Bad medicine

One of my moments of fun at the end of the week is getting my ‘Friday dose of woo’ over at Respectful Insolence. It never ceases to amaze me that people can invent and promote the kind of stuff reported there, and that some people seem to believe it. The most recent entry contains something that is implausible whatever your branch of science and reading about it is an almost psychedelic experience. It’s called the SCIO.

Another place to sample some of the dubious medicine to be had via the net is over at The Little Black Duck’s blog. He discusses the subject of hair mineral analysis, something that sounds rather conventional and much more believable than the SCIO.

Shinga has been talking about food allergy and intolerance tests, another very plausible and conventional sounding set of tests.

While it might be easy to spot the rather dodgy nature of the SCIO, allergy testing and hair analysis sound much more plausible; and all these things have ‘scientific evidence’ presented to add weight to their claims. Shinga and the Little Black Duck show that it’s necessary to go back to the scientific and medical research literature and have a careful look at it to really evaluate whether these tests are actually of benefit to real individual patients. Allergy tests can be very useful – providing you’re doing the right test in conjunction with a good history of the patient’s symptoms.

I’ve talked before about what the RCPath have to say about diagnostic tests. Neither the allergy tests nor the hair mineral analysis would fulfil their criteria. They may sound more plausible than the SCIO but in the end they are no better.

Anonymity

Dr Michelle Tempest has written an interesting post on bloggers and anonymity, or lack of. When I set up my blog I didn’t even consider the possibility of not being anonymous, maybe because one of the great attractions of the internet is the ability to hide who you are.

So why am I anonymous on here? I don’t need to hide because I express controversial opinions as I don’t think I do and the things I say on here are the same things I say in the real world. A good reason for anonymity is to preserve the anonymity of my colleagues and hospitals. Sometimes I talk about them and they might not want to be exposed on the internet; maybe worse, they might think I’m talking about them when I’m actually talking about somebody different. Anonymity for me and my colleagues is a solution to this. Either that or naming all names so there can be no misunderstanding but that’s hardly acceptable.

Another reason for being anonymous is that it’s a bit of fun. Sometimes I wonder if anybody I know in real life reads this blog (actually they probably don’t!) and has realised who I am, or if somewhere, somebody is erroneously suspecting one of their colleagues of being me. It ‘s also a play on the slight stigma attached to being a pathologist. Sometimes it’s easier not to be specific about what you do because of the comments you might get. It reminded me of the stereotype of the Alcoholics Anonymous meeting where new members stand up and say: ‘I’m K and I’m an alcoholic’ – being honest about what they were. That’s where the name of the blog came from, and it kind of follows on from the name to be anonymous as well.

RCPath talk tough

I have obviously happened on this issue rather late, but I noticed this document on the RCPath website the other day. It’s a response to another document I hadn’t heard of before, a discussion paper called ‘The future of the medical workforce’, published by NHS Employers.

I read the RCPath’s response first and it’s quite a strong-worded response considering pathologists often hedge their bets with phrases like ‘suspicious but not diagnostic of’ in histology reports. I wondered what had provoked this and read the offending document. This is a piece of writing supposedly about the recent ‘reconfigurations’ in the NHS, the European working time directive (EWTD) etc and the effects these things have had, and will have, on how doctors work, how they are trained and how many are needed. To me it looks like a load of vague waffle written by somebody who uses the buzzwords but doesn’t really understand the issues. It talks about ‘mergers and closures of some smaller units’, the reduced training time for doctors due to MMC and EWTD without any hint that the authors have considered the effect of these things on patients and doctors and whether these are a good thing or not. The document is full of ‘key questions’ and I’m glad to see the RCPath have answered many of these in their response. Here are a couple of examples:

‘Is there a need for a new specialist grade below consultant?’ ask NHS Employers.
RCPath response: ‘No’

‘What will the doctor of the future look like?’
RCPath response: ‘Here is a likely distinction between expectation and reality. The doctor of the future should be fully competent in the clinical management of patients through a deep understanding of the scientific and pathological basis of disease. The reality is that he/she will be a politically-correct apparatchik who responds to clinical situations in a protocol-driven and codified manner. If such an event occurs, it will be highly detrimental for the medical profession and patients alike as well as being severely damaging for society as a whole.’

