Friday, 29 February 2008

On the move

I loathe supermarkets. If at all possible I avoid them - either the nice supermarket delivery man brings things to me, or I survive on whatever my local shop stocks. I particularly hate supermarkets when I visit and find that everything has been moved around and I can't find anything. I trail up and down the aisles getting more and more cross and muttering madly about supermarkets and their nasty habits.

So you may be surprised to find, when you visit the library, that we've moved stuff round. Why do we do that?

Two reasons. The most pressing is that we're trying to fit quart into a pint pot, or almost 6000 books where we used to have under 5000. We've got rid of our current journals display, we've put as many older journals as possible in our store, and the book stock has crept round on to the start of the journals shelves.
It annoys us too - we go running to the shelf where we know a particular book lives, only to find that it is now two shelves up, one shelf down, on the next bay, or - worst of all - has actually moved to the next aisle. The positive side of this is that we really look at the books on the shelves and discover exciting things we had forgotten we had - or some real horrors that are whipped off the shelves to be got rid of.

The second reason is also to do with fit. In the old days there were medical libraries, full of medical books, arranged using the National Library of Medicine (NLM) classification scheme. Its emphasis is on diagnosing and treating the bits of people that go wrong, so books are arranged by bits of people and age group - knees, elbows, abdomens, minds, women's stuff, young people, old people.

As libraries have become multidisciplinary it has become ever harder to squeeze books into the classification scheme. Social issues aren't illnesses, neither are performance management, mentoring, poverty, career development or any of the other topics we now stock. We've outgrown NLM and are moving to the Wessex scheme, which looks rather similar, but has extra bits to accommodate those areas of health that aren't just about fixing the bits of us that go wrong. So some topics will be moving not just from one shelf to another, but right across the library.
The library is small. You're not going to get lost if you decide just to mooch along the shelves looking for what you want. You might even find books you didn't know we had. Use the little yellow tags on the shelves that point to key topics (obesity, poverty, leadership) and the book guide on the end of the bookcases. Or ask the library team - we're here to help.

Thursday, 28 February 2008

Two heads are better than one

The worst part of visiting the optician, for me, is the trial by coloured target. "Where do the black circles appear clearer - on the red, or the green?" Different lenses are passed across my eyes. "The red? Or the green?" My reply is possibly, maybe, perhaps the red is just a tad clearer? And I always long for the optician to say "that's right! Well done! The circles are clearer on the red." Instead, no matter how I try to make my answer sound like a question the optician only nods sagely and scribbles on a little card. Did I get it right? Have I made a mistake? Have I ruined my eyesight through inappropriate specs prescribed because I can't decide whether the circles are clearer on red or green?

Sir Roy Calne, in a letter to today's Lancet (access with your Athens password), says that it's the same for hospital patients. Arrive at a meeting with your consultant and she or he will offer you a swathe of options and ask you to chose one. Sir Roy describes being made to make important decisions about your own health care as akin to "being catapulted onto a tightrope wearing a blindfold, and then being asked to chose whether to jump to the left or the right". It would make sense to ask the doctor what they would chose, were they in your shoes, but "policy discourages an answer to this very reasonable and pertinent question."

The government is very keen on patient choice. A lot of this is about how, when and where you receive treatment. You can pick a hospital that is nearer to your own home, or perhaps nearer to a relative who will be able to visit. You can check to see which of the various targets your local hospitals are achieving. You can speak to friends and neighbours and find out about there experience. You can shop around, as it were, to find the best place for you.

If you have chronic illness then you've lived with it for years and years. It's not the same as being a doctor who has studied it, but you have plenty of first hand experience of what helps and what doesn't. You're considered to be an expert patient.

For the non-expert (amateur?) patients among us we can read up about our illness on the internet. The days when ordinary people had to rely on simple first aid manuals in the public library, and had no access to medical papers, are over and done. Some journals are free online for everyone to look at. We can form an opinion about what treatment we would or would not like. We might take into consideration the experiences of friends and relations who may have had the same illness. We're grown ups and we don't want to be spoken down to by an omnipotent and paternalistic doctor. We don't want to be told what to do.

