Surgical errors

[got banned]

I've just read in the "Sunday Times," that surgeons are responsible for the majority of medical "accidents" in the UK.

Mostly, this is due to a lack of communication skills between the team, and has, according to the Royal College of Surgeons, been brought about by the arrogant attitude of some surgeons.

Is this a true reflection of the real world?

[obgraham]

Couldn't find the Times article online, Banned, but it likely depends on the definition of terms. I expect that in sheer numbers, nonsurgical errors, such as medication errors, falling out of bed, etc, far outweigh surgical errors.
But leaving that big clamp in there, or chopping off the wrong leg, usually gets more attention, not to mention more cash.

[Mac the Knife]

"I've just read in the "Sunday Times," that surgeons are responsible for the majority of medical "accidents" in the UK."

Can't find the article, so I don't know, but I wonder what they mean by "accidents"? I would have thought that errors and misjudgements in the prescribing of medicines would be far greater than surgical "accidents", but still.

Looking back over a long surgical career I can't recall many "accidents" in the sense of major errors, which I have witnessed. Only a couple that have resulted in the death or disability of the patient. I recall quite a few "errors of judgement", some mine and some by other people, which have resulted either in a longer hospital stay or a less favourable outcome, but these hardly qualify as "accidents".

"Mostly, this is due to a lack of communication skills between the team, and has, according to the Royal College of Surgeons, been brought about by the arrogant attitude of some surgeons."

Most "accidents", whether surgical or aviation related are due to lack of communication (look at Comair in Kentucky). Truly arrogant surgeons, just like arrogant pilots, can often be unpleasant and may well be dangerous, but I haven't met very many.

The idea that surgeons are arrogant is an old canard that won't go away and I think it stems from an understandable lack of familiarity with our particular work. The public seem very attached to the stereotype of Sir Lancelot Spratt and TV series after TV series just reinforces this.

The spineless Royal College of Surgeons, now dominated by a claque of non-clinical academics pursuing knighthoods and social workers eager to demonstrate their loyalty to the dubious principles of the New Left, would now say anything, no matter how false and lickspittle, to curry favour with the Bliar government.

Surgery is a most unnatural activity. We're all familiar with the idea of "personal space", in the sense that there is a certain distance that we keep from other people physically. Surgery not only violates personal space (just as nurses and physios do), but actually breaches the skin, our ultimate physical defence, and invades the inside of the body. There's an analogy with penetrative sex, if you like. Anyway, to do this, to actually take a knife and cut into someone, especially at first, requires overcoming deep cultural and "race memory" inhibitions.

To do this regularly, and in oftimes uncertain situations, demands a significant degree of certainty. I would suggest that this certainty is what is often seen as arrogance. As Treves wrote, "He [the surgeon] must have courage, be quick to think and prompt to act, be sure of himself and captain of the venture he commands".

Surgery itself teaches us humility, often quite brutally, and the vicissitudes of chance and nature contrive early to humble most of us of any God-like illusions. Ambroise Paré, the great 16th century French surgeon said, "I dressed him and God healed him".

Aviating is an almost equally unnatural activity and demands an equal, though different, degree of certainty. Once again, this is often seen as arrogance, while in fact it is just the necessary mindset to allow a person to take 500+ people into the stratosphere at just under Mach 1 and be reasonably confident of seeing them safely on the ground at their destination.

I submit that in a world where it is unfashionable for men and women to be strong and steadfast in their purpose and which glorifies the pallid-souled, limp-wristed ditherer that more and more of us who actually know what we are doing will be labelled arrogant.

[got banned]

Thanks for the replies, unfortunately I can't fing a web link to the article, which basically said that the lessons from the Bristol scandal havn't been learnt, and teamwork and communication in surgical teams is still sadly lacking- leading, in some cases to disaster- an example quoted was that of a surgeon amputating the wrong leg, and a urologist removing th wrong kidney (the patient died.)

The article hinted that the team were afraid to question the almighty surgeon, which I found a little incredible.

I do remember a simillar scenario years ago, involving an airline captain (a trident I think), selecting an incorrect flap setting, resulting in a crash- at the time, it was thought that the young inexperienced pilot knew that the setting was incorrect, but was too frightened to point out the error to the captain.

Do surgeons routinely hold meetings with their wider team to discuss quality issues?

[BelfastChild]

Do surgeons routinely hold meetings with their wider team to discuss quality issues?

Do we what?????????? Where I work we have a morbidity and mortality meeting every three months. We review the work of the entire unit. Look at number of operations performed, type of operation, who's doing them etc. We review all deaths and serious complications and try to determine why they happened and how they may be prevented in future. And we are not unique - every surgical department does this.

In addition, each surgeon in the unit has to undergo a peer reviewed audit annually for CPD issues.

So the answer your question - yes we do

[got banned]

Found the article, it's here http://www.timesonline.co.uk/article/0,,2087-2340502.html

Must admit, on 2nd reading, it does appear a little wishy washy, although a little frightening that their own Royal College, is being so critical.


