- Email: [email protected]
Empowerment of individuals to reduce cardiovascular disease
CORRESPONDENCE
Empowerment of individuals to reduce cardiovascular disease Sir—We support Nicola Holt and colleagues’ concept (July 22, p 314)1 that in the long-term the best method to have a major impact on cardiovascular disease is to empower individuals to manage their own cardiovascular risk factors. This approach is particularly important given the huge numbers of individuals at risk from cardiovascular disease. It is clear that if we continue to use current methods, most family doctors and practice nurses will be occupied full time with the prevention and treatment of cardiovascular disease, with little or no time for patients who have other disorders. However, in relation to the use of statins after myocardial infarction, we suggest a simple solution. In 1996 we audited the Coronary Care Unit at St George’s Hospital, London, UK. On discharge only 13% individuals who had had a myocardial infarction were taking a statin.2 However, we also found that 89% of patients had had their cholesterol measured on admission to the Coronary Care Unit, because the measurement of cholesterol formed part of the nursing admission protocol. Therefore, it was decided to empower the Coronary Care Unit nurses to make sure that the medical teams responsible for the individual patients with myocardial infarction in the Coronary Care Unit were constantly reminded to put patients on a statin within a few days of admission. A follow-up audit showed that in 149 patients with myocardial infarction who were discharged from the Coronary Care Unit from January to December, 1998, more than 68% were taking a statin. This number included 85% of patients with a total cholesterol on the day of admission of higher than 5·0 mmol/L and 91% with LDL cholesterol of more than 3·0 mmol/L. This simple manoeuvre of empowering Coronary Care Unit nurses as part of the Coronary Care Unit protocol to request the use of statins (ideally nurses in the Coronary Care Unit should be allowed to prescribe the statin but current UK National Health Systems regulations do not allow this) provides a simple solution that works and does not need to involve the very important, but much longer-term, strategy of empowering individuals to manage their own cardiovascular risk factors.
1196
C G Missouris, *G A MacGregor Department of Cardiology, University Hospital Lewisham, London, UK; and *Department of Medicine, St George’s Hospital Medical School, London SW17 0RE, UK (e-mail: [email protected]) 1
2
Holt N, Johnson A, de Belder MA. Patient empowerment in secondary prevention of coronary heart disease. Lancet 2000; 356: 314. Khong TK, Missouris CG, Murda’h M, MacGregor GA. The use of HMG Co-A reductase inhibitors following acute myocardial infarction in hospital practice. Postgrad Med J 1998; 74: 600–01.
Medical migration Sir—Peter Bundred and Cheryl Levitt (July 15, p 245)1 and your editorial2 focus on the financial and economic features of doctors moving from less-developed to more-developed countries. Although Bundred and Levitt do mention the frustration of the returnee from overseas training who finds he cannot practice what he has learnt, they seem to believe that the main motive for migration is financial and that the loss to lessdeveloped countries is primarily economic. I would like to introduce two further points. Such migration of doctors is not only for better salaries. “Brain push” is equally important and, in some countries is more important than financial considerations. Brain push exists in all authoritarian countries, where people are forbidden to engage in criticism of any kind and are not allowed even to express scepticism. Intellectuals do leave such environments. Bundred and Levitt might think that doctors should put up with poor economic conditions for the sake of solidarity with their countrymen, but do they also suggest that they themselves, if given the opportunity to migrate, would remain in Canada and the UK if Robert Mugabe or, say Laurent Kabila came to power there? Doctors use their qualifications as a passport to freedom, intellectual and emotional fulfilment, and professional satisfaction. Professional satisfaction applies also to doctors returning from overseas postgraduate training. Medical schools and postgraduate training in less-developed countries have been aligned to more-developed countries concepts of and metropolitan in organisation, specialisation particular. I know of no medical school in Africa that teaches medical care appropriate to the circumstances in the country. Makerere Medical
School used to provide such training. The concepts of makerere have, however, succumbed not to Idi Amin but to the combined pressures of western imagery and the insistence of professional organisations in moredeveloped countries that Makerere must not follow an obsolete outdated pattern of medicine in organisation, technology, and training, or the qualifications could not be recognised in those countries. Now the graduates of medical schools in the less-developed countries find that they have not been trained, to work in their own countries. Doctors and surgeons are no longer trained in any school, whether North or South, for work in the periphery, in isolation, and austere environments. Such an assignment requires generalists, and generalists are frowned upon. What had been corrupted is not the heart, it is the mind. This corruption will not be remedied by compensation payments and codes of conduct when recruiting doctors from overseas. Imre J P Loefler PO Box 30026, Dropping Zone no 53, Nairobi, Kenya 1
2
Bundred PE, Levitt C. Medical migration: who are the losers? Lancet 2000; 356: 245–46. Anon. Medical migration and inequity of healthcare. Lancet 2000; 356: 177.