However, do we really want to be left entirely to our own devices? My head aches, I pop into the chemist buy some aspirin. If the headache persists I want to be able to talk to someone who can tell me what to do about it. My sex life seems a little dull so I go online and stock up on viagra. When I ignore the warnings on the packet and my vision turns blue I have no one but myself to blame.

Roy Calne suggests we've moved from thinking that the doctor knows best to thinking that the patient knows best. Surely what is needed is a balance, a conversation between adults. On the one side the doctor has his or her education as a foundation, then CPD and reading the evidence layering on top of that, interwoven with experience of similar patients, similar cases. The patient has their own reading they have done. Perhaps, because their one interest is their own particular illness, they have read more thoroughly or more recently than the physician who has more than one illness, more than one patient, to consider. The patient has their own particular wants and needs, based on their religion, their outlook, their personal situation.

The library current awareness page covers stories on patient information, involvement and experience. We have book on consulting skills. We can help you find the best evidence to make sure you - and your patient - make the right decision, together.

Wednesday, 27 February 2008


Targets - the NHS is full of them. There are targets for how long you wait to see a GP, how long you wait in A&E, how long you wait to be seen by a specialist. Where do all these targets come from - and are they any good?

Targets are part of performance management and quality assurance, making sure that everyone has a good level of care. The targets from a wide range of places. Colchester General (Essex Rivers) has recently had its PEAT inspection. PEAT stands for Patient Environment Action Team. It's part of the National Patient Safety Agency and has been inspecting hospitals since 2000, looking at cleanliness and the food available.

NHSLA is the NHS Litigation Authority - formerly known as the Clinical Negligence Scheme for Trusts or CNST. The NHSLA works for Trusts when claims of negligence are made against them. The more a Trust can be shown to be working to avoid negligence claims the less insurance it pays to cover itself against such claims. NHSLA looks at governance, "competent and capable workforce" (which includes the training people have access to), environment (which is about the human environment - bullying and harassment - as much as about avoiding hazards for slips, trips and falls), clinical care (including record keeping), and "learning from experience" which is about record keeping, complaints procedures and so on.

Next up is Standards for Better Health. These standards cover safety (child protection, infection control, waste disposal etc), clinical and cost effectiveness, governance (corporate and financial, including training staff), "patient focus" (food, patient information, complaints systems), "accessible and responsive care", care environment and amenities (safe and clean), and public health.

The four hour wait in A&E is a Department of Health checklist and the 18 week target - which has a website of its own - is an NHS initiative. NICE does some measuring, too, as does Dr Foster (but not on the public website), and the Healthcare Commission provides an "annual health check" on all trusts.

So many targets - but do they do any good? In 2004 the government pledged to reduce the number of NHS targets. Academics accuse NHS managers of fiddling targets, while ministers admit that trusts are "systematically rigging" targets. The 18 week targets means it's impossible to book an appointment in advance and the 4 hour wait target is adversely affecting patient care because the clock has become more important than the needs of the patient.

However, targets have helped drive down waiting lists. Targets measure (some aspects) of what goes on and encourage improvement and change. If a trust is very good then it can rise to foundation status, freeing it from some of the targets and central government control so that it can work flexibly to provide what is needed locally.
Books in the library on quality and performance management? But of course.

Tuesday, 26 February 2008

Let the mourners come

Spring has surely sprung because as I drive each morning down the Avenue of Remembrance I am flanked by a host, a crowd of golden daffodils. A yellow daffodil is the symbol of Marie Curie Cancer Care. They are getting a lot of media coverage at the moment, which may - or may not - be down to actor Hugh Grant fronting this year's appeal.

As well as raising money Marie Curie are raising awareness about where we choose to die. Two thirds of us, apparently, would like to die at home.

