https://www.iwww.iwantgreatcare.org/ - A scary future of medicine?

An idea that appears to be constantly winning favour is the idea of patients taking firm control of the care they receive. I have no disagreement to increased patient autonomy in medicine but when it comes to health poor decisions can cause an unbelievable amount of damage just look at the MMR scandal. Any decision in medicine needs to be clearly thought through especially those that affect how patients interact with there doctors.

 The website iWantGreatCare was set up in 2008 by the renal special Dr. Neil Bacon and allows patient to rate the doctors who treat them. The site has recently joined up the HIV charity: The Terence Higgins Trust. The site aims to be a “TripAdviser” for health putting consumers not regulators in charge of the health care system. As a change in the doctor-patient relationship it promises to be a significant one. The site is probably not the only one of its kind I just pick it as an example for a more general movement where patients control the care they receive.

  I have many reasons to be very dubious of the worth of such a radical change. I fear the system will be too open to abuse and misuse. I have so many worries I resorted to listing them:

1.      Do patient make rational decisions on how the doctor was or are they just angry at waiting times or unfortunate accidents?
2.      Are patients qualified judge how well a professional carries out an often complicated and difficult job?
3.      Is patient satisfaction actually a good measure of how good a doctor is? I personally would prefer a competent but antisocial doctor that makes good decisions to a charismatic doctor that harms his patients through bad decisions.
4.     Will the system be abused by doctors trying to further their own private careers?
5.     Will the system ruin lives and livelihoods? Would one bad review ruin your reputation and spell the end for the medical career? iWantGreatCare claims to have sophisticated systems in place to detect a remove unfair comments made by patients but I cannot believe that any system like this is completely effective.
6.      Does patient rating put too much pressure on patients? What do you do if you are not entirely satisfied with the care you received but don’t want to seem ungrateful?
7.    I think any such system would be rife with selection bias. Only people either extremely satisfied or dissatisfied with their care would bother to make a review whilst the vast majority of people in the middle would not. Would a rather chaotic mix of reviews result showing dividing doctors into the good and then bad and ignoring the fact that doctor quality probably follows a normal distribution.

Would the system only show doctors on the wings of the data?

 For these reasons I am doubtful that patient ratings is the best way to allow patients a better understanding of the care they receive. I cannot provide evidence to justify my fears instead I will treat them as hypotheses to be proved or disproved if such a system ever becomes universally accepted and used. History has shown us that the doctor-patient relationship is a fragile thing built upon the framework of ethics and the concept of disease and medical treatment at the time. I would mess with it unless we were certain we knew what the consequences would be.

I would recommend looking at Dr. Bacon’s arguments for patient rating at:

http://info.iwantgreatcare.org/

Personally they do little to calm my doubts.

What does glucose look like?

 While I was meant to be revising I found out an interesting bit of biochemistry. One strange property of glucose is that it can reduce Tollen’s solution, a test for an aldehyde group, which is a carbon atom double bonded to an oxygen atom and single bonded to a hydrogen atom carbon at the end of a carbon chain. If you look at a ring structure of alpha and beta glucose you will notice that no such aldehyde group exists:

Where an aldehyde group does exist however is in the straight chain version:

the straight chain version- aldehyde at the top

In a solution the two ring isomers are in equilibrium via the straight chain isomer in what is know as ring closure: an internal or intramolecular reaction. Unlike most chemical reactions when one or more reactants make one or more products this is one molecule essentially reacting with itself.

The straight chain isomer isn’t actually that straight at all we just draw it that way to look good on a page. In reality as the molecule flexes the aldehyde group on carbon-1 comes close to the hydroxyl group (OH^-) on carbon-5. The hydroxyl group can then attack the electron dense aldehyde double bond. The pi-bond of the aldehyde group breaks. The bond is the hydroxyl group then breaks and the hydrogen ends up on the oxygen of carbon-1. Carbon-1 then bonds to the oxygen on carbon-5 to make a ring.

 However there are two ways the hydroxyl group can attack the aldehyde group. If it comes over the carbon atom, alpha-glucose will be formed the OH^- below the molecule. If it comes under beta-glucose with the OH^- above the molecule will form.

Once again things are a bit more interesting and complicated than exam syllabi make things out to be.

Primum Non Nocere

Nonmaleficence exemplified in the Latin maxim ‘primum non nocere” is held up by some to be the most important principle in medical ethics.  Abstaining from harming the patient is usually a good thing to consider given the potential of all medical treatments to damage as well as help but why is the principle considered to be the doctor’s primary concern?

The phrase “primum non nocere” has an uncertain origin. The exact phrase was not used by Hippocrates although he does say things similar such as “the physician must... have two special objects in view with regard to disease, namely, to do good or do no harm”. The “primum” however is nowhere to be seen. The phrase has been attributed to Thomas Sydenham, an English physician born in 1624 and fought for parliament in the English civil war (and incidentally the first to proscribe quinine in the form of cinchona bark for malaria).  However the justification for the nonmaleficence as the sole basis for ethical medicine is probably not for historical reasons.