There are some surgeons who have a seriously flawed opinion of their own capabilities,” he said. “If you are a surgeon and doing dangerous work you need to have a degree of self-assurance and confidence but it can turn into arrogance.

Does a appear a little subjective.

[Mac the Knife]

Thanks for the link got banned.

I have to say that I think that this is an appalling article. Emotive language like "patients are dying on operating tables" (by implication, in droves), without any substantiation. I can't find Gidding's original statements on the RCS website so I can only comment on the quotes.

It is not contested that surgery in the NHS is not all that it might be and the reasons are not simple. The relentless attacks on the probity and standing of surgeons by the press and Government have had serious effects on morale, the full repercussions of which have still to be felt. That the RCS should denounce the very surgeons that it certified is a very strange abrogation of responsibility.

That surgical training is in serious trouble is indisputable, but for the RCS to fault the surgeons rather than the new training schemes which they themselves, in consultation with the GMC and the Government introduced, is disgraceful.

If, as Giddings infers (based on what evidence?), that surgeons "believe they are infallible" and "have a seriously flawed opinion of their own capabilities" then who is to blame?

Many older surgeons now feel, as I do, that the RCS no longer represents them and is pursuing some bizarre agenda of it's own that has nothing to do with either classical surgery or it's roots.

The implication that every surgical unit is a Bristol waiting to happen is bizarre, unlikely and alarmist. First of all, the facts at Bristol were complex and very far from the widespread perception of virtual homicide. Secondly, the evidence that such errors of technique and judgement are widespread is paper-thin. Quite what Gidding's purpose might be in making such an inflammatory statement is unclear.

Surgical deaths are a fact of life and aren't always someones fault. Deaths can be reduced to a very low figure, but cannot be completely eliminated, the more so since we are operating on an increasingly ageing and unfit population. The inference that surgeons are indifferent to these is fantastic. I have myself recently had an unexplained patient death and the experience is terribly distressing.

The mooted figure of 20,000 surgical deaths/year is extraordinary. Quite how the 2159 recorded by the NPSA transmogrifies into this is perplexing since all perioperative deaths must, by law, be reported. The reason given, "that only a fraction are reported" implies deception on a massive scale, for which there is precious little evidence.

The implication that Marc de Leval, a surgeon of immense experience and skill (whom I met several times when I worked at GOS) found himself incompetent is unfair and untrue. You can read a fuller story at http://www.hospitaldoctor.net/hd_news/hd_news_article.asp?ID=3769&Section=Feature To couple this with a single anonymous anecdote about a wrong kidney removal (when did this occur?) is invidious and seeks to create the impression that fatal medical blunders are the order of the day.

Yes, wrong legs get amputated (this must be very uncommon, I'd like to hear some stats on this for the last 10 years). Yes, wrong kidneys get removed (ditto). But this is neither common not commonplace.

For an excellent review of where we are and where we have come from see http://www.ctsnet.org/doc/5644

I'm glad I'm mostly private these days, and doubly glad that I'm not practicing in the NHS.

[Re-entry]

Mac, I have learnt a lot from your posts. But I must hit the 'wooooaaah' button.You assert that most aviation accidents are due to lack of communication. This is simply not true. A short visit to any accident investigation database (e.g. NTSB) will soon dispel this. Yes, communication in the cockpit is important, and CRM is a vital part of what is now described as TEM ( threat and error management). I agree with your analogy of an unnatural environment, which is why airlines have developed the procedures they use and require from their flight crews. These mitigate the possibility of serious consequences. Communication with other crew and ATC is an integral part of the safety net, but to identify it as the major cause of accidents is just not factual.

[Mac the Knife]

Forgive me Re-entry. I am not an expert in aviation accidents and perhaps should have written "many" rather than "most". I used the same word that the article used - "Mostly, this is due to a lack of communication skills..." to make an analogy with aviation and should have been more careful. Additionally, I don't necessarily agree with the conclusion of the RCS - many mishaps are anaesthetic related, which doesn't seem to get a mention.

Surgery is more like general aviation than airline transport and I know that the vast majority of mishaps are in GA rather than AT. If I read the data correctly, most accidents in GA come from disregard or sloppiness of basic procedure like QNH errors, weight and balance checks, fuel management errors, flight into adverse weather and skill based errors. As one of your publications says, "there are literally thousands of unique ways to crash an airplane." Many errors in surgery are of this nature - fortunately few result in a "crash"!

I think one can stretch the aviator/surgeon analogy a bit too far - yes there are some similarities, but there are even more important differences.

In AT, CRM has vastly improved communication on the flight deck and rather belatedly surgical bodies are trying to borrow aspects of the principles of CRM to improve communication, but I believe that it is basic training, rather than CRM, that needs the most work.

[Re-entry]

'Aviation is not inherently dangerous. It's just very unforgiving of errors.'
Maybe this would be an analogy to surgery. Only thing is, I screw up, I die with 'the patients'.

[slim_slag]

Perhaps an experienced surgeon is flying the same piper cub as he soloed on, just rather better?

