more_vertThe difference between treatments was below the relevance margin of 3 percentage points. Therefore, adjuvant APBI using multicatheter brachytherapy after breast-conserving surgery in patients with early breast cancer is not inferior to adjuvant whole-breast irradiation with respect to 5-year local control, disease-free survival, and overall survival.
Preference: Surgery
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[Comment] Accelerated partial breast irradiation: the new standard?
In The Lancet, Vratislav Strnad and colleagues1 present 5-year results of a large, international, randomised trial testing standard whole-breast radiotherapy against accelerated partial breast irradiation (APBI) after breast-conserving surgery, in a selected low-risk population of women. The APBI technique entailed a 4–5-day postoperative course of radiotherapy delivered via radioactive sources inserted into breast tissue surrounding the operation site, the so-called tumour bed. The study design tested for non-inferiority with a primary endpoint of local recurrence in 1184 patients recruited from 16 centres, and 5-year local recurrence was less than 2% in both arms.
Thousands of doctors join NHS strike
Around 45,000 junior doctors are estimated to have gone on strike across England as part of a stand-off with the British Government over proposed changes to contracts they believe will lead to unsafe work hours that will compromise patient safety.
Striking doctors established picket lines outside more than 100 National Health Service hospitals and clinics, according to the British Medical Association, in the first such industrial action in more than 40 years.
The NHS reported that 1279 inpatient operations and 2175 outpatient services have been cancelled as a result of the strike, while thousands of junior doctors honoured a commitment to attend work to ensure that accident and emergency departments were not affected by the protest.
NHS England said that 39 per cent of junior doctors had reported for duty – a fact seized on by Health Secretary Jeremy Hunt to imply that the industrial action did not have widespread support.
The NHS said that altogether 71 per cent of rostered staff, including junior doctors, other doctors and consultants, had showed up for work.
NHS England National Incident Director Anne Rainsberry said the strike had nonetheless “caused disruption to patient care, and we apologise to all patients affected. It’s a tough day, but the NHS is pulling out all the stops, with senior doctors and nurses often stepping in to provide cover”.
But the BMA said it was misleading of Mr Hunt to claim the strike was a flop because so many junior doctors had reported for work.
“Since we asked junior doctors who would be covering emergency care to go into work today, it is hardly surprising that they have done so, along with those who are not members of the BMA,” a BMA spokesman told the Daily Mail. “The simple fact is the Government cannot ignore the thousands who have today made it quite clear what they think of the Government’s plans.”
Several hospitals and NHS trusts placed striking doctors on a ‘black alert’, claiming they were operating under emergency conditions because an influx of cases.
Sandwell Hospital in West Bromwich declared a level 4 incident and directed striking junior doctors to return to work.
But the BMA condemned such declarations as a ploy to try to thwart the protest.
BMA Chair Dr Mark Porter said doctors had given the NHS ample warning of the impending strike to ensure hospitals could make adequate preparations and minimise the disruption to patients, such as by deferring scheduled surgery and consultations.
Striking doctors in several locations reported there were no obvious circumstances that warranted emergency declarations by their local NHS, and said that although they were equipped and prepared to abandon the strike at a moment’s notice if their services were required, they would continue to take industrial action until that time.
The doctors are striking over a plan by the Government to force them on to contracts which would increase requirements to work long shifts, including on weekends and out-of-hours. They claim there are inadequate safeguards against unsafe working hours, potentially compromising patient care and safety, while the BMA declared an in-principle objection to the Government’s aim of removing the distinction between weekend and after-hours work and the rest of the working week.
Mr Hunt said numerous studies had shown that people received lesser care on weekends than they did during the week, and “I can’t, in all conscience as Health Secretary, sit and ignore those studies”.
“We have to do something about this. People get ill every day of the week,” the Minister said, and criticised the strike as “wholly unnecessary”.
But one of the striking doctors, emergency medicine consultant Dr Rob Galloway, said the Government had left doctors with no option but to take industrial action.
Writing in the MailOnline, Dr Galloway said there was “no doubt” that junior doctor contracts needed reform, and there needed to be improvements in handling unscheduled care on weekends.
But he said that the Government, through the approach it had taken, had squandered what would have been strong support for reform.
