D. Gorman

Cerebral Protection by Lidocaine During Cardiac Operations: A Follow-Up Study

BACKGROUND A previous study showed less postoperative neurocognitive impairment in open-chamber cardiac surgery patients given lidocaine for 48 hours after induction of anesthesia. In the present study, we aimed to test the benefit of a 12-hour infusion in a broader group of cardiac surgery patients, including those undergoing coronary artery bypass graft surgery. METHODS This was a randomized, double-blind, intention-to-treat trial. Before cardiac surgery, 158 patients completed 7 neurocognitive tests and a self-rating scale for memory. They received a 12-hour infusion of either lidocaine in a standard antiarrhythmic dose or placebo, beginning at induction of anesthesia. The cognitive tests and memory scale were repeated at postoperative weeks 10 and 25. A deficit in any cognitive test was defined as a decline in score by more than or equal to the preoperative group standard deviation. RESULTS All tests were completed by 118 and 107 patients at 10 and 25 weeks, respectively. The proportions of patients in the lidocaine and placebo groups exhibiting a deficit in one or more tests were as follows: 45.8% versus 40.7% at 10 weeks, and 35.2% versus 37.7% at 25 weeks (not significant). There were no significant differences between groups in self-ratings of memory function or length of intensive care unit or hospital stay. CONCLUSIONS Lidocaine was not neuroprotective. The result of the previous trial may represent a type 1 error. Alternatively, benefit may be more likely for open-chamber surgery patients exposed to larger numbers of emboli or with a longer lidocaine infusion.

Prolonged exposure to one percent carbon monoxide causes a leucoencephalopathy in un-anaesthetised sheep

A total of 15 Levine-prepared adult un-anaesthetised sheep were exposed to 1% carbon monoxide (CO) in air for between 45 and 150 min. This exposure caused a reversible increase in blood carboxyhaemoglobin concentration and heart rate, and a similarly reversible decrease in electroencephalographic frequency and level of consciousness. sheep were either normotensive or slightly hypertensive. Sheep brains were subsequently examined for histopathological changes at either 5 or 14 days post- exposure. No dead neurons or apoptotic cells were seen, but most sheep given a prolonged exposure to CO had some axonal damage and associated gliosis. This damage was concentrated about necrotic micro-foci in the peri-ventricular white matter. These results suggest that a leucoencephalopathy is a primary consequence of acute and sub-acute CO toxicity.

Purchasing better, innovative and integrated health services.

About 50years ago, Paul McCartney and John Lennon complained that ‘money can’t buy me love’; based on the Commonwealth Fund’s 2014 review, it would appear that money cannot buy a credible health system either. Although comfort might be derived for the Fund’s top ranked health systems (i.e. the UK, followed by Switzerland and Sweden), using the Institute for Healthcare Improvement’s Triple Aim as a yardstick (i.e. better individual and population health, and reduced health costs), none of the Organisation for Economic Co-operation and Development (OECD) countries would be considered successful. The top ranked UK National Health Service (NHS) is already financially distressed, reform is underway but is likely too little and too late and further innovation is considered urgent. Key processes of reform, such as a scheme to improve the quality of primary healthcare, and attempts to shift healthcare to community settings for older people have failed. If that is the state of the top ranker, little wonder the concern then that exists for the US, which was ranked last of the 11 nations considered by the Fund – despite an expenditure on healthcare that is more than twice that per capita in the UK. The New Zealand health-funding situation is typical. Between 2000 and 2008, productivity was apparently lost in most domains of the health service, despite significant increases in costs. An unpublished analysis in 2013 by the New Zealand Institute of Economic Research showed that although pharmaceutical inflation was negligible – consequent to constraint on subsidies and bulk purchasing – total health cost growth was still estimated as 8.5% p.a., compared to the equivalent measure of gross domestic product (GDP) growth (nominal GDP) of about 6% p.a. For all OECD nations, healthcare is increasingly unaffordable. There are two issues. The first of these is health funding, which is challenged by an ageing demographic and increasing chronic disease burden. This challenge exists whether or not systems are largely insurance or taxation based, or blended. Not surprisingly, there is increasing attention to social insurance, employment-based, group and not-for-profit mutual schemes, such as those operated in Germany, the Netherlands, Singapore, South Korea and Switzerland. We are aware of, and encourage, putative models of health insurance that promote compliance in people with chronic disease and consequently reduce the consumption of healthcare. However, the subject of this editorial is the second issue, which is how health services are purchased, and in particular, how purchasing can result in better, innovative and integrated services. We can learn from historical approaches to purchasing (Tables 1,2). We have alluded to the difficulties faced by the NHS and in the US. The failure of the NHS primary care pay-for-performance scheme warrants analysis. Despite the framework title (i.e. Quality and Outcomes Framework), ‘activity’ was incentivised. Not surprisingly, these activities and consequent costs increased, but subsequent studies have not shown any improvement in acute or chronic disease, or in population health outcomes. The conclusion is that whatever is incentivised needs to be intrinsically valuable. The EDITOR ’S NOTE