The RCPath’s conclusion says: ‘Overall, this is a naive document that exposes many errors and misconceptions currently held by employers and managers within the NHS. There continues an inherent advocacy of a ‘top-down’ directive approach without an acceptance that medically trained doctors are probably best suited to develop the environment necessary for good clinical care within society. Obvious lack of appreciation of fundamental constraints such as time and money do not engender confidence in the proposed discussion or consultation process as advocated at the beginning of this document.’

Neither of these documents is very long and they make interesting reading, particularly if you’re careful to read between the lines. I think the RCPath is pretty spot on in the majority of what is said, I just wish they’d shout about it more.

Is it rewarding?

Before I started to specialise in pathology nobody ever asked me this question. Now even other doctors ask me if pathology is rewarding. Is this because people, including other doctors, think that being a doctor (translation: seeing patients) must be rewarding and that being a pathologist (translation: not seeing patients) might not be?

What surprises me is that anybody thinks I’d be doing the job if I didn’t find it rewarding. If I preferred seeing live patients I wouldn’t have switched from the specialty I originally started training in after my house jobs; and if I decided I didn’t like it I had given up by now and be doing something else like the author of this article in the BMJ.

Some people (maybe the ones who thought up MMC?) think that my years of training in something other than pathology are a waste of time. They think junior doctors can make do with a quick run round three different specialties, probably not of their own choosing, and then be propelled straight into rush-through training in a specialty they may never have done since a 2 week placement in med school.

So has my previous training made me a better pathologist? Well it didn’t really help with things like how to do an autopsy, use a microscope or look at histological sections. What it did do was show me how difficult it can be to make a clinical diagnosis, the wide range of presentations there can be for a single illness, how to pick up clues from the history and external examination, when and how different pathology specimens are taken and what clinicians want to know from them. Being a good pathologist isn’t just about looking down the microscope, it’s about looking at the whole clinical picture in conjunction with the histology – this is why we often complain about a lack of clinical information on pathology requests.

My previous experience has, I think, made me a better pathologist than I would have been if I’d come into pathology straight from house jobs. It also showed me, as the author of the BMJ article found, that sometimes you have to try something for more than just a couple of months to be sure it is or isn’t for you.

So having tried something else I can say that pathology is definitely rewarding. You get the same diagnostic challenge but without having to be up all night. You can drink your coffee while working (maybe not in the mortuary!), do something practical like cut-up and autopsies to get out of the office for a bit and there’s always the MDT if you want to argue with/talk to other clinicians. The main advantage is that every specimen is a sort of ‘virtual patient’ meaning you can do something to help patients all over the hospital every day by providing a verdict on their specimen; which is what medicine is all about.

Secondhand consultation

One of the disadvantages of being a doctor is that non-medical friends and colleagues like to ask you about their relatives’ medical problems, somehow thinking you are a better source of advice about their aunt’s odd rash that you’ve never seen than the consultant dermatologist their aunt saw last week.

Sometimes they casually mention that their granddad has been ill for the last month and their mother wants to persuade him to see a doctor. They think their mother is worrying unnecessarily and want you to advise. They describe granddad’s symptoms: a bit of back pain, weight loss and indigestion. This has happened to me a few times and I’m faced with trying to persuade them that granddad really should see the doctor sooner rather than later but without sounding too alarmist. It could be something bad like cancer of the stomach or pancreas but it might not be and I can’t make a diagnosis based on secondhand symptoms. I don’t say what I think it might be and I don’t know if anybody else in the same situation would but I do encourage them to make sure their relative sees the doctor. Dr Shroom also sees similar patients in A+E where I imagine the pressure to come up with a likely diagnosis is greater. It’s difficult knowing when to talk about something that is only a suspicion and when to avoid worrying somebody unnecessarily. Whichever end of the experience you’re on it isn’t nice.