Alongside attacks that called the commitment and integrity of doctors into question, Dr Galloway said the Government’s offer amounted to an effective pay-cut for out-of-hours work, making it even harder for hospitals to recruit and retain staff.
“If you want to improve weekend care, why on earth would you impose a pay cut for staff doing this vital weekend work, pushing them out of the NHS? The new contract as it stands will make things worse, and lead to a recruitment and retention crisis.”
The World Medical Association had thrown its support behind the junior doctors.
WMA President Sir Michael Marmot said the peak international medical organisation recognised the right of doctors to take action to improve working conditions that may also affect patient care.
“In this case, it is clear that patient care would suffer in the long term if the Government’s proposals to change the working hours of junior doctors goes ahead,” Sir Michael said, adding that the doctors had received widespread support from the public and NHS colleagues.
He urged the Government to “establish a new working relationship with junior doctors. It is essential that trust is restored on both sides, for the sake of patient care”.
The 24-hour strike is due to end this evening, Australian Eastern Standard Time.
Unless the dispute is resolved, further strikes are planned for 26 January and 10 February.
Adrian Rollins
Picture credit: William Perugini / Shutterstock.com
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[Comment] Genetics and phenotypes in inflammatory bowel disease
Inflammatory bowel diseases, encompassing Crohn’s disease and ulcerative colitis, have long been recognised as very heterogeneous diseases at the clinical level. Farmer and colleagues1 were among the first to report that location of disease was a major driver for disease presentation, complications, and rates of surgery. More recently, the Montreal and Paris classifications (ie, modified Montreal classification for use in paediatric inflammatory bowel disease) have tried to standardise clinical phenotypes further, acknowledging that age at diagnosis, and location and extent of disease in Crohn’s disease and ulcerative colitis, and disease behaviour in Crohn’s disease, are the main factors affecting disease course and prognosis.
[Comment] Coronary artery disease: a dam in the river for ranolazine
Coronary artery disease is the largest contributor to cardiovascular diseases and the number one cause of death in western countries. Percutaneous coronary intervention (PCI) has become the most commonly done interventional procedure in medicine, and coronary artery bypass grafting (CABG) has become one of the most commonly done forms of major surgery.1,2 The number of CABG operations done each year has remained constant, whereas the number of PCI procedures has increased and now accounts for an increasing proportion of revascularisation procedures.
[Perspectives] Magdi Yacoub: a lifelong affair with the heart
Professor Sir Magdi Yacoub began his career in cardiac surgery’s pioneering days at a time when surgeons had an unspoken licence to be adventurous. Not surprisingly, he has accumulated an immense depth and breadth of experience in operations on children as well as adults. But so, of course, did others. What then was special about him? One colleague who has had ample opportunity to watch Yacoub at work is anaesthetist Gavin Wright. He first met him in the 1980s, and worked with him for three decades.
Government rethinks kick in the guts for patients
Patients have been saved from being left with huge unexpected out-of-pocket expenses after the AMA intervened to secure a delay in major changes to Medicare benefits for abdominal surgery.
The AMA acted after the Health Department, in a letter sent to AMA President Professor Brian Owler on 17 December, gave just 14 days’ notice of significant amendments to Medicare items for lipectomy services, which involve the removal of large flaps of skin left hanging from the gut following rapid weight loss.
Increasingly, lipectomies have been performed on people who have lost significant weight following lap band surgery or other medical interventions.
A review of Medicare Benefits Schedule items for lipectomy services conducted in 2013 found a large increase in the number of claims made in the previous decade. Most of the procedures were carried out on women between 35 and 54 years of age.
In its letter to Professor Owler, the Department said that the review had found little strong evidence regarding the effectiveness, safety and quality of lipectomies.
“But [the review] concluded that patients with a major abdominal apron following massive weight loss due to bariatric surgery or other weight loss measures were the most likely patient population for clinically relevant lipectomy, with personal hygiene and ulceration as the main clinical issues,” the Department said.
In April, the Medical Services Advisory Committee, which oversees the listing of services on the MBS, supported changes to Medicare items for lipectomies recommended by an expert working group.
But the Government did not act on this advice until deciding to implement the changes as part of its Mid Year Economic and Fiscal Outlook deliberations, and it announced they were to come into effect from 1 January 2016.
