Cervical cancer and the Pap smear - another set of revised guidelines

Following upon the mammogram revisions, the American College of Obstetricians and Gynecologists have issued their own guideline revisions for the Pap smear in young girls. But not much debate here.

The timing of the revisions is pure coincidence, they say.

Mammogram madness - where is the objectivity?

A raging debate has emerged in the US over the recent release of the report by the U.S. Preventive Services Task Force (USPSTF) revising the recommendations for screening mammograms in women between 40-50 years of age. Stridently vocal critics of the report argue that this was part of some cost cutting measures, and that relaxation of these guidelines would lead to breast cancers not being detected early in these women and consequently more cancer deaths. The trouble with the arguments from these critics was that there was little to offer other than anecdotes.

The debate did focus my attention on how difficult it is to get truly objective information. I don't really know too much about who is right in this debate, but it did seem to me that at least the Task Force did try and base their findings on objective scrutiny of evidence. What disappointed me was that the major physician and oncology groups just lent their voices to the din by adding more and more anecdotes to support screening. Where is the objectivity? Where is this much touted 'evidence-based' medicine? (see NPR Report)

My question is, can we count on doctors to be objective in their recommendations? Can we even count on governmental reports to be objective given that governments themselves have become players themselves in this game of medical monopoly.

In a recent CNN report Alice Park writes: "If the brouhaha following a government advisory panel's recent change in breast-cancer-screening recommendations has proved anything, it is that even modern medicine does not rely on statistics, scientific facts and clinical outcomes alone."

How true. How sad. Oncology groups tend to gain by increasing hype and hysteria since they result in more screening, and more early treatment revenues.

This debate will not end soon. So far the Ministry of Health and Health Promotion Board have remained silent. How objective will they be, I wonder?

H1N1 mortality risks

So we get closer and closer to reality as the CDC revises its figures which suggest that the mortality for the dreaded H1N1 infection is somewhat less than the seasonal flu. Based on their figures we would be looking at a mortality rate of anywhere between 0.007-0.045% (average about 0.017%).

A recent report from the La Jolla Institute for Allergy and Immunology: "...the conservation of a large fraction of T-cell epitopes suggests that the severity of an S-OIV infection, as far as it is determined by susceptibility of the virus to immune attack, would not differ much from that of seasonal flu. These results are consistent with reports about disease incidence, severity, and mortality rates associated with human S-OIV (swine-origin H1N1 influenza virus)" further confirms its lack of threat.

How did we all get it so wrong? And what are we going to do with all those vaccines that nobody needs?

Doctor training smugness

There was a certain smugness in Dr Lim Suet Wun's (CEO of National Healthcare Group & Tan Tock Seng Hospital) blog about training doctors. He made reference to a recent survey among medical students,.... "recent feedback from 3rd, 4th and final year YLL medical students rated training at TTSH very highly." Indeed. He should be smug. TTSH has always been highly regarded for their consistent emphasis on training and mentoring.

What he didn't mention was which hospital was at the bottom of the survey.

We all know... but we but won't tell. (Hint:It isn't anything to do with Dukes as they have been credited with 'superior pedagogy')

Fermenting away in academia?

Spotted in a Straits Times report...about how the new university will add to the ferment in Singapore. Sigh.... such has become the quality of English practised by our journalists.

Chemotherapy errors - human factors design, management problems

So it appears that the problem is related to the fact that the two pumps looked identical.

" Mr Khaw laid the blame on the similarity in appearance of the two pumps which were mixed up, and said that he would be providing feedback to the manufacturers.
He said: ‘The pumps look almost exactly the same…This is very dangerous when there are two pieces of equipment and one is millilitre per hour, and one is millilitre per day – you are causing unnecessary risk to the users of this device.’
The key thing, he emphasised, is to learn from this incident and prevent similar mistakes from occurring. "

While it is right that the staff involved should bear some responsibility for being careless, Minister is right in not over apportioning blame on the hands that pulled the trigger.

A significant part of the responsibility should lie with the manufacturers, who were too dumb to design their pumps properly. Did they not consider the user in their design? Sadly it is too common to see engineers in their rush to get a working piece of equipment out into the market place, sacrifice all human factors considerations. It doesn't matter if the user gets into all kinds of problems, or have difficulties in getting the equipment to work properly. This is something I hope the new Singapore University of Technology and Design will address. It's not just a matter of getting an innovative product out into the market place, it is about getting a well designed product out. One that takes into considerations the needs of the user. This is called Human Factors Engineering.

Yet another part of the responsibility should be borne by the management. Did they not see this as an accident waiting to happen? Did it not seem clear to them that if you have two pieces of equipment looking exactly like each other, some one's going to make the mistake of using the wrong piece of equipment? Did they not do a risk assessment of the procedures they used in the chemotherapy unit? Even though the design of the equipment left a lot to be desired, they could just as easily have stuck on a strip of red tape distinguishing one from another. A simple solution that could have prevented this disaster. Just that nobody bothered.

Chemotherapy errors.... what gives?

To the credit to the team involved they reacted pretty quickly and didn't try and sweep the error under the carpet. But what a horrendous error! It is no comfort to say that errors like this can happen, and can happen elsewhere as well...

The question is how can such a monumental error occur in a situation which should be regarded as nothing less than 100% error free. I am sure the hospital and the MOH are now scrambling with their Boards of Inquiries.

But I can tell how 2 people checking a procure can make an error.

There are simply 2 people looking at different things and not really checking with each other. I have seen it happen so many times in ward procedures, and you wonder what is the intention for the checking process. Clearly a checking process is instituted without understanding what the process is supposed to check. Take for example the checking on NRIC numbers.... Staff#1 reads of the case sheet while Staff#2 'checks' the number on the patient's bracelet. Sounds good. But wait..... if Staff#2 didn't get enough sleep and reads an 8 for a 3, even if you repeat the process 10 times, the same error will be reproduced. It is true that the chance of a nexus between a case sheet with an 8 meeting a bracelet with a 3 is very small, but when it does occur the error will not be detected. It's like trying to proof read your own report.

Likewise, in this case.

If Staff#1 reads the instructions and Staff#2 inputs the programme, and if Staff#2 makes the error of inputting hours instead of days, the error will be neither be detected nor prevented. The process only prevents errors caused by the same staff reading and inputting the error.

People who write such procedures need to rethink a bit more about what they are doing...