Being a doctor

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Being a doctor
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Life is short, science is long opportunity is
elusive, experiment is dangerous, judgement is
difficult. It is not enough for the physician to
do what is necessary, but the patient and the
attendants must do their part as well and the
circumstances must be favourable. Aphorisms
Hippocratic Writings, Penguin Books, 1983, page
206
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Three Paradoxes

• Doctors have never before been able to do so
  much for patients but doctors are still
  criticised and unhappy
• Society has never spent so much on health care
  but health care is still short of resources
• People have never lived so long but the
  prevalence of disease and disability has never
  been higher

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THE IMPLICATIONS OF MODERN MEDICAL PRACTICE

• Before Simple, ineffective, and safe
  (mystical authority)
• Now Complex, effective, and
• dangerous (partnership)

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The Role of Doctors

• Diagnosis and Treatment Need for a broad and
  deep scientific education
• Caring Understanding humanity through
  education and reflective practice and with well
  developed communication skills
• Research Basic, clinical and population based
• Leadership Learning to work in and with
  multidisciplinary teams
• Management Taking responsibility for individual
  patients,population health and the delivery of
  health care

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DIAGNOSIS

• What is wrong
• Why is it wrong

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• WHAT IS WRONG?
• WHY IS IT WRONG?
• WHAT CAN BE DONE?
• WHAT SHOULD BE DONE?
• WHO SHOULD DO IT?
• WHAT CAN I EXPECT?

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What can be done Integrative
MedicinePatient-centered care and focuses on
healing the whole person mind, body and spirit
in the context of community. Educates and
empowers people to be active participants in
their own care, and to take responsibility for
their own health and wellness.Integrates the
best of Western scientific medicine with a
broader understanding of the nature of illness,
healing and wellness.Makes use of all
appropriate therapeutic approaches and
evidence-based global medical modalities to
achieve optimal health and healing.Encourages
partnerships between the provider and patient,
and supports the individualization of
care.Creates a culture of wellness.
Bravewell Collaborative. 2008.
Definition of integrative medicine.
http//www.bravewell.org/integrative_m
edicine/integrative_care
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What should be done

• Depends on patients circumstances medical and
  social
• Involves discussions between the whole health
  care team
• Needs to be informed by community knowledge
• Cost as well as clinically efficient
• Involves discussions with the patient and family
• Above all the patient must decide and have the
  necessary understanding to make choices

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First of all I would define medicine as the
complete removal of the distress of the sick, the
alleviation of the more violent diseases and the
refusal to undertake to cure cases in which the
disease has already won the mastery, knowing that
everything is not possible to medicine. The
Science of MedicineHippocratic Writings, Penguin
Books 1983, page 140
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Who should make treatment decisions?Gallup
telephone survey of 1,008 adults in UK, Aug 2002
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Difference between preferred and actual place of
deaths
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Preferences for place of deaths may change with
altered circumstances, e.g., difficult symptoms,
lack of particular help at home etc.

• SE London has a high share of deaths in hospitals
• Given patient preferences, there seems to be a
  discrepancy between place of death and patient
  preference, mainly
• Hospital to home setting
• Hospital to hospice setting

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Hospital
Hospice/ specialist palliative care centre
Care home
Home
Values have been scaled up to allocate 5 not
accounted for in originally reported data, 2 on
hospital, 1 on each of other three
groups Source England, Wales and Scotland
(2000) Telephone survey Priorities and
preferences for end of life care in England,
Wales and Scotland (2003) Telephone Survey
NCHPCS/ Cicely Saunders Foundation National
statistics 2003
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END OF LIFE

• End of Life Service Provider (ELSP) will
• Offer opportunity to join the care at EOL
  register
• Provide for a structured conversation about
  preferences, support and anticipatory planning
• Provide comprehensive information concerning
  services and support for the person and carers
• A comprehensive care plan
• A single point of contact e.g. via an 0800 number

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JAMA, November 8, 2006 Vol 296 2255-2258
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• Introduction of shared electronic records
  multi-site case study using diffusion of
  innovation theory
• Trisha Greenhalgh, Katja Stramer, Tanja Bratan,
  Emma Byrne, Yara Mohammad, Jill Russell,
• BMJ 2008337a1786

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• PATIENT HELD RECORD WITH COPIES OF
  SUMMARIES, PLANS, AND LETTERS
• Increase patient autonomy
• Improve information availability
• Facilitate electronic substitution
• Facilitate patient choice in primary care