At one time no one spoke of sex, with disastrous consequences for some. Now everyone's happy to talk about how often, how many, who with. The new taboo is death. We don't have funerals where we wear black and mourn the dead - instead we turn up in brightly coloured clothes to "celebrate the life". Even in South Wales, now, the body is no longer laid out in the front room (although recent experience shows that a goodly turn out at the chapel of rest to view the body is still expected). We talk about someone "passing way", "passing on", "falling peacefully asleep."

Death is difficult for both parties - the dying person and those they will leave behind. When we speak to the dying or the bereaved we feel we don't know what to say, or are afraid of saying the wrong things. How much easier to say nothing. Organisations like Cruse exist to support the bereaved. Everyone from the Royal College of Psychiatrists and Bupa to the BBC have information to help with bereavement. But what about help while our loved one is dying?

Palliative care is about more than just mopping the brows of little old ladies, propped up on goose feather pillows, surrounded by their loving families and passing peacefully away. It is about helping the terminally ill come to terms with the fact that their life is ending, helping to ease their physical pains and discomforts, and supporting those who will be left behind. It is about listening to the choices that people make about how and where they want to die. Sadly dying isn't like it is in those 1940s films of Victorian subjects - pale faces, freshly laundered bed linen, the final whispered words. Dying can take a while and can be painful; it can distort and degrade those we love, it can put an enormous strain on relationships. Death also involves an awful lot of paperwork.
Much of the information on death and dying is aimed at cancer sufferers or the elderly. You don't have to be old or have cancer to die. It's easier to find information on coping with bereavement for children than coping with dying. Even Great Ormond Street focuses on the paperwork, with nothing at all on how to face death as a child.
The library has a collection of books on palliative care, including books on communicating with the dying and their families, and plenty of books on coping with bereavement and loss. Some of the books deal with how people of different faiths approach death. There are books on coping with death at the very beginning of life through miscarriage and still birth.
Hospices are at the core of modern care for the terminally ill and the dying. Our nearest hospice is St Helena.

Monday, 25 February 2008

Keep taking the tablets

Today is Monday, so I have duly received a copy of the Current Awareness Bulletin from the National Prescribing Centre Bulletin. I forward the email each week to a lucky band of people - but you can just as easily read it on their website.

The Centre also has a lively blog that provides a “quick and succinct commentary” on news items related to prescribing. Each entry follows a set pattern. There is a link to the original paper that sparked the comment, some background and details of the study. There is also a "so what" section that explains what - if any - impact the study may have in practice - and an "action" section which says whether or not the NPC recommends you change your practice.

If this has whetted your appetite for pharmacological information then visit the Clinical Knowledge Service's drugs pages. CKS is part of the National Library for Health and is primarily aimed at GPs. While you're looking at the National Library for Health you'll find a section on drugs that links to the BNF, BNF for Children and the National electronic Library for Medicines.

If you want to know about the companies behind the drugs then try PharmaLive Search which lets you just search the bits of the new that are relevant to the pharmaceutical industry. More information on this resource on the Alt Search Engines site (with a nod in the direction of Phil Bradley's blog for alerting me to this).

If finding pharmaceutical and pharmacological information yourself is proving a chore then try your nearest Medicines Information Pharmacist. Essex Rivers staff have their own helpful MI team which produces a regular newsletter.

On the one hand....

Last week I read in the news that sleeping in the afternoon is bad for you. On the very same news feed was an item showing that sleeping in the afternoon is good for you.

This was only unusual in so far as both items turned up on the same day. There are plenty of contradictory stories on anything health-related you care to mention.

Lowering cholesterol is good for your heart...but may give you stomach cancer. Going on the pill protects you from some cancer but increases your risk of others. Drinking wine protects against colds, heart disease, stroke, diabetes, dementia….but increases your risk of breast cancer.

What’s a person to do? Hippie Neil in The Young Ones exhorted his friends not to sleep for fear it would give them cancer. The Telegraph identifies a new food fad - orthorexia - whose suffers are obsessed with "bad" foods and additives, sometimes leaving themselves malnourished in their attempts to avoid certain foodstuffs.

