situation now is just as farcical as it ever was. Juniors are asked to lie about the number of hours worked to ensure trusts are compliant with the directive, or made to ‘voluntarily’ opt out of the directive when signing their contracts. Hospitals have been forced to shake up their rota systems, leaving junior doctors to work the majority of night shifts and weekends, meaning that although they were indeed working fewer hours, they were missing most of their important teaching and training sessions. Of recent medics who wanted to carry on and specialise, 22 per cent were turned down by hospitals because they lacked skills or experience –a fault of their working rotas. Junior doctors that I talk too now tell me that the only way to get work done is to sneak back into the hospital when everyone else has gone home, avoiding the managers policing the working hours. They are being made to work intense shifts doing work that should be delegated to people who are less well trained in what is a gross misuse of highly skilled staff and will lead to a dearth of properly trained specialists in the future.
So it really doesn’t come as any surprise at all that latest figures show nearly a quarter of junior doctors drop out of their NHS training in England after two years. To be fair, not all are lost from medicine as some take gap years or move to other parts of the NHS to work, but many head abroad to work in Australia, New Zealand and other parts of the world where they can enjoy a better working life. All I can say is ‘clever them.’
Hospitals are clearly struggling to cope with the introduction of the 48-hour week and are running understaffed rotas where juniors have to work on thinned-down teams with no specialist guidance. Hospitals need to look more closely at how they organise their rotas and how to reduce much of the unnecessary bureaucracy and menial work that takes up so much of the junior doctor’s time.
Until the problem is sorted doctors will continue to leave. And who can blame them?

Egg Donors should volunteer for the right reasons

The government's fertility regulator has announced that it is considering lifting the UK ban on selling eggs and sperm to try to ease the shortage that they say is driving thousands of couples to go to foreign fertility clinics. It claims it’s decision is based on allegations that clinics in countries like Hungary, the Czech Republic and Slovenia, popular with couples unable to conceive naturally, routinely ignore safety guidelines. Women attending there have multiple embryos implanted into the womb to increase the chance of a pregnancy occurring, but unfortunately this also increases the likelihood of multiple births, and so to the health risks to both mother and baby.
Currently, British clinics are banned from paying for eggs and sperm directly, but can pay up to £250 in expenses which hasn’t exactly filled potential donors with an enthusiastic desire to go through with the complicated process of donation. Several different alternative options are now being explored from simply doubling this sum, to copying the system in Spain, where women are paid €900 for each cycle of eggs. The regulatory body is also examining an alternative option: to allow women to be paid many thousands of pounds, enticing them with considerable lump sums, as happens in the USA.
All this makes me rather uncomfortable. There is something intrinsically wrong with a ‘cash for body parts’ situation. Families of organ donors do not benefit financially from their deceased relative’s decision to donate, and blood donors don’t get paid either. I feel that so too should egg and sperm donations be done for altruistic (or egotistic) reasons and not for large wads of cash. I am well aware of the counter arguments; egg donation is far more invasive than giving blood and so deserves some sort of compensation for the time and risks involved. Women need to have their cycles synchronised with the matched recipient and then undergo a two-week course of hormone injections, daily blood tests and ultrasounds until they have produced several ripe follicles. Harvesting those follicles then involves a minor operative procedure, time off work is inevitable and complications can occur. But look at the situation in the USA, where cutting-edge reproductive technologies and infertile couples are providing young women with thousands of dollars for their eggs. Tempting adverts can be seen in college newspapers making donating eggs seem like an easy way to earn money and help meet the demands of rising costs, without any explanation of what actually is involved. More worryingly are the reports that the excess of young women wanting to exchange their eggs for cash is creating a cohort of doctors who are exploiting the desperation of childless couples by offering a ‘designer genes’ service for couples prepared to pay exorbitant fees for the perfect combination of brains and beauty. The higher your exam marks and the better your bone structure, the more your eggs are worth. This terrifies me as it is nothing more than a sordid form of eugenics, selecting those characteristics deemed desirable by society and selecting out those, like homosexuality and being ginger, that aren’t. A genetic underclass will be created of those whose attributes do not meet the high expectations of the prospective parents.
Getting pregnant and having a baby is not an absolute right, as so many women seem to think. Nor is choosing the type of child that you have. Donating your eggs to help others should be a noble, selfless and altruistic act, having total control over the phenotype of your baby is certainly not. It’s selfish and a gross violation of the laws of nature.

Same sex wards can work

Our great leaders are about to announce their rather ambitious plan to put an end to mixed sex wards in hospitals. It’s certainly not the first time this desire has been voiced. Tony Blair called for their abolition in 1996, when Labour was still in opposition, saying it should not be beyond "the collective wit" of ministers to achieve. 14 years on and it clearly was. Its successful implementation has been a goal that has eluded ministers for years.
As with many of the government’s ideas this one seems rather attractive on paper, but as soon as the practicalities of achieving it across the board are considered, it shows itself to be an unrealistic aspiration. Many of our hospitals are old Victorian buildings that would require extensive renovations in order for them to comply. These are unlikely to occur since we are living in a time of massive public service cutbacks and a pre-existing shortfall of hospital beds. I do understand the feelings of anxiety, exposure and vulnerability that mixed sex wards may create, to say nothing of those dreadful ‘backless’ hospital gowns that leave little to the imagination. If it is indeed the case that patients are left uncovered in front of patients of the opposite sex then it seems to me that a simpler and more urgently needed solution would be to improve the training and discipline of nurses and doctors on such wards, perhaps by bringing back the concept of ‘Matron’. These dragons may have been feared by all, and certainly struck terror into the heart of every junior doctor who crossed them, but boy did they get things done properly.