On the barriers to significant innovation in and reform of healthcare

This is the first in a series of editorials that will address the reasons why healthcare remains largely refractory to the innovation and reform required for ongoing system sustainability, affordability and fitness for purpose. The series is based on the following observations: 1 There is a growing mismatch in regard to demand, supply and affordability in all Organisation for Economic Co-operation and Development countries’ healthcare systems. Innovation is required, but healthcare is ‘paradoxical’ in this context. 2 Healthcare systems are vulnerable to ‘micro-change’. These changes make healthcare planning and investment difficult; in some cases, the ‘micro-change’ has mitigated the demand, supply, affordability mismatch, whereas many others have aggravated it. 3 By contrast, healthcare systems are essentially resistant to ‘macro-change’. The core operating model, which is hospital based and doctor led, has not really changed over the last 150 years, despite a profound change in disease burden. Given the natural history of almost any industry studied of ongoing disruptive change, healthcare and education are exceptions. There are many commonalities for the latter two, one of which is that they are both dominated by professional power elites. The barriers to ‘macro-change’ in healthcare consequently need to be identified and addressed for necessary and overdue innovation to take place. For this series, eight core barriers to innovation have been identified, each of which will be the subject of individual editorials. These are introduced briefly here. 1 Provider-centric models of healthcare in which many consumers of that care are passive. The hypothesis is that real innovation will only occur when healthcare becomes ‘patient-owned’. An example of this is underway in New Zealand where disabled people are literally given the budget to purchase their own support services. Other local small steps towards patient-owned care include self-ownership of health records and advanced care plans, but how can this be accelerated? To put this in marketing terms, what is needed for citizens to get some ‘skin in the game’ of health and healthcare – bearing in mind the extant cohort of anxious well-worried sick ‘over-consumers’? A major shift in the orientation of private insurance schemes is also necessary to alter the current proconsumption bias. 2 Shortfalls in clinician and health system leadership. Leadership has been a popular subject, but, with few exceptions, the address has been too strategic. In particular, the problem definition has been poor, which does not inherently lead to tactical solutions. If the answer to the ‘question’ is better health system leadership, then the question itself will determine what should be done. For example, if the question is where is the next generation of health system governors and managers going to come from – the answer will be talent spotting and mentoring. By contrast, if the question is what is needed for a sustainable and fit-for-purpose health system, then the solution will have to address behaviour at the patient–provider interface. The solution will be based on contextual and values-based leadership training as a fundamental domain of professionalism for all health professionals. 3 Inadequate health system intelligence. Intelligence is another subject that has received attention, which has not made an appreciable difference to the status quo of healthcare. A distinction is made between data (e.g. the number of pharmacists who engage in clinical practice beyond dispensing) and intelligence (e.g. what would need to be done to encourage other pharmacists to take up such extended practice). The pharmacist example is cited because the absence of such a key piece of intelligence led to a very unsuccessful innovation development and legislative change in New Zealand. The time of annual practising certificate renewal is an obvious point of ‘capture’ for both qualitative and quantitative intelligence gathering for the regulated healthcare workforce. However, how is similar intelligence obtained for the very large unregulated workforce? 4 Restrictive business models and (often perverse) funding and remuneration systems. There are numerous examples of ‘failed’ business models, and funding and remuneration systems, in healthcare – varying from poorly constructed pay-forperformance schemes, to activity-based transactional funding, and to essentially incentive-free capitation/ population-based funding. These models and systems have generally inhibited innovation, and or caused a loss of productivity, and have usually not resulted in improved quality of individual healthcare or better population health – and most have not reduced the cost of healthcare. Indeed, many have added cost and not value. bs_bs_banner

As clear as MUD.

