Evidence, guidelines and possible solutions

I was looking at the guidelines on the management of community acquired pneumonia (CAP) in adults: This got me interested into looking at the BTS guidelines update 2009 ( https://www.brit-thoracic.org.uk/document-library/clinical-information/pneumonia/adult-pneumonia/bts-guidelines-for-the-management-of-community-acquired-pneumonia-in-adults-2009-update/ ).

Here are some observations and thoughts on it.

The 2009 British guidelines for pneumonia in adults:

Has 12 Authors W S Lim, S V Baudouin, R C George, A T Hill, C Jamieson, I Le Jeune, J T Macfarlane, R C Read, H J Roberts, M L Levy, M Wani, M A Woodhead

Endorsed by 10 major clinical professional societies British Thoracic Society Standards of Care Committee in collaboration with and endorsed by the Royal College of Physicians of London, Royal College of General Practitioners, College of Emergency Medicine, British Geriatrics Society, British Infection Society, British Society for Antimicrobial Chemotherapy, General Practice Airways Group, Health Protection Agency, Intensive Care Society and Society for Acute Medicine

502 references

45 pages of guidelines, 6 pages for the synopsis of the guidelines

Giving us 137 specific guidelines for management of CAP in adults.

Very extensive and formidable work. Would not have been easy to do and
must have consumed a lot of time and other resources.

The evidence was classified as ABCD. You know all about it but I detail
here for the purpose of my own clarity.

A+ A good recent systematic review of studies designed to answer the
question of interest

A - One or more rigorous studies designed to answer the question, but
not formally combined

B+ One or more prospective clinical studies which illuminate, but do not
rigorously answer, the question

B - One or more retrospective clinical studies which illuminate, but do
not rigorously answer, the question

C Formal combination of expert views

D Other information

BTS guidelines' recommendations are based on the following evidence levels:


4 A+ evidence recommendations (3%)
8 A- recommendations (5%)
19 B+ recommendations (17 + 2 : some recommendations have some
sub-sections with different levels of evidence) (13%)
6 B - recommendations (4 + 2 : some recommendations have some
sub-sections with different levels of evidence) (4%)
19 C recommendations (13%)
91 level D recommendations (62%)

147 evidence points resulting in 137 recommendations

My commentary

It looks like an overwhelming majority of recommendations are based on level C and D evidence which in my mind translates basically as 'individuals' opinions'. To put it radically, level C and D 'evidence' is mere opinion masquerading as evidence just because it comes in a list where the level A is properly scientific.

Whom would I trust for my own care, if I had pneumonia? I would trust our own local clinicians' opinions more as it will have local and personal context than someone who has published (guidelines comprising of 75% opinion) but has no bearing on who we are and what we do. Even the 25% level B recommendations are according to the definition 'do not rigorously answer the question'. If I had CAP why would I want my clinical treatment based on recommendations that do not rigorously
answer the question combined with the opinion of non-local physicians?







Solutions

The way forward would be groups of local clinicians agreeing on local delivery protocols based on their personal local knowledge, context and resources. Once agreed, the outcomes of the delivery can be tracked and the protocols continuously improved. We know this approach reaches us a better place than externally mandated approaches.

This blog site has outlined some ideas on this approaches which can be found at:
http://successinhealthcare.blogspot.co.uk/2012/01/hemadris-four-fundamental-questions-for.html
http://successinhealthcare.blogspot.co.uk/2012/09/letter-to-my-nieces.html
http://successinhealthcare.blogspot.co.uk/2012/08/clinical-wrongology.html

There are significant unresolved issues on the question of evidence based practice. They need to be dealt with by the Quality Improvement approaches. Let us do it.

©M HEMADRI

Follow me on Twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

PS:  If you want to learn more about QI and creating local shared baselines formally, you may want to sign up for the University of Hull course where I teach this http://successinhealthcare.blogspot.co.uk/2015/06/msc-in-healthcare-improvement-leadership.html 

If you wanted to consult me feel free to get in touch by leaving a comment or by contacting me on FB or Twitter

Choices that Indians abroad and Indian doctors make

Indians fought for their British masters in World War 1

The Indian army personnel who died in World War 1 were commemorated recently. The Indian army during that time numbered 1.5 million soldiers, nearly 1 million fought in the war. About 75000 died and about a similar number injured. 170000 animals came from India 3,700,000 tons of supplies and stores came from India that was worth about £80million. Another £146 million monetary contribution was also provided. £1 in 1917 would be about £340 today (2015) – do the math.

Here is the most fascinating aspect of this:

All the 1.5 million were volunteers. Yes you read that right volunteers.

I heard on BBC Radio that there was even a 70 year old ‘prince’ who went to meet the Viceroy so that he can go to Europe to fight in person on behalf of the empire.