Rather bizarrely the government makes much of the apparent indignity of the sexes having to share bathrooms. I’m not really sure why this should be such a problem -surely there are bigger and more pressing health issue that need tackling than whether Mrs Jones prefers to find the loo seat left down when she pays a visit? As is so often the case it’s not only the idea that is questionable, but also the way in which ministers attempt to enforce their ideas. NHS trusts will be warned that they will face fines if they do not get rid of their remaining mixed sex wards by the end of the year. Just what an already cash strapped trust needs when trying to implement a change that will require a considerable increase in spending to achieve.
Just how necessary are these proposed changes? In a recent survey of 150 patients admitted to a variety of different wards 24 per cent said that they had no preference as to the type of ward they went on, and 57 per cent actually preferred mixed sex wards; their reasons being that they felt it created a more normal atmosphere and better reflected the outside world. The concept of segregating the sexes stemmed in part from the data that in the community young men commit most violent crime, and women were said to report feeling vulnerable on mixed wards. But in an institutional or hospital setting research has found a very different picture. There, women have equal rates of episodes of violence, there was considerable spread in age range, and that age and gender failed to predict assaultiveness. I cant help feeling that all this is a bit of a sly distracter however; same-sex wards may be nice to have, but must come secondary to safe clinical care and good medical outcomes. Assessing your hospitals worth by how comfortable you stay was, as you would a hotel, is most definitely flawed. Patient satisfaction and consumer choice are all very well politically, but isn’t therapeutic benefit the one main issue on which health care planners should focus? What effect will same-sex wards have on therapeutic outcome? I’m not sure anyone actually knows the answer. Yet.

Time to stop milking it?

As the government desperately scans through it’s extensive list of expenditures looking for areas in which it can make cuts, the spotlight fell on the ‘free milk for kids’ scheme. Scrapping it could save around £60m per year, and yet almost as soon as it was suggested publicly, No 10 hastily released a statement saying the scheme would remain. But the damage has already been done and the usual militants are stepping in, shrieking with outrage that such a proposal could even have crossed anyone’s mind.
Yet if you suppress the initial knee jerk reaction and look at the science behind it one can see that it’s actually a perfectly sensible, even advisable idea. The scheme is the only remaining part of what was known as the Welfare Food Scheme, first introduced in 1940 to protect pregnant women and young children against wartime food shortages, but now, in this time of gross nutritional excess, is an outdated and unnecessary idea. Indeed scientific evidence is amassing that suggests regular consumption of milk may be bad for you, by not only by causing some diseases but also by failing to prevent others for which it has traditionally been seen as a panacea.
Experts now say that after the first year of life children require no milk of any type. The former director of paediatrics at Johns Hopkins School of Medicine estimated that half of all iron deficiency in US infants results from cows' milk-induced intestinal bleeding. He proposed that infants drink so much milk (which is very low in iron) that they have little appetite left for foods containing iron; at the same time, by inducing gastrointestinal bleeding, milk causes iron loss. The same certainly applies to British infants too.
Cow's milk is simply just that: for cows. Man is the only animal that drinks milk into adulthood. It’s higher in sugar than humans need, and although high in calcium, only around 30% of it is available for use by the body, as compared to 60-70% for fruits, grains, legumes, nuts, roots, seeds, and vegetables.
There is also a theory that a protein found in milk mimics closely a protein found on the insulin producing cells of the body. If the body develops an allergic reaction to this milk protein then it is also stimulated to destroy the insulin cells through an autoimmune attack, a possible cause of diabetes.
The pro-milk lobby will scream ‘osteoporosis’ in their defence. But whilst milk is often sited as being key in the development and maintenance of strong bones, even this has now been questioned. When looked at globally it can be seen that the countries with the highest rates of osteoporosis, also have the highest consumption rates of milk and dairy products –it does make you think. Milk proteins contain phosphorous and sulphur compounds that acidify the blood. In order to correct this acidity, the body actually draws calcium from the bones, weakening them.
Instead of recommending multiple servings of dairy to ward off the dreaded osteoporosis, we would probably do better to advise women, and especially teenage girls, to take more exercise. A 15-year study published in the BMJ found that exercise may be the best protection against hip fractures, and that a reduced intake of dietary calcium does not seem to be a risk factor.
So perhaps it really is time to re-evaluate this dinosaur of a tradition and ask ourselves the question: is providing our kids with free milk actually doing more harm that good? Current evidence suggests that it might be.