All risks are relative, of course. And the headline may not convey the true facts. As Grandma used to say - everything in moderation.

Friday, 22 February 2008

On air

Have you got an MP3 player yet? Are you struggling to fill its endless gigabytes of memory with Artic Monkeys, or the Ring Cycle, or whatever tickles your aural fancy? Have you thought of putting some of that memory space to better use? If you join the merry world of podcasting you'll be able to update yourself on all sorts of things while you are driving, stuck on a train, or relaxing in the bath.

Since I last mentioned podcasting on this blog I've come across the Guardian's podcasts. They vary in length from under 5 minutes to almost an hour. As well as keeping up with the latest UK and foreign news, politics and sport, you can listen to items on science and technology or life style. One of today's life style offerings looks at the current fad for drinking bottled water and asks if there is any real benefit. If the Guardian isn't your cup of tea then the Times has podcasts on sport, music and arts. The Telegraph podcasts page offers business and arts stories, and a link to a page of videos.

BBC radio continues to offer a range of general interest podcasts, along with help on getting started. is an online directory of podcasts. The science and nature/medicine listing currently has over 200 entries. A quick glance down the list shows the range and scope - podcasts for medical students on useful themes with added music (the breast cancer item has music from the film Titanic, apparently), FAQs on travel and blood clots from the Vascular Disease Foundation and an update on flu.

My main quibble with this site is that when I tested it today it was painfully slow, and gave up the ghost totally at one point. has podcasts from the (American) National Institutes of Health and there is a wide range of podcasts on PodcastBlaster, where the science and medicine subsection looks more useful than the health section, which appears to be devoted to fitness and dieting. The site also offers a history of podcasting and tells you how to create your own podcasts.

Thursday, 21 February 2008

A brand new look

The Department of Health website has had a makeover. It has brightened itself up with a splash of purple to go with the green and white, so is now resplendent in the colours of the All England Lawn Tennis Club or perhaps those of the women's suffrage movement. The various boxes that appear on each page have softly curving corners. For those fond of "before and after" pictures there is a full set of snaps of the website in all its former incarnations.

The makeover is more than skin deep. There's a nice clear, obvious link to NHS Choices and NHS Direct for patients. There are separate sections for health care, social care and public health. A new section called "managing your organisation" has everything for the manager from finance and estates to equality and leadership.

The publications section looks pretty much as before and still assumes that you know that the item you are looking for is a circular, letter, bulletin or news release.

I'm not sure if this is new, but I tried searching yesterday for Standards for Better Health. As ever I found it faster via Google (search for "standards for better health" A standard search on the site left me with 500 results - the actual document I wanted coming up third on the list. When I tried again putting quote marks round the words I got just 32 hits, with the paper I wanted appearing on the top of the list. I also got (and this is new) the option to limit my results to news items, consultation, guidance etc.

Don't forget that if you are an Anglia Ruskin student nurse looking for basic DH publications on your reading lists you'll find them all on this library's website.

Consultations, statistics and FOI have their own sections with links from the home page, and National Service Frameworks have their own section under "health care".

In case you are wondering about the picture...I've failed to find anything that encapsulates new looks, makeovers or beauty treatments, and ended up searching for "catwalk." I thought this little cat was somewhat cuter than any of the models in frocks!

Wednesday, 20 February 2008

One in a million

More on relative risk and quality of information. Phil Bradley's blog alerted me to an item that looks at the incidence of inaccurate data on breast cancer web sites. Apparently 5% of sites looked at contained inaccuracies. The conclusion is that patients should be sceptical of things they read online.

I'd agree that a spot of scepticism is always useful, but it seems to me that the result of this study is that a whopping 95% of websites looked at had no inaccuracies. I find that really heartening - it restores my faith in the quality of online information. Having said that I am, of course, suffering from a common problem here. I haven't read the paper in Cancer that reports the study. I haven't even read the abstract. I've just read the Reuters report on the paper. Did the original paper say how many inaccuracies there were on each of the offending sites? Or how big those inaccuaries were? Or how important? How did they select the sites they looked at? The Reuters report doesn't say.