In her letter to Professor Owler, Health Department Assistant Secretary Natasha Ryan admitted that the rapid implementation of the changes meant there was little time to give doctors and patients notice. But she argued the nature of the changes meant they were likely to cause “only minimal inconvenience”.
But the AMA told the Department patients already booked in for a lipectomy, particularly those undergoing the procedure in January, were likely to be left badly out-of-pocket as a result of the extremely tight timeframe.
“There may be cases where patients are booked for services in January, who will now not be eligible for Medicare rebates and, therefore, private health insurance rebates,” the AMA warned. “Without proper notice to the relevant medical practitioners, the Department may be exposing some individuals to having to pay the full costs of treatment, [including both] the medical and hospital costs”.
The AMA said the period of notice given by the Department was “unacceptable”, and urged for a delay.
It said there was no material reason why the changes had to be implemented so quickly, and the decision showed “a lack of insight by the Department in how the health system works and how changes need to be planned for.
Following strong representations from the AMA, the Department has announced that the changes will be deferred until 1 April 2016.
Adrian Rollins
Women stopped from getting to the top
Women are struggling to make it into the upper echelons of the medical profession despite comprising an increasing majority of those embarking on a medical career.
Australian Institute of Health and Welfare figures show that last year women made up 40 per cent of the medical workforce and 53 per cent of early-career practitioners, including just over half of all specialists in training.
But, despite this, researchers have found that they are failing to progress through to senior positions in representative numbers, comprising less than a third of specialist college board members and medical school deans, 33 per cent of state Chief Medical Officers and just 12.5 per cent of large hospital CEOs.
A study of medical leadership in Australia, published in BMJ Open, has found that women are under-represented in medical leadership roles due to a combination of ill-informed attitudes and inflexible work and career demands.
Through detailed interviews with a sample of 30 medical leaders (22 of whom were men), a team of researchers from Melbourne University, Monash Health and Deakin University found although some thought the representation of women at senior levels would increase because of the pipeline of females entering the profession, the majority – both men and women – identified a series of barriers that prevented women from advancing.
“Most interviewees believed that gender-related barriers were impeding women’s ability to achieve and thrive in medical leadership roles,” the researchers said, and identified three broad impediments – perceptions of capacity, organisational arrangements and professional culture.
The most commonly-cited barrier was parenthood, with several medical leaders referring to an inherent incompatibility between high-level leadership and motherhood.
But several remarked on the tendency of managers, and women themselves, to underestimate their capabilities.
A number of leaders interviewed for the study, Reasons and remedies for under-representation of women in medical leadership roles, reported that women were often “not taken really seriously”, and were consider to be “too feminine” to be an effective leader.
In their findings, the researchers said that, as in other professions, the lack of women in senior leadership positions was justified by a range of explanations including it was “too soon” to see women in these roles, they were too busy with their families, or were not natural leaders.
The researchers said the basis for these explanations was thin, pointing out that women have made up a sizeable proportion of the medical workforce for decades and are still not moving into leadership roles in numbers consistent with their representation in the workforce.
On the career-limiting impact of parenting, they said that “cultural assumptions that childrearing and household responsibilities impede women from entering leadership roles is, at least in part, based on discriminatory social norms”.
They pointed out that inflexible work arrangements made this a structural, rather than inherently biological, barrier. Some of those interviewed for the study suggested that, rather than following a standard linear path, medical careers could be structured to follow a more M-shaped trajectory that would support women to enter, or re-enter, leadership roles at an older age “if that suited their life-course”.
The researchers cited cultural norms and unconscious biases in the medical profession about what a leader should look like, and how they should behave, as another impediment faced by women.
They also identified other institutional impediments. For example, because the responsibilities for childrearing and maintain a household continue to fall disproportionately on women, they tend to gravitate towards specialties that give them the time and flexibility to fulfil these roles, such as general practice and public health medicine.
But these specialties, the report said, tended to have a less influential presence in large health services compared with traditional male-dominated specialities, such as surgery.
“Achieving meaningful change will require us to move beyond ‘fixing the women’ to a systemic, institutional approach that acknowledges and addresses the impact of unconscious, gender-linked biases,” the researchers said. “Revisiting rigid career structures, providing flexible working hours, offering peer support, and ensuring appropriate development opportunities, may all assist women to enter leadership roles.”
