St. Patrick

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At some time St. Patrick may have walked down from Slemish, stood at the edge of Black Mountain, and he too may have gazed over the Lagan Valley. Beauty and tragedy. I live on the banks of the Lagan where the Vikings and Irish battled, my town-land Aughnafosker – ‘fields of slaughter’, a remnant of the long lost lives. I grew up in 1970s Belfast, a place of more lost lives.

More has been written about St. Patrick, than he wrote. Claimed by more people than he ever knew. A slave, taken captive again and again by religious, political and cultural groups to support their ends, many well meaning, some not. I hear there was a parade in New York! The organisers finally invited the PSNI to parade alongside An Garda Síochána but were then pressured to divide these Irish men and women, who wanted to parade in celebration of their patron saint.

People, first divided, it then becomes divisive, fellow humans driven apart, excluded, expelled, rejected, despised, to a stage where they can ultimately be de-humanised. In Belfast this weekend it was great to hear the steps taken to reverse this and to include more sections of our community, to try to include. Yet the job is not finished.

We need open arms and a generous spirit toward one another. 

We still need to ask: Who are we still excluding? 

Maybe next year we can have a St. Patrick’s Day, even more, for everyone.

– Jonnie

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“Stand aside Doctor, I’m a Politician / Journalist / etc..”

Healthcare decisions need to be based ‘primarily’, on sound scientific and clinical evidence. Unfortunately, this evidence is all to often swept aside.

“It’s often difficult to make someone understand something when their income depends on their not understanding it.” – Mark Fendrick

If we don’t have ‘evidence based medicine’, you may recognise the alternatives. BMJ

  • Eminence based – experience, is worth any amount of evidence. “making the same mistakes with increasing confidence over an impressive number of years.”
  • Vehemence based – speak loudly and with authority.
  • Eloquence based – the carnation, silk tie, ‘silver’ tongue and verbal eloquence.
  • Providence based – when in doubt do nothing. If the practitioner has no idea what to do, the decision may be best left in the hands of the Almighty.
  • Nervousness based – defensive approach ‘do everything to avoid litigation and hope it works’

Professor N Waugh (2006) added:

  • Propaganda based – the drug company says.
  • Pressure based – people want…..,

And then:

  • Charity based – The pressure / lobby / patient group (who need cash to stay afloat) say!
  • Nolan based“I’m gonna to phone Stephen Nolan, if you don’t…”

Clinical and Cost effectiveness 

The requirement for proof of clinical effectiveness ‘should’ be a no brainer. The only difficulty should be when having to make decisions based on the cost effectiveness of a range of clinically effective interventions.

Is it, a disgrace that millions are wasted on Clinically and Cost ‘ineffective’ interventions? Then, there’s no money to ensure interventions which do work, are received by all those who would benefit!

Why? Because of the alternatives to Evidence Based Medicine?

Dr Jonnie McCrea

What should Healthcare learn from Farmers?

I have a dear friend, who has been farming in Ireland since he was a boy in the 1930’s. He was one of the first in the country to have a tractor and when NASA was going to land on the moon, they joked he was behind it as he was wanting to buy land for farming, on the moon.

Some years ago I was teaching ‘evidence based practice’ to healthcare professionals and on one of my holidays was up visiting him. He wanted to understand what my job was. He was horrified to learn that so much within medicine was based on received wisdom or quite simply tradition and that there was often such reluctance, by health professionals, to change their clinical practice. His comment was:

“Farming is always changing, it has to”

What really got him going was the lack of evidence for the clinical effectiveness and cost effectiveness of what healthcare professionals were doing. The analogy was quite clear:

“If someone came to the farm trying to sell me something and they had no proof that it worked, I’d run them of the farm” 

Yet, many of our health professions continue to attend courses, learn how to do treatments, spend time doing it, and then years later some ‘heretic’ finally does some research which shows it was all nothing more than smoke and mirrors. Do they blush, resign, demand their money back from those who sold them these courses? No! They just quietly move on, like dumb beasts, to the next fad of pseudo-science. Over 130 years ago the charge was made against a certain healthcare profession that:

“it is content to spin theories before the imagination of its believers, and to amuse the patient while the disease runs its own course” – BMJ 1879 October 4th, p 579.

Little has changed in the attitude of many health care professionals in over 100 years. His opinion of doctors and “the whole lot of them”, didn’t improve much:

“I knew they were no good. I’d be better going to the vet!”

Year after year the scientists, those who know what they are talking about, say:

Do the things we have proof for. Stop doing the things for which we have no evidence of clinical or cost effectiveness.

But, nobody listens. They’re all too busy!! 