I think got banned is playing with us :)

[got banned]

got caught ;)

[Tigs2]

i have done quite a bit of research on this in the past and there are some interesting facts that arise.

If you look at the lengths we go to now to minimise error in aviation, i.e Mandated CRM and Human Factors for starters, we are now in a position where we as a profession are pretty safe. In 2004, there were approximately 16 million air movements world wide. Approx 2500 people died in air incidents (many in light aircraft).

In the same year alone, it is estimated by the insurance companies that almost 750,000 people died as a result of medical negligence in the United States alone!! Yes you read the right number. The total figures are split into about 10 cause groups, of which Surgical error was one, which accounted for just over 30,000 deaths. It is estimated that the deaths run at a rate equivelent per capita of population, interestingly this turns out to be about in the right ball park as in the same year it is estimated that 70, 000 people died in the UK as a result of medical negligence of one form or another. Major contributing factors do seem to be the communication issues, fatigue, stress and lack of supervision (due to undermanning).

Back to the USA in the same year 530K people died as a result of cardiac disease, and 510K people died as a result of cancer. Therefore Human error killed more people than either Cancer or Cardiac disease. Think of the money we (quite rightly) put into research in both these disease types, and compare to how much we put into the prevention of deaths caused by Human Error in medicine!

Any Surgeons, Docs interested in a little (infact huge) project? Pm me.

[Mac the Knife]

some would say 250k is an underestimate

Urrr... Where is the 250k and what is it an underestimate of?

Anyway, checkout the UK deaths data for 2004 at http://www.statistics.gov.uk/downloads/theme_health/Dh2_31/DH2No31.pdf

Download http://www.statistics.gov.uk/downloads/theme_health/Dh2_31/Table2.19.xls and look at rows 945 (ICD Y40) to 1065 (ICD Y84.8)

Row 991 (Y60-Y69) - 'Misadventures to patients during surgical and medical care' - (11 males and 21 females) is worth a look.

Now, either Stats UK are out by an order of magnitude or two OR there is a cover-up of holocaust proportions going on OR the bash-medicine brigade are telling porkies. You decide.

And Tigs2, next time you get some chest pain or your kid breaks an arm falling out of the apple-tree you'd best stay home and figure it out yourself!

:ok:

[tart1]

Tigs2 please check your PMs. :)

[slim_slag]

Row 991 (Y60-Y69) - 'Misadventures to patients during surgical and medical care' - (11 males and 21 females) is worth a look.
Yeh, but it's one thing to say 'I f***ed up in a death and complications meeting, and another thing to say it on a death certificate.

It's going to be more than 21 a year. There are surgeons out there who get all heroic and do things they shouldn't, but in general it's on people who are going to die quite soon anyway. So they don't kill the patient as such, but maybe they make the final weeks a bit more uncomfortable than they should be. But hey, that's what diamorph is for :)

One thing that has changed recently is that in the brave new NHS world surgeons are more likely to stab their colleagues in the back for personal advancement. So any underperforming surgeons are going to be turned in by their mates a lot more than in the past. In the old days it was not the done thing, the two guys who turned in the Bristol lot had to become GPs, lol.

But in general I'd not be too concerned about going under the surgeons knife myself, and besides it's the anaethetist you should really be worried about :)

[Mac the Knife]

Yeh, but it's one thing to say 'I f***ed up in a death and complications meeting, and another thing to say it on a death certificate.

Well, it would be the coroner rather than the surgeon/anaesthetist, but we all know that they're also part of the conspiracy.......

It's going to be more than 21 a year.

Quite possibly (don't men count too?), but if you extrapolate the 750,000 quoted from the USA to the UK population it comes out at 150,000/year rather than 32. With about 500,000 deaths per year in the UK that implies that just under 1/3 are due to medical negligence.

That works out at the equivalent of 300 fully-loaded 747s crashing fatally every year in the UK alone.

Since medical care probably saves less than 150,000/year in the UK then abolishing medicine will obviously save many lives.

:ok:

[gingernut]

Sorry about the 250k thing- wrong post.

Since medical care probably saves less than 150,000/year in the UK then abolishing medicine will obviously save many lives.

I do remember reading somewhere that the mortality rate in North America did drop dramatically, when there was a doctors strike, but I can't remember the fine details. Wasn't it Ivan Illich who reported this?

[slim_slag]

Illich was a bit of a radical, quite enjoyed reading his stuff. Think it might have been Israel but might have happened in the US too. Of course a reduced death rate could be explained by not having people at work to sign death certificates, and you ain't dead until a doctor says you are :)

Mac, I don't think there is a conspiracy and I also think the vast majority of surgeons are very well trained and very competent. I don't accept the high figures given, and apologies for my poor arithmentic. However a coronor can only act on the information given to him. If he does want to know more he will genrerally get somebody to call the houseman, and we all know the joke about housemen and mushrooms. More often than not the houseman's bumbling answers will be enough to keep the coronor happy. They missed Shipman for gods sake.