According to most reports India was a relatively rich country at that time. There are some accounts that a Rupee was worth about US $10 around WW1 time. The wealth was not available to an overwhelming majority of Indian people, the wealth was available mainly and overwhelmingly to Britain. Indian people in India were treated quite badly by the British on all accounts. Yet, 1.5 million Indians and their local masters volunteered to fight and sacrifice their lives for their British rulers. Even the great Gandhi asked people to join the armed forces.

This is a remarkable achievement of the British Empire to encourage and motivate people to support them; that ability is truly amazing and deserves congratulations.

The intriguing question is why so many Indian’s volunteered to fight and die for their colonial masters? Why did they allow so many resources to be plundered?

Did the Indians feel that given a choice of their previous muslim rulers or their own local kings and princes versus the British – supporting the Empire was the better option? Did the Indians have genuine loyalty and affection towards the British? Did the Indians have an inkling that this was a long term game and playing with the British was appropriate in 1917? Or is there something in the Indian psyche that makes them support their invaders and colonisers more than their own local people (caste, local rulers’ oppressiveness, lack of local opportunities, personal greed may have all played a part)? Given the long history of these things there seems a certain naivety or gullibility or personal selfishness that becomes apparent.

Make no mistake – I am not talking here about the extraordinarily tragic stories of people who were made indentured labour, oppressed populations and other aspects of cruel history. I am only talking here about volunteers – people who had a choice and chose the colonial British.

My knowledge and analytical ability has to take a pause as I am unable to give more reasons. But, I would like to move to looking at this through a healthcare lens.

Some stats (as though stats convinced anyone!)

The population of India is 1.278 billion

The number of registered doctors in India 885233 as of 2013

India hence has less than 0.69 doctors per 1000 population

The intake into medical colleges in India as of 2013 is 41569

The number of registered doctors in UK is 267146

The UK population is 64.1 million.

This means the UK has 4.6 doctors per 1000 population

If the number of non-practising doctors are removed from the calculation then the UK  has 3.68 per 1000

If we removed the doctors who obtained their primary medical qualification outside UK then the UK would have less than 2.63 per 1000 population

The intake into medical schools in UK is 7900 per year (as of 2013)

36.8% of doctors registered in the UK are from outside UK (their primary medical qualification i.e. MBBS is from outside the UK)

The number of doctors with a primary medical qualification in India registered in UK 24995 (as of 2014)

Stats done, lets move on.

Indian doctors abroad (especially in the UK)

From conventional economics point of view doctors in India are in short supply with great demand and even in a low income situation it should be very attractive for doctors in India to remain in India; potentially and in reality often doctors in India are relative high earners.

Yet about 25000 Indian qualified doctors work in UK. About 125000 doctors of Indian origin working in the western English speaking world, with possibly tens of thousands more working in other countries (eg middle east).

It is also thought and even recognised that Indian doctors are significantly disadvantaged and possibly even discriminated when they work abroad. I have personal knowledge of UK where the statistics and the narrative certainly does not show Indian qualified doctors are equal, there is a strong feeling and growing evidence that they are discriminated against. Examination results, sanctions by the regulators, senior posts, etc all show that International Medical Graduates and Black and Minority Ethnic do not do well in the UK.

Yet, non-UK primary medical qualification holders form 36.8% of the doctors in UK of whom 25.8% are from non-European countries with 9.4% from India. No one forced them to come to UK. They are voluntarily coming to UK.

What is happening here? 

Indians (especially Indians abroad even more especially Indian doctors abroad) need to think about how they make their choices

Is discrimination the reason? Like the rest of the world, India has discrimination too, worse in some areas than others. If discrimination was the reason, why have Indian doctors working in the UK chosen to be subject to UK style discrimination than Indian style of discrimination?

Is it the ability to contribute to the health of the population? Why do Indian doctors want to contribute to the health of the British population when the need for the Indian population is much higher?

We can talk about many aspects such as opportunities, economics, corruption, ethics, etc. The point is that the evidence shows that BME population in white societies do get the wrong end of the stick. My main question is why do Indians and in the context of this writing Indian doctors choose the wrong end of the British stick (and choose not to subject themselves to the wrong end of the Indian stick)?

A lesson for India is perhaps that the Indian stick is much harsher in day to day terms and India needs to do something about that.

But for individuals, is there a different explanation? Are Indian doctors in the UK and in the rest of the western world the equivalent of the WW1 Indian volunteers? Remember the aged prince who went to the viceroy demanding he personally fight on behalf of the British empire?

There will always be mobility of labour. The mobility of labour that the western citizen generally seem to choose is one where he/she will be treated well, the western person does not seem to volunteer to work for or sacrifice his/her life for populations who treat them badly (that is why the British people left India along with their imperial government, as they did in many other countries).

The more I think about this topic the more I am convinced that there is something about seeing oneself as a winner (which is slightly different from actually being the winner), or siding with whom we think as the winners. Power is a great influencer of cultural values, especially conventional power (money and military).  Conventional power has a certain vicious attraction where even those who suffer its negative effects begin to support it. Might propagates culture and might is often very harmful.

