Posts Tagged ‘Medical blog’
I’m at at the JFK centre in Washington this week to attend a meeting with big ambitions for healthcare. TEDMED is a meeting which celebrates (not a word often used in the context of healthcare meetings, trust me) the imagination, innovation and inspiration that occurs at the intersection of science, technology, government, business, art and education.
Yesterdays’ opening session showcased no less than 4 different performances from the arts community who showed us things (through dance, song writing, wordplay, humour and extraordinary feats of imagination) that we would have never thought possible. Although I have always had an awareness that arts had something to offer healthcare, I had never before this considered that the Arts might have the potential to help doctors and health care providers think differently – to inspire us to take big imaginative leaps of faith or to inspire us to think about things which we thought weren’t possible. The idea that a cardiology, oncology or rheumatology meeting would be opened by a group of acrobats on skateboards might seem ridiculous to those not attending TEDMED but I’m beginning to see its charm.
I had quietly assumed that the opening sessions might place an emphasis on some new great feat of technology. Two of the opening presentations made strong arguments on how the most important elements of change that need to take place in healthcare have nothing to do with technology at all. Bryan Stevenson, a public interest lawyer spoke about harnessing the power of identity in shaping peoples’ expectations of themselves, and how recognising our essential humanity should be at the core of any intervention. Rebecca Onie social entrepreneur and co-founder of Health Leads reminded us how the most important interventions in health don’t even need to involve any clinical input. Those of us caught up in the frenzy of the untold promises of the technological revolution in medicine need to take stock.
‘In attempting to follow the narrative of man’s ambitious progress towards a state of technological and political perfection, we have sacrificed opportunities to remind ourselves of the quieter truths which we know about in theory and forget to live by in practice’ – Alain de Boton
When I was training as rheumatologist in the 1990′s, it would have been fairly common for a rheumatologist to offer reassurance to a newly diagnosed patient with Osteoarthritis (OA) by telling them how lucky they were not to have rheumatoid arthritis. At that time rheumatologists weren’t terribly good at effectively treating Rheumatoid arthritis (RA) or Osteoarthritis (OA) but as RA tended to get worse much more quickly, it was a consolation of sorts.
Hand osteoarthritis
Modern treatments for RA are now very effective at reducing symptoms of the disease and are also capable of dramatically slowing its progression. The treatments are so good in fact, that it has made us all realize how poor we still are at treating OA. It is ironic therefore, that I find myself 20 years later, contemplating that some of my OA patients might fair better if they had RA. If recent media reports are to be believed, help may be on the way for OA sufferers in the form of a nutritional supplement. Sound familiar? Read on….
Osteoarthritis
OA is by far the commonest form of arthritis. It is thought to be a largely degenerative disease but its cause is unknown. The disease can effect any joint but commonly affects the hands where is affects 50% of the population over the age of 60 years. Although it tends to be a more slowly progressive condition than untreated RA, severe OA can be every bit as disabling and destructive as bad rheumatoid arthritis. Originally thought to be primarily a disorder of cartilage (cartilage becomes damaged all OA patients), we now know that this may not be the whole story. There’s some evidence from MRI scans, that one of the first structures to become affected in OA is the ligaments around joints and theres also some evidence of problems occurring the bone and in the lining cells (synovium) of the joint.
Treatments for OA
- Just when you thought it was safe to back in the water
Chondroitin Sulphate – New trial published
A recent publication in the Sept 2011 edition of the Arthritis and Rheumatism journal has confirmed that Chondroitin Sulphate, another fish derived dietary supplement is safe and is more effective than placebo treatment in the treatment of some symptoms of osteoarthritis of the hand. The study suggests that patients who have hand OA and who take 800mg of pharmaceutical grade Chondroitin Sulphate every day for 3 months, have pain scores which are significantly better than those who have taken placebo tablets. Pain scores in the treatment group improved by an average of 8.8 (on a scale ranging from 0 to 100) more than in those those taking placebo treated patients. Despite the apparent small improvement in pain scores, the requirement for additional pain relief in the form of paracetamol / acetaminophen was unchanged in the Chondroitin sulphate taking patients.
There was also a statistically significant improvement in hand function (patients could do more with their hands) amounting to 3 points on a 30 point scale and they loosened out more quickly in the morning (by about 4 mins) compared to those on placebo. These benefits only occurred in those who have been taking the drug for 3 months. The study didn’t report what happened patients after the 6 month protocol ended so its not clear whether any of the benefit was sustained.