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The Role of Doctors

• Diagnosis and Treatment Need for a broad and
  deep scientific education
• Caring Understanding humanity through
  education and reflective practice and with well
  developed communication skills
• Research Basic, clinical and population based
• Leadership Learning to work in and with
  multidisciplinary teams
• Management Taking responsibility for individual
  patients,population health and the delivery of
  health care

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The Hippocratic Oath I will use my
power to help the sick to the best of my ability
and judgement I will abstain from harming or
wronging any man by it. Whatever I see or hear,
professionally or privately which ought not to be
divulged I will keep secret and tell no one.
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THE DUTIES OF CARE

• To protect life and health
• To respect autonomy
• To treat justly

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General Medical Council (www.gmc-uk.org)

• Good medical practice (2001)
• Seeking patients consent (1998)
• ConfidentialityProtecting and providing
  information (2000)
• Withholding and withdrawing treatment (2002)

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• Conscience
• Contract

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• Medical professionalism signifies a set of
  values, behaviours, and relationships that
  underpins the trust the public has in doctors.
• Medicine is a vocation in which a doctors
  knowledge, clinical skills, and judgement are put
  in the service of protecting and restoring human
  well being. This purpose is realised through a
  partnership between the patient and doctor, one
  based on mutual respect, individual
  responsibility, and appropriate accountability.
• In their day to day practice, doctors are
  committed to
• integrity
• compassion
• altruism
• continuous improvement
• excellence
• working in partnership with members of a
  wider health care team
• Doctors in Society, Royal College of Physicians,
  2005 www.rcplondon.ac.uk

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The Role of Doctors

• Diagnosis and Treatment Need for a broad and
  deep scientific education
• Caring Understanding humanity through
  education and reflective practice and with well
  developed communication skills
• Research Basic, clinical and population based
• Leadership Learning to work in and with
  multidisciplinary teams
• Management Taking responsibility for individual
  patients,population health and the delivery of
  health care

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Clinical research
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Forty-two clinical cases I have
written this down deliberately, believing it to
be valuable to learn of unsuccessful experiences
and to know the cause of their failure.
Hippocrates

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The chief cause of poverty in science is
imaginary wealth. The chief aim of science is not
to open a door to infinite wisdom but to set a
limit to infinite error.
Bertolt Brecht, Galileo Quoted by
Skrabanek and McCormick in Follies and Fallacies
in Medicine 1989
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It is a bad sign in acute illnesses when the
extremities become cold. AphorismsHippocratic
Writings,Penguin Books 1983, page 231
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Undetected hypovolaemia leading to Hyponatraemia
and death

• Intravenous fluids for seriously ill children
  time to reconsider
• Duke T, Molyneux EM, Lancet 2003, 362,
  1320-1323
• Intravenous fluids for seriously ill children
• Holliday MA et al, Lancet 2004, 363, 241
  

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Gene therapy for primary immunodeficiency a
clinical reality
Molecular Immunology Unit ICH Dept of
Immunology GOSH Dept of Pharmacy
GOSH Thrasher et al, American Society of Gene
Therapy, Boston 2002
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Serendipity and medical discovery

• Polyethylene, artificial hips
• Aspirin
• Chlorpromazine
• Imipramine
• Lithium
• Valium
• Cephalosporins
• cyclosporin

• Penicillin
• Quinine
• Smallpox vaccination
• Nitrous oxide, ether
• Antihistamines
• Nitrogen mustard
• Oral contraceptives
• Cervical smears
• X-Rays
• Heliobacter

Serendipity, Royston M Roberts John Wiley and
Sons Inc. 1989
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The Role of Doctors

• Diagnosis and Treatment Need for a broad and
  deep scientific education
• Caring Understanding humanity through
  education and reflective practice and with well
  developed communication skills
• Research Basic, clinical and population based
• Leadership Learning to work in and with
  multidisciplinary teams
• Management Taking responsibility for individual
  patients,population health and the delivery of
  health care

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Leadership is of the spirit, compounded of
personality and vision its practice is an
art. Management is of the mind, a matter of
calculation, of statistics, timetables and
routine its practice is a science. Managers are
necessary, Leaders are essential
Field Marshal Viscount Slim
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Team work,management and leadership
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• T together
• E everyone
• Who is responsible?
• A achieves
• M more

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Why should doctors be involved with management?

