In the past week we have heard of two stem cell successes. In one a man was transplanted with a new trachea (windpipe). A 36-year-old man whose own cancerous trachea had to be removed was treated with the procedure on 9 June at the Karolinska University Hospital in Stockholm, Sweden, by Paolo Macchiarini.
No donor was needed for the new procedure. Instead the tissue was custom-built to fit the patient, then coated inside and out with his own stem cells. The treatment began after Alexander Seifalian of University College London received detailed scans of the patient's diseased trachea. Using these, Seifalian constructed a bespoke replacement from a novel polymeric material that he has developed and patented.
Two days before the operation, the team took 200 ml of bone marrow from the patient and from this extracted 40 ml of mesenchymal stem cells. By pouring these on top of the synthetic organ in a bioreactor developed by Harvard Bioscience of Holliston, Massachusetts, the trachea was successfully coated inside and out with the patient's own cells.
During surgery, Macchiarini's final touch was to add patches of the patient's nose lining to the inner surface of the trachea. These later grew into a layer of epithelial cells matching those lining the inner surfaces of the respiratory tract.
"The big conceptual breakthrough is that we can move from transplanting organs to manufacturing them,” says David Green, the president of Harvard Bioscience – although he adds that the concept would work best for simple structures such as tracheas, ureters and blood vessels.
In another stem cell development, a company called FCB-Pharmicell based in Seongnam, South Korea, became the first in the world to receive official approval for a stem-cell-based procedure to treat people who have survived heart attacks. In the newly approved procedure, stem cells are extracted from the patient's bone marrow, multiplied in the lab then injected directly into the heart through the coronary artery.
Little clinical data is publicly available to prove that the procedure benefits patients, but according to press reports last week, the company says that in trials, patients showed 6 per cent improvements in heart function six months after the procedure, compared with untreated patients.
It is important to recognize that these reports do not derive from embryonic stem cells which have to be produced from spare embryos manufactured by IVF, but from mesenchymal stem cells which come from the patient's own tissue (often bone marrow) that carries neither ethical not rejection risk.
Showing posts with label medicine. Show all posts
Showing posts with label medicine. Show all posts
Wednesday, July 20, 2011
Thursday, July 14, 2011
Praise
Here's a wake up call to any medical teachers out there; do you praise your fellows?
Eddie Blackburn, who was Professor of Haematology at Sheffield, used to make a habit of writing a letter praising the authors of papers that he read in the British Journal of Haematology.
William Mayo, the founder of the Mayo Clinic used praise to encourage young doctors.
One of them said, "You'd read a paper at a staff meeting and afterwards he'd see you in the lift or the hall, and would shake your hand and put his hand on your shoulder with a quiet, 'Good work,' and a straight warm look that made you think he meant it. Or perhaps a day or two later you'd get a note from him, just a short one saying something like, 'Dear -------, I learned more about ------- from that paper of yours the other night than I ever knew before. It was a good job.' Believe me, a fellow prized those notes."
Eddie Blackburn, who was Professor of Haematology at Sheffield, used to make a habit of writing a letter praising the authors of papers that he read in the British Journal of Haematology.
William Mayo, the founder of the Mayo Clinic used praise to encourage young doctors.
One of them said, "You'd read a paper at a staff meeting and afterwards he'd see you in the lift or the hall, and would shake your hand and put his hand on your shoulder with a quiet, 'Good work,' and a straight warm look that made you think he meant it. Or perhaps a day or two later you'd get a note from him, just a short one saying something like, 'Dear -------, I learned more about ------- from that paper of yours the other night than I ever knew before. It was a good job.' Believe me, a fellow prized those notes."
Saturday, January 23, 2010
Anemia.
Anemia simply means that you don't have enough blood. The main function of blood (but not the only one) is to carry oxygen from the lungs to the tissues where it is used. It does this with the red stuff in blood, which is known as hemoglobin. On meeting oxygen the hemoglobin undergoes a subtle change to oxy-hemoglobin, and when it releases the oxygen it changes back. Oh, and by the way, the abbreviation for hemoglobin is Hb (not Hg. Hg is the chemical symbol for mercury).
