- Email: [email protected]
Medical advice for sick physicians
Media distortion of dangers of
diagnostic
radiology SIR-A programme shown on UK television on April 22, 1996 (Panorama, "The X-ray Files" BBC1), presented a seriously distorted view of diagnostic radiology, emphasising the dangers but not the benefits. The producers relied heavily on an American scientist whose views are unsupported by any peer-reviewed evidence. Radiologists in the UK are keenly aware of the potential hazard of ionising radiation, are responsible under the POPUMET regulations’ for clinically directing such examinations, and are liable in law should we contravene these regulations. The Royal College of Radiologists (RCR) with the help of the National Radiological Protection Board has published guidelines for referring doctors to encourage the appropriate use of
radiological
procedures.2
These RCR guidelines contain within the general introduction an indication of the radiation dose of various examinations in relation to natural background radiation. For example, a chest radiograph uses the equivalent of 3 days of natural background radiation and a computed tomographic examination of the abdomen the equivalent of 4 years of natural background radiation. To put the danger of medical diagnostic radiation-induced cancer in perspective, there is a natural risk of a fatal cancer of 1 in 4-that is, 25% of the population will die from cancer. At the dose levels used in diagnostic radiology this risk is increased by each procedure by between one in a million and one in a few thousand, with most examinations falling within the former risk group.3 The cancer risk of a chest radiograph is about the same as that from smoking one cigarette. As with every clinical intervention, an examination with ionising radiation should be undertaken only if the expected benefit exceeds the potential harm. After the ill-conceived Panorama programme, many patients have questioned the need for an X-ray examination and have sought further advice. I hope that no-one who needs such an examination is dissuaded from undergoing it as a consequence of the
collapse. Intravenous amiodarone-in common with most antiarrhythmics-may indeed cause a fall in blood pressure. However, the guidelines are intended only for those clinical situations in which arrhythmias follow a cardiac arrest or in which there is reason to believe that the arrhythmia may precipitate a cardiac arrest in a vulnerable patient: this is not the setting of uncomplicated supraventricular tachycardia. Amiodarone is the last of four listed drugs that might be considered in this emergency setting if the arrhythmia is refractory to simple measures, and in the absence of hypotension. The recommendation is also made that expert help should be sought before any of the four drugs is used. Moreover, the dose does not "greatly exceed standard recommendations" at least for critical situations. For example, the British National Formulary and the data sheet from Sanofi Winthrop both state that, for extreme emergencies, 150-300 mg may be given over 3 minutes and repeated after 15 minutes. An adequate perfusing rhythm does not, of course, justify administration as rapidly as this even in the context of cardiac arrest. A revision of the European guidelines was under discussion from December, 1995, and has now been approved. The amendments will include changes to the doses recommended for amiodarone. The revision is not because current doses are believed to be inappropriate for the context in which they should be used, but because we have accepted suggestions that identical authoritative recommendations would aid compliance in emergency situations. To this end, we have decided to specify doses that match as closely as possible those that are given in the data sheet. This has not necessitated major changes. Arrhythmias associated with cardiac arrest are often fatal, whatever the treatment. The wise physician must seek the most favourable balance between the hazards of critical conditions and the risks that are frequently inseparable from treatment. The guidelines are intended to aid that process.
*Wolfgang Dick,
Leo Bossaert,
European Resuscitation Council,
Douglas Chamberlain
PO Box 13, B-2610
Antwerpen (Wilvijk) Belgium
programme. 1
Royal College of Radiologists, 38 Portland Place, London W1N 4JQ, UK
1
2
3
Ionising radiation (protection of persons undergoing medical examination or treatment) regulations 1988 (SI1988/778). London: HM Stationery Office, 1988. Royal College of Radiologists. Making the best use of a department of clinical radiology: guidelines for doctors. 3rd ed. London: RCR, 1995. National Radiological Protection Board. Estimates of late radiation risks to the UK population. Documents of the NRPB, 1993; vol 4: no
4.