Adrian Rollins
Flight into danger
Picture: Dr Jenny Stedmon on deplotyment with the Red Cross to the Philippines following Typhoon Haiyan
It was not getting in to Ebola-struck Sierra Leone that most worried Red Cross medico Jenny Stedmon – it was getting out again.
“I flew in on an Air France flight, and the day after I arrived they stopped flying. All borders were shut,” she recalls. “It was a very volatile situation.”
Dr Stedmon, an emergency physician and anaesthetist, was a member of one of the first medical teams deployed by the Red Cross to Sierra Leone as the scale of the west African outbreak – which would eventually claim more than 11,000 lives – started to become clear in mid-2014.
The Brisbane-based anaesthetist, who has worked as a volunteer for the Red Cross for more than 20 years, was among the first medical specialists the humanitarian organisation contacted as it organised its initial response to the unfolding crisis.
A week after getting the call Dr Stedmon, leaving behind a worried husband, found herself immersed in a medical emergency the like of which she had not encountered before through deployments as far afield as Thailand, Yemen, Sudan, East Timor, Nepal and the Philippines.
Before each deployment, the Red Cross sends their volunteers oodles of information, and ensures they have the supplies and equipment they will need when they arrive.
But because nothing like the Ebola outbreak had been encountered before, Dr Stedmon admits all were going in “a little blind”.
The mission was to set up an Ebola treatment centre on the grounds of one of Sierra Leone’s main hospitals to help cope with the flood of cases arriving on a daily basis.
“Everyone was on a learning curve,” Dr Stedmon remembers. “I had never put on personal protective equipment in my life. There was a lot of fear.”
The Red Cross team learned what they could from World Health Organisation workers who had already been in-country for some time, and did what they could.
As an anaesthetist, Dr Stedmon usually works as part of the surgical team. But in emergency situations such as this, people just pitched in where they could provide the greatest help.
In battling Ebola, she found most of her time spent delivering medicines, water and food to the sick: “This was really basic health care delivery”.
After a month working in such a physically and emotionally demanding environment, Dr Stedmon and her colleagues were due to be rotated out.
But getting out of a country isolated by the international community was always going to be a challenge, and so it proved.
Eventually, she was driven across Sierra Leone to the border with Guinea where a waiting canoe carried her and her suitcase across the river. It was a white-knuckle ride, with the humanitarian worker more than a little alarmed by the strong possibility she might drown.
Once across, she was taken to an airfield at “a little place in the middle of nowhere”. Her fellow travellers included a health worker who was the sole survivor of a team massacred by frightened villagers who believed they were spreading Ebola rather than trying to fight it.
The experience caused Dr Stedmon to reflect that, “You never know where the danger is going to come from.”
Though danger is an inescapable part of working in areas afflicted by war or disaster, Dr Stedmon has never been directly attacked.
“I have been lucky so far,” she said. “I have never actively been involved in a violent act [and] I have never been impeded in my work.”
But she has had some good friends who have not been so lucky.
One of her best friends, New Zealand nurse Sheryl Thayer, was among six Red Cross workers assassinated by gunmen in a brutal attack on a field hospital near Grozny in Chechnya in 1996.
Another friend was seriously injured when a land mine blew up the Red Cross vehicle she was riding in near Fallujah in Iraq.
The Red Cross itself takes the safety and security of its staff and volunteers very seriously, Dr Stedmon said.
During her deployment in 2004 to the Yemen civil war, for example, the organisation took care to make sure the field hospital she worked at was away from the front lines, and even though there was “a lot of shooting going on, none [was] near us”.
Similarly, during the Sudan civil war, Dr Stedmon worked at a field hospital set up right on the border with Kenya, and patients were flown in by plane for care for everything from snake and hyena bites to landmine injuries and gunshot wounds.
Through all these deployments, Dr Stedmon has generally found local people and combatants, from whatever side, have respected the Red Cross’s neutrality.
But she is worried that a shift in attitude seems to be underway that could render Red Cross work ever more hazardous.
“I would never say it’s not dangerous…but I get the feeling there is erosion of respect and knowledge of the symbol [going on],” Dr Stedmon said. “Most people are reasonable, but there appears an increasing number of situations where there is no respect.