The body has sensors for how much oxygen it is getting and it responds to a deficiency by sending a signal to make more blood. More about that later.
Everyone needs slightly different amounts of blood, which is why everybody has a different hemoglobin (Hb) level. Reasons why you might need more Hb than other people include living at altitude, your Hb molecule is slightly different so that it doesn't release oxygen to the tissues so well, having something wrong with your lungs so they can't transmit oxygen to the blood so well, and smoking, so that some of your Hb is constantly bound to carbon monoxide, rendering it unavailable to oxygen. A reason why your Hb might be set lower than other people's is that your Hb molecule is ultra-good at releasing oxygen to the tissues.
So what is a normal Hb? No-one knows what is normal for you, but we recognise that there is a wide distribution of values and we talk about a reference range. If your level falls below the reference range then you are anemic. But not everybody who has a level below the reference range is anemic for them. Very rare individuals have a low Hb normally (I'll tell you why later).
For man the reference range for Hb is 13.5-18.0 grams per deciliter (g/dl) for men and 11.5-16.0 g/dl for women. Many people are surprised at how wide the range is and some reference ranges for different laboratories have a tighter spread than this. In the past 20 years it has been customary to give Hb values in grams per liter in many laboratories so teh ranges would then be 135 to 180 and 115 to 160 g/L.
Why do women have so much lower Hbs than men? It's because of the testosterone which enhances other chemicals that stimulate the bone marrow.
As far as CLL patients are concerned I have always thought it strange that Rai stage 3 and Binet stage C patients are defined by the same reduced Hb level in both men and women, when plainly a man has to be much more anemic to reach these stages than a woman does. I wonder if this is why women seem to do better than men?
There are dozens of causes of anemia and many different ways of classifying them. I prefer to use the size of the red cell to do this. Red cells are by far the most numerous cell in the blood. In a teaspoonful of blood there are 25 trillion of them (or if you are English 25 billion; ie 25 million million). Red cells are round, flat discs with a dimple on each side, and red in color. Their diameter is about 7 microns and their average volume is between 80 and 96 fl. We call this the mean cell volume (MCV). Again different labs have their own reference range (I have seen 78-92 and 80-100). What does fl stand for? Femto-litres which means 10 to the power of minus 15 litres or 0.00000000000001 litres. That's pretty small!
We could call red cells an MCV lower than the reference range microcytic; those with an MCV greater than the reference range macrocytic; and those with MCVs within the reference range normocytic.
A red cell is 99% hemoglobin (the rest is membrane and a few enzymes); so a small red cell has a deficiency of hemoglobin. Here is a link to a good picture of Hb.
In my picture
the green, yellow, blue, and gray colors make up the four polypeptide subunits of hemoglobin. These polypeptides are collectively known as the globin chains and in common or garden hemoglobin (known as HbA) there are two alpha chains and two beta chains. Each subunit has its own heme group (shown in red.)
I have also reproduced a chemical structure for heme. I don't expect any but chemistry students to follow this. Take my word for it that it is made up of four porphyrin rings, but notice, right at the center the letters 'Fe'. Fe is the chemical formula of iron and it is here that the iron fits in.
The availability of iron controls the production of hemoglobin, and anemias with deficiencies of hemoglobin (microcytic anemias) are microcytic becuse they have too little iron or too little globin.
The body has sensors for how much oxygen it is getting and it responds to a deficiency by sending a signal to make more blood. More about that later.
Everyone needs slightly different amounts of blood, which is why everybody has a different hemoglobin (Hb) level. Reasons why you might need more Hb than other people include living at altitude, your Hb molecule is slightly different so that it doesn't release oxygen to the tissues so well, having something wrong with your lungs so they can't transmit oxygen to the blood so well, and smoking, so that some of your Hb is constantly bound to carbon monoxide, rendering it unavailable to oxygen. A reason why your Hb might be set lower than other people's is that your Hb molecule is ultra-good at releasing oxygen to the tissues.
