Archive for September, 2009

Money for nothing

I am deeply in love with the NHS. Our relationship has been rocky and we have had our fights and spats over 4 hour targets and spending cuts. But at heart we were made for each other.

Even if the relationship did only have its beginnings as a way to have a healthier population to send into battle following the disasters of the Boer war.

But in principle it is brilliant. Universal (though i’m not sure it applies to aliens from other parts of the universe – see District 9 for an example) health care free at the point of delivery.

Health care made simply extraordinary leaps in outcomes (in terms of lives saved, and saved well) from the 1930’s to the 1970s (see the wonderful Rise and fall of modern medicine for examples) but to be honest we’ve gone into somewhat of a decline in the past 30 or 40 years.

Now if you watch TV or what you read in the papers then you wouldn’t think that – what with all the sexy new drugs and fancy scanners then surely we’re moving forward. But in reality we’re not. If you take away all the fancy diagnostic technology that gives us all the pretty pictures of the tumour that’s gonna kill you (that we still can’t fix) – take that away and we may as well be living in the time of MASH.

[There are of course exceptions but the overall trend has been poor since we largely cured childhood leukaemia and figured out smoking caused cancer]

In contrast our spending on health care has rocketed. Though our outcomes are perhaps not much better.

Even the NHS (as much as I moan) has seen huge increases in its budget. My concern is where has all the money gone to…

Across the pond they have one fifth of the population with no health care insurance.

This is different from saying they have no access to health care – hospitals are obliged to provide care to patients who present to their Emergency Department (ED). This leads to

a) lots of sore throats and sore toes turning up at EDs

b) patients with serious illnesses only presenting to hospital when they’re really sick and have had symptoms for months.

This is hardly ideal.

Since the Obama health care debate got started I’ve been tremendously interested in the nonsense that it being talked about it and particular about the current state of their system.

It has made me realise how good a job we often do with health care in this country. Given the limited resources that we have (and they will always be limited in any country) we manage to do a better job than the mighty US health system. Just because you can get your coronary angiogram the next day instead of 4 weeks later does not make your health any better. All you get is choice, not better health – presumably why Americans like it so much, given the obsession with choice, individualism and self-determination.

I now subscribe to the institution that is EMA (Emergency Medical Abstracts) or the Rick and Jerry show –  a monthly two and a bit hour podcast where these two guys go through 40 studies on a wide variety of topics. And in general they tear them to shreds, picking apart errors and methods and conflicts of interest in a way that would warm the cockles of Ben Goldacre‘s heart.

They are both of the opinion that the US needs universal health care. Part of the reason they believe this (i think) is because they are emergency physicians –  they are the only sector of the US health care “market” that provides free health care at the point of delivery. There are large powerful sections of the medical community in the US who have a vested interest in the status quo. The cardiologists want to provide your angio for you the next day, whether or not best practice and evidence says you need it or not.

There are too many specialists with too many procedures in the US. You want a camera up your arse to investigate your vague bowel symptoms? Sure thing.

Emergency Physicians have no vested interest in this. We don’t have our own specialist procedure that makes us unique – we are the last of the hospital generalists.

And so when these guys speak I listen to them. Rick Bukata has a series of essays on this that i’ve just been reading and they make me want to jump and shout “preach it brother”. But I’m Irish and white and couldn’t pull it off too well.

I’ll make a few brief summary points.

What he describes as the 5 myths of the US health care system:

MYTH 1: THE US HEALTHCARE SYSTEM IS THE BEST IN THE WORLD

– It isn’t. It may be for a small minority, but certainly not in general.
– in 2000 WHO ranked the US health system as 32nd in infant survival, 24th for life expectancy and 54th for fairness (whatever that is…)
– in 2007 they paid 16.2% of their GDP on healthcare for this illustrious position
Some of the others for comparison


[Money per person spent on health care]
Australia = $2,960
Austria = $3,462
Belgium = $3,326
Canada = $3,505
Denmark = $3,643
Finland = $2,546
Germany = $3,247
Iceland = $3,285
Ireland = $2,945
Italy = $2,520
Japan = $2,529
Luxembourg = $4,223
Netherlands = $3,391
Norway = $4,233
Sweden = $3,075
Switzerland = $4,311
United Kingdom = $2,560 (data from 2004)
United States = $6,567

– So they pay more than twice as much as us for their health care yet their outcomes are no better, and probably worse.