Somewhat contrary to popular perception, it is both very and increasingly common for people to have medically unexplainable symptoms; this is also referred to as ‘medically unexplained disease’ or MUD. The basis of MUD is ‘symptoms’ that cannot be fully explained by an ‘organic’ cause. Managing patients with such a condition is a challenge for physicians, as most people present with a high level of concern and worry about their symptoms and are difficult to reassure. Perhaps the most important role for physicians is to restrict the likelihood of harm caused by unnecessary investigations and treatment. The subject of MUD is controversial and has been so both before and after a chronically fatigued Florence Nightingale took to her bed; the prevalence, outcome and cost of MUD is now such that it ‘deserves’ editorial attention. Treating doctors often feel frustrated and inadequate, and sufferers frequently think they have been rejected; many receive little or no support, or meaningful care on the one hand, or ‘consume’ considerable and usually unhelpful healthcare on the other. There are several reasons for this controversy. First, MUD is frustratingly common and increasingly so. In a range of primary care settings: • Complaints of chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain and numbness were responsible for as much as 40% of all visits, but only 26% were ever ‘medically explained’; • More than 25% of all patients in studied English general practices had symptoms that were not medically explicable; • Between 25% and 50% of patients had unexplainable symptoms in various cohorts, which made this problem the most common category of complaint in primary care patients; • Medical explanations were found over a 3-year period in a North American general practice for only about 10% of those presenting with chest pain and headache, and in less than half of those whose primary initial complaint was fatigue, dizziness, oedema, numbness, back pain, dyspnoea, abdominal pain and insomnia, and in another similar study, more than half of patients presenting with a physical symptom had ‘resolved’ by 5 years while a third remain medically unexplained. This level of MUD is also true but less well studied in developing communities. Predictably, given that a common reason for a referral from a primary to a secondary care physician is the former not being able to identify a medical explanation for a patient’s symptoms, the rate of persistence is even greater in secondary care settings – the symptoms of 25% of patients with MUD managed by primary healthcare providers persisted for more than a year compared with 50% in secondary care. Second, the label of medically unexplained symptoms or disease is itself part of the problem. It is an unhelpful term for patients at a time when they are often seeking an explanation for their symptoms, as it promotes a mode of thinking about the issue that regards symptoms as either being ‘organic’ or ‘psychological’, and perhaps most importantly, the term characterises the patient’s complaints by what they are not rather than what they are. This frustration has led the working group revising somatoform disorders for the new version of the American Diagnostic and Statistical Manual of Mental Disorders to propose the term ‘Complex Somatic Symptom Disorder’. Debate continues about the number of symptoms required to reach the threshold for this diagnosis, but it is clear that health-related anxiety will be part of the criteria. Third, many patients who have unexplained symptoms often present with more than one symptom. Some symptom clusters are diagnosed as a functional somatic syndrome, such as chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome. In fact, there is considerable overlap of symptoms between these and other functional somatic disorders. The eventual diagnosis is largely determined by which medical specialty the patient is referred to rather than the set of symptom complaints because each medical specialty has at least one term for these patients. Fourth, mood and anxiety disorders may not be more common in people with MUD or associated with worse outcomes, but most patients with somatoform disorders have MUD and do not improve. Three or more general physical symptoms or unexplainable symptoms are positively associated with depression, anxiety, substance abuse, and service use and psychological distress. A significant mental health underpinning of any biopsychosocial concept of MUD is also supported by a number of other observations: Internal Medicine Journal 42 (2012)

Encouraging and rewarding the good behaviour of healthcare providers.