So what is a normal Hb? No-one knows what is normal for you, but we recognise that there is a wide distribution of values and we talk about a reference range. If your level falls below the reference range then you are anemic. But not everybody who has a level below the reference range is anemic for them. Very rare individuals have a low Hb normally (I'll tell you why later).
For man the reference range for Hb is 13.5-18.0 grams per deciliter (g/dl) for men and 11.5-16.0 g/dl for women. Many people are surprised at how wide the range is and some reference ranges for different laboratories have a tighter spread than this. In the past 20 years it has been customary to give Hb values in grams per liter in many laboratories so teh ranges would then be 135 to 180 and 115 to 160 g/L.
Why do women have so much lower Hbs than men? It's because of the testosterone which enhances other chemicals that stimulate the bone marrow.
As far as CLL patients are concerned I have always thought it strange that Rai stage 3 and Binet stage C patients are defined by the same reduced Hb level in both men and women, when plainly a man has to be much more anemic to reach these stages than a woman does. I wonder if this is why women seem to do better than men?
There are dozens of causes of anemia and many different ways of classifying them. I prefer to use the size of the red cell to do this. Red cells are by far the most numerous cell in the blood. In a teaspoonful of blood there are 25 trillion of them (or if you are English 25 billion; ie 25 million million). Red cells are round, flat discs with a dimple on each side, and red in color. Their diameter is about 7 microns and their average volume is between 80 and 96 fl. We call this the mean cell volume (MCV). Again different labs have their own reference range (I have seen 78-92 and 80-100). What does fl stand for? Femto-litres which means 10 to the power of minus 15 litres or 0.00000000000001 litres. That's pretty small!
We could call red cells an MCV lower than the reference range microcytic; those with an MCV greater than the reference range macrocytic; and those with MCVs within the reference range normocytic.
A red cell is 99% hemoglobin (the rest is membrane and a few enzymes); so a small red cell has a deficiency of hemoglobin. Here is a link to a good picture of Hb.
In my picture
the green, yellow, blue, and gray colors make up the four polypeptide subunits of hemoglobin. These polypeptides are collectively known as the globin chains and in common or garden hemoglobin (known as HbA) there are two alpha chains and two beta chains. Each subunit has its own heme group (shown in red.) 
I have also reproduced a chemical structure for heme. I don't expect any but chemistry students to follow this. Take my word for it that it is made up of four porphyrin rings, but notice, right at the center the letters 'Fe'. Fe is the chemical formula of iron and it is here that the iron fits in. The availability of iron controls the production of hemoglobin, and anemias with deficiencies of hemoglobin (microcytic anemias) are microcytic becuse they have too little iron or too little globin.
Wednesday, November 11, 2009
How long to train a surgeon?
Concern has been raised about the training of doctors. Gretchen Purcell Jackson and John L Tapley, pediatric surgeons from Nashville, have just published an article in the BMJ which suggests that our surgeons are in danger of being seriously undertrained. Typically, a surgical training takes 5 years to obtain the necessary skills to be come a general surgeon with extra years for research and subspecialty training. Educational psychologists have shown that acquiring an elite level of expertise or performance requires 10 years of intense involvement and 10,000 hours of practice. This would be true for musicians, chess players or Olympic divers. The authors suggest that surgery, which requires both manual dexterity and cognitive understanding, needs twice that amount of training.
In the States surgeons are rejecting the idea that an 80 hour working week is sufficient to train a surgeon while in Europe the working-time directive is insisting on a 48 hour week. Sleep researchers have demonstrated that heavy night call, defined as every fourth or fifth night, compromises attention and vigilance as much as alcohol intoxication. One institution that introduced the 80 hour week found it produced happier trainees with a better quality of life but it also may well have compromised the surgeons' educational experience.
5 years at 80 hours a week does give the necessary 20,000 hours, but only if no more than 2 weeks holiday is taken. How can Denmark train its surgeons with a 37 hour week?