[Mac the Knife]

Aha, Gingernut is a deconstructionist, lekker! A disciple of Derrida, no less! A Medical Nemesis indeed! That explains a lot (like maintaining the futility of schooling, but we can come back to that later).

The late great Richard Asher (who first described Munchausen syndrome) is supposed to have arranged outpatient sessions where the patients never actually saw a doctor (or a nurse).

The old people drank hospital tea and had a good gossip about life, the neighbours & everything and then went home. Allegedly it was a great success.

Not really possible in today's Metropolis world of strict appointments and censorious receptionists, but that's progress for you...

A lot of old people (particularly in these days of the nuclear family) are very lonely and a visit to the doctor lends importance to the day. [These days of course, the Practice Nurse would soon send them packing so as NOT TO WASTE THE DOCTOR'S TIME and get the social workers to put their dog down and bundle them off to Supervised Housing]

Asher also remarks that the schoolboy says, "I scored two goals today!", while the old person says, "I had two funny turns today" - he was a very wise man.

AA Milne(Christopher Robin loathed the stories and refused to visit his dying father) wrote a sticky but apposite poem called "The Dormouse and the Doctor"

There once was a Dormouse who lived in a bed
Of delphiniums (blue) and geraniums (red),
And all the day long he'd a wonderful view
Of geraniums (red) and delphiniums (blue).

A Doctor came hurrying round, and he said:
"Tut-tut, I am sorry to find you in bed.
Just say 'Ninety-nine' while I look at your chest....
Don't you find that chrysanthemums answer the best?"

The Dormouse looked round at the view and replied
(When he'd said "Ninety-nine") that he'd tried and he'd tried,
And much the most answering things that he knew
Were geraniums (red) and delphiniums (blue).

The Doctor stood frowning and shaking his head,
And he took up his shiny silk hat as he said:
"What the patient requires is a change," and he went
To see some chrysanthemum people in Kent.

The Dormouse lay there, and he gazed at the view
Of geraniums (red) and delphiniums (blue),
And he knew there was nothing he wanted instead
Of delphiniums (blue) and geraniums (red).

The Doctor came back and, to show what he meant,
He had brought some chrysanthemum cuttings from Kent.
"Now these," he remarked, "give a much better view
Than geraniums (red) and delphiniums (blue)."

They took out their spades and they dug up the bed
Of delphiniums (blue) and geraniums (red),
And they planted chrysanthemums (yellow and white).
"And now," said the Doctor, "we'll soon have you right."

The Dormouse looked out, and he said with a sigh:
"I suppose all these people know better than I.
It was silly, perhaps, but I did like the view
Of geraniums (red) and delphiniums (blue)."

The Doctor came round and examined his chest,
And ordered him Nourishment, Tonics, and Rest.
"How very effective," he said, as he shook
The thermometer, "all these chrysanthemums look!"

The Dormouse turned over to shut out the sight
Of the endless chrysanthemums (yellow and white).
"How lovely," he thought, "to be back in a bed
Of delphiniums (blue) and geraniums (red.)"

The Doctor said, "Tut! It's another attack!"
And ordered him Milk and Massage-of-the-back,
And Freedom-from-worry and Drives-in-a-car,
And murmured, "How sweet your chrysanthemums are!"

The Dormouse lay there with his paws to his eyes,
And imagined himself such a pleasant surprise:
"I'll pretend the chrysanthemums turn to a bed
Of delphiniums (blue) and geraniums (red)!"

The Doctor next morning was rubbing his hands,
And saying, "There's nobody quite understands
These cases as I do! The cure has begun!
How fresh the chrysanthemums look in the sun!"

The Dormouse lay happy, his eyes were so tight
He could see no chrysanthemums, yellow or white.
And all that he felt at the back of his head
Were delphiniums (blue) and geraniums (red).

And that is the reason (Aunt Emily said)
If a Dormouse gets in a chrysanthemum bed,
You will find (so Aunt Emily says) that he lies
Fast asleep on his front with his paws to his eyes.

These days it would be a PC Social Worker rather than a doctor but the moral of the tale is even more appropriate.

BTW, Illich was nothing if not consistent. During his later years, he suffered from a cancerous growth on his face that, in accordance with his critique of professionalized medicine, he attempted, unsuccessfully, to treat with traditional methods. He regularly smoked opium to deal with the pain caused by this tumor. At an early stage, he consulted a doctor about having the tumor removed, but there was too great a chance of losing his ability to speak, he was told, so he lived with the tumor as best he could.

His confused Hubbardian rhetoric (deconstructionists speak a special metalanguage that is deliberately obscure) is no longer fashionable, but his legacy lives on in a functionally illiterate generation.

"The absence of the transcendental signified extends the domain and the play of signification infinitely."

Good stuff!

:ok:

[Mac the Knife]

However a coronor can only act on the information given to him. If he does want to know more he will genrerally get somebody to call the houseman, and we all know the joke about housemen and mushrooms. More often than not the houseman's bumbling answers will be enough to keep the coronor happy. They missed Shipman for gods sake.