MYTH 2: THE UNINSURED HAVE EQUAL ACCESS TO MEDICAL CARE THROUGH THE EMERGENCY DEPARTMENTS

– chronic conditions are not dealt with well in the ED. Ask me – i haven’t a notion of the best way to treat chronic high blood pressure. (I also don’t care so don’t ask)
– he quotes a study that after adjusting for age, smoking, gender, education-  lack of insurance itself lead to a 25% increase in mortality independent of income level

MYTH 3: A FREE MARKET IS THE BEST WAY TO GET THE HIGHEST QUALITY HEALTH INSURANCE FOR THE LOWEST COST

– this one makes some degree of sense but doesn’t work out in practice. When you need your gall bladder out you don’t shop around, you just go to the nearest surgeon and your insurance company picks up the bill.
– the consumer cannot influence price and quality
– for example Medicare (the government funded insurance scheme for over 65s) uses 3% of costs for admin while admin for private insurance companies was 16%

MYTH 4: WE JUST CANNOT AFFORD TO COVER EVERYONE

– every other industrialised nation manages to do so (and for a lot cheaper)
– there is huge scope to reduce costs

  • train more generalists (no one wants to do primary care cause there’s not as much money in it)
  • decrease unnecessary procedures – eg US does three times as many angioplastys as Canada with no improvement in life expectancy
  • decrease the ludicrous charges (one example of an ibuprofen pill costing $25 and an injection, not even the drug just the process of an injection costing $300)

– estimates of providing cover vary from $65 – $130 billion a year but note that half of this is already spent on the care provided to the uninsured that turn up at the ED

MYTH 5: PHYSICIANS ARE LARGELY VICTIMS IN THE CURRENT SYSTEM

– this is my favourite, it destroys the notion of the caring, decent doctor – when in fact we haven’t even got our own house in order. Perhaps… who would dare say it… that we have vested interests in making lots of money…
– doctors are the major determinants of health care costs – we order all the tests, we call the patient back for clinic visits. This is fine when it’s needed but the huge variation in physician behaviour leads us to think that perhaps some of the tests and drugs and admissions aren’t necessary
– incidentally if you read the studies and know your medicine then it turns out that that’s right – we order far too many tests or the wrong tests and use the wrong treatments
– my own personal favourite was a study that looked at how test ordering dramatically reduced at a hospital when it’s computerised test ordering system introduced the price of each test beside the tick box. I’d be interested to see how that would impact practice in the UK where we just order tests often without thinking cause neither us nor the patient will be billed for it.

Gilead

I started reading this on zoomtard‘s (with all the Karl Barth I can see why he liked it. Really you should keep the Zoommatics thing going. Otherwise I’ll have to read Barth myself and that’s just not on)  and Transfarmer‘s recommendation.

[That in itself is worth discussion – very few things in my life I have discovered on my own. Simy introduced me to almost every cool thing I ever got involved in, Da introduced me to sarcasm and writing (and so much more), Liz to Anne of green Gables… Not so much Liz. (You introduced me to much more than that I just thought I’d take the piss while I could.)

I listen to Pedro the lion because someone I knew listened to it, Skeeno introduces me virtually all my new music, Spuddy pulls his weight in that department too, Phil has bought me more books than hot dinners. I know these people because of people.

I enjoy what I enjoy not because I discovered it in a vacuum but because other people did before me. These things I enjoy have had quite remarkable influences on my life (fight club changed my life I tell you) and I let them because these other people introduced them to me.

Books are dangerous things. You open a book or listen to a song and a few years later you’re not the same.

I’ll stop there.]

Back to Gilead. A letter (a really long book length letter) written by an elderly dying preacher to his still young son. So that the son will know the father as he gets older.

It is nearly a year since Dad died. And this is what I think about. Gilead. The thoughts of a dying man. And I miss him.

To quote:

There have been so many fine days this summer that I’ve begun to hear talk of a drought. Whatever is coming I’d be sorry to miss it…

Dad died with a coming financial crisis that at least gave him an ironic laugh. Before swine flu, before Obama, before Spotify, before Transfarmer, before sitting here in a pub in Ballyconnell with me wishing i could give him a ring and laugh about it all.

Worth an extra non-dad related quote

He could knock me down the stairs and I’d have worked out the theology for forgiving him before  I reached the bottom. But if he harmed you in the slightest way, I’m afraid theology would fail me.

Canal song – Part 3

We ended up in an Italian restaurant last night. It’s weird how many small Irish villages have really cracker restaurants sometimes. Well fed and waiting impatiently for 10 pm when we felt it would be respectable to go to bed.

Slept till 9am.