On a similar theme I've today posted a link on the current awareness page to a paper in JNCI looking at women's perception of risk of recurrence of Ductal Carcinoma In Situ. Women with DCIS are understandably anxious and that leads them to believe that the chances of it recurring are far higher than is actually the case. It's just as well that there is no link between having an anxious - or any other type - of personality, and cancer.

For accurate statistical data on breast and other cancers, Cancer Research UK is a good starting point.

Tuesday, 19 February 2008

Please be advised that your evening repast may be found situated within the family pet

This blog has been rather quiet of late. I've been away on leave, and although I've had access to the internet I had other things to do and didn't post a single thing.

Since I've been back I've been reading patient leaflets. I proof read them. A lot of people who write leaflets apparently don't have a spell check on their PCs. I check the evidence behind any statements made. I check that the material hasn't been plagiarised (i.e. blatantly copied from elsewhere without permission or proper attribution). I ask tricky questions about the copyright of the various pictures, diagrams and other embellishments that appear. And I despair over the quality of English used.

Why is it that although we manage to use simple words and sentence structures face to face, we get hit by some horrible wordiness every time we put finger to keyboard? If a patient asks where the canteen is you say, "oh - the canteen's on the second floor. Follow the signs to Cafe Blue." If we want to put a paragraph in a leaflet about the canteen we write, "canteen facilities may be found situated upon the second floor." If a patient rings up and asks about bringing their life savings and all their jewellery with them when they are admitted we say, "it's best to leave all your valuables at home. I'm afraid we don't have anywhere really safe to keep them here". If we write that down it transmutes into something awful on the lines of "Please be advised that it is not recommended to bring valuables..." (and I can't even face typing the rest of it.)

For those of you who are Essex Rivers staff there are guidelines on the intranet about patient leaflets. There are plenty of guides on writing patient information. There are plenty of guides on writing simple and straightforward English. My simple tip would be to read - out loud - everything you write. And then see if you can actually imagine saying that to a patient or anyone.

I sometimes feel we have an obsession with writing our own leaflets. Why reinvent the wheel? (Or - in NHS speak - "Do once and share.") Find someone else's evidence-based, up-to-date, well-written leaflet. Then you have two options. Contact them. Ask them to allow you to use their text. Get their written permission. Then make the leaflet your own - add your own logo, your own phone number and so on. Please, please do not try to "improve" the leaflet by adding extra words that really aren't needed.
Option two? Well, why not be really radical and not write a leaflet at all? That's right. Don't write one. Buy in copies of the perfect leaflet you found elsewhere, show your patients how to find it on the internet, or give them a phone number to call for their own copy.
You'll find good quality information for patients in the National Library for Health, at Patient UK and through NHS Choices. For cancer information the major cancer charities produce excellent information and the Great Ormond Street factsheets are useful for childhood illnesses. The American National Institutes for Health are also a good source of straightforward patient information, but these may need to be tweaked to have UK versions of drug names and so on added.

Friday, 8 February 2008

The thigh bone is connected to the hip bone

I caught a snippet the other day of a radio programme entitled "Where's the femur?". This question- a simple one you might think- was one a junior doctor on a ward apparently failed to answer correctly. Well, dur!

I mentioned the programme to someone who had heard more than a snippet. He thought that the "junior doctor" in question was actually a medical student. Still not a good scenario - a medical student who doesn't know where to find a bone that most of us have heard of.

Look at the story this way. You're student. You're in a real live hospital full of patients. You are sweeping along in the wake of God - oops - I mean a consultant. You draw up to a bed. Consultant warbles at length about the poor patient who is there, in their jimjams, feeling like a specimen at the zoo. Suddenly the consultant is turning to you. It's like being back in school, with the Headmaster glaring at you. "You! You child! Battle of Agincourt! Come on ! Hurry!"