Hmmm.... Post-mortems are not infrequent, and mandatory in the case of unexplained death or misadventure so the pathologist might have something to say. Coroners don't just accept what they're told, otherwise you might as well get one of the seccys to sign people off and as for "..the houseman's bumbling answers" keeping the coroner happy, forget it! Have you ever dealt with the coroners officer?

It may have changed since I practiced in the UK, but the coroners were actually quite strict - you couldn't write "old age" as a cause of death for some 98 year old, you had to write something acceptable - if you couldn't say what exactly your centenarian had died of, it was treated as an unexplained death and there had to be a PM.

"They missed Shipman for gods sake." - Yes, and because of the actions of one unbalanced man old people now have to die in pain (the hospices are full of AIDS and cancer patients) because GPs are now afraid to give then adequate analgesia in case they are accused of killing them.

Bravo!

[gingernut]

Fan.....blooming.......tastic.

Mac, don't you think that you could be wasting your talents operating on patients?

I think you'd have far more fun in primary care :)

PS what's a lekker?

[slim_slag]

Oh the stories I could tell.....

Take a look at this 2003 report (http://www.archive2.official-documents.co.uk/document/cm58/5831/5831.pdf) Mac. Death Certification and Investigation in England, Wales and Northern Ireland (Large PDF)

Page 16, para 4b. Critical defectsThe certification and coronial processes are separate from each other. The coroner has no information on or responsibility for deaths not reported to him. No public authority is tasked or resourced to see that the certification process is being properly carried out and that deaths which ought to be investigated by the coroner are reported for investigation. There is thus little to stop an unscrupulous doctor from “certifying his way out of trouble”.
So we have gone from an alarmist newspaper report on surgical errors to palliative care in the community. Think we definitely got caught :)

[Mac the Knife]

There is thus little to stop an unscrupulous doctor from “certifying his way out of trouble”.

Technically you are correct. If the widespread manslaughter (for that is what it is at best) of UK patients that you allege is going on then obviously it has to be stopped.

As I have shown, declaring a moratorium on all medical care would go some way towards diminishing this ongoing medical massacre. Gingernut has demonstrated that withdrawing medical "care" results in a dramatic fall in mortality rates so "the fact speaks for itself"!

Obviously we need to ensure that the current generation of morally defective practitioners are fully supervised at all times until they can be replaced by functionaries of greater integrity. I would suggest a lay panel (obviously it could not include other "doctors") to review all diagnoses and treatments before these are implemented. It would be best if surgeons were assigned a "minder", designated to be present whenever surgery was performed in order to supervise procedures and prevent concealment of their daily blunders.

In fact, as Illich so perceptively pointed out, it's all nonsense anyway and the sooner all us mad dogs are shot the better!

"I would say that deconstruction is affirmation rather than questioning, in a sense which is not positive: I would distinguish between the positive, or positions, and affirmations. I think that deconstruction is affirmative rather than questioning: this affirmation goes through some radical questioning, but it is not questioning in the field of analysis." Jacques Derrida

PS: You may also care to investigate BALPA and the AAIB. Worldwide, an astonishing number of passengers simply fail to reach their destinations. This horrifying fact has been hushed up for years and families hunting for their loved ones simply meet a blank wall of denial. I have conclusive proof that some years ago, BALPA reached an agreement with extraterrestrials to provide human subjects for investigation and slavery. They're all in it. For further details send a stamped addressed envelope to Mrs V. Barkhuisen, P.O. Box 56, Groot Marico, RSA.

[rhovsquared]

MacTheKnife you obviously care what you are doing, take great pride in your work and think the patients deserve the best care you can deliver:ok: I don't think you care if the whole RCPS where watching you, but it will never happen in general, the whole damn medical/legal system needs a total revamping the incentives are low and the risks high; I wish more 'docs' where like pilots;) If only folks paid attention and cared more about what they where doing. I watched some amazing work done on folks by surgeons regardless of their incomes or whatever!!!



TurboJets Only:}
rhov:)

[gingernut]

Just thought for a moment Mac was coming round to my way of thinking.

Gingernut has demonstrated that withdrawing medical "care" results in a dramatic fall in mortality rates so "the fact speaks for itself"!

Well maybe Ivan has got a point.

Come on we all know the script, medicine isn't actually that good at stopping people dying, is it?

Some of it works, some of it we don't know if it works, and some of it is positively dangerous.

Luckily, we do seem to be focussing more on the former, rather than the latter.

[Mac the Knife]

...maybe Ivan has got a point

There is certainly a good point to be made that there is unnecessary medication (and to a lesser extent surgery) going on. Unfortunately Illich didn't make it. Illich's belief (or what can be made out of it, for he is awfully woolly) is that the whole of Western though (not just medicine) is wrong. For all that, I think it is useful to read.

The point that Illich makes (which I have emphasised at length elsewhere in these forums) that most of the advances in public health have been by improvements in sanitation, clean air, clean water and housing is not a new one. The Victorians were well aware of it, which is why, among other things, Bazalgette was taxed with building the London sewer system.

