Monthly Archives: April 2017

Would you give knee surgery to the FAT MAN?

I do understand your plight, Mr Smith.  An arthritic knee can be extremely painful.  And you say it’s so bad you can’t even walk from the living room to the kitchen.  That’s actually very good news!  Yes, yes … awful … but terribly good news. If you can’t walk to the kitchen, you can’t eat. If you can’t eat you’ll lose weight.  And the faster you lose weight, the sooner we’ll schedule your knee surgery.

On 15 March 2017, Dr David Black, NHS England’s medical director for Yorkshire and the Humber, sent a letter of praise to the Rotherham Clinical Commissioning Group (RCCG).  The RCCG had decided to restrict the access to smokers and “dangerously overweight patients” of hip and knee surgery.  The letter was leaked, and it has triggered, according to the Guardian, “a storm of protest.”

The title of this blog is a play on David Edmond’s book, Would you kill the fat man, an exploration of moral philosophy and difficult choices about the valuation of human life. The RCCG’s decision intrigued me. It was essentially a decision about rationing a finite commodity — healthcare. In a world of plenty, rationing healthcare is a non-question.  In the real world, however, in a world of shrinking healthcare budgets and a squeezed NHS, resources must be allocated in a way that means some people will receive less healthcare or no healthcare.  Fairness requires that the rules of allocation are transparent and reasonable.

While you ponder, whether you would give knee surgery to the FAT MAN, I have a follow-up question.  Would you want to see a doctor who would deny you knee surgery because of some characteristic of yours unrelated to whether you would benefit from knee surgery?

I am sorry Mrs Smith, today we decided not to offer clinical services to women, people under 5’7″, or carpenters. We need to cut the costs of our clinical services, and by excluding those groups, we can save an absolute bundle.

I have heard it said of the doctor, academic and human rights advocate, Paul Farmer, that he would regularly re-allocate hospital resources from Boston to his very needy patients in Haiti.  He used to raid the drug stocks of a Boston hospital, stuff them in his suitcase and fly them back to his patients in Haiti.  I have no idea if the story is true or not. It does mark, however, one of the great traditions of medicine.  The role of a doctor is to advocate vigorously for the health (and often social) needs of the patient.  The patient actually in front of them.  The one in need.  Because, if your doctor will not advocate for your health needs, who will?  This is why all the great TV hospital dramas show a clash between the doctor and the hospital administrator.  Administrators ration.  Doctors treat.  The doctor goes all out to save little Jenny, against all odds.  The surly hospital administrator stands in front of the operating room, hand outstretched and declares (Pythonesque): “None shall pass.”

Under the current NHS system of clinical commissioning groups, there are family doctors who are simultaneously trying to make rational decisions about the allocation of limited resources to a population, and trying to be the best health advocates for the patient in front of them.  That screams conflict of interest. If you live in the catchment area of the RCCG and want my advice, check out which doctors are part of the RCCG.  If your doctor is one of them, change doctor immediately. Treating you, advocating for your health interests is what you need and should want.  Unfortunately, if she is part of the RCCG when she is treating you, you are not her principal concern.  Run(!) assuming of course that you don’t need knee surgery.

Should smokers and overweight people receive knee surgery?  Let’s start with smokers.  Why would you not want to treat a smoker?  It is difficult to come up with arguments that are not so outrageous that they are embarrassing to make. But I won’t let personal embarrassment get in the way of stating the top two silly arguments that came to mind:

  1. Smoking is a disgusting habit and anyone who smokes deserves all the pain they get?
  2. Smokers won’t live as long as non-smokers, so the investment in surgery to reduce pain and improve mobility in smokers will not have the net benefits to society as the same investment in non-smokers.

The arguments for restricting the surgery to people who are not overweight are similarly cringe-worthy.  There are also clinical reasons for prioritising the overweight.  The load on joints resulting from increased weight creates greater wear-and-tear and, the broader inflammatory processes that obesity triggers also seem to increase the risks of osteoarthritis — affecting hands as well as knees.  [See for example, here and here].