European guidelines
on
resuscitation
SiR-We have noted with concern the letter from O’Kane and colleagues (Feb 10, p 400),’ "Dangers of European resuscitation guidelines". The guidelines on peri-arrest arrhythmias were produced after wide consultation within the European Resuscitation Council and with many national organisations in Europe that have an interest in resuscitation. Cooperation was received informally from representatives of the European Society of Cardiology, although it must be emphasised that the responsibility belongs to the Council alone. O’Kane and colleagues are concerned that an intravenous dose of 900 mg amiodarone over 1 hour may be used for "uncomplicated supraventricular tachycardia in a periarrest situation" and lead to hypotension or even circulatory
1558
O’Kane D, Campbell NPS, Wilson CM, Adgey AAJ, Dalzell GWN. of European resuscitation guidelines. Lancet 1996; 347: 400-01.
Dangers
Michael J Brindle
Medical advice for sick
physicians
their own health, and Scally of the difficulties arising p 1059)’ highlights from this attitude. The position may be rather more alarming than he supposes. 200 questionnaires were sent to doctors, chosen at random, and I received 110 valid replies. Less than half had any sick leave in the previous 2 years and, of those who had, most had taken between only 1 and 5 days; this is considerably less than one might expect of other health-care workers. I asked whether the doctors had ever worked when they felt too unwell and 87-3% replied that they had. There is a clear need to determine whether this finding is true of all doctors. Scally discusses the role of the occupational health service in caring for sick doctors. In my survey, about half the respondents were hospital doctors and they all had access to an occupational health service, but not one had ever attended the department when they had been ill. I suggest that doctors are putting themselves at a disadvantage vis-avis other hospital staff by ignoring what their occupational health department has to offer. Doctors are becoming increasingly managed and they may find in their occupational physician a useful ally; certainly the doctors
SIR-Doctors
(April 20,
are
indifferent
to
some
with whom I have had dealings have told me that they found the encounter advantageous. If sick physicians were to contact the occupational health service at their nearest hospital, they would find that the staff would be pleased to offer their services. In the present economic and political climate, the staff may wish, or be forced, to ask for financial compensation. However, occupational physicians would, I am sure, be pleased to offer their colleagues in general practice free advice. I certainly would, and I wish that I were
authority. Our patients are now having to travel to the National and the Hammersmith hospitals to take medication, which should have been available here, because our ethical committee maintains its refusal.
asked.
1
John Kellett Division of Geriatric Medicine, St George’s Hospital Medical School, University of London, Cranmer Terrace, London SW17 0RE, UK
Sonneborn K, Collier J. Ethics committees. Lancet 1996; 347: 833-34.
H A Waldron Department of Occupational Health,
St
Mary’s Hospital,
London W2 1NY, UK
1 Scally G. Physicians can’t heal themselves. Lancet 1996; 347: 1059.
SiR-Scally1 is dismissive of doctors’ efforts to help themselves. He has not understood the arguments that persuaded the Nuffield Provincial Hospitals Trust working party2 to regard doctors as a special case. A policy of reporting doctors who may or may not be impaired through illness would result in fewer doctors seeking appropriate help. The major difficulties are to persuade doctors to seek help, to take appropriate sick leave, and, above all, to ensure that confidentiality is maintained. To suggest that this might be achieved by strengthening the occupational health services ignores the fact that the service exists only in skeletal fonn in the National Health Service, and makes little or no provision for general practitioners. Even if it were possible to recruit and train sufficient doctors to provide a comprehensive occupational health service, costs would be enormous-and it is not clear that such doctors have the necessary skills to deal with the most common problems that cause concern to the profession. The Nuffield group suggested attempting to coordinate existing services at a regional level. The costs of achieving this would be modest, perhaps less than the cost of two occupational health physicians. One of the functions of these local groups would be to draw attention to conditions not conducive to health, and one can understand the anxiety such an independent view might generate among health service managers.
Low rates of Paget’s disease of bone and osteosarcoma in elderly Japanese SiR-Osteosarcoma has two age peaks among US whites (more pronounced in males) at 15-19 and 75-79 years. The second peak is attributed largely to Paget’s disease of bone, with a prevalence of about 3-6% in white males and 2-4% in females over age 55 in the US and UK, with lower rates in the rest of Europe, especially Scandinavia.’ Considerable within-country variation has been reported. The prevalence of Paget’s disease in Japan, as determined from 6900 skeletal scintigrams, was 0-22% (sexes combined).2Although the incidence of osteosarcoma in Japan rose from 0-16 to 0-33
Figure: Osteosarcoma incidence
per 100000 per year
by age
Sydney Brandon National Counselling Service for Sick Doctors, Park Square West, London NW1 4LJ, UK
1 Scally G. Physicians can’t heal themselves. Lancet 1996; 347: 1059. Taking care of doctors’ health. Report of a working party. Nuffield Provincial Hospitals Trust 1996, New Cavendish Street, London W1M 7RD, UK.
