The Naked Soldier
Nobody has ever thought that a simple mask can eliminate the risk of a viral infection.
But, not even any soldier has ever thought that a camouflage uniform can save him from a bullet.
Nothing is new about Coronavirus, mentioned in a JAMA podcast as early as October 7th 2019, speaking of protective medical equipment. Times were not suspicious.
However, even a simple mask, in a patient who coughs in a crowded waiting room, or at the counter, would not be a bad idea. At least, this could reduce the potential contamination of surfaces and people.
There would also be indirect effects, perhaps unexpected, such as keeping an eye on distances, without the need for written reminders, or ensuring personal hygiene, particularly in places generally frequented by the most fragile.
As for the doctor - speaking personally, it is certainly not the fear of contracting an infection that stops me from going to work - protective equipment should be available by default, such as time to wash and clean surfaces, where necessary , between patient and patient. Not so much for myself, but as for the people I do my best to take care of.
At the moment, we are a bit like naked soldiers sent to the front to fight an invisible enemy.
All this is true regardless of the severity of the Coronavirus infection, on which it is still difficult to pronounce in absolute terms.
Concerning message unless clarified. First and foremost: as per WHO guidance, healthcare workers involved in the direct care of patients should use the following PPE: gowns, gloves, medical mask and eye protection (goggles or face shield). Patients with suspect infection should avoid to attend the surgery in the first place and message should be clear. Invite and promote using telemedicine to evaluate suspected cases of COVID-19 disease, thus minimizing the need for these individuals to go to healthcare facilities for evaluation.
Reduce number of people attending the surgery at the same time, so to reduce the possibility of crowded spaces, perhaps advising and supporting longer appointments.
There are legitimate fears of "discrimination" by insurance companies, employers and society following genetic testing. The balance between pros and cons is particularly delicate when there are no cures, or effective treatments, and / or when the penetrance is incomplete. It is also necessary to establish whether relatives of someone with a positive predictive genetic test should be informed of the results and risks. I am not sure that at the moment public and GPs are sufficiently informed about the above problems.
I posted elsewhere my "concerns" about the Babylon project (https://www.linkedin.com/pulse/remote-consultations-all-glitters-gold-edoardo-cervoni/). I now read: "From the evidence, Ipsos Mori evaluated that the model could have ‘positive impact’ on the recruitment and retention of GPs who wouldn’t remain in general practice otherwise." The bottomline question remains unchanged: why is this the case?
This does not go far enough. There is no mention at all opiate-induced hyperalgesia. This may well be far more common than addiction is a indeed defeating the objective of the pain treatment by itself. We are also becoming aware that chronic opiate administration can increase the proportion of MOP/DOP neurons and that those changes are persistent.
I can just subscribe, in full, the comments from Vinci Ho. Of course, there is also the "little matter" of having accepted a donation for £1M which in principle should be returned. The fact is that a College should not be a political Institution, in my humble opinion and sticking to it could very much attract more "subscribers".
"GP at Hand costs could ‘jeopardise’ other health services if not mitigated", and may I add: NOT ONLY. It may well jeopardise patients' care. Vinci Ho makes strong points on the topic.
My professional experience is in keeping with the observations described in this study. Heterogeneous pooling is a very well known challenge to any clinical research, particularly when all the variables at play are unclear, but I think this was an important publication.
In fact, many of us did read it.
I would like to highlight some limitations of the survey published by Pulse.
The outcomes certainly do not reflect the motivations that led me to choose the career of locum and agency director.
I do not think there can be any objections to the fact that the results of a survey are a function of the questions that this raises.
In this survey 2 key questions are missing: "would you work as a Partner if this was much more independent of NHS management?" and "Do you trust management at the CCG level and above?".
The survey shows that, substantially, many locum GPs would like to work less, flexibly, but earning more money. In that case they would be willing to become Partners.
It is a state of the obvious.
The reason why I chose to work as a locum after 10 years of service as GPwSI ENT for the local PCT is very, very, different from the above.
For me it was the great incompetence and absence of acumen as well as empathy, which I noticed when the PCT closed down. Pulse covered very well at that time my personal experience.
Regardless of the illogical "economic loss" for the PCT, and damage to the planning of personal and professional aspects of my life and, above all, of my very young family (not compensable at all even with a lucrative bonus exit which has never been of my interest), the most shocking thing to it was the observation of an absolute lack of administrative acumen and of medium-long term planning.
I had an average of one line manager per year over the 10 years period, hence that should not have been a surprise to me.
There are then obvious illogicities, such as that it is not possible to set a maximum limit on the number of patients to be seen in a day or home visits. For me it is very similar to not setting a speed limit on a high-density urban road, or not penalizing a dangerous driving. If a doctor perceives that the work load is excessive, perhaps on that day for the type of pathology or patient seen or other reason, the Principal should be able to modify the list of available appointments accordingly.