So, what would a farmer do? 

  • Keep up to date with relevant research, attend scientific meetings.
  • Continually evaluate current practice.
  • Discard ineffective or inefficient practices immediately.
  • Have ‘ruthless’ scientific rigour and integrity

I know one farmer who did this!

Dr Jonnie McCrea

With thanks to my dear friend, who I miss chatting to, so very much!

Health fraud – More integrity in a tin of Baked Beans?

For many decades the profile of ‘Evidence Based Practice’ has been raised in the Medical, Nursing and Allied Health Professions. Now, directives to use ‘evidence based practice’ are more prevalent in professional guidance documents and clinical guidelines. There have also been greater constraints imposed on the advertising, for example, of health and beauty products. Yet ‘Health fraud’ remains an issue and we should always be cautious.

More integrity in a tin of Baked Beans

“You buy a tin of beans and it says ‘Baked Beans’ on the label. What do you expect to find when you open it?”

Yet, when purchasing health products we frequently have to place our trust in the sales person or the healthcare professional.

“But, will it do what it says on the tin?”

U.S. Food and Drug Admnistration

For many years now the U.S. Food and Drug Administration has hosted a web page specifically dealing with ‘Health Fraud’. Some of the ‘Tip-offs‘ they suggest to help you identify a Health Fraud are:

  • One Product Does It All
  • Personal Testimonials
  • Quick Fixes
  • ‘Natural’
  • Time-Tested or New-Found Treatment
  • Paranoid Accusations
  • Meaningless Medical Jargon

Professional regulation

The professional and regulatory bodies of the health professions, such as the British Medical Association (BMA) and General Medical Council (GMC) for doctors, have the role of helping to ensure the highest standards of their members. Indeed this regulation helps to give us the high level of confidence we have in our health care professionals.

We are all aware of cases over the years where such bodies have had to investigate malpractice. In 2010, as reported in the ‘TheTelegraph‘, the GMC struck off Dr Robert Trossel for providing unproven Stem Cell and other treatments to patients with Multiple Sclerosis. The chairman of the GMC fitness to practise panel stated:

”You have exploited vulnerable patients and their families… You have given false hope and made unsubstantiated and exaggerated claims to patients suffering from degenerative and devastating illnesses… Your conduct has unquestionably done lasting harm, if not physically, then mentally and financially, to these patients and also to their families and supporters.”

So what can the lay person do?

Faced with ill health or serious disease we can be in a vulnerable and desperate position. We should challenge those selling us products, bearing in mind the guidance of the US FDA, discuss concerns with local trading standards, be aware of the bodies which regulate Healthcare Professionals, discuss the evidence supporting treatments with your GP and look up reputable websites such as ‘NHS Evidence‘ and ‘The Cochrane Library‘.

And finally, learn from the cases where things have gone wrong.

Dr Jonnie McCrea

“Son, please don’t tell them I’ve fallen”

As a community based Physiotherapist for many years, I had the privilege of seeing hundreds of elderly folk in their own homes or sheltered accommodation. With advancing years, came increasing frailty, and then, all of a sudden the normal physical tasks of getting around their homes became a physical struggle. Sometimes this was precipitated by illness or the worsening of a medical condition.

Then the first fall, and the next! I have seen horror and grief in the eyes of so many who have suffered a fall. They feel they are the only one. They are ashamed of themselves. They fear that living independently in ‘their own wee home’ is coming to an end.

Folk have looked at me, taken me by the arm, and said, “Son, please don’t tell them I’ve fallen”. They don’t want people to worry, they fear being put in a home, and probably many other reasons. Yet, this is not a hopeless situation!

The research –

A Royal College of Physicians report, Falling standards, broken promises, notes that: “only 19% of relevant non-hip fracture patients… participated in any form of exercise programme, which represents a major wasted opportunity in terms of ‘respond to a first fracture prevent the second”… “Less than one in twenty patients, even in the non-hip fracture group, commenced an evidence-based therapeutic exercise programme of more than 12 week duration.”

A Cochrane Review which looked at 111 trials with 55,303 participants Interventions for preventing falls in older people living in the community concluded that “…exercise interventions reduce risk and rate of falls”. Indeed, individually prescribed multiple-component home-based exercise was a most effective intervention for both reducing the rate of falls and risk of falling (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97). These studies showed the rate of falls decreased by about 35%.

Who can reduce their rate of falls?

Research has indicated that if you: 1) Live independently in the community, 2) Fall frequently or feel at risk, 3) Are aged 65 years or over, or 4) Find daily home tasks are pushing you to the limits of your stability then, you are likely to benefit!

Dr Jonnie McCrea