2
Ethics committees SIR-Sonneborn and Collier (March 23, p 833)’ fail
to
why they have refused ethical approval of an openlabel continuation study of a treatment for Alzheimer’s disease. This trial would answer two important questions: (1) does the drug slow progression of the disease? and (2) are there side-effects in long-term use (since such medication is likely to be taken for several years)? "Every patient who is enrolled in an open-label study" is not "one less who might be included in a more rigorous controlled trial", since after 6 months in such a trial most patients have reached the point where their score on the mini-mental state examination is too answer
low
to
or over, there was no late from peak (figure). special tabulations: 236 from the cases of osteosarcoma Osaka Cancer Registry, 1968-1992, and 508 cases from the US Surveillance, and End-Results Epidemiology (SEER) Program, 1973-1993. Only one Japanese male with osteosarcoma was known to have Paget’s disease. Paget’s disease classified by McKusick as an autosomal dominant disorder (MIM no 16725), has been tentatively mapped to chromosome 6p21-3.The racial difference in osteosarcoma rates shown in the figure supports the belief that the late peak in whites is secondary to Paget’s disease, and indicates that Japanese are inherently resistant or are not exposed to an environmental cause of the disease.
per 100 000 per year at
aged
The data
were
*Yuichi Ishikawa, Hideaki Tsukuma, Robert W Miller *Department of Pathology, Cancer Institute, Tokyo 170, Japan; Department of Field Research, Center for Cancer and Cardiovascular Diseases, Osaka, Japan; and Genetic Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
1
Barker
DJP. The epidemiology of Paget’s disease of bone. Br Med Bull
1984; 40: 396-400. 2
qualify.
The protocol has now been approved by 130 committees and by an external assessor appointed by the health
60
3
Dokoh S, Morikawa S, Shimbo S, et al. Fifteen cases of Paget’s disease of bone. Roentgenographic, scintigraphic and histological findings. Nippon Acta Radiol 1985; 45: 1206-29. McKusick VA. Mendelian inheritance in man. Baltimore: Johns Hopkins University Press, 1994.
1559
diagnostic
radiology SIR-A programme shown on UK television on April 22, 1996 (Panorama, "The X-ray Files" BBC1), presented a seriously distorted view of diagnostic radiology, emphasising the dangers but not the benefits. The producers relied heavily on an American scientist whose views are unsupported by any peer-reviewed evidence. Radiologists in the UK are keenly aware of the potential hazard of ionising radiation, are responsible under the POPUMET regulations’ for clinically directing such examinations, and are liable in law should we contravene these regulations. The Royal College of Radiologists (RCR) with the help of the National Radiological Protection Board has published guidelines for referring doctors to encourage the appropriate use of
radiological
procedures.2
These RCR guidelines contain within the general introduction an indication of the radiation dose of various examinations in relation to natural background radiation. For example, a chest radiograph uses the equivalent of 3 days of natural background radiation and a computed tomographic examination of the abdomen the equivalent of 4 years of natural background radiation. To put the danger of medical diagnostic radiation-induced cancer in perspective, there is a natural risk of a fatal cancer of 1 in 4-that is, 25% of the population will die from cancer. At the dose levels used in diagnostic radiology this risk is increased by each procedure by between one in a million and one in a few thousand, with most examinations falling within the former risk group.3 The cancer risk of a chest radiograph is about the same as that from smoking one cigarette. As with every clinical intervention, an examination with ionising radiation should be undertaken only if the expected benefit exceeds the potential harm. After the ill-conceived Panorama programme, many patients have questioned the need for an X-ray examination and have sought further advice. I hope that no-one who needs such an examination is dissuaded from undergoing it as a consequence of the
collapse. Intravenous amiodarone-in common with most antiarrhythmics-may indeed cause a fall in blood pressure. However, the guidelines are intended only for those clinical situations in which arrhythmias follow a cardiac arrest or in which there is reason to believe that the arrhythmia may precipitate a cardiac arrest in a vulnerable patient: this is not the setting of uncomplicated supraventricular tachycardia. Amiodarone is the last of four listed drugs that might be considered in this emergency setting if the arrhythmia is refractory to simple measures, and in the absence of hypotension. The recommendation is also made that expert help should be sought before any of the four drugs is used. Moreover, the dose does not "greatly exceed standard recommendations" at least for critical situations. For example, the British National Formulary and the data sheet from Sanofi Winthrop both state that, for extreme emergencies, 150-300 mg may be given over 3 minutes and repeated after 15 minutes. An adequate perfusing rhythm does not, of course, justify administration as rapidly as this even in the context of cardiac arrest. A revision of the European guidelines was under discussion from December, 1995, and has now been approved. The amendments will include changes to the doses recommended for amiodarone. The revision is not because current doses are believed to be inappropriate for the context in which they should be used, but because we have accepted suggestions that identical authoritative recommendations would aid compliance in emergency situations. To this end, we have decided to specify doses that match as closely as possible those that are given in the data sheet. This has not necessitated major changes. Arrhythmias associated with cardiac arrest are often fatal, whatever the treatment. The wise physician must seek the most favourable balance between the hazards of critical conditions and the risks that are frequently inseparable from treatment. The guidelines are intended to aid that process.