 In choosing treatments the potential for harm is certainly a factor the must be weighed up against the treatments chance of success. Fixing even simple bone fractures through surgery would be a quick and appealing option if not for the major risks inherent in any surgical operation (and the cost). Even antibiotics have enormous potential to harm especially if used inappropriately when they have a very real risk of leading to the development of antibiotic-resistant strains of bacteria such as MRSA. Whilst the side-effects of any treatment are a serious concern weighing them up does not appear to be more challenging than most of the tasks and issues a doctor has to deal with on a regular basis. Is nonmaleficence unfairly emphasised? Why also are doctors in particular targeted with the responsibility of doing no harm when the roles of, for instance, a soldier or airline pilot have perhaps an even greater potential to cause death and destruction?  

 To some what separates nonmaleficence form other principles of medical ethics for instance beneficence (the duty of doing good) is a matter of scope. Whilst doctors have a duty to everyone to do no harm the doctor’s duty to good is strictly limited to the patients whose treatment he or she is currently involved in.

However just because we have a duty to do no harm to all does not necessarily mean that nonmaleficence has priority when it conflicts with other principles for instance when Nonmaleficence conflicts with respect for autonomy if a patient does not consent to a life saving treatment. Like people’s perception of good and what they seek to gain from a treatment, each patient will have their own perception of risk and harm. Palliative care may be acceptable for some whilst others may want curative treatment options despite major risks involved.  

Whilst nonmaleficence cannot, in my opinion, be the most important principle of ethical medicine I would not goes as far to say that “primum non nocere” deserves to be confined to the history books. The principle of nonmaleficence itself is vital when combined with other ideas such as justice and autonomy in deciding the best course of action. 

How the UK exports death- Tobacco in the developing world

 I was shocked recently by a BMJ article by Tony Dalamothe entitled: “Deaths from smoking: the avoidable holocaust’.  (http://www.bmj.com/content/344/bmj.e2029). He will no doubt cover the topic better than me so I am in debt to him for explaining the subject. In the article he presents a bleak view of the attitude to smoking. “About 100 million people died from smoking in the 20^th century- twice as many as Stalin, Hitler, and Pol Pot were together responsible for.”  He attribute the lack of response to the smoking related diseases pandemic to libertarian views that people have the right to spoil the own health and to the profit-motivated dealings of tobacco companies. He quotes the word of a World Health organisation committee in 2001: “Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists.”

I’ll expand on what Tony Dalamothe says slightly. Whilst the smoking rate in the UK (shown here as a percentage) has been steadily falling since 1960, step by step due to one piece of legislation then another, the future of smoking is unclear. If the observed trend continues (line A on the graph) the UK will be smoker free by 2040. Line B is the scenario where the smoking rates reduces to just a small number of die-hard smokers who refuse to quit despite all legislation. Line C shows the ideal situation; smoking rates decline until smoking itself becomes considered socially unacceptable and smoking rates plummet because it become easier to legislate against without political opposition. Whatever happens smoking in the UK looks to be going down.

 The situation in the developing world is shockingly different however where smoking rates are increasing by about 3.4% per year. For every three cigerettes smoked world wide at least one is in China.(http://news.bbc.co.uk/1/hi/3758707.stm#china0). Tobacco companies have looked to the developing world for a market with enough wealth to afford a luxury (albeit a deadly on) like smoking under government which lack the tough control needed to enforce smoking legislation and cannot afford to ignore the tax benefits smoking provides. In this environment tobacco companies can make millions at the expense of the health of the people. As two of the biggest tobacco companies, British American Tobacco and Imperial Tobacco, are British this effectively means the UK is a net exporter of smoking-related diseases.

 How we respond to the spread of tobacco in the developing world is a difficult issue. It would be hard to instruct and help developing countries to legislate on tobacco without fitting the much-hated stereotype of the prosperous westerners reliving the glorious days of the British Empire when a white man was needed to solve the big problems for the blacks. Given that our own companies are doing the damage any move of this sort would be obviously hypocritical. Tony Dalamothe takes the view that the only thing we can do is chuck these companies out of the country because they shame us all the time they are here. Is the only ethical way to deal with the problem would be to try to ignore the death and suffering from tobacco until developing countries have the confidence to legislate against the problem themselves?

 (I recommend visiting the website of British American Tobacco and Imperial Tobacco for an entertaining PR masterpiece in excuses and apologies: http://www.bat.com/group/sites/uk__3mnfen.nsf/vwPagesWebLive/DO52AMD7?opendocument&SKN=1

http://www.imperial-tobacco.com/index.asp

 The company’s overall message about delivering a high quality product, value for shareholders and responsibly farmed goods tries to hide the spread of smoking-related death and irresponsible selling that goes on. Worse still the companies are trying to jump on the anti-smoking bandwagon by campaigning against black-market tobacco that is more easily accessed by children (and no doubt harming their profit margins).)