"Illich sees three levels of iatrogenesis. Clinical iatrogenesis is the injury done to patients by ineffective, toxic, and unsafe treatments."

That this can occur is indisputable. That it occurs on the scale that Illich and Gingernut maintain is poorly supported. That doctors wholesale are indifferent to such harm is even less supported. Incidentally, many "alternative" treatments are either ineffective (e.g. Zuma's garlic, beetroot and potato for HIV/AIDs) or toxic and unsafe (e.g. Virodene and Laetrile).

"Social iatrogenesis results from the medicalisation of life. More and more of life’s problems are seen as amenable to medical intervention."

This I agree with. Simple anxiety and depression (I'm not talking about major depressive illnesses) are no longer seen as normal variations in the spectrum of experience but bad things to be medicated away. Medicine is a victim of it's own success here - drugs justifiably used for major problems are extended to minor ones, with little success and significant problems. Misguided attempts by a nanny State to legislate away "the slings and arrows of outrageous fortune" have led to a culture of entitlement and undermined self-determination and personal responsibility.

But this is part of a greater problem. Western society continues to evolve at a vertiginous pace and pressures on people come on faster and are greater than ever before. The near extinction of the extended family means that young persons rarely have an Uncle Bob or a Gran within easy reach to turn to for consolation or advice. Women are under pressure to perform not only as mothers but as businesspersons in their own right. The gimme-gimme ethic that measures success purely in terms of bling and money is profoundly selfish and doesn't seem to lead to much happiness.

"Worse than all of this for Illich is cultural iatrogenesis, the destruction of traditional ways of dealing with and making sense of death, pain, and sickness. "

This is true too, but again it is a function of societal change rather than medical malevolence. The old-style wake may well have allowed a group to integrate a death more easily but would be hard to revive since the old extended groupings are mostly gone. The sin-eaters of Wales (and elsewhere) would hardly be acceptable now. Funerals are no longer the formal affairs that they used to be (burial is expensive) - Grandpa's ashes sit on the mantelpiece for a while until they're thrown out in the next move.

"The overwhelming majority of modern diagnostic and therapeutic interventions which demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members."

This is mostly nonsense unfortunately. Because of the stringent safety rules, the medicine that keeps Uncle Jim's blood pressure from spraying out of his ears cost a fortune to develop and the company has to get their money back somehow. And the artificial hip that allows Auntie Dot to walk to the shops again could hardly be installed by the family.

He does make some very silly statements - "Depression, infection, disability, dysfunction, and other specific iatrogenic diseases now cause more suffering than all accidents from traffic or industry." None of these are generally or even specifically iatrogenic, indeed, apart from infection all are functions of society rather than medicine (with a few tiny exceptions).

His belief that pain somehow empowers or enriches people's lives is a very old idea. Many many writers and philosophers have explored this alley. The Catholic Church (and Illich was a Catholic priest before he became a critic of industrial society) tells us to "offer up our pain to the Holy Souls". Solzhenitsyn in particular, in the last part of "The Gulag Archipelago" embraces this belief. Personally I believe that a modicum of suffering (in the larger sense) is needed for us to be wholly human, but that severe or unrelieved suffering impoverishes rather than enriching. Only sadists think it is good for you.

..medicine isn't actually that good at stopping people dying, is it?

Ultimately no - for life's a dying disease. In the interim - well, I wonder what planet you're living on! That is really a pretty silly statement if you think about it for a bit.

I think that the real problem is that young medics and paramedics are not taught the history of medicine, know very little history generally and have little or no experience of what societies are like without any effective medicine. Being at two removes from clinical medicine, medical administrators and medical theorists (particularly those with a political axe to grind) are particularly prone to these errors.

A little story. Once upon a time in 1890 (or 1940) a child was feverish and coughing. Someone went to get the GP and he eventually came round in his gig or his motor and was ushered into the normally unused parlour. The child was produced and he gravely examined the child, percussing and auscultating the chest. A few nostrums were prescribed (there was nothing else) and advice about diet and warmth given before he left. The next day he came to see the child again. High fever, tachycardia and tachpnea - a real pneumonia. That evening no improvement. The next morning worse, the fever is spiking at 104F - the doctors shakes his head, "It's touch and go now I'm afraid Mr Brown, I'll be back later". That evening the child is delirious, nothing will persuade her to drink. "I think I'd better stay for a while Mrs Brown", and the doctor, wrapped in his old ulster, settles down by the cot with a teaspoon and some cold sweet tea. At 3am the fever is 105F, the child is burning up, the crisis. At 4am the child is suddenly soaked with sweat and the temperature is 99F - is this the lysis or just another hope? At 6am the temperature is still down and the child is awake and asking for her mum. "I think she'll be alright now Mrs Brown", he says and sets off for his morning surgery.

