Driving change.

I was in a cab. This happens sometimes – a quick hop from the station to one of the hospitals I work in.  I chatted with the cabbie about the weather, as is common for the Englishman. It was lashing down, which is not uncommon, so to speak.

“Does the weather affect your fares?”

-oh yes. Day like today… People driving the kids to school… Fills the roads, slows the journeys.

“But good for you, right? More people take a taxi? I heard that the best days for a taxi driver are hot and sunny in the morning then raining in the afternoon so people who are out jump in a cab”

The logic seemed sound to me. People taking unexpected journeys they had to do because external forces changed their situation.

-Well, yes and no. More fares, perhaps, but the journeys are shorter.

And that was it, neatly summed up. If someone has gone out on foot their journey is going to be relatively short when they decide to take a cab. 

-It pains me to carry some teenager two hundred yards in the rain when I’ve been waiting on the rank for an hour

“I see. More fares doesn’t equal price of fewer longer rides”

-Exactly. Course the best days…. [checked the T-junction we were at, looked over at me] is when there’s a suicide, a person on the train line.

We drove off. 

-Bunch of people need to get to London or Brighton and they’re stuck at the station. Good drives, good fares.

He wheezed.

-Or a flood in the tunnel. Happy times.
Suicides on the rail line. Red letter day for a cabbie, apparently.

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Wagging the dog.

-it’s a pet dog!
Great! I like dogs
-it’s going to replace your old one!
Oh. I liked my old dog. We understood eachother, had lots in common. Everyone liked the old dog. He sometimes grumbled but was essentially sound.
-No. No, we need a new dog. It’s been decided. We’re giving you a new dog.
But why?
-Some people weren’t sure about your old dog. They saw that the streets were messy with litter. And dogs are on the streets, so they want to change your dog
My dog doesn’t cause the litter though!
-No. No, we need a new dog. It’s been decided. We’re giving you a new dog. You should be grateful; you can concentrate all your love and affection on the new dog.
Will this make the streets better though?
-That’s nothing to do with it! Here’s your new dog. And here’s the nice thing. We’ll let you make the collar for it!
Dude-er, the dog, er
-Make us a pretty collar. For the new dog. You can own the collar
Mate. This dog has only got three legs
-Make us a pretty collar. A real nice one
It’s got three legs! I mean, I can work with that. I can make a pretty collar for it…
-A really pretty one…
…just, you know it’s only got three legs right? Our last one had four
-A really, really pretty collar
Yeah, I get that.
-Because we’re going to Crufts!
We’re going to Crufts with a three-legged dog?
-Yes! Isn’t that great! So make sure the collar is pretty because everyone will be watching.

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Further comment on the Saatchi Bill

We had beer.

Probably I’d had a few. But I recall all the conversation. With a good friend of mine, later my Best Man, we supped a pint in The End Of The World. It’s a pub. I think it’s in Camden. This is why I assume, retrospectively, that I might have had a few. It’s not an area I know and can’t think why we were there. But some out of the box thinking was there.

Very early Noughties, possibly end of the nineties, we were talking about science journalism. An idea was born, two-fold, “The Journal Of Negative Results” and “The Journal Of Anecdotal Evidence”

If you’re reading this post, you almost certainly know my feelings about the Saatchi Bill and might not believe that this was our conversation. I assure you it was. Hand on heart.

We talked, as one does, about how this could be a great idea, a non-judgemental forum (I had recently written my dissertation, ‘Whistleblowing in the NHS,’ so the idea was fresh in my mind) and it could aid discoveries and new pastures. We rallied on this idea for the evening and I was enthused that my friend, recently into web design, and I would make this happen.

We didn’t keep momentum going. I got caught in a busy job and the idea rested.

Of note my friend is now CTO of a major open access Science academic website. I said I’d give him some cash to invest. Regret not having it to hand back then.

So, anyway, the idea was born. It was well intentioned.

