Tag Archive for: Jonathan Glass

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Public Pronouncements and Individual Responsibility

jonathan-glassThe articles beneath headlines in the media relating to medicine rarely contain anything truly revolutionary or even anything particularly new despite what the headlines might have suggested.  We have all seen headlines promising a new cure for cancer, condemning an individuals practice and suggesting they are a charlatan and articles suggesting doctors are under-treating patients and depriving them of life changing care or over-treating patients and wasting and misusing limited resources.  More often than not the hyperbole of the headlines fail to truly represent the truth.  What is claimed to be new turns out to be old news, cures for cancer never show the results that were promised, and the extremes of over or under treatment are never quite as extreme as suggested.

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A week or two ago we have seen the newspapers filled with headlines about a list of 40 treatments or tests that form part of current practice that are deemed unnecessary.  This list was originated from the ChoosingWisely group, an American group now established in the UK.  This organisation encourages both patients and clinicians to question what they are doing and whether certain processes or interventions are wise, necessary and appropriate resource efficient.

Much of the recommendations on these lists in these sites are undoubtedly true and worth looking at to make sure your practice is mainstream although much of the advice is old and well established.  The AUA has 10 recommendations on the US based Choosingwisely.org website the vast majority of which are simply current practice (don’t do a bone scan in men with low risk prostate cancer), however one or two make me feel uncomfortable and one or two differ on the UK and US websites.

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The recent headlines were predictable –  ‘40 common treatments and tests that doctors say aren’t necessary‘ & ‘Senior doctors condemn 40 treatments and tests as being of little or no use‘. Among the advice that reached the headlines obtained from the UK site (choosingwisely.co.uk) was the statement ‘Unless a patient is at risk of prostate cancer because of race or family history, PSA based screening does not lead to a longer life’.  The UK site has also commented on the use of chemotherapy in ‘advanced’ cancer saying it may not be appropriate – also evidently true.  The US site includes the recommendation that creatinine is not measured in men with benign prostate disease and minor lower urinary tract symptoms. 
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One particular problem with these public health, committee lead recommendations and advice is that treating populations is easy.  Populations don’t sue public organisations, individual patients sue individual practitioners and therein lies the nub.  What may be right as an idea – not measuring creatinine in men with low grade LUTS – is fine until the chap who has significant renal impairment walks in to your clinic and asks you why you didn’t measure his creatinine when he saw you a year ago.   Not measuring a PSA seems fine until the patient with missed prostate cancer reappears and suggests he asked you about testing his PSA, but as he had no family history and wasn’t black you told him it wasn’t necessary;  you showed him a website and explained to him we’d be wasting resources if you tested his PSA.   He may not understand that the delay may not have impacted on his survival.  Patients don’t hear that if they perceive there has been a delay in establishing a diagnosis.

Treating individuals, caring for the person across the table from you is very different from making pronouncements about populations.   It’s easy to recommend that chemotherapy is not used, until you are the one being offered a chance, if only small, of being offered some hope and a chance of survival.

I recognise that resources are not endless and that it is right for clinicians and healthcare workers in all sectors to think about how resources are used. The problem however is that the user of healthcare resource – the patient – wants their care to be lowest risk, independent of cost, and increasingly they are resorting to using legal channels if they perceive that care has been anything other than perfect.

Of the men on those panels not recommending use of PSA, I wonder how many of them would refuse to have it checked, or indeed would refuse chemotherapy if it was their only, if slim, hope?

 

Jonathan Glass

Consultant Urologist

Guy’s & St Thomas Hospital

 

The Urological Ten Commandments

Capture“It is my ambition to say in ten sentences what others say in a whole book.” – Friedrich Nietzsche

The EAU guidelines on lower urinary tract symptoms have been published recently.  These contain 36,000 words.  It was pointed out to me that the American declaration of independence contained 1300 words and The Ten Commandments just 179 words.

The challenge was therefore to write ten commandments for urology in 179 words.  The rules I set were that I should write them whilst keeping  the spirit of the structure of the decalogue as closely as possible.  (It may be worth rereading the original before reading on).  So here goes.