Fast forward to 2006. Another child is feverish and coughing. A phone call is made and an appointment booked. The child is seen by the practice nurse who diagnoses a lower respiratory tract infection. She intercoms the doctor, "Little Lucy Brown has got a nasty chest infection. I think some Augmentin will sort her out", "Sure, carry on". The family exit, clutching their bottle of Augmentin. By that evening the temperature is down and the child is feeling better. Next morning she is apyrexial and there's a check call from the practice, "Oh good, I'm so glad. I'd keep her off school for a few days though. Pop down to the practice and I'll leave a chit at reception".

Which doctor gets the most satisfaction? Which doctor gets the love and respect?

This is a serious problem for medicine today. So many potentially serious illnesses have become trivialised by therapeutic advances that the role of the doctor has become almost marginal for many of them. The real heroes (unsung most of the time - who today remembers Banting and Best) are the pharmacologists and researchers who created the medicines. The antiheroes are of course the drug companies, especially when things go wrong..

Some of it works, some of it we don't know if it works, and some of it is positively dangerous.

Antibiotics work and we know how and why
Beta-blockers work and we know how and why
Analgesics work and we know how and why for most of 'em
Proton pump inhibitors work and we know how and why
Antihistamines work and we know how and why
Steroids work and we know how and why
Antihypertensives work and we know how and why
Chemotherapy often works (ask the guys in the Hodgkins thread) and we know how
NSAIDS work and we know how and why
Anaesthetics work, but we still aren't quite sure how! Forgo them if you're a purist.
Antiarrhymics work and we mostly know how
Antiepileptics work (mostly) and we know some of how

ALL of them are dangerous if misused - are you insisting that medicines have an infinite therapeutic index? That isn't realistic. I'm reminded of my great-grandmother who'd never been to the movies in her life - when asked why, she said, "I'll go when they've got it right".

I think it's good to question and I teach my students to doubt and investigate. I myself question many of the wonder procedures that emerge from time to time as well as wonder treatments both conventional and alternative.

To be a doctor and a surgeon is for me the most thrilling and exciting thing in the world. In exchange for this one assumes grave duties and arduous responsibilities. To be worthy of the trust that patients place in one demands self-discipline, continued study and moral rigour.

I think it is terribly sad that a young person like Gingernut, in an administrative position, feels such scepticism about the motives of his medical colleagues and so many doubts about the usefulness of medicine at all.

Perhaps a little real primary medicine and surgery out in the bush would renew his faith.

[gingernut]

Thanks Mac, I'm sorry, but I haven't got the expert knowledge of Illich, as you have.:eek: And I must admit. I'm more interested in the future than history, which, I can't always asess the accuracy of.

There is certainly a good point to be made that there is unnecessary medication (and to a lesser extent surgery) going on.

I'm not too sure about this statement, I'm a keen advocate of evidence based medicine (and surgery), but still I see victims of procedures which could have been prevented, maybe more in the surgical world than the medical one. (Tonsillectomies are a good starting point.)

Clinical iatrogenesis is the injury done to patients by ineffective, toxic, and unsafe treatments." couldn't agree more, but, thankfully, us, (health care professionals), are becoming more adept at sifting out the wheat from the chaff.


Social iatrogenesis results from the medicalisation of life. More and more of life’s problems are seen as amenable to medical intervention." although it makes every nerve and bone in my body quiver, I must confess Mac, I agree. Although, I've just had a rather splendid bottle of Chablais, and a very good lamb vindaloo, is it up to you to deny me a large dose of a Proton Pump Inhibitor to ease my morning symptoms?

Incidentally, many "alternative" treatments are either ineffective (e.g. Zuma's garlic, beetroot and potato for HIV/AIDs) or toxic and unsafe (e.g. Virodene and Laetrile).

Dead right- we as "professionals" dish out enough unevidenced snake water, why replace it with even more rubbish?

Simple anxiety and depression (I'm not talking about major depressive illnesses) are no longer seen as normal variations in the spectrum of experience but bad things to be medicated away.

Oh dear, agreeing again, is it time to get back to the speed camera thread on jet blast ? Yes, unfortunately primary care clinicians have probably over medicated their stressed and anxious population with various drugs (SSRI's in the main). Can you help me differentiate between the two? Can you chaps in secondary care tell the difference- if so, let me know, I'll spread the secret!We've probably not had the guts , previously, to suggest other (credible) measures such as pumping up their exercise regime :ok: . Our quango's (NSF's/NICE) have provided some back-up.

Personally I believe that a modicum of suffering (in the larger sense) is needed for us to be wholly human, but that severe or unrelieved suffering impoverishes rather than enriching. Only sadists think it is good for you.
well lets hope that ALL our attitudes, values and beliefs are reflected by this statement.