Fast forward (you can do the wobbly hand thing, whatever) to the current day. The Saatchi Bill hopes to promote innovation, prompt new ideas (despite specifically not applying to research) and ‘stop cancer’.
Admirable aims, no one could disagree.

I was fortunate to attend the recent debate at KCL about the Bill. It was awe-inspiring to be in the presence of so many people who have advanced scientific discovery AND healthcare. I was humbled.

A question, very fairly put, however, was ‘what you can you do when there is no data?’
If there is no data (stand back EBM!) can you justify a new intervention? Does innovation need the Medical Innovation Bill to do something new?

I felt I could pipe up here. I raised the point of a case I had dealt with where we tried an innovative treatment which was used in a patient about to go into cardiac arrest. It worked, although that is not the issue, probably. The important message is that at no point was I concerned that I would be in legal trouble for innovating. Never did that hold me back. I worked in the patient’s best interests, and I suspect that phrase was even in my mind at the time.

I felt arrogant standing in front of 130 people, boasting how I’d saved a life. That is my job, however, and it entailed an important point. In the times when there is no data, no EBM, one still feels protected by Bolam and Bolitho. The Saatchi Bill is not required.

I finished by explaining how we had written up and presented the case. We tried something new without data, with out fear of legal implications, we wrote it up to further medical education. Therefore the bill, and the proposed register, are not required.

After the debate I was asked an extraordinarily good question by a young lady. I didn’t get her name, possibly she is studying neuroscience- I don’t know.

“If you’d given the drug and it hadn’t worked, would you still have written it up?”

Glorious. What a marvellous question.

I’d love to say that we would have written it up, but that isn’t true. Should we write up negative innovation results? That stuff doesn’t make good reading (“it doesn’t tell me what I *should* be doing!”) and possibly the volume would be overwhelming. And how does it look for your workplace, if you’re constantly trying things that don’t work or are harmful?!

I had been asked a very relevant question.

Negative results are published all the time. Many are not, but may be discussed between colleagues and at conferences. For the individual case, that crucial first case, that first innovation, we do need an openness for these.

So innovation is not stunted. But perhaps our sharing of knowledge, of What Not To Try, could be better.

Let’s put the Medical Innovation Bill to bed. But let us use this chance to debate what we could be doing to share information, to share experience. We all have our own journals of anecdotal medicine and negative results in our experience. Let’s think about how we can share that more.

Now that’s a sobering thought.

On qualifying and The Secret

Finishing Medical School is a revelation. The hiatus between studying to be a doctor and becoming one is a glorious time, free of cares and worry of exams, and with the sound security that very soon you’ll be earning mega-bucks for playing golf midweek.
But there is a darker side, a hidden side.

Shortly, sometimes immediately, after passing finals you’re ushered into a special room. At my medical school we had to wear a special gown, as did all the staff.
Brought into a room on your own, sat down with the Clinical Dean who is wearing a very special gown. A red one. He explains;

“Now that you’re a qualified doctor we need to tell you a few home truths…

“Vaccines don’t work!”

I still recall the cackle that went up from the three or four senior members of staff as this was said. I looked around confused.

The Dean wiped a tear from his laughing face,

“See the thing is, we know vaccines don’t work, in fact we know they kill people. But we inject people with these poisons to keep them all in check. We do it to cause Autism. It’s entirely man-made.

“Without Autism, many of us would be out of a job. And we can’t have that, could we?”

The argument seemed so persuasive, I was forced to concede…

“And cancer,” he continued, “we need cancer. It’s true that we could cure it overnight with a simple remedy that we don’t like people talking about, but we’re getting rich off of it and long may it continue”

“Getting rich?”

“Off of the Pharma, Big Pharma, my boy!”

The Dean was on his feet now, wrapping his arm around my shoulders and embracing me. His right hand was high on my thigh.

“Big Pharma! Now you’re a proper doctor we can let you into the secret!”

Letting go, he caught the eyes of his colleagues as he rounded back to his desk. It had lit candles on it, black ones, like voodoo and stuff.

“The secret.”