Although, the prime purpose in reducing surgeons' hours has been to enhance patient safety, it seems to have had the opposite effect where it has been tried. at one center preventable and non-preventable complication rates increased significantly after the introduction of an 80 hour week. In New York, where Teaching Hospitals adopted the 80-hour week but non-teaching hospitals did not, there were increases in unintentional punctures and thromboembolic events in those with the hours restrictions. The extra duties have to be done by someone - the answer is often moonlighting or else lying about hours.
When I think back to my own training, in the early days I worked alternate nights and then on a 1 in 4 rota. Hematologists in the UK have to obtain both the MRCP like internal medicine specialists and then the MRCPath like pathologists. They are also expected to publish. I completed my training 6 years after qualifying, but I did take work home. It may well be that surgeons need a longer period of training because of the 'piano practice' required. Musicians don't expect their instruments to start hemorrhaging uncontrollably.
When I was younger there were trainee surgeons in their early forties. Such were the rewards in private practice that they were prepared to put up with this extended training. Nowadays we see consultant surgeons appointed in their early thirties. They do far fewer operations than their forbears, both in range and number. I know one surgeon who never opens an abdomen, but is an expert in taking out lymph nodes and removes spleens through a laparoscope. Perhaps they are all a lot more talented than they used to be.
In the States surgeons are rejecting the idea that an 80 hour working week is sufficient to train a surgeon while in Europe the working-time directive is insisting on a 48 hour week. Sleep researchers have demonstrated that heavy night call, defined as every fourth or fifth night, compromises attention and vigilance as much as alcohol intoxication. One institution that introduced the 80 hour week found it produced happier trainees with a better quality of life but it also may well have compromised the surgeons' educational experience.
5 years at 80 hours a week does give the necessary 20,000 hours, but only if no more than 2 weeks holiday is taken. How can Denmark train its surgeons with a 37 hour week?
Although, the prime purpose in reducing surgeons' hours has been to enhance patient safety, it seems to have had the opposite effect where it has been tried. at one center preventable and non-preventable complication rates increased significantly after the introduction of an 80 hour week. In New York, where Teaching Hospitals adopted the 80-hour week but non-teaching hospitals did not, there were increases in unintentional punctures and thromboembolic events in those with the hours restrictions. The extra duties have to be done by someone - the answer is often moonlighting or else lying about hours.
When I think back to my own training, in the early days I worked alternate nights and then on a 1 in 4 rota. Hematologists in the UK have to obtain both the MRCP like internal medicine specialists and then the MRCPath like pathologists. They are also expected to publish. I completed my training 6 years after qualifying, but I did take work home. It may well be that surgeons need a longer period of training because of the 'piano practice' required. Musicians don't expect their instruments to start hemorrhaging uncontrollably.
When I was younger there were trainee surgeons in their early forties. Such were the rewards in private practice that they were prepared to put up with this extended training. Nowadays we see consultant surgeons appointed in their early thirties. They do far fewer operations than their forbears, both in range and number. I know one surgeon who never opens an abdomen, but is an expert in taking out lymph nodes and removes spleens through a laparoscope. Perhaps they are all a lot more talented than they used to be.
Tuesday, January 27, 2009
The Placebo Effect
Penicillin was a wonderful discovery. Before that doctors had very few medicines that worked - morphine, aspirin, digoxin, ether, chloroform, atropine, adrenaline, cocaine, and very few others. Penicillin opened the door to a huge pharmaceutical revolution that continues to this day. Despite this, there have been doctors around for thousands of years. Whatever did they do?
Their practice was very similar to that of the purveyors of alternative medicine today. First, they had a uniform. It differed from age to age, but when I was young it included a frock coat, top hat and arrogant affect. Later doctors had white coats and other paraphernalia. Nowadays it is likely to be surgical scrubs.
Second, they had equipment. To be honest it is very hard to distinguish the various noises heard down a stethoscope - chest physicians always believe the X-ray rather than their 'tubes' and cardiologists want an ECHO whatever their stethoscope tells them. Anyone other than an ophthalmologist looking with an ophthalmoscope is probably making it up, and ophthalmologists prefer to use a slit lamp.