You go beetroot red, you stare at your shoes, and you whisper "I don't know, Sir". The roar comes back "You don't know, Sir? You don't know the date of the Battle of Agincourt? Class! Look upon this child. He doesn't know when the Battle of Agincourt was." Class giggles, you pray for the ground to swallow you up, and Headmaster sweeps off down the corridor.

I'm not saying that this was the attitude of the consultant. Some of this is to do with the fact that there is nothing like being put on the spot to make your mind go blank. But there is a question to be asked about bedside teaching. Being able to do something is not the same as being able to teach it. Teaching is a skill in istelf. There is a definite surge of interest in medical teaching and how it is done. Nurses have already been thinking about teaching and learning for a while. We have plenty of books in the library that look at how adults learn, at teaching, assessing, mentoring and coaching, at learning styles and reflective practice. And our current awareness service has a section on education issues.

The other issue is anatomy. Some claim that there is not enough anatomy teaching. There is certainly no shortage of anatomy books. Favourites here include Ellis's Clinical Anatomy, Gray's Anatomy, Ross and Wilson and Tortora.

For those who prefer to learn online there is the Visible Human from the Univeristy of Colorado, offering 3D models and movies. You'll find basic line drawings through the Univesirty of Iowa's Anatomy Atlases. The award winning e-anatomy site uses CT and MRI for its pictures. Other online anatomy resources arw listed on the Radiology Student Resources website and on the University of Virginia's anatomy pages. On a more basic level there is a great bit on the BBC website that has bones and other bits of the body with facts, figures, diagrams and games. So there is really no excuse for not knowing where to find your femur.

Thursday, 7 February 2008

Same again, please

I often find that when I answer the phone the query is a simple one - "can I renew my library books?" And the answer is always yes - probably.

Why probably? Well, in principle all books are issued for three weeks at a time, and can be renewed twice. That means you can hang on to them for a grand total of 9 weeks - just over 2 months, which seems pretty reasonable to me.

So when can't you renew them? You can't renew them if they are horribly overdue. It's a matter of fairness. The person who is good and rings to renew on the due date gets the books for 9 weeks. If we let you renew when you ring because you've finally looked at that third overdue reminder you've already had the books for 9 weeks - why should you get them for longer? The point of library books is that they are a shared resource and everyone gets to have a go. If you hog a book for 9 weeks, renew and repeat twice that's an awful long time when that resource isn't available to anyone else.

You can't renew them if someone else has reserved them. This is tricky because often the reason you still want the book and someone else also wants it is that you are cramming for the same exam or studying the same module. Look at it this way. When you come in and ask for a book and it's out on loan to someone else you don't want me to let that person have the book for 6 more weeks. You want me to get that book back NOW! So its only fair that if you've got the book you bring it back.

How do you get around this? Well - sometimes I think you bite off more than you can chew. You go off with 6 big, fat, in depth books, and you know you're only going to get time to look at one or two. Why not just take a couple and then come back for the others when you have time? Or photocopy (within the law, of course) the section you really need.

The other option is to buy your own. Borrow the book from the library, read it, confirm that you really can't live without it for the duration of your course/exam revision, come to us, ask us for the full details and a current price. Then either order it from Amazon, or try Tomlinsons. They are the supplier we use and generally give a small discount on all titles - unlike Amazon where discounts vary from generous to non-existant depending on the popularity of titles. When you're done you can always make space on your bookshelves by selling your book through Amazon or ebay, or donating it to a charity bookshop.

So how do you go about renewing? The easiest way is to ring us up, during opening hours, with your library card at the ready, and read us the number on the front of the card. You can leave us a voicemail message or an email. In which case please give us that library number, and leave your name and contact details. If there is a problem with renewal then we'll contact you.

Renewals online? Not yet - sorry.
Oh - and finally - if you are renewing becasue you've finished with your book but can't get it back to us then don't forget the book drop box.

(c) creative commons attributed

Wednesday, 6 February 2008

Pick and mix

The world of health librarians is buzzing this afternoon with the question of EMBASE and whether it's worth forking out hard cash for it. Those of us in the NHS are lucky enough to have access to it through our NHS Athens password. But is it worth it? And what is it anyway?

