Aidan Kehoe’s web loghttp://www.parhasard.net//images/favicon-32x32.png2021-10-18T21:41:57ZAidan Kehoekehoea@parhasard.nethttp://www.parhasard.net/entry/2021/10/18/23:41/2021-10-18T21:41:57Z<p>
I note that Atul Gawande (who is in general great, let me clarify where I’m
coming from) published recently on two specific examples of a relatively
unsuccessful health system, per dollar spent, versus a very successful health
system, per dollar spent. <a
href="https://www.newyorker.com/magazine/2021/08/30/costa-ricans-live-longer-than-we-do-whats-the-secret">The
unsuccessful health system was the USA as a whole, and the successful health
system was Costa Rica, a middle-income Central American country of five
million people.</a></p>
<p>The reason this is interesting is that Costa Rica is not Singapore, it is not
Switzerland, it is not a country that jumps out as having the general
organisational talent that tends to translate to successful export-oriented
industries, and the associated very healthy GDP per capita with resources to
spend on healthcare. It would be completely unremarkable for one more
newly-industrially-impressive country to have good health outcomes, and Prof
Gawande is correct in underlining how important and interesting this is.</p>
<p>I am writing this post today to give some related perspective, on the
difference between health care in the Republic of Ireland (non-NHS) and
Northern Ireland (also technically not NHS, given that it is devolved, but on
the health side, the HSC in Northern Ireland is pragmatically much the same as
the NHS). My own context is that I am a GP who works in both, in Northern
Ireland currently in Emergency Medicine.</p>
<p>In Ireland, and elsewhere in the English-speaking world, there is a lot of
attention given to the NHS, and there are many voices in .ie that focus on how
attractive the NHS is. I fully agree that where I work in the Republic
vs. where I work in Northern Ireland, the NHS is more attractive to patients
attending hospital, and usually to doctors and nurses, than is the situation
in the Republic; but this isn’t the complete picture. A salient fact arguing
in this question is that people the Republic live slightly longer in slightly
better health that people in Northern Ireland.</p>
<p>Prof Gawande mentions this, but to clarify further: the more we learn about
health on a population level, the cheaper the interventions get. Getting the
population to not smoke is much cheaper than dealing with the myocardial
infarctions and lung cancers that will arise in an appreciable proportion of
those who smoke develop them.</p>
<p>Implementing the marketing and agricultural incentives to have people not be
obese is much cheaper than paying for the knee replacements and the
polypharmacy of dealing with type 2 diabetes, and the home supports to have
meals delivered to people who can’t make it to the kitchen to cook because of
their body mass index of 70 kg/m².</p>
<p>Vaccinations are cheap, cheap, cheap and very effective.</p>
<p>The most bang for the buck is in this sort of population-level intervention,
and this would be even more true if you could amortise it across the
population of the US (320 million!).</p>
<p>Unintuitively for most people, the next most effective intervention is likely
an available, affable and able primary care physician, see <a
href="https://www.globalfamilydoctor.com/InternationalIssues/BarbaraStarfield.aspx">Barbara
Starfield’s</a> work. Most people are terrible at judging the possible
underlying severity of any symptom, and it turns out, if they can see a doctor
soon and without fuss for almost anything, it seems to make them live longer.</p>
<p>And on this subject: statins and blood pressure control are cheaper
(especially for the exchequer in our mixed system where many people pay for
their drugs) than rehab for debilitating strokes or emergent stents for
STEMIs. Cancers picked up earlier are easier treated than cancers picked up
later. Type 2 diabetes avoided (or controlled by diet) is cheaper than
complicated type 2 diabetes managed with amputation</p>
<p>Secondary care (the hospitals) comes next after primary care. The North and
the Republic are reasonably comparable when it comes to public health. The
North is a little bit worse on primary care; while there is not (in theory) a
need to pay a GP, care is rationed by willingness to keep calling the phone
line of the surgery. The incentive to do this is less in the Republic, where
private patients are not going to pay without having had contact with a
doctor. The two jurisdictions are much less comparable in secondary care, and
this comes down to differing political will. In order of most pleasant to
least pleasant interactions for patients:</p>
<p><ul> <li>Southerners and Northerners who interact with private hospitals in
either jurisdiction, are completely happy with the private system. They are
seen quickly, have their investigations and interventions quickly, the quality
of the decision-making is excellent. The private hospitals are funded by
non-obligatory health insurance ± fee-for-service, so the money follows the
patient. There is indirect cross-subsidy in that those providing the service