*Wolfgang Dick,
Leo Bossaert,
European Resuscitation Council,
Douglas Chamberlain
PO Box 13, B-2610
Antwerpen (Wilvijk) Belgium
programme. 1
Royal College of Radiologists, 38 Portland Place, London W1N 4JQ, UK
1
2
3
Ionising radiation (protection of persons undergoing medical examination or treatment) regulations 1988 (SI1988/778). London: HM Stationery Office, 1988. Royal College of Radiologists. Making the best use of a department of clinical radiology: guidelines for doctors. 3rd ed. London: RCR, 1995. National Radiological Protection Board. Estimates of late radiation risks to the UK population. Documents of the NRPB, 1993; vol 4: no
4.
European guidelines
on
resuscitation
SiR-We have noted with concern the letter from O’Kane and colleagues (Feb 10, p 400),’ "Dangers of European resuscitation guidelines". The guidelines on peri-arrest arrhythmias were produced after wide consultation within the European Resuscitation Council and with many national organisations in Europe that have an interest in resuscitation. Cooperation was received informally from representatives of the European Society of Cardiology, although it must be emphasised that the responsibility belongs to the Council alone. O’Kane and colleagues are concerned that an intravenous dose of 900 mg amiodarone over 1 hour may be used for "uncomplicated supraventricular tachycardia in a periarrest situation" and lead to hypotension or even circulatory
1558
O’Kane D, Campbell NPS, Wilson CM, Adgey AAJ, Dalzell GWN. of European resuscitation guidelines. Lancet 1996; 347: 400-01.
Dangers
Michael J Brindle
Medical advice for sick
physicians
their own health, and Scally of the difficulties arising p 1059)’ highlights from this attitude. The position may be rather more alarming than he supposes. 200 questionnaires were sent to doctors, chosen at random, and I received 110 valid replies. Less than half had any sick leave in the previous 2 years and, of those who had, most had taken between only 1 and 5 days; this is considerably less than one might expect of other health-care workers. I asked whether the doctors had ever worked when they felt too unwell and 87-3% replied that they had. There is a clear need to determine whether this finding is true of all doctors. Scally discusses the role of the occupational health service in caring for sick doctors. In my survey, about half the respondents were hospital doctors and they all had access to an occupational health service, but not one had ever attended the department when they had been ill. I suggest that doctors are putting themselves at a disadvantage vis-avis other hospital staff by ignoring what their occupational health department has to offer. Doctors are becoming increasingly managed and they may find in their occupational physician a useful ally; certainly the doctors
SIR-Doctors
(April 20,
are
indifferent
to
some
with whom I have had dealings have told me that they found the encounter advantageous. If sick physicians were to contact the occupational health service at their nearest hospital, they would find that the staff would be pleased to offer their services. In the present economic and political climate, the staff may wish, or be forced, to ask for financial compensation. However, occupational physicians would, I am sure, be pleased to offer their colleagues in general practice free advice. I certainly would, and I wish that I were
authority. Our patients are now having to travel to the National and the Hammersmith hospitals to take medication, which should have been available here, because our ethical committee maintains its refusal.
asked.
1
John Kellett Division of Geriatric Medicine, St George’s Hospital Medical School, University of London, Cranmer Terrace, London SW17 0RE, UK
Sonneborn K, Collier J. Ethics committees. Lancet 1996; 347: 833-34.