• Ethical responsibility to practise with efficacy,
  effectiveness,efficiency,equity and economy
• To maximise clinical freedom for the benefit of
  patients
• To provide LEADERSHIP

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The Six Es

• EFFICACY Does the treatment work
  
• EFFECTIVENESS How well does it work
  in practice (outcome)
• EFFICIENCY Is maximum output
  obtained for minimum
  input
• EQUITY Are those most in need
  receiving priority
• ECONOMY Is expenditure justified
  compared to opportunity costs
• EXCELLENCE Quality

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Life is short, science is long opportunity is
elusive, experiment is dangerous, judgement is
difficult. It is not enough for the physician to
do what is necessary, but the patient and the
attendants must do their part as well and the
circumstances must be favourable. Aphorisms
Hippocratic Writings, Penguin Books, 1983, page
206
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The organisation of healthcare
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80 of health care spending is on chronic
conditions which afflict 44 of the population
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Framework for Action

• Chronic Disease Management
• Access
• Inequalities and Health Status

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Tackling inequalities
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Wagner chronic care
model Community resources and policies Provider
organisations need links with community-based
resources Healthcare organisation Organisations
need to view chronic care as the
priority. Self-management support Patients
themselves become the principal caregivers
Delivery system design Redesign of the structure
of medical practice may be required Decision
support Evidence-based guidelines provide
standards for optimal care. These should be
available to patient and healthcare staff alike.
Clinical information systems data, held in
electronic form, facilitates efficient and
effective management of care for example,
patient registries and reminder systems.

RCP London 2004
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Integrated Care Centre (Polyclinic)

• Minor injuries and walk in primary urgent care
  centre
• Chronic disease management inc specialist OPD
  clinics
• Mental Health inc cognitive behavioural therapy
  etc
• Diagnostics
• Physio Occupational health
• Minor ops, endoscopy cystoscopy etc.

• Wellbeing and fitness centre
• Community centre
• Voluntary service training centre
• Social services
• Nurse led intermediate and acute nursing care
  beds
• Pharmacy
• Complementary therapies

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Figure 4 A Model for Clinical Networks.
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Major Challenges

• Productivity
• Quality
• Integrated Care
• Health

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What is performance?
CLINICALQUALITY
FUNCTIONAL OUTCOME
PATIENT EXPERIENCE
VALUE

COST

• Level of the individual condition
• Clinical quality includes outcomes and safety
• Functional outcome as measured by PROMs
• Patient experience includes access and
  satisfaction measures

Source VHA Michael Porter
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Major Challenges

• Productivity
• Quality
• Integrated Care
• Health

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Integrated Care

• Kaiser (USA) has fewer age adjusted bed days than
  the NHS 327 vs 1000 per 1000 pop. per year
  shorter lengths of stay (Feachem BMJ 2002 324
  135 Ham BMJ 2003 3271257)
• Veterans Health Administration (USA) had a 50
  fall in bed usage between 1994 and 1998, dramatic
  improvements in the care of chronic illnesses
  were noted
• Chronic disease management, Dept. of
  Health 2004
• See also Managing Chronic Disease
• Dixon et al Kings Fund 2004
  

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Healthcare for London

• Task is to transform health and health care
• Sponsored by Londons 31 PCTs and SHA
• London Commissioning Group acts as board for HfL
  programme
• LCG reports to PCTs and SHA
• Clinical Advisory Group and Patient Advisory
  Group
• CAG links to PEC chairs and Medical and Nurse
  Director networks

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The outsider can judge care but only the insider
can improve it Only those who deliver care can
in the end change care
D. Berwick, 1994
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Clinical Advisory Group

• Multidisciplinary
• Members establish networks with specialist
  colleagues, within PCTs or clusters of PCTs or
  across London
• Provide clinical leadership for commisioners

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Work in Progress(1)

• Consultation on Framework for London concluded
• Each project lead by a PCT chief executive
• Polyclinics
• Trauma
• Stroke
• Long term conditions (diabetes)
• Unscheduled care (access)
• Local Hospitals

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Work in Progress(2)

• Mental health Services
• Children and Young People
• Planned
• End of life services
• Health population and individual
• Pathology
• Diagnostic services etc etc

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Within PCTs the ranges are important
Chart for illustrative purposes only
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Figure 1 The Impact of Changes on the District
General Hospital
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Developing a competitive biomedical hub in London
The Global Medical Excellence Cluster (GMEC)

• Launched by Tony Blair in December 2006
• Combining world class medical universities,
  pharmaceutical companies and leading hospitals to
  promote regional collaboration, innovation and
  competitiveness.

Bay Area
Shanghai
Tel Aviv
London
San Diego
Singapore
Boston
Dubai
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Major Challenges

• Productivity
• Quality
• Integrated Care
• Health

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• Healthy people and a Healthy
• Society

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The dignity of a physician requires that he
should look healthy, and as robust as nature
intended him to be. Hippocrates
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The physician must have a worthy appearance. He
should look healthy and well nourished. He must
look to the cleanliness of his person, wear
decent clothes and use perfumes with harmless
smells.

Hippocrates