OECD nations face a mismatch between healthcare demand, supply and affordability. The question is how to influence the behaviour of healthcare providers so as to reduce the demand for and cost of healthcare. Clearly, provider behaviour is linked to system quality, but even apparently sensible remuneration may not result in ‘good’ health worker behaviour. A holistic approach to ‘reward’ appears essential. We will review Australasian systems, compare the UK and US experiences, discuss the psychology of paying healthcare providers to perform and then suggest four work streams. Australia and New Zealand have mixed public and private health systems. Australia has a high level of private elective procedures and the right to private healthcare is enshrined in the constitution. The underpinning fee for service system has been vigorously protected by the Australian Medical Association. The non-procedural medical specialties are less financially rewarding in both countries; the procedural specialities inevitably attract relatively more doctors, as do urban centres. Substantive upfront payments and higher salaries are used to attract doctors and nurses to remote and rural Australia. This has had an adverse effect on the New Zealand workforce. These incentives have had mixed success and have not guaranteed retention. Four-year visas issued to migrant healthcare workers can mandate a workplace region, but many are subsequently accepted for permanent residence and relocate. Australia’s Medicare covers 85% of scheduled general practice fees. Attempts have been made to incentivize for better outcomes and improved team work through the Medicare Benefits Schedule – for example, paying for coordinated care plans for chronic conditions and for mental health nurses to be employed through general practices. Both countries will be challenged to fund the growing demands of the aged-care sector; those working in residential settings are relatively lowly paid. Primary care payments differ. Australia has a fee for service system, whereas New Zealand introduced a capitation in 2001. Until recently, both jurisdictions tried to control costs by limiting the number of doctors trained or the cohort able to achieve reimbursement, as there is a strong correlation between the number of doctors and services rendered. New Zealand Medical Council data show that capitation has neither increased overall general practitioner ‘productivity’ nor shifted care to areas of need. There is considerable relevant international experience. A Cochrane review examined the impact of payment systems in primary care. Although more services are delivered in a fee for service system compared with capitations and salaries, there is no difference in patient outcomes. The Quality and Outcomes Framework (QOF) was introduced into the UK in 2004. About 25% of general practice income is determined by performance metrics. These include clinical standards in coronary heart disease, cancer, asthma and diabetes; standardized surveys of patient experiences; organizational standards; plus, additional services, such as screening and maternity care. The most recent study of patient outcomes found that there was no change in blood pressure management attributable to the QOF, nor reduced incidence of stroke, myocardial infarction or heart failure, and concluded that financial incentives may not be enough to improve quality of care. An evaluation of chronic disease management and patient access reached similar conclusions. By contrast, attainment of desired metrics by general practitioners exceeded that expected to the extent of ‘embarrassing’ some local budgets. Overall, it would seem that general practitioners were paid to do what that they were doing already and or what they should have been doing anyway; arguably, a culture arose in which practices concentrated on incentivized interventions. The arguments for and against the QOF were addressed in the British Medical Journal last year; the conclusion was that the QOF distorts priorities and is not as effective in improving patient outcomes as enhancing team work and facilitating evidence-based practice. Not surprisingly, following an extended focus on payments, emphasis in the UK has shifted to staff satisfaction and engagement, as measured by career opportunities, workload, participation in decision-making and team work. These latter factors appear to correlate with better patient experiences. Internal Medicine Journal 41 (2011)