Does is work?
The reported improvement in arthritis pain in the Chondroitin Sulphate treated patients was small. Whatever the small improvements in these outcome measures, there is no evidence from this study that chondroitin sulphate had any effect on the metabolism of cartilage.
Low expectations
It is a measure of the low expectations that we have for the treatment of OA that a study like this would have been published at all. Most studies of the effectiveness of a new treatment in RA, for example, would demand an improvement of at least 20% in a number of outcome measures and most rheumatologists wouldn’t be happy with response rates of at least 50 – 70% or complete remission. We have along way to go before we achieve anything near this OA. OA is likely to derive from disease processes in a number of structures within joints, and perhaps its naiive to expect that a drug directed at one component like cartilage might have an effect on all of the others.
Better than nothing?
Although Chondroitin sulphate may be a little better than taking nothing at all, I would be surprised if many rheumatologists will be routinely recommending it to their OA patients. It is unlikely that any scepticism within in the rheumatology community will prevent the inevitable marketing push from nutriceutical companies promoting this product on the basis of these largely disappointing results.
Fortunately there are many options available that make this disease more bearable for people but the search for a treatment to halt its progress continues.
In the last year I’ve taken to wearing theatre scrubs at work instead of my usual suit, shirt and tie attire. This was initially because I started cycling to work and it was simply too much hassle to put clean shirts in my backpack or drop clean clothes into the office over the weekend. After a few days wearing them in my clinic, I haven’t gone back.
As scrubs are usually the preserve of better paid medical specialists such as surgeons, anaesthetists and cardiologists, people tend to look twice when they a rheumatologist wearing them. Once you get over the funny looks and questions, wearing them has had some unexpected bonuses which I’d like to share.
1. Comfort
Scrubs are comfortable to wear, cool and make me feel much more relaxed than a stuffy shirt and tie.
2. Hygiene
As a rheumatologist, I perform minor surgical procedures for most of my working day as part of my clinic (such as joint injections). These require a degree of sterility. Scrubs are almost certainly more hygienic than my suit and most certainly more hygienic than my favorite tie which I bought 4 years ago (it looks and smells fine but has never been to the dry cleaners – and it has certainly never been inside an autoclave).
3. Less Ironing
No more ironing shirts for work as my scrubs are processed in the hospital. Although I would normally do all of my ironing myself, my wife is delighted too. For me you understand.
4. Far less money spent on suits and ties
Prior to this I would have bought a couple of suits each year, a few ties and work shirts. As I don’t wear suits and ties outside work, I haven’t bought any this year at all.
5. Looking important.
Unfortunately rheumatologists are not always taken as seriously as we should be in the pecking order of hospital medical hierarchy. Whilst in scrubs, medical and surgical colleagues and nursing staff seem to treat me more deferentially because they mistake me for a surgeon or interventional cardiologist. Although I’m still waiting for my income to increase accordingly my new outfit (which makes me look like I mean business and on my way to something more pressing than a rheumatology clinic) I find it easier to jump the queue in the canteen.
6. Patients don’t mind
Patients don’t seem to care either way. As long as you treat them well and come up with the goods most don’t mind how you’re dressed (up to a point). I explain to them it’s for all of the reasons above (but not necessarily the reasons listed below).
7. Early de-stressing from the work environment
Putting the scrubs on in the morning and taking them off in the evening allows you to treat them as a kind of theatrical costume. I ‘get into character’ by putting them on and then ‘get out of character’ by taking them off. By removing your work clothes before leaving work allows you to divest yourself of any unpleasant work associations before you leave the building and facilitates an early start to your out of hours relaxation time. I have also found that being dressed in my shorts T-shirt and cycle helmet is a deterrent to colleagues thinking of asking me to do that last minute consult on my way home for the evening. It’s harder to say no in a suit.
The Bottom line
For those physicians amongst you thinking about doing it, just go for it. You’ll feel more relaxed, do less ironing, spend less time shopping for suits and you might even get home sooner. If changing what you wear to work is the most adventurous thing you do this year, you should probably get out more.
Dr. Ronan Kavanagh is a Rheumatologist who works in private practice at Western Rheumatology in Galway, Ireland. He also runs The Musicians’ Clinic in Galway.
Offices are based in Suite 19, Galway Clinic, Doughiska, Galway Tel +353 91 720095. Email info@wrh.ie. He’s on twitter @RonanTKavanagh
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