generally train in the public system and have long-term jobs there; their
education is in general funded by the exchequer</li> <li>Next comes the public
system in Northern Ireland. <br> This is funded to quite a high level per
patient seen; the GDP per capita in Northern Ireland is substantially below
England, but e.g. the ED locum doctor rates are much better. The will to
address waiting lists for e.g knee replacements is also higher than in the
south, so the waiting lists are shorter.</li> <li>Then comes the public system
in the south.<br> In terms of patient experience and in terms of mental health
for the doctors, this is a mess. Long waiting lists for anything
non-life-threatening, doctors who have limited insight into your social
circumstances (because they are not long off the plane from Sudan or Pakistan
(interestingly the East European doctors subjectively tend to perform worse
than the Commonwealth doctors, despite being fellow Europeans; it’s likely
that the system is more similar in the former British Empire, and that makes
the biggest difference)) when you do see them; the consultants (the doctor
managers) are usually stressed beyond belief at the patient load they are
carrying because the doctors making the decisions (comparable to residents in
the US system, but with no guarantee of an attending (consultant) post at the
end) tend to be, well, not all doing everything they can to get a good
recommendation letter (which to be clear, would involve full-intensity
caffeine-needed engagement at a level appropriate to someone with the local
cultural background who got 625 points on the Leaving and a perfect score on
the HPAT). </li> </ul></p>
<p>Because you need to train in the public system, because that’s where the
medical indemnity is cheaper, and because the public system is so stressful,
the usual approach from the (many, the country trains far more doctors than it
needs) Irish doctors is to emigrate to Australia after their intern year. This
works out well for Australia (.ie offers a good medical education, they get
good junior doctors basically for free) and well for the doctors (better
weather, more money, better quality of life).</p>
<p>A huge thing I admire about the NHS is NICE, the National Institute for
Clinical Excellence. They have spent the money to sit down, hash out, and come
to a freely-available conclusion on many questions that twenty years ago would
have required the input and the interaction from consultant, a specialist.</p>
<p>Both jurisdictions do the wrong thing in terms of how to direct resources for
an individual patient. The German and Dutch model of regulated, private
insurance, a »gesetzliche Krankenkasse« that you pay yourself and that is
covered by the government once you are unemployed or retired is the correct
model; it means that resources follow the sick patient, and the waiting lists
that are the scourge of the Irish model (and, but less so, of the NHS model)
don’t arise, because suddenly it makes more financial sense for an orthopaedic
surgeon to do more hips or knees on Saturday or of an evening. There is less
direct financial conflict of interest where the entity paying for the service
is not responsible for choosing the standard of care provided, and this
reduced financial conflict of interest is to the benefit of the patient. </p>
<p>My understanding (and I may be wrong) of why we haven’t adapted this correct
model is that those who are willing to come here to work as managers to change
things are mostly from the NHS (rather than the Netherlands or Germany (or,
theoretically, Switzerland)). There’s an easy answer to that for the first few
managers to implement things; pay more money. Five to ten years of it would
do, if these managers are willing to train locals, this isn’t the
brain-drained country of 1989, there are plenty of locals perfectly capable of
picking up what to do and how to do it. And then you can drop back to the
prevailing rate for the current civil servants.</p>
http://www.parhasard.net/entry/2021/05/06/23:26/Breeze, and the less exciting echelon problem of actual vs. current.Breeze, and the less exciting echelon problem of actual vs. current.2021-05-06T21:26:25Z<p>
A friend of mine put up débris as the word of the day in the IRC channel we
both join now and then, and that prompted me to look up its etymology, and
more particularly whether it is related to English breeze.</p>
<p>Not at all, as it turns out, and the OED2 entry is further of interest in
that has <a href="http://languagehat.com/translation-problems/">an echelon
problem</a> in rendering the continental (“standard average European”)
actuelle / aktuell / actual etc. as “actual” (which is not the current
English meaning) rather than “current” (which is).</p>
<p>Anyway, the full entry for breeze from the second edition of the Oxford
English Dictionary below, for your edification.</p>
<p>breeze (<span class="IPA">briːz</spam>), n.² Forms: 6-7 <b>brize, brieze</b> , 7 <b>brise, brese</b> , <b>breze, breaze</b> , 7–8 <b>breez, breese</b>, 7<b> breeze</b>.<br />
[In 16th c. <i>brize, brieze,</i> app. ad. OSp. (and Pg.) <i>briza</i> (mod.