Third, they had a ritual. Part of this is the medical examination. We hospital doctors are apt to scoff at general practitioners who don't examine their patients, and certainly the physical is good for some things. I once was referred a case of anemia to investigate by a consultant surgeon. Imagine his embarrassment when I stuck a finger in the rectum and detected a stonking great, bleeding carcinoma. Most complicated is the neurological examination with its reflexes and finger-nose pointing. But whenever a neurologist came to see one of my patients the first thing he would do was ask for an MRI scan, no matter what we had found on examination.
The physical examination is of absolutely no use when performed by a junior doctor. They do not have sufficient gravitas. The examination should be undertaken with a serious face at a deliberate pace, with pauses for reflection and many a "Hmm" interspacing the touching. "Say '99'" is a wonderful device; it shuts the patient up and adds a sense of mystery. It is very important that the patient completely disrobes. Stethoscopes poked through a gap in the clothing do not have the same therapeutic effect.
Ritual is very important. The consultation should always begin with the doctor rising to greet the patient. Hand shaking is very effective even if it does spread germs. Eye contact is good. Taking the history well is more important than anything and it is vital to let the patient tell his or her story in his or her own words. Leading the witness misleads the physician. It is important to get the story right, but of even more meaningful is the process of instilling in the patient the feeling that he or she is of value and worth listening to. Without the enormous modern medical bureaucracy the doctor of old had time to listen and put the patient at ease.
Never let anyone tell you that alternative practitioners have nothing to offer. Of course their oils and needles have no therapeutic effect, vast doses of vitamins and strange diets are completely useless. Enemas are good for constipation and colonic washouts are useful as preparation for colonoscopy, but they incorporate no magic cures. A recent study demonstrated that acupuncture needles stuck in the wrong places were as effective as needles stuck in the proper meridians - but they were effective. Just as doctors in the 1930s were effective. They all make use of the placebo effect.
'Placebo' is Latin for 'I please'. The placebo effect is what happens when a doctor goes through all the ritual of diagnosing and treating a patient and prescribes colored water. Although this sounds like deceit and fraud, the fact is that a proportion of patients will get better from whatever they are suffering. Ye, whatever they are suffering from. You might well expect a response from patients with chronic fatigue or headaches or backache, but placebos can heal up ulcers, abolish angina and even produce remissions in cancer.
Studies have been done on the placebo. Two pills are better than one. Injections are better than pills. Green pills are better than red ones, unless you are looking for a stimulant effect when red or orange ones are best. It is even possible to cure nausea by instilling a drug designed to make you vomit, directly into the stomach if you are able to convince the patient that what you are giving is an anti-emetic rather than an emetic.
You may believe that you are immune to the placebo effect, but if you are then why do you buy branded painkillers rather than straight ibuprofen. I know they work better but why? Because of the placebo effect. And they cost more. That's part of the placebo effect; expensive placebos work better than cheap ones.
Back in 1972, that sensible physician Richard Asher (yes, he was Jane's father) wrote, "If you can believe fervently in your treatment, even though controlled tests show that it is quite useless, then your results are much better, your patients are much better, and your income is much better too. I believe this accounts for the remarkable success of some of the less gifted, but more credulous members of our profession, and also for the violent dislike of statistics and controlled tests which fashionable and successful doctors are accustomed to display."
The problem with placebos is that they involve lying to patients. Placebos don't work if you say to a patient, "I'm giving you a sugar pill. There is absolutely no reason why it should make you better except for the 'placebo effect' which no-one understands but it probably acts psychologically." Or do they? A trial of sugar pills for pain that had been diagnosed as 'neurotic' was carried out at Johns Hopkins Hospital, with just such an explanation. The patients improved considerably.
Never apologise, never explain, goes the old adage. But we can't get away with that these days. We are obliged to tell patients the truth and to explain fully what we are about to do. The Philosopher and doctor Raymond Tallis has written, "The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention."
Alternative practitioners are not burdened by the same restrictions. They can look into your eyes and give you an explanation that sounds sciencey, but is in fact gobbledygook. Watch the TV for adverts for anti-aging creams to see what I mean by sciencey.