On the case for an interview in medical student selection

Every other biennial Ottawa Conference on Clinical Competence is held outside North America, and in 2008, the venuewasMelbourne (Ozzawa2008). Theconferencewas arranged into plenary sessions and concurrent streams, one of which was related to the selection of medical students. During one of these sessions, a presenter from theMiddle East was questioned by a delegate from Europe about the importance of the medical student selection interview findings the former had presented. Notwithstanding the problems in language, therewas also a schism in understanding. The questioner sought data on the specificity and sensitivity of the interview and its positive and negative predictive power. In our opinion, an undue focus on these aspects is both naive and misses the point. The utility of an interview as part of medical student selection is uncertain but certainly worthy of debate. Our medical school has used an interview, and at times a multifaceted interview process, as part of the selection mechanism since the first students were recruited at the end of 1967. All three of us have been subject to this system and have strong, both good and bad, memories of the event. As such, we have a bias that needs to be declared a priori. The first dean of the school reportedly introduced an interview at the outset to identify ‘bad buggers’. The modern view is that the interview should serve other wider purposes, although finding bad buggers is still desirable. The nature of the questioning from the European delegate at Ozzawa illustrates a commonly held perspective. Quantitative rationale brings comfort, and comfort is a sought-after commodity for medical student selection panels as the stakes are high and the competition is intense. The selection is rich in emotion for everyone involved, and the outcome is literally life-changing. The reality is that medical student selection defies simple quantitative expressions. A prediction has to be predictive of something. It would be nice if we could agree what is a good doctor and then see how well our selection processes predict the extent to which our graduates satisfy the agreed elements of ‘goodness’. As far as we can see, there areno tools yet toprovide aquantitative estimateof a ‘good doctor’, and the very nature of an ethical doctor is intrinsically paradoxical; that is, we believe that a good doctor is a person who does the right thing on the one hand and is also someone who challenges systems, people and dogma and so on, on the other hand. The 20-year UK predictive study, which showed that the best predictor of ‘success’ for a doctor in their career was academic performance at school, used bald measures of success, such as ranking on medical school examinations, performance in house officer posts, time to achieve membership qualifications as well as publications and postgraduate qualifications; ‘A’ level results correlated positively with the first three outcomes. Given the data available to us about both previous academic performance and entering careers of choice and the misalignment of career choice by medical graduates and community need, it could be argued that academic performance at school might be a negative predictor of a graduate becoming a useful doctor. It is just as difficult to define a bad doctor in a way that facilitates statistical analysis; bearing in mind, we started this process 40 years ago to identify bad buggers. The likelihood, nature and outcome of a complaint during a medical career are highly dependent on factors that are outside a doctor’s control, such as the nature of the discipline and the medicolegal milieu in which he or she practises. Although a report of unprofessional behaviour as a medical student is a statistically significant risk factor for subsequent regulatory problems, the positive predictive value in this context is very low. Based on our experience,wewould be thefirst to admit that a structured interview alone does not detect all those with undesirable Editorials

Early evidence of a regulated response to hypoxaemia in sheep that preserves the brain cortex

Hypoxaemia consequent to inspired carbon monoxide (CO), and to other causes, often does not injure the brain cortex. At least five types of brain and heart protective cardiovascular response to hypoxaemia have been reported. The underlying mechanism is unknown. The present study was designed to test the hypothesis that the reaction to inspired CO involves the amygdala as this structure is thought to be central to stress responsivity; involvement would support the additional hypothesis that the somatic response to CO-hypoxaemia is regulated. Eighteen ewes were randomly allocated to control and two CO groups. The CO groups were exposed to 1% CO for 120 min and killed either 5 or 15 days later. This exposure caused isolated white matter brain injury and a transient increase in protein-kinase C (gamma) activity in the pyramidal neurons in the nuclei of the central and basal-lateral amygdala and in the neurons of the audio-cortex (p < 0.05). This was associated with evidence of a sympathetic response. It would seem reasonable to hypothesise both that the amygdala is important in the processes by which the hypoxaemic effects of CO on the brain are prevented, delayed and/or mitigated and that these processes are regulated.