He paused, tasting the anticipation in the air.

“The secret.
The drugs don’t work. Never have. But the pharmacology companies need to make it look like they do,” he tapped the desk for emphasis, “That’s the deal. And they pay us to keep prescribing them.”

“But my salary would be from the NHS, I thought…?”

“Oh yes, your ‘declared’ salary,” he smiled at his colleagues then grinned back at me, “but not your main one!

“The Pharmacological giants will pay you individually extra monies, thousands of pounds, into a hidden account which you mustn’t mention to anyone, not even your wife. In exchange for this money, every doctor in the country – and it’s only a hundred thousand of us or so – keeps quiet about this exchange and we live better lives!”

My mind reeled. It turned out that the hippy lady with the deaf child was right. He had been deafened by Big Pharma and not by that herb she was stuffing in his lug holes all those years. Where was she now? Probably killed off by a man in a suit with chemicals made by men in laboratories for speaking out.

“So I just keep quiet and I’ll be rich?”

“That’s right boy! We all use this trickle effect – In fact it’s better than that, it’s a cycle! We make the people sick with our vaccines and toxins and chemicals, we prescribe the drugs that don’t make them better and everyone shares the cash!

“You just have to sign here to agree.”

He pushed the paper toward me.

“But you mustn’t tell anyone, right?”

Trembling as I looked to the form, my confidence swelled as I picked up the pen.

A comment on the Medical Innovations Bill

I tried to steer clear of writing about the Medical Innovations Bill. There are many people writing many excellent articles on it already, but I wish to put some personal opinion forward. I hope it is taken in the spirit it is intended.

I’m not against innovation. I’m not against the principle behind the Bill, that is, to innovate and find a cure for cancer. I’m also very open to discussion. I welcome this and, of course, any corrections. Best contacted @fourhourtarget

I have tried to discuss the Medical Innovations Bill (commonly referred to as the Saatchi Bill, even the team do that) but have been hindered. The main problem is that I simply cannot find doctors who are in favour of it.
I cannot find doctors who are in favour.
This should speak volumes, this should set alarm bells ringing like mad! I know *one* doctor who has declared his position as pro-Saatchi, but he’s also got some pretty wacky ideas of alternative medicine, which I note he also makes a lot of cash from. Just saying.

I tried to approach the Saatchi Bill team, but as yet any of my questions have gone unanswered or indeed unacknowledged. **they contacted me via twitter on 18th November and invited a telephone conversation; we are emailing currently**
I imagine that my tweets are seen as antagonistic or impertinent questions; “please give an example of the innovation you expect” might be seen as confrontational. It genuinely isn’t, I genuinely want to know these answers because I believe in the concept of innovation and support it. I think the Bill is going the wrong way about it and only sensible debate will prove a solution. It is a shame they will not engage.

I put my hands up to sending at least one potentially antagonistic tweet, the ‘founded by a pr guru, written by a parliamentary draughtsman, promoted by two ex-journalists. No medics”
However, if you find that antagonistic or incendiary, ask yourself why. They are facts as taken from the Medical Innovation Bill website. You’ve got to know where to cut your cloth.

So a straw poll at a recent #SaatchiBill event suggested that 87% of doctors had not used an innovative treatment in the last decade. This excluded ‘trial drugs and recognised off licence”. This was immediately touted by the Saatchi PR team as evidence that doctors don’t innovate. No definition was given as to what innovation is.
What these doctors fail to realise is that we are using innovative techniques every day. Twelve years ago if you had a heart attack in London, and were lucky enough to have it in the hours 9-5 weekdays, your gold-standard treatment would be thrombolysis, clot thinning drugs. A decade later you can pretty much expect that your London heart attack patient will go for PCI (Primary Cardiac Intervention) as standard, 24 hours a day.
Now the doctors doing those procedures aren’t necessarily the ones inventing this treatment, but they are using it. They’re using the innovative procedures. I fear those doctors in that Saatchi meeting have forgotten just how far and rapidly things progress. There has been massive innovation in medicine in the last decade. To suggest otherwise is blinkered.
When I was a house officer we had some drugs and techniques which were extremely specialised and rarely used. Now I use some of these every day. Not every doctor can be a pioneer into new research, some are treating the patients with the best practice that their peers have uncovered. It’s not failure of novel innovation, it’s the facet of innovation that treats people.