Medline is synonymous some circles with literature searching. Rather like Google it has become everyone's first - and last - port of call for everything. And if you don't find what you are looking for there...well, surely it's not out there to find?
Medline is big, but it is not the be all and end all. There is important, useful information out there that isn't indexed in Medline, and a whole collection of other databases that do index some of that material.

Cinahl is for nursing and allied health - but please don't let that turn you off if you are a doctor. It has good coverage of physiotherapy journals which can be useful for rheumatologists. Cinahl is also good for covering those journals where articles ask how the patient feels, rather than focussing on what the clinician does to the patient. And if you are wondering if a nurse-led unit would be a god send or a disaster than Cinahl will find papers to help.

Psycinfo is the mental health database. It goes back in to the mists of time (well - the 1880s, anyway) and indexes books as well as journals. It covers psychology and neurology as well as psychiatry.

And so to EMBASE. It's big - almost as big as Medline. It has a European bias, where Medline is North American. It indexes more non-English language publications. Its particular strengths are pharmacology, genetics and biomedical sciences.

All of the databases have some overlap. The overlap between Medline and Embase, depending what you are looking for, varies between 10% and 87%. Sometimes it's reassuring to get the same results from two or more databases - you can feel more certain that you aren't missing anything. Sometimes turning to another database transforms a search disaster into information heaven.

Medline is the only one of these databases to be available for free, in the guise of Pubmed. The others have to be bought - which is where your Athens password comes in. The joy of bringing them all together (currently under Dialog Datastar, soon to be under NLH Search 2.0) is that they look the same, are searched in the same way and you can flip between one database and another or search across more than one database at once.

So Medline is quick, its easy, it's familiar - but why stick to the Big Purple One when there is a whole quality selection to chose from?

Tuesday, 5 February 2008

Presumption of innocence

I once heard a joke about a sheriff who stopped a woman in a car and cautioned her for illegally fishing, because her husband had left his fishing gear in the boot of the car and she was near a river. She was adamant she wasn't intending to fish, but the sheriff replied - "you've got the tackle - how do I know you're not going to use it?" In that case, parried the women, I'm accusing you of rape. The sheriff is gobsmacked - rape?! But he hasn't even touched her!! "I know," replies the women, "but you've got all the tackle - how do I know you're not going to use it?"

In English law we have the concept of the presumption of innocence - more commonly known by the phrase "innocent until proven guilty". The idea is that it's much harder to prove innocence than to prove guilt. If you are guilty the prosecution should be able to find witnesses to your crime, traces of your DNA or fingerprints at the crime scene. If you were home alone last night, no witnesses, no alibi, can you positively prove beyond doubt you were there and not up to no good elsewhere?

Sometimes guilt is easily proved. You were seen by witnesses, you left fingerprints, there are recorded phone conversations or CCTV images. Similarly cause and effect can be easy to demonstrate. Yesterday I walked into the open drawer of my desk (ouch) and today I have a big bruise on my shin. Cause and effect.

It's a little harder with health issues. It took years to link smoking and lung cancer. But it's not possible to say that if you smoke you will die of lung cancer - or that if you don't smoke you wont. Roy Castle, who never smoked, died from lung cancer. Conversely we all know elderly relatives who smoked 40 a day for 60 years or more and died peacefully in their beds of old age.

At the moment scientists keep looking at mobile phone use. So far there is no positive link between phone use and cancer - but is that because there is no link to find? Or because we haven't yet proved the link? Or haven't waited long enough for the cancers to start appearing?

What about aluminium and breast cancer? Various eminent scientists have said that there is no link, although they admit that more research needs to be done. Just because the police haven't yet had time to investigate a crime does it mean that crime hasn't been committed?