Once upon a time in 1890 (or 1940) a child was feverish and coughing. Someone went to get the GP and he eventually came round in his gig or his motor and was ushered into the normally unused parlour. The child was produced and he gravely examined the child, percussing and auscultating the chest. A few nostrums were prescribed (there was nothing else) and advice about diet and warmth given before he left. The next day he came to see the child again. High fever, tachycardia and tachpnea - a real pneumonia. That evening no improvement. The next morning worse, the fever is spiking at 104F - the doctors shakes his head, "It's touch and go now I'm afraid Mr Brown, I'll be back later". That evening the child is delirious, nothing will persuade her to drink. "I think I'd better stay for a while Mrs Brown", and the doctor, wrapped in his old ulster, settles down by the cot with a teaspoon and some cold sweet tea. At 3am the fever is 105F, the child is burning up, the crisis. At 4am the child is suddenly soaked with sweat and the temperature is 99F - is this the lysis or just another hope? At 6am the temperature is still down and the child is awake and asking for her mum. "I think she'll be alright now Mrs Brown", he says and sets off for his morning surgery.

it's a great story, but did the doctor make a difference, and was that the best use of his time ?

well, I wonder what planet you're living on! Earth, more specifically somewhere between Liverpool&Manchester, and you're more than welcome anytime:-)


Which doctor gets the most satisfaction? Which doctor gets the love and respect?
Is it all about respect for the doctor? Shouldn't we be respecting our patients? Power to the elbow of the doc who stayed up all night, but is that the best use of his/her time?

Antibiotics work and we know how and why
Beta-blockers work and we know how and why
Analgesics work and we know how and why for most of 'em
Proton pump inhibitors work and we know how and why
Antihistamines work and we know how and why
Steroids work and we know how and why
Antihypertensives work and we know how and why
Chemotherapy often works (ask the guys in the Hodgkins thread) and we know how
NSAIDS work and we know how and why
Anaesthetics work, but we still aren't quite sure how! Forgo them if you're a purist.
Antiarrhymics work and we mostly know how
Antiepileptics work (mostly) and we know some of how

Well Mac, we could deconstruct these arguments all night, (antibiotics and the rise of resistant strains, the latest guidelines on not starting hypertensive patients on beta blockers, how some compound analgesics are worse than useless, PPI's and the delay in the diagnosis of gastric cancer (not sure about this one !!), Anihistamines and rebound effect, Steroids- have saved many lives, but why is the useage in France five times that of in th UK?, Chemotherapy- again ,why the different regimes around the world?- surely joined up thinking between radiotherapists/surgeons/physicians/nurses etc would make more of a difference? NSAID's - are we killing more than curing?

Anaesthetics? can only speak anecdotally- wonderfull stuff- and I must apologise to the rather buxom dental nurse!l

Its a nice list of things you think make a difference, but I note that you haven't included such greats as tar inhallations, cox II inhibitors, HRT and that wonder of ante-natal morning sickness, thallidomide.

Don't be terirbly sad, I'm making a difference in my own bit of bush;)

To be a doctor and a surgeon is for me the most thrilling and exciting thing in the world. In exchange for this one assumes grave duties and arduous responsibilities. To be worthy of the trust that patients place in one demands self-discipline, continued study and moral rigour.

We all feel the same:-) but it's not the preserve of doctors and surgeons.

Take care. :-)

[Mac the Knife]

"..did the doctor make a difference, and was that the best use of his time ?"

You don't know anything about, or understand, the bond of healing that exists between doctor and patient. To say that the doctor might as well have gone home (and done what?) bespeaks a profound ignorance of the spiritual and supportive aspects of healing. A fundamental omission.

"Is it all about respect for the doctor? Shouldn't we be respecting our patients? Power to the elbow of the doc who stayed up all night, but is that the best use of his/her time?"

I sort of thought you'd hit on respect. It's a very unfashionable word. No-one is supposed to respect anyone [except gangstas who will cap you if you disrespect 'em]. You make the serious mistake of believing that respect equals servility and that respect only cuts one way. The fact that you immediately leap to the conclusion that the doctor did not respect his patient and family bespeaks a major prejudice. I suggest that your inbuilt belief that doctors do not and will not respect their patients unless compelled to is fantastic nonsense.

"..we could deconstruct these arguments all night.."

I said, "ALL of them are dangerous if misused - are you insisting that medicines have an infinite therapeutic index? That isn't realistic.". Must I repeat myself?

Are you suggesting that all these drugs should be withdrawn. That doesn't seem very sensible.

Thalidomide was marketed from 1957 to 1961, i.e. over 45 years ago, when trials for drug safety were far less rigorous. It's a bit like referring to the early Comet accidents today. I think that bringing it up in a discussion of medicine today is the equivalent of Godwin's Law/Rule about Nazis.

"..it's not the preserve of doctors and surgeons."

Their responsibilities and duties are unique, so yes, it is. The Regional Ops. manager for an airline is not a pilot and neither are the cabin crew.

Mac :ok:

PS: Thalidomide was found to have other, potentially beneficial effects in the mid 60's. It is currently used for treatment of leprosy, multiple myeloma, Kaposi's sarcoma and several other conditions.

[gingernut]

I suggest that your inbuilt belief that doctors do not and will not respect their patients unless compelled to is fantastic nonsense.

You don't know anything about, or understand, the bond of healing that exists between doctor and patient.

well, I wonder what planet you're living on!

sad that a young person like Gingernut, in an administrative position,

All assumptions I'm afraid Mac.