“It’s probably getting more dangerous to work for the Red Cross than when I started. That is my gut feeling.”
It is why Dr Stedmon is so passionate in her support for the ICRC’s Health care in Danger project, which aims to highlight attacks on health workers and educate combatants about the need to respect Red Cross neutrality.
“The time has come for the medical profession to stand up and say it’s not acceptable. We should be able to treat people in safety.”
What it is like to volunteer for the Red Cross
Training:
Three-day basic training course;
Week-long medical course drawing on expertise in areas like war surgery and emergency medicine.
Pre-deployment:
Detailed briefing notes; vaccinations; medical kits
Deployment:
Duration – typically three months, though in intense disaster response situations one month.
Equipment and supplies – apart from personal belongings, everything else supplied.
Support – extensive network of experienced in-country staff look after travel, accommodation, logistics
Costs – Red Cross covers air fares, food and shelter, and provides a per diem
Work absence – Dr Stedman has the support of her employer, Redlands Hospital, and takes unpaid leave for duration of deployment (gives them some scope to employ a locum if needed).
Post-deployment: extensive debriefing
Adrian Rollins
The drive to care, regardless
A hysterical woman is dumped at perimeter of an Australian Defence Force camp. Her abdomen has been crudely sliced open and then stitched up. Wary soldiers suspect she has been implanted with a live bomb.
A team of volunteer Australian Army Medical Corps doctors, accompanied by a bomb disposal expert, carefully operate on the woman, successfully extracting a land mine that had been inserted behind her rib cage and designed to go off as it was being pulled out.
It is a harrowing but true scene from Mohamed Khadra’s latest book, Honour, Duty, Courage, in which he seeks to answer why doctors and nurses with well-paid jobs and comfortable lives in Australia put it all on hold to go to poor and violent places to help complete strangers.
So who are these men and women, and why do they do it?
After picking at the puzzle for years Professor Khadra, a urological surgeon as well as an author, thinks he has a pretty fair idea.
“These are people driven to put their own needs and wants last,” Professor Khadra, who is head of surgery at Sydney Medical School, says. “They have an innate sense for protecting and nurturing others, and for fairness.”
For the book, Professor Khadra talked extensively to many men and women who have volunteered to serve the Australian Army Medical Corps in deployments that have plunged them into the heart of brutal armed conflicts.
What he found were people with an overriding sense of duty that drove them to serve, both at home and abroad.
“These are the people who are on multiple committees for the hospital, the college and the department. They are the ones who at high school organised charity days,” he says.
Professor Khadra himself shares many of these characteristics – in addition to his clinical work he serves on medical boards and committees, is a senior examiner, a head of department and is an active researcher.
But he says he is “completely humbled” by the selflessness and humanity of those who have served, and continue to volunteer for, army deployments.
“Some people ask what medicine can do for them. These people feel a duty to give back to medicine.”
But Professor Khadra’s account shows that they pay a high personal price for their devotion.
The relentless mental and physical demands of working in a forward medical post, faced daily with the threat of death and evidence of unspeakable depravity, mean anyone who serves in these roles does not leave unchanged.
“I don’t think you can see the atrocities to the depth that they have seen and not come back altered,” he says, though in recent years there has been improvements in support for those returning from service.
Not only do they bear emotional scars, but there is often a financial cost.
Professor Khadra says the payments the volunteers receive can be enough to keep the doors of their private practice open and pay their staff, but little more.
He says that most have only modest financial resources, and when they return after three months’ absence they often have to re-build their practice from scratch because patients have moved on to other practitioners.
To add indignity to the situation, often they face resentment from colleagues who have had to carry a bigger workload during their absence or, in at least one case Professor Khadra knows of, be accused of using their military service to try and drum up business from GPs.
Balanced against these disincentives is the powerful pull of duty.
But will that continue to be enough to ensure the Medical Corps will continue to play the role it has?
Professor Khadra is not sure.
He says there is a perception that those who have entered medicine in the last decade do not have the same sense of duty to give back as those who have come before them – a view fuelled by the difficulty encountered in finding younger colleagues willing to take on teaching duties.
But Professor Khadra is hopeful that, when the time comes, people will continue to step up as have the generations before them.
Adrian Rollins