This makes very uncomfortable reading but those of us who have chosen to leave families behind voluntarily, who have chosen to benefit an even more an already advantaged population, those of us who have chosen to submit ourselves to disadvantage and discrimination by the west, do have to wonder whether we are naïve, whether we are gullible and whether we are selfish. Indians abroad often see themselves as winners, Indians in India often see their compatriots abroad as winners.This illusion of feeling as though you are winning while losing can be addictive and almost permanently disorienting.

If we are the new era equivalents of the Indians who volunteered to fight for the British imperial masters in WW1, our development needs are so profound that it will not be a surprise if takes generations to address.  If we really want to be winners (not just seen as winners) there needs to be a different mind set where volunteering into a generally negative situation is not a trade off for personal benefits or for some vague notions of future benefits (which will mostly remain unrealised).

If we willingly subject ourselves to abuse, there will always be someone who will willingly abuse us.

©M HEMADRI 

Follow me on twitter @HemadriTweets

References

http://www.cwgc.org/foreverindia/

http://www.gmc-uk.org/doctors/register/search_stats.asp

http://www.mciindia.org/AboutMCI/AnnualReports.aspx
http://www.bbc.co.uk/programmes/b04l0zq5

PS:

I am a doctor with a primary medical qualification from India and every word above is applicable to me.

Will be grateful if you can follow this blog

NHS in India - be aware of what it means

This blog post was originally published as a guest editorial at Soumyadeep Bhaumik's Caffeinated Works & Random Musings which is one of the largest healthcare blogs in India

(http://soumyadeepb.wordpress.com/2013/01/04/the-uk-nhs-in-india-be-aware-of-what-it-means/)
Reposted here.

I follow Indian healthcare with some interest.

I have wondered about 'why do doctors who work in India and want to continue to work in India take up exams such as FRCS, MRCS, etc?' Many of these exams are conducted in India. I suppose I should give those doctors the benefit of the doubt and think that they do it as a part of knowledge improvement and knowledge validation with an international perspective. Many though may have commercial marketing motives. I ask myself if the content and the style of these exams are suitable for non-western practice? I think not, but that is purely my view.

Now the news of NHS wanting to go to India. The NHS in UK is a government funded public service healthcare system. Is that the model the NHS will follow in India? The NHS in UK is increasingly outsourcing its activity to the private sector and inviting private sector in to the NHS. However, the NHS in its new wisdom may be choosing to go to India to provide services as a private provider. Which is the exact opposite of what the NHS does here in UK. The policy and strategy confusion seems to be immense and contradictory. The NHS currently does not have any great operational experience of purely private provision.

Why would the Indians allow the NHS to do the exact opposite of what they do in UK in terms of business model, inside India? It is a question that should be asked in the Indian parliament; I am sure it will be asked if and when trouble arose.

More relevantly, why would the NHS itself want to do this? The reasons are not that difficult to fathom. India is a growing market in general, healthcare is a really high growth market, there is a clear need for more high quality providers. The non-commercial UK NHS wants to take commercial advantage of these factors to make money for UK. It is nothing else apart from money making. Money making in itself is not such a bad thing, only to couch it in the language of healthcare improvement, helping populations, transferring expertise, spreading knowledge and other obviously superficial euphemisms reflects poor intentions. I am a believer in the primacy of intentions.

I wonder if the NHS would still go to India if it was required to provide 72% of its Indian services in rural India (that is the percentage of population that lives in rural India) to the same standard and more or less the same price that they provide in urban India? I ask because that is exactly what the NHS prides itself in UK; providing more or less the same standard of service at more or less equivalent costs all over UK. Well, if you want to be an international business thats how you begin to think; Coke and Pepsi do that, produce soft drinks, distribute it to all corners of India at almost the same price; which is exactly what they do anywhere in the world. Will the NHS do in India what their business model does in UK? Would the NHS in India treat the rich and the poor equally as they are required to do in UK?

I suspect that is not what the NHS in India will be about. I sincerely hope the NHS in India will make me eat my words as that will be a win-win for everyone.

The principles of care, content of education, models of care delivery that are needed in India are different. India is perhaps already suffering from a techno-centric, finance driven, western oriented, urban focussed, doctor obsessed healthcare system. As long as we are clear in our minds that whether it is examinations such as MRCP/FRCS/MRCOG/MRCGP which are conducted in India or a possible NHS as a provider in India are simply commercial businesses operating in India for profit making; as long as we recognise and be constantly aware of this its fine. Once we start assigning higher value, philosophical or operational, we will be doing a disservice to the Indian public by deliberately misleading them. Those of you who are highly sensitive amongst the Indians should also reflect on whether this is a form of cultural and knowledge colonialism.

I am British and work in the NHS. I am an admirer of the NHS system and I believe the NHS in UK does a great job in terms of many clinical, operational and cost parameters. It is my vested personal interest that NHS in India is successful commercially. I am of Indian origin and have family in India, hence creating awareness of potential sub-optimisations is probably my broader duty.

M. HEMADRI

Follow me on twitter @HemadriTweets