Time for a medical educational change in time

If the successof thenowtime-independentandcompetencydependent training programme conducted by the Faculty of Occupational Medicine (AFOM) of the RACP is anything to go by, then it may be timely to discard time as a facsimile of competency in other programmes of undergraduate and postgraduate medical education. The AFOM reform was a response to the Australian Medical Council accreditation report on the Royal Australasian College of Physicians (RACP). It has been in place long enough for some confidence to be derived from the experience. Trainees can sit any of the exit assessments at any time, in any order and as many times as needs be to show that they can meet the stated competencies. The latter are in continual reform to render them increasingly explicit and to meet changing perspectives of what an occupational physician should be able to do. The quality of the training is now measured by transit times (time from enrolment to graduation) and not by examination-specific pass rates. The process is very attractive to older trainees and especially those who have partly or fully trained outside Australasia. Time spent in a training scheme can only ever be a reasonable basis for assuming competency if there are sound master–apprenticeship relationships in place and if the medical student and junior doctor learning and workloads ensure a reasonable exposure to disease. Moreover, understandings of thenatural and treatedhistories of those disease processes must be assured. These assumptions do not appear to be currently valid. There is a worldwide and an across-community interest in issues ofmedical competency and its relation to training and the design-financing of health services. Perspectives vary widely in scope, stance and sense of urgency. It is reasonable that the demand for a faster and cheaper supply of vocationally independent doctors is being led by Governments and health authorities. The current 10to 15-year minimum period taken to achieve independent function by doctors is obviously too long in terms of addressing existing community needs. The consequent shortfall of local medical graduates has resulted in an increased reliance on overseas-trained doctors and has spawned concepts of nurse practitioners and physician assistants with general scopes of practice. It is interesting to note that the only strong evidence in support of the effectiveness and safety of the latter is derived from care that is at the least complex end of the clinical spectrum or that is overseen by physicians. One response in Australia to the demand for faster training has been the introduction of 4-year graduateentry ‘undergraduate’ medical programmes. The accusation has arisen that these contracted programmes have been created at the expense of critical curriculumelements and especially within basic sciences such as anatomy. The campaign in this regard has been waged largely by surgeons through the media and appears to be anecdotally based. Nevertheless, it is clearly preferable that shortened medical education programmes of the future involve the accelerated learning of comprehensive curricula. The basic sciences need to be preserved in undergraduate curricula as scientifically predicated and evidence-based practice is one of the major reasons for the privilege our profession deservedly enjoys in the ‘health marketplace’. Importantly, the wider health-provider and consumer communities will need to be reassured by explicit assessments of publicly agreed and declared competencies. The issue of competency is very much to the fore in the ongoing debate about the utility of the first postgraduate years of medical practice. Our impression is that core competency is probably eroded during, and perhaps by, the first of these years (the traditional intern’s year). The problem is multifactorial in origin. The contributors include the assumption of shift work, which makes it difficult to see disease evolution, and by union and regulatory authority originated constraints on duties and the geriatric bias of patient groups in large urban hospitals. Even allowing for the effect of a workforce increasingly comprised of overseas-trained doctors whose first language is not English and the anecdotal nature of the complaints, it would seem to us to be only a matter of time before passing a professional exam, such as that used by the legal and accountancy professions, will be requisite for the progression of junior doctors from provisional to full registration. This additional ‘hurdle’ would be entirely in keeping with the competency orientation and dependency we are advocating. The AFOM experience shows that there are two fundamental barriers to introducing postgraduate timeindependent training. These are agreeing to an explicit set of competencies and developing reliable ways of

Utility of regular medical examinations of occupational divers

The utility of regular medical fitness‐for‐diving examinations of occupational divers is unknown. The aim of this audit was to investigate the impact on the employment of occupational divers of a 5‐yearly medical examination and an annual health surveillance questionnaire administered in intervening years. The medical records of all New Zealand occupational divers registered with the Department of Labour for at least 5 years were audited (n= 336). Each record included at least two full medical examinations (mean spacing of 5.6 years). An impact on career was defined as the diver being issued with either a conditional certificate of fitness or being graded as temporarily or permanently unfit for diving. The means by which the relevant medical issue was identified was recorded. Ten (3%) of 336 divers had an assessment outcome, which had a career impact. One was considered permanently unfit, four were temporarily unfit, and five were issued with conditional certification. Two were identified by respiratory function testing and eight by way of their responses to the questionnaire; none was found by the medical interview and examination process. The questionnaire system did not ‘miss’ any divers who developed a critically important health problem, and detected most of those with less important problems. Five yearly medical examinations have a low detection rate for important health problems, but remain useful for discussion of risk understanding, acceptance and mitigation.