H A Waldron Department of Occupational Health,
St
Mary’s Hospital,
London W2 1NY, UK
1 Scally G. Physicians can’t heal themselves. Lancet 1996; 347: 1059.
SiR-Scally1 is dismissive of doctors’ efforts to help themselves. He has not understood the arguments that persuaded the Nuffield Provincial Hospitals Trust working party2 to regard doctors as a special case. A policy of reporting doctors who may or may not be impaired through illness would result in fewer doctors seeking appropriate help. The major difficulties are to persuade doctors to seek help, to take appropriate sick leave, and, above all, to ensure that confidentiality is maintained. To suggest that this might be achieved by strengthening the occupational health services ignores the fact that the service exists only in skeletal fonn in the National Health Service, and makes little or no provision for general practitioners. Even if it were possible to recruit and train sufficient doctors to provide a comprehensive occupational health service, costs would be enormous-and it is not clear that such doctors have the necessary skills to deal with the most common problems that cause concern to the profession. The Nuffield group suggested attempting to coordinate existing services at a regional level. The costs of achieving this would be modest, perhaps less than the cost of two occupational health physicians. One of the functions of these local groups would be to draw attention to conditions not conducive to health, and one can understand the anxiety such an independent view might generate among health service managers.
Low rates of Paget’s disease of bone and osteosarcoma in elderly Japanese SiR-Osteosarcoma has two age peaks among US whites (more pronounced in males) at 15-19 and 75-79 years. The second peak is attributed largely to Paget’s disease of bone, with a prevalence of about 3-6% in white males and 2-4% in females over age 55 in the US and UK, with lower rates in the rest of Europe, especially Scandinavia.’ Considerable within-country variation has been reported. The prevalence of Paget’s disease in Japan, as determined from 6900 skeletal scintigrams, was 0-22% (sexes combined).2Although the incidence of osteosarcoma in Japan rose from 0-16 to 0-33
Figure: Osteosarcoma incidence
per 100000 per year
by age
Sydney Brandon National Counselling Service for Sick Doctors, Park Square West, London NW1 4LJ, UK
1 Scally G. Physicians can’t heal themselves. Lancet 1996; 347: 1059. Taking care of doctors’ health. Report of a working party. Nuffield Provincial Hospitals Trust 1996, New Cavendish Street, London W1M 7RD, UK.
2
Ethics committees SIR-Sonneborn and Collier (March 23, p 833)’ fail
to
why they have refused ethical approval of an openlabel continuation study of a treatment for Alzheimer’s disease. This trial would answer two important questions: (1) does the drug slow progression of the disease? and (2) are there side-effects in long-term use (since such medication is likely to be taken for several years)? "Every patient who is enrolled in an open-label study" is not "one less who might be included in a more rigorous controlled trial", since after 6 months in such a trial most patients have reached the point where their score on the mini-mental state examination is too answer
low
to
or over, there was no late from peak (figure). special tabulations: 236 from the cases of osteosarcoma Osaka Cancer Registry, 1968-1992, and 508 cases from the US Surveillance, and End-Results Epidemiology (SEER) Program, 1973-1993. Only one Japanese male with osteosarcoma was known to have Paget’s disease. Paget’s disease classified by McKusick as an autosomal dominant disorder (MIM no 16725), has been tentatively mapped to chromosome 6p21-3.The racial difference in osteosarcoma rates shown in the figure supports the belief that the late peak in whites is secondary to Paget’s disease, and indicates that Japanese are inherently resistant or are not exposed to an environmental cause of the disease.
per 100 000 per year at
aged
The data
were
*Yuichi Ishikawa, Hideaki Tsukuma, Robert W Miller *Department of Pathology, Cancer Institute, Tokyo 170, Japan; Department of Field Research, Center for Cancer and Cardiovascular Diseases, Osaka, Japan; and Genetic Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
1
Barker
DJP. The epidemiology of Paget’s disease of bone. Br Med Bull
1984; 40: 396-400. 2
qualify.
The protocol has now been approved by 130 committees and by an external assessor appointed by the health
60
3
Dokoh S, Morikawa S, Shimbo S, et al. Fifteen cases of Paget’s disease of bone. Roentgenographic, scintigraphic and histological findings. Nippon Acta Radiol 1985; 45: 1206-29. McKusick VA. Mendelian inheritance in man. Baltimore: Johns Hopkins University Press, 1994.
1559