Apparently it was breezy overnight. One of the metal gates on the back of the pub had blown off. Or rather the wall had blown off and taken the gate with it.

We had to endure another gruelling carry of the loaded Kayaks down to the river. couldn’t be more than 100 yards but was pulling the arms out of us by the end of it. We are such light weights.

Back in the water for 10.30 am and on our way. The rain joined us. Most upsetting.

By Lunch (which was a cup of coffee on one of the IWAI marinas) the sun came out and made it a very pleasant afternoon.

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While it’s wonderful having the facilities in place, it is a bit of a spoiler on the view to have all the marker posts throughout the waterways just to stop some idiot piling a cruiser into a sand bar.

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It was here that the going got a bit tougher. Up until this point we had been blessed by having the wind mainly behind us and whatever flow was in the canal was in out favour. At the point we turned into the river Erne and had to go both against the flow and against the wind. Not nearly so pleasant.

We did find this very pleasant old cottage facing onto the river.

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Finished in Belturbet about 3.30 pm. Tired and a bit hungry. Good trip.

Canal song – Part 2

Sleeping in tents is something that seemed like a good idea at the time you thought of it. But in general by the time you get round to it you wish you were in your own bed.

Sleeping in a tent on a small uninhabited island in the middle of a Cavan lake seemed like a great idea till it started raining quite so heavily.

Against my usual better judgement (and the 6 quid per mb charge) I used the phone to check the weather. It gave vague promises of a bright spell from 9-10am and then rain till some time in early November. I waited till one of us could wait no longer to get up and pee (it was Phil) then crawled from my sleeping bag to greet the dampness.

Saving grace is the fact that we only planned to spend one night camping. As a general rule only ever spend one night camping. Unless the weather is guaranteed. And in Ireland it’s never guaranteed.

I had such great plans for a lovely cooked breakfast that came to a squelching halt with the rain. The only aim was to get packed up and in the canoes as quick as possible.

Unfortunately with the rain the wind had picked up significantly so our first paddle of the day was a slightly breezy run across the main channel of the lake to get to a bit of shelter on the otherwise.

We did get lost.  Or should I just say that I got us lost.  All these lakes look the same to me really. How should I know. It was only briefly lost. And pleasantly so.

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Once you’re in the kayak with the spray deck on and the kag and a hat you’re pretty cosy. Rain becomes something of an irrelevance.

The wind however is a different story. Trying to cross a lake with the wind even a few degrees off your direction leads to a constant battle to keep the canoe going in a straight line.  Couple that with the waves cast up by the wind and it actually becomes really quite hard work.

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It never really brightened up all day but I must say it was almost nicer because of it. All my memories of Fermanagh have grey skies in them and it seems only fitting that Cavan should be the same.

A grand total of 3 and a half hours after starting out we arrived at Ballyconnell, (hardly very long paddling is it? I realise that, if you wanted a blog on endurance kayaking then you came to the wrong place) promptly missed the best stopping point and had to struggle back upstream against the wind to make it to the marina.
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So two men walk into a bar in ballyconnell dressed in shorts, sandals and life jackets and ask for a room for two. No wonder we got funny looks.

We also had to carry two canoes down the main street (it’s not very main) to get them to the pub we’re staying in. Pretty sure that’s not something that happens every day.

The shower you have after a couple of days living in your own filth is always the best one. The shoulders are begonnign to feel the strain now a bit. Most pleasant surprise is that a pint of guiness here is only 3.20 euro. Pleasantly surprised compared to the 4.50 euro in Dublin. Maybe I should move here.

Canal song – Part 1

[Before I even start, my dearly beloved Canon IXUS died, the lens won’t come out. 5 years isn’t bad for all the water, sand and dirt it had thrown at it. So all the pictures are from the iPhone and of dubious quality]

So it begins again. Off on another trip. Off on another paddle in the Ireland rarely seen. Kind of like lesser spotted ulster except without Joe Mahon.

This trip started as me and wee Phil wondering what to do with a week’s holiday at then end of September with him just back from 2 months saving lives (and maybe even the world) in Africa.

The original plan was to canoe from Lough Erne in Fermanagh all the way to Limerick. This was perhaps slightly ambitious.

It then became a 5 or 6 day trip to Athlone and then 4 days to Carrick on Shannon and now it’s 3 days from Ballinamore to Belturbet. Good call I say.

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Took us about two hours from portadown to find Ballinamore. Down roads I’ve never driven before. Always a good experience.

Just as we’d organised supplies and got a bite of lunch the rain came on. Typical.