The debate that still rumbles on is MMR. MMR stands accused of causing autism. There is plenty of evidence - eyewitness accounts from hundreds of parents who had happy, normal children who were changed into troublesome and troubled children about the time of their MMR vaccine. The judge says that this evidence is circumstantial. Certainly MMR was hanging around looking suspicious - perhaps wearing a hoody and smoking - but that isn't proof that it committed the crime.

Since then their have been endless papers trying to prove MMR's innocence beyond doubt. Today MMR is in the papers again with yet another study failing to prove a link between MMR and autism. Is there no link? Or are scientists asking the wrong questions, looking at the wrong children, or the wrong numbers? (The Guardian calls this latest study "huge" but it only covers 250 children).

The key issues here are risk and evidence.

What is the actual risk of a child developing autism? Of an unvaccinated child catching measles? Of a child dying from measles? How can we understand relative risks? Read Reckoning with Risk, Risk by Lupton and Risk Matters in Healthcare.

And evidence - what is evidence? Are all health interventions guilty until proven innocent? Is it wise to assume every new idea will kill us until we can positively prove otherwise? Is evidence only evidence when it tells us what we want to hear? What value does the experience of ordinary people have in the hierarchy of evidence? If one scientist publishes a paper that says magnets don't relieve arthritis pain, but I can find 50 friends who say they do - who is right? What is good evidence? There are many books in the library on evidence, statistics, reading and understanding papers.

What can any of us do? Be vigilant. Be critical of the evidence. Use our brains.

Monday, 4 February 2008

Testing, testing

The BBC reported on Saturday that junior doctors cheerfully order tests to be carried out even when they know that the results wouldn't mean a thing to them. The report didn't say if juniors were confident that someone else would come along to interpret the test. Perhaps they just feel they ought to be doing something when they are baffled and that patients will be reassured to hear "we're running some tests".

Could patient pressure be to blame? There's a story in today's Telegraph about a little girl diagnosed with cancer. Initially no one seemed to know the cause of her aches and pains and in the end a journalist suggested that the mother "demand blood a test." There is no indication of what kind of blood test - blood can be tested for many things. Is this patient power at an extreme? What else could we demand?

Apparently too many patients demand antibiotics for colds - which are, of course, viral, and therefore do not respond to antibiotics. In the mean time the overuse and abuse of antibiotics leads to ever more horror stories about flesh eating, drug resistant bugs.

Is there a balance needed between the patient's right to be involved and the need to respect the knowledge and training of a doctor or other healthcare professional? On the one hand we have the concept of the expert patient. Most geriatricians aren't old, rheumatologists don't generally have arthritis, and many obstetricians are male. The patient is the person who lives with a disease - especially chronic illness - day in and day out. Surely in some ways they know more about that illness than their healthcare provider?

On the other hand there is the pesky know-it-all patient who has looked up their symptoms on the internet and has only come to tell you what to prescribe for them. My favourite example of this is the cartoon of the chap in his GP's surgery with an internet diagnosis. The GP remarks "I sometimes wonder why I spent 10 years training to become a GP. Your analysis and medication would work perfectly...if you were a goat"

Doctors aren't alone in this. Parents ring up schools to explain to dimwit teachers that they have given their child the wrong grade for their homework or course work. And surely we're all familiar with the joke about the garage tariff with the most expensive price being for work done "with customer's advice"?

One way to help patients be experts rather than pests is to point them towards websites that provide them with good quality health information, like NHS Choices, Patient UK and BBC Health. Help them understand how to evaluate information - perhaps using the QUICK quality information checklist, pointing out the HoN logo or telling them about the Quackwatch site that rounds up and explains the worst urban myths, scare stories, and lies around health.

The other way to avoid the pest is to listen to them and try to work with them, not against them. There are plenty of books on communicating with patients - it really is the key to a good patient/healthcare professional relationship.

And for those of you still struggling with the meaning of lab tests - read up on it in the library. We recommend A Guide to Laboratory Investigations, the Oxford Handbook of Clinical and Laboratory Investigation and Understanding Laboratory Investigations. On the net you'll find the Lab Tests Online resource.

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