Sir—The issue of reducing the loss to less-developed countries of their doctors because of migration to moredeveloped countries raised by Peter Bundred and Cheryl Levitt1 and in your editorial2 deserved serious attention. In addition to the suggestions made for more-developed countries, I suggest that less-developed countries also need to take serious initiatives to develop strategies at the country level to reduce the loss. Since the education of doctors, and many other professionals such as engineers, is almost completely subsidised by taxpayers’ money in many countries, such as India, these professionals should pay back to the government the amount spent on their education if they migrate. Since these emigrants earn much more elsewhere than in their native countries, reimbursement does not seem unreasonable. In addition, implementation of the suggestion of Bundred and Levitt for the more-developed countries to pay the less-developed countries for doctors who emigrate to them could compensate for the loss of intellectual and professional
THE LANCET • Vol 356 • September 30, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
Empowerment of individuals to reduce cardiovascular disease Sir—We support Nicola Holt and colleagues’ concept (July 22, p 314)1 that in the long-term the best method to have a major impact on cardiovascular disease is to empower individuals to manage their own cardiovascular risk factors. This approach is particularly important given the huge numbers of individuals at risk from cardiovascular disease. It is clear that if we continue to use current methods, most family doctors and practice nurses will be occupied full time with the prevention and treatment of cardiovascular disease, with little or no time for patients who have other disorders. However, in relation to the use of statins after myocardial infarction, we suggest a simple solution. In 1996 we audited the Coronary Care Unit at St George’s Hospital, London, UK. On discharge only 13% individuals who had had a myocardial infarction were taking a statin.2 However, we also found that 89% of patients had had their cholesterol measured on admission to the Coronary Care Unit, because the measurement of cholesterol formed part of the nursing admission protocol. Therefore, it was decided to empower the Coronary Care Unit nurses to make sure that the medical teams responsible for the individual patients with myocardial infarction in the Coronary Care Unit were constantly reminded to put patients on a statin within a few days of admission. A follow-up audit showed that in 149 patients with myocardial infarction who were discharged from the Coronary Care Unit from January to December, 1998, more than 68% were taking a statin. This number included 85% of patients with a total cholesterol on the day of admission of higher than 5·0 mmol/L and 91% with LDL cholesterol of more than 3·0 mmol/L. This simple manoeuvre of empowering Coronary Care Unit nurses as part of the Coronary Care Unit protocol to request the use of statins (ideally nurses in the Coronary Care Unit should be allowed to prescribe the statin but current UK National Health Systems regulations do not allow this) provides a simple solution that works and does not need to involve the very important, but much longer-term, strategy of empowering individuals to manage their own cardiovascular risk factors.
1196
C G Missouris, *G A MacGregor Department of Cardiology, University Hospital Lewisham, London, UK; and *Department of Medicine, St George’s Hospital Medical School, London SW17 0RE, UK (e-mail: [email protected]) 1
2
Holt N, Johnson A, de Belder MA. Patient empowerment in secondary prevention of coronary heart disease. Lancet 2000; 356: 314. Khong TK, Missouris CG, Murda’h M, MacGregor GA. The use of HMG Co-A reductase inhibitors following acute myocardial infarction in hospital practice. Postgrad Med J 1998; 74: 600–01.
Medical migration Sir—Peter Bundred and Cheryl Levitt (July 15, p 245)1 and your editorial2 focus on the financial and economic features of doctors moving from less-developed to more-developed countries. Although Bundred and Levitt do mention the frustration of the returnee from overseas training who finds he cannot practice what he has learnt, they seem to believe that the main motive for migration is financial and that the loss to lessdeveloped countries is primarily economic. I would like to introduce two further points. Such migration of doctors is not only for better salaries. “Brain push” is equally important and, in some countries is more important than financial considerations. Brain push exists in all authoritarian countries, where people are forbidden to engage in criticism of any kind and are not allowed even to express scepticism. Intellectuals do leave such environments. Bundred and Levitt might think that doctors should put up with poor economic conditions for the sake of solidarity with their countrymen, but do they also suggest that they themselves, if given the opportunity to migrate, would remain in Canada and the UK if Robert Mugabe or, say Laurent Kabila came to power there? Doctors use their qualifications as a passport to freedom, intellectual and emotional fulfilment, and professional satisfaction. Professional satisfaction applies also to doctors returning from overseas postgraduate training. Medical schools and postgraduate training in less-developed countries have been aligned to more-developed countries concepts of and metropolitan in organisation, specialisation particular. I know of no medical school in Africa that teaches medical care appropriate to the circumstances in the country. Makerere Medical
School used to provide such training. The concepts of makerere have, however, succumbed not to Idi Amin but to the combined pressures of western imagery and the insistence of professional organisations in moredeveloped countries that Makerere must not follow an obsolete outdated pattern of medicine in organisation, technology, and training, or the qualifications could not be recognised in those countries. Now the graduates of medical schools in the less-developed countries find that they have not been trained, to work in their own countries. Doctors and surgeons are no longer trained in any school, whether North or South, for work in the periphery, in isolation, and austere environments. Such an assignment requires generalists, and generalists are frowned upon. What had been corrupted is not the heart, it is the mind. This corruption will not be remedied by compensation payments and codes of conduct when recruiting doctors from overseas. Imre J P Loefler PO Box 30026, Dropping Zone no 53, Nairobi, Kenya 1
2
Bundred PE, Levitt C. Medical migration: who are the losers? Lancet 2000; 356: 245–46. Anon. Medical migration and inequity of healthcare. Lancet 2000; 356: 177.
Sir—The issue of reducing the loss to less-developed countries of their doctors because of migration to moredeveloped countries raised by Peter Bundred and Cheryl Levitt1 and in your editorial2 deserved serious attention. In addition to the suggestions made for more-developed countries, I suggest that less-developed countries also need to take serious initiatives to develop strategies at the country level to reduce the loss. Since the education of doctors, and many other professionals such as engineers, is almost completely subsidised by taxpayers’ money in many countries, such as India, these professionals should pay back to the government the amount spent on their education if they migrate. Since these emigrants earn much more elsewhere than in their native countries, reimbursement does not seem unreasonable. In addition, implementation of the suggestion of Bundred and Levitt for the more-developed countries to pay the less-developed countries for doctors who emigrate to them could compensate for the loss of intellectual and professional
THE LANCET • Vol 356 • September 30, 2000
For personal use only. Not to be reproduced without permission of The Lancet.