Why should I care? I’m an ED doctor. I have nothing material to gain from whether the Saatchi Bill is adopted or not. But I believe it will be wrong for patients.

Consider it another way. Patient advocates and the Saatchi group are concerned about the cures that we are missing by not innovating. Can we briefly consider those treatments that might have flourished under Saatchi Bill.

Activated Protein C was a drug marketed in the early noughties as an adjunct for sepsis treatment. I recall hearing the drug rep talk about it; the aims, the physiology, the in vitromade sense. It had NNT (numbers needed to treat to save a life) of 7. That, in drug terms, is phenomenal. A course costed 20k, which doesn’t sound to bad, per patient.
Now, if this drug were brought out under the Saatchi Bill, we might have a central register of patients and use , but no ongoing trial, strictly co-ordinated. When we started a patient on this drug we had to call a central office in Europe to register. The need for strict trials doesn’t seem to be engendered yet into the bill. Why is this important?
Activated Protein C doesn’t work. A Cochrane review in 2011 decided it didn’t work in vivo and it was scrapped. Without centralised big data collection, RCT and openness to scrutiny we would never know this.

In a similar vein, the CRASH (Corticosteroid Randomisation After Significant Head injury) trial looked at steroids, which stop swelling, in head injury, where swelling is a problem. Made sense, see?
No, the steroids increased mortality.

Doctors working alone, sporadic trials etc will not reveal these problems. Unchecked we’ll go on with good natured and sensible sounding practice that does more harm then good. This is the real danger of the Saatchi Bill. It could put serious innovation back years and cause significant morbidity in its wake.

Coming back to the 13% have innovated number, and finding that one of these was for an (undiscussed-I don’t know the detail) treatment for snake bite I asked myself, Have I innovated?
I had a patient who was very unwell with an unusual overdose. We gave a drug which was not previously recorded as bring given as a treatment, though we hoped it would work. I did not have long to make this decision. The drug was drawn up as I told the patients son, ‘he’s about to go into cardiac arrest, you might want to step outside.’ No one had given this drug (apparently) before for this. Was I worried about being sued? No. I was acting in the patient’s best interests and my team was in agreement. I didn’t need a bill to protect me or make me safe.

If you feel you need a bill to protect you… Shouldn’t you ask yourself why you’re doing what you’re doing?

My patient survived. We wrote the case up. That’s how we learn and progress in evidence based medicine. That’s why I don’t believe we need the Saatchi Bill.

Comments welcome. Keen to debate sensibly. Looking for someone who will.

An instant solution to staffing problems

“I don’t do this job for the money…but I wouldn’t do it without it”

I started this blog a few days ago, writing about an electrician who wanted cash in hand and acted like he was doing me a favour. He’s not, ‘cos I pay the tax and he is skimping on it. But a bit more on that shortly. I’ve deleted that bit as it is distracting.

Tonight’s #bbcqt brought about the problem of staffing in the NHS and, more specifically, the large amount paid to Locum and agency staff. I have a solution.

Pay overtime in cash.

That’s it, nothing more.
I’m not suggesting this is to promote an HMRC fiddle, not at all; we’re not tradesmen sucking our teeth and grimacing at a wall. I simply suggest that if a short-staffed department calls you at 7 in the morning to see if you can do an extra shift, the prospect of cash in your hand at the end of the day might motivate you more that in 3-4 weeks time in your monthly wage.

It sounds simplistic, but it is. And it motivates. And it’s cheaper than agency. And you could even tax it before it’s given out, if avoidance is your worry.

Cash in hand. Staffing solved.

Just a idea. I’d be intrigued in what people think.

Ta.

M