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Though the silly misly type of Irish rain that makes you nervous that it might start pissing down any minute.

The shannon-erne waterway has a remarkable history. Originally planned to revolutionise industrial transport in the 19th century. In it’s 10 operating years it carried 8 barges. Not exactl profitable for having dug a 60km canal though the west of Ireland.

It’s introduction came just as the railways exploded onto to the scene. Hardly a fair fight. It took us just over 30 minutes to drive from the beginning to the end of our route that we planned 3 days for.

It got reopened for the tourists – mainly Germans (it seems) in rented cruisers in 1994 and seems to be popular enough to still be running.
The locks are automatic controlled by little pass cards and control panels. All very exciting. But we realised after the first one that it’s probably easier just to carry the canoes round them.
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I thought I’d go gentle on phil to start with and we only had 6 mile or so for the first day, especially as we only started at 3 pm.

Tonight we’re camping on church island. A tiny place a few hundred yards across in the middle of Lough Garadice (never entirely clear if the Lough is meant to come before or after it’s name). There’s an old (proper old) broken down church and that’s it.
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Lit the BBQ, drank some coffee and set the camp. Wonderful really. Just needs to be a bit wamer and it’s perfect. There’s a marina a few hundred yards across the lough and earlier a band was playing 80s rock classics at a quite phenomenal volume. The wind carried it well.

Read a good third of Gilead in one night by the light of the gas lantern and pondered how different a life we lead compared to a hundrd or so years ago. And indeed how different a life we lead compared to the majority of the planet.

22.45: Curled up in the sleeping bags hoping sleep comes easy and the zombies don’t rise from the graves of the abandoned church and gouge out our eyes while we sleeep. Not sure that’s gonna help me sleep thinking like that.

Incidentally – finally got the new David bazan album. About flipping time.

Saturday morning (who’s gonna play with me?)

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It’s been a while since we’ve attempted the Upper Bann. There was the incident. It kind of put us off.

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But our canoe evangelism has paid off and we’ve managed to get Leggy and Dave round to buying their own canoes.

So at 8.30 on a misty september morning we’re sitting in Leggys’s house watching him take the wrapping off his paddle. I love amateurs.

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Leggy has the enviable pleasure of having a house that backs onto the river. I get very jealous.

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Had the best of times paddling through the mist. Felt like somewhere nice and foreign. I.E. not Portadown.

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There were no major incidents. Apart from the odd part being too shallow. Which is a bit embarrassing if you’re into canoeing – that your major trauma involved being in a river so shallow you could walk across it.

Made it to Portadown just as the sun was breaking through the mist.

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Why’d you go and make things so complicated

I love my evidence based medicine (EBM), (maybe i should get a t-shirt with that on it…) i love my journals, and studies and audits.

They simplify medicine for me. I  love reading through characteristics of certain classes of patients and their symtoms and findings and test results. And how if you put enough of this together that you can then figure out what their disease is.

And then once you’ve figured out what their disease is you can provide an intervention and hopefully make them better. The science behind all this is great.

However. There exists a bit of a gulf between the numbers, between the audits and the papers and the list of characteristics, between all these and the patient sitting in front of me.

You see the patient sitting in front of me doesn’t care about any of this. They care because they’re short of short of breath or whatever. They care about getting out of here and going back to vegetating in front of the TV eating twinkies or getting back to the farm to get the cattle in. They care not for evidence based medicine. They hurt my feelings.

Perhaps patients are irreducibly complex in an equation. EBM makes them reducible – and saves lives as a result. However it makes me dehumanise them a bit to get there. Is that too strong? Perhaps so.

Patients are the most wonderful, annoying, fascinating, frustrating bunch of people to work with.

They do not tell you about pure pathology, about the narrowing in their coronary arteries. They tell you about this funny “tightness” that they get. And they won’t tell you that it’s exertional, they’ll tell you that sometimes they get it when they watch TV, sometimes they get it on tuesdays.

Patients are too complicated. They do not have typical symptoms. They will have their chest pain while feeling suicidal. They will have classic symptoms of a pulmonary embolism while at the same time having classic symptoms of pyelonephritis.

They quite clearly haven’t read the script.

Perhaps this is why I love evidence based medicine and logistic regression analysis and Bayes theorem (I’m not sure about the last two, I have only a vague understanding) so much. Because it makes life simpler. Honestly it does.

To do this I must ignore their love for twinkies and the need to get the cattle in. I must ignore all their glorious complex humanity.

As much as I love you dear patient you must become a collection of symtpoms, signs and test results if you want to live through the night.


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