I am also aware of a significant proportion of partners earning considerably more than I do, of course.
To conclude, if it is true that my revenues have unsurprisingly doubled working as a full-time locum, the reason why I do not consider the possibility of joining a Partnership is my inability to receive directives that I can easily anticipate going to bad end, or not delivering clinical benefit, or perhaps taken for exquisitely political reasons.
Likewise, I have the greatest appreciation and respect for the Partners able to work on that interface I do dislike, and I would do anything I possibly can to lessen their workload in return.
Well written article. In my experience, the best guidance is in Dr Snelsons' statement:"Activities, behaviour and progression of symptoms are also key elements", this compounding with the outcomes of general observations.
"The old maxim that specialists know more and more about less and less until they know all about nothing has validity. ". I love it. Until we fail to acknowledge that the patient on one single medication and for one problem which is affecting only one organ (or part of it) does not exist - unless for a very limited amount of time when framed in a lifetime period - we shall continue to underestimate the importance of Primary Care figure advice and management. The good news is that, it seems to me, Medical Schools are doing their part in reinvigorating the appeal and role of General Practice.
I think that Dr David Turner's idea should not be easily dismissed. Also, Tony's input is a meaningful one.
Fact is that Primary Care should look at optimisation rather than rationalisation and this cannot be done without a greater patients' involvement. Financial costs and their burden on the ability to deliver good services are real and not just "political battle fields.
So, yes. I think we should put the idea to a test. Ultimately, what works in Country does not have to necessarily work- somewhere else and vice versa.
Quote: "They did caveat that vitamin D supplementation was still appropriate for groups at high risk of rare conditions such as rickets and osteomalacia, which can result after prolonged lack of exposure to the sun."
it seems to me that it is quite likely that there is some work to be done on "normal" reference range for VitD, which is most likely to be also linked to ethnicity and seasonality. It is possible that, taking into account the "pandemic" prevalence of "low VitD" according to blood test results in otherwise healthy adults and children, the reference range should be "adjusted downwards".
It may be added that, as someone else highlighted before me, VitD testing should be done appropriately to be meaningful.
I do agree with Vinci Ho in terms of plausible "forecast" being made. However, anyone, and particularly so medical professionals, should avoid misrepresentation. It seems to me that the BMA is trying to work and act professionally and of this I am very pleased.
6 years ago seems to be an Ocean of time nowadays. In fact, it was just then that Dr Singh, GP and Dr Leder, Professor of Philosophy, were chanting the benefits of the human "touch in the (medical) consultation". I am concerned that financial interests, conflict of interests, money cutting exercises, and political benefits pressures may all work in a direction that may be "innovative", but not beneficial to the patient and particularly those more in need. I also subscribe most of the comments and I remain puzzled when hearing that physical examination is not a must.
I can just subscribe Vinci Ho comment.
It all depends on what you define as NHS. The fragmentation and degree of privatisation, alias subcontracting, of the current healthcare system is such that it has very little resemblance, if any, with the one devised at the time of the NHS introduction.
The data presented confirm in full my observations “on the field”. I hope to be wrong, but early retirements may be coupled by an exodus of young and less young colleagues of unforeseen magnitude. This being the case, the outlook of NHS funded primary care and secondary care is not that good at all and even a substantial amount of money being poured in it could then lessen the professional pressures - and risks.
There are many considerations here that could be made and surely I remain to be convinced that there is a logic ground for thinking that something like Babylon will be a cost and time effective "experiment". I would surely advocate that the Babylon "owners" could run a "privately funded" trial in a "private practice only" context, and for a few years. If successful, then NHS could consider contracting Babylon. To be said about AI: be mindful much of the clinical data that we feed AIs is imperfect, hence we should not expect perfect answers. In fact, errors could scale-up vertiginously. Recognising that is the first step in managing the risk. Decision-making processes built on top of AIs need to be made much more open to scrutiny. As someone else said before me: "Since we are building artificial intelligence in our own image, it is likely to be both as brilliant and as flawed as we are".
I am actually moved by the letter signed by Dr Lyvia Dabydeen,
Dr Hilary Klonin, and Dr Sethu Wariyar. For whatever reason, this seems to be a far more plausible description of the events. If, after having read that letter, anyone thinks that Dr Bawa-Garba should not have been given the possibility to work as a doctor ever again (which she did for a few years after the accident, by the way), then it would be worthwhile reflecting on our profession and its future. Who are we going to attract? Perhaps, Mathematics, Physics and Economics will have an easy ride in their attempt to attract the most talented students.