I can’t find the RCCG’s arguments for restricting access to knee surgery for smokers and people who are overweight, but prima facie it looks a lot like a variant of victim blaming.

Full disclosure.  I am all for the rational allocation of resources.  I think smoking is a disgusting habit. I am overweight and trying to do something about it.  I also think that the arguments for resource allocation need to be more explicit about the social values upon which they are often implicitly based.

Babies have less than a 1 in 3 chance of recovery from a poor 1 minute Apgar score

We recently completed a study of 272,472 live, singleton, term births without congenital anomalies recorded in the Malaysian National Obstetrics Registry (NOR). We wanted to know what proportion of births had a poor 1 minute Apgar score (<4); and the likelihood that they would recover (Apgar score ≥7) by 5 minutes.

As we noted in the paper:

While the Apgar score at 5 minutes is a better predictor of later outcomes than the Apgar score at 1 minute, there is a necessary temporal process involved, and a neonate must pass through the first minute of life to reach the fifth. Understanding the factors associated with the transition from intrauterine to extrauterine life, particularly for neonates with 1 min Apgar scores <4, has the potential to improve care.

Surprisingly, to me at least, we could find no research looking at that 1 minute to 5 minute transition.  Ours was a first.

From the 270,000+ births, you can see (Figure 1) that the probability of a 5 minute Apgar score ≥7 rises dramatically as the 1 minute Apgar score increases. There is an almost straight line relationship between a 1 minute Apgar score of 1, a 1 minute Apgar score of 6, and the chance of  a 5 minute Apgar score ≥7.

Fig 1: The probability (with 95% CI) of an Apgar score at 5 min (≥7) given any Apgar score at 1 minute

A 1 minute Apgar of 6 almost guarantees a 5 minute Apgar score ≥7; in contrast a 1 minute Apgar of 3 has only a 50% chance of recovery, and a 1 minute Apgar of 1 has only less than a 10% chance of recovery.

Fortunately, only 0.6% of births had poor Apgar scores (<4).  The type of delivery (Caesarean section, or vaginal delivery) and the staff conducting the delivery (Doctor or Midwife) were both significantly associated with the chance of recovery.  The challenge is working out the causal order.  Do certain kinds of delivery cause poor recovery, or are babies likely to have poor recovery delivered in particular ways?  Does the training of Doctors or Midwives exacerbate/improve the risks of poor recovery, or are babies likely to have poor recovery delivered by particular personnel?

Our study cannot answer the questions, but it does raise interesting points for future studies of actual labor room practice — questions not easily answered with registry type data.



Zika Causes Birth Defects In 1 In 10 Pregnancies

Well … Not really.  But that was the misleading headline of an article I saw in the “healthy living” section of The Huffington Post. And then chased it up to its source — an article published by Reuter‘s journalist Julie Steenhuysen.

There were 3,978,497 births in the US in 2015.  Assuming similar numbers in 2017 (and no seasonal variation which is unlikely), you would be looking at a whopping 400,000 births with a Zika virus related birth defect.  The usual rate of birth defects in the US from all causes is about 3 per 100, so with a cumulative total in excess of three times the current numbers one could anticipate a swift, dramatic (and possibly ineffective) response from the government.

Moving down from the headline, however, a very different story is revealed:

About one in 10 pregnant women with confirmed Zika infections had a fetus or baby with birth defects, offering the clearest picture yet of the risk of Zika infection during pregnancy, U.S. researchers said on Tuesday.

No longer is it 1 in 10 pregnancies. Its 1 in 10 pregnancies with Zika.  The facts are not half as dramatic as the headline.  What am I talking about?  “Not half as dramatic”?  The total number of pregnancies in the US Zika Pregnancy Register for 2016–2017 (on 8 April 2017) was 1,311. Fifty-six of the pregnancies resulted in liveborn infants with birth defects, and 7 of the pregnancies were associated with losses with birth defects.  That just doesn’t sound as impressive a number as the headline suggested.  Undoubtedly personally tragic, but far from as significant a population health issue.