1) I am a logical specialty. Thou shall investigate thoroughly prior to undertaking intervention for I am a specialty that avoids surprises.
2) Though interested in the whole of medicine thou will perform no other procedures other than urological.
3) Thou shalt not base intervention on old imaging for the clinical situation could have changed.
4) Remember that 80% of diagnoses can be made with history alone.  Thou shalt listen carefully to your patient to this end.
5) Honour sound surgical principles.  Urological tissue is forgiving but anastamoses under tension will not heal.
6) Thou shall not ignore haematuria.
7) Thou shall not leave a stent and forget it has been placed.
8) Thou shall not adopt new technology without proper clinical evaluation unless it is part of a trial.
9) Thou shall not fail to see the images yourself in assessing the patient before you.
10) Thou shall not fail to assess the potential for harm before embarking on a surgical procedure. If you would not do it to your family, your neighbour or friends, you will not do it to the patient who is in your clinic.

I put these out for discussion.  Other offerings please.

 

Jonathan M. Glass @jonathanmglass1

The Urology Centre, Guy’s Hospital, London, UK.   

[email protected]

 

The Death of the Junior Surgeon

jnrdocheadstoneI think I attended a meeting recently at which I fear, after many years of being slowly deprived of oxygen by various organisations, a component of a profession which I love and to which I have devoted so much of my life, finally started to give up the fight and started to die.

I am involved in training as a training programme director as well as being a local trainer. As a TPD I have had to watch the separation of the London and KSS training programmes. This has happened, despite sitting in a room of thirty to forty senior trainers who all voiced the opinion that this is detrimental to the future of urology training for our trainees. The trainees also voiced an opinion that this was wrong but still it went ahead.

Recently, I sat in a room where, again, a group of thoughtful intelligent doctors spoke about the future of junior doctor training. We are about to impose a change in the training of foundation year doctors imposed upon our excellent organisation from what for most of us is a faceless organisation with whom we will never interact directly. We will be moving them into community-based jobs that no senior doctor round the table believed was in their interests or in the interests of the future of Britain’s healthcare, but we will still oversee that process.

And what test is being applied to what our junior doctors should be doing to justify these changes? The question – do the jobs they are doing have to be done by a doctor?

I can’t imagine for a second that this question can be critically applied to the new foundation year jobs in community work and answered affirmatively.

Furthermore when the role of any of our jobs is deconstructed, how much of that role needs to be done by a doctor? We can give up prescribing to a pharmacist, blood taking to a phlebotomist, ward based care to a physician’s assistant, outpatient follow-up (assuming it will be permitted in the future) to a nurse specialist, diagnostic procedures to a radiographer, diagnostics to a nurse consultant, audit to a data manager, construction and development of the department to an administrator, training programme planning to deanery educationalists, perioperative support to a clinical psychologist, etc, etc, etc.

How much of the work of a junior doctor has ever had to be that of a doctor?  The job of the junior doctor has always been all of these, whilst learning from and being inspired by the beauty of a carefully constructed ward consultation by a senior clinician who understood the subtleties of human interaction and the tensions and uncertainties of the patient lying in the bed in front of him or her. The junior doctor didn’t mind devoting much of his or her young life and many hours of hard work, including performing some menial tasks, because the new recruit was intelligent enough and committed enough to realise that hours spent on the wards and in clinic would turn themselves, currently a piece of apparently formless clay, into a fine piece of highly polished china.  They would, yes with hard work, hours spent studying, and arguably obsessional attention to detail and a constant desire to improve, become a fantastic  diagnostician, a remarkable clinician and, in some cases, a technically brilliant surgeon and the most wonderful observer of the human condition.

Which of any of our jobs must be done by a doctor? That is not a reasonable question to apply to much of what any doctor, or indeed I suspect what any professional, does in their day to day work. It is the totality of what they do that defines their role, not the minutely dissected individual parts of their job.  When dismembered, no organism has the functional beauty of its form when complete, nor is it able to survive when it is disassembled.

I fear that that is true of our glorious profession. What would Bright, Hodgkin or Astley-Cooper say if they could guide us now?

I am no Luddite. I work in a branch of medicine that has thrived in the technological development of its specialty, in a department that has led the way in introducing new ways of working, new ways of thinking about how care should be provided with a better understanding of patient processing and what frustrates patients when they access healthcare. We as a group have demonstrated how we are willing to embrace change when we perceive it to be for the benefit of our patients.

I have sat and watched changes being introduced, as have many of us over the years, suspicious that not all changes are really in the interests of the future of medical care. However, I sat down after attending the meeting to which I referred earlier and found myself asking these questions.

In Judaism, at a burial and for a year after the death of a close relative, we recite kaddish, the memorial prayer. Is it now time to recite kaddish for the role of the junior surgical hospital doctor?

Jonathan Glass – Consultant Urologist, Guy’s & St Thomas’ NHS Foundation Trust

 

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