Actually, I think it is possible to invoke the placebo effect without telling lies and good doctors do it all the time. After I retired I handed on my patients to other physicians. I was surprised at how many of them promptly died. There was no change in treatment, only a change of treater. One patients illustrates the case starkly. She had cancer of the body of the uterus. She had refused surgery, chemotherapy and radiotherapy and all I did was see her, take a blood test and talk to her. I was astonished that her cancer did not progress. It remained static for three years. Then I retired and six months later she died. Somehow she had fixed on me as a walking placebo.
It should be possible to say to a patient without too much mendacity, "We have exhausted the latest treatment - we must now start thinking for ourselves. This is a concoction that I have tried before in cases like yours and it sometimes works. I don't know how it works - I could make up a scientific sounding explanation if you like - but I won't insult your intelligence. It is important though that you take it in the way that it is prescribed. You must take it on an empty stomach (and here you can invoke any ritual you think they will wear - standing on one leg, facing Mecca, drinking out of the back of the cup or prunes for breakfast) and I will see you every week if you can afford it. Unfortunately, it's not cheap, but if it works it will certainly be worth it."
Some of these people could sell snow to the Eskimos.
Their practice was very similar to that of the purveyors of alternative medicine today. First, they had a uniform. It differed from age to age, but when I was young it included a frock coat, top hat and arrogant affect. Later doctors had white coats and other paraphernalia. Nowadays it is likely to be surgical scrubs.
Second, they had equipment. To be honest it is very hard to distinguish the various noises heard down a stethoscope - chest physicians always believe the X-ray rather than their 'tubes' and cardiologists want an ECHO whatever their stethoscope tells them. Anyone other than an ophthalmologist looking with an ophthalmoscope is probably making it up, and ophthalmologists prefer to use a slit lamp.
Third, they had a ritual. Part of this is the medical examination. We hospital doctors are apt to scoff at general practitioners who don't examine their patients, and certainly the physical is good for some things. I once was referred a case of anemia to investigate by a consultant surgeon. Imagine his embarrassment when I stuck a finger in the rectum and detected a stonking great, bleeding carcinoma. Most complicated is the neurological examination with its reflexes and finger-nose pointing. But whenever a neurologist came to see one of my patients the first thing he would do was ask for an MRI scan, no matter what we had found on examination.
The physical examination is of absolutely no use when performed by a junior doctor. They do not have sufficient gravitas. The examination should be undertaken with a serious face at a deliberate pace, with pauses for reflection and many a "Hmm" interspacing the touching. "Say '99'" is a wonderful device; it shuts the patient up and adds a sense of mystery. It is very important that the patient completely disrobes. Stethoscopes poked through a gap in the clothing do not have the same therapeutic effect.
Ritual is very important. The consultation should always begin with the doctor rising to greet the patient. Hand shaking is very effective even if it does spread germs. Eye contact is good. Taking the history well is more important than anything and it is vital to let the patient tell his or her story in his or her own words. Leading the witness misleads the physician. It is important to get the story right, but of even more meaningful is the process of instilling in the patient the feeling that he or she is of value and worth listening to. Without the enormous modern medical bureaucracy the doctor of old had time to listen and put the patient at ease.
Never let anyone tell you that alternative practitioners have nothing to offer. Of course their oils and needles have no therapeutic effect, vast doses of vitamins and strange diets are completely useless. Enemas are good for constipation and colonic washouts are useful as preparation for colonoscopy, but they incorporate no magic cures. A recent study demonstrated that acupuncture needles stuck in the wrong places were as effective as needles stuck in the proper meridians - but they were effective. Just as doctors in the 1930s were effective. They all make use of the placebo effect.
'Placebo' is Latin for 'I please'. The placebo effect is what happens when a doctor goes through all the ritual of diagnosing and treating a patient and prescribes colored water. Although this sounds like deceit and fraud, the fact is that a proportion of patients will get better from whatever they are suffering. Ye, whatever they are suffering from. You might well expect a response from patients with chronic fatigue or headaches or backache, but placebos can heal up ulcers, abolish angina and even produce remissions in cancer.
Studies have been done on the placebo. Two pills are better than one. Injections are better than pills. Green pills are better than red ones, unless you are looking for a stimulant effect when red or orange ones are best. It is even possible to cure nausea by instilling a drug designed to make you vomit, directly into the stomach if you are able to convince the patient that what you are giving is an anti-emetic rather than an emetic.
You may believe that you are immune to the placebo effect, but if you are then why do you buy branded painkillers rather than straight ibuprofen. I know they work better but why? Because of the placebo effect. And they cost more. That's part of the placebo effect; expensive placebos work better than cheap ones.
Back in 1972, that sensible physician Richard Asher (yes, he was Jane's father) wrote, "If you can believe fervently in your treatment, even though controlled tests show that it is quite useless, then your results are much better, your patients are much better, and your income is much better too. I believe this accounts for the remarkable success of some of the less gifted, but more credulous members of our profession, and also for the violent dislike of statistics and controlled tests which fashionable and successful doctors are accustomed to display."
The problem with placebos is that they involve lying to patients. Placebos don't work if you say to a patient, "I'm giving you a sugar pill. There is absolutely no reason why it should make you better except for the 'placebo effect' which no-one understands but it probably acts psychologically." Or do they? A trial of sugar pills for pain that had been diagnosed as 'neurotic' was carried out at Johns Hopkins Hospital, with just such an explanation. The patients improved considerably.
Never apologise, never explain, goes the old adage. But we can't get away with that these days. We are obliged to tell patients the truth and to explain fully what we are about to do. The Philosopher and doctor Raymond Tallis has written, "The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention."
Alternative practitioners are not burdened by the same restrictions. They can look into your eyes and give you an explanation that sounds sciencey, but is in fact gobbledygook. Watch the TV for adverts for anti-aging creams to see what I mean by sciencey.
Actually, I think it is possible to invoke the placebo effect without telling lies and good doctors do it all the time. After I retired I handed on my patients to other physicians. I was surprised at how many of them promptly died. There was no change in treatment, only a change of treater. One patients illustrates the case starkly. She had cancer of the body of the uterus. She had refused surgery, chemotherapy and radiotherapy and all I did was see her, take a blood test and talk to her. I was astonished that her cancer did not progress. It remained static for three years. Then I retired and six months later she died. Somehow she had fixed on me as a walking placebo.
It should be possible to say to a patient without too much mendacity, "We have exhausted the latest treatment - we must now start thinking for ourselves. This is a concoction that I have tried before in cases like yours and it sometimes works. I don't know how it works - I could make up a scientific sounding explanation if you like - but I won't insult your intelligence. It is important though that you take it in the way that it is prescribed. You must take it on an empty stomach (and here you can invoke any ritual you think they will wear - standing on one leg, facing Mecca, drinking out of the back of the cup or prunes for breakfast) and I will see you every week if you can afford it. Unfortunately, it's not cheap, but if it works it will certainly be worth it."
Some of these people could sell snow to the Eskimos.
Thursday, October 09, 2008
Struck off!
A warning for doctors who recommend alternative therapies appeared today in the records of the General Medical Council. A doctor had been a patient's GP until 1995, but when she transferred to another GP, she continued to advise her on alternative therapies. In 2004 the patient was admitted to hospital cardiomyopathy which was treated and the patient discharged on drugs. Two months later the doctor sent a message to the patient telling her to stop her digoxin and then a few days later e-mailed her telling her to stop all her heart medication and sent a further message advising homeopathic remedies and diet. Eight days later the patient was admitted to hospital and died. The cause of death was given as 'acute heart failure due to treatment discontinuation'.
In 2007 the GMC fitness to practice panel ordered that the doctor be suspended from the medical register for one year, and this year her situation was reconsidered. The doctor complained that she had done nothing wrong, and that given the chance she would do the same thing again. Accordingly the Panel erased her name from the Medical Register.
In 2007 the GMC fitness to practice panel ordered that the doctor be suspended from the medical register for one year, and this year her situation was reconsidered. The doctor complained that she had done nothing wrong, and that given the chance she would do the same thing again. Accordingly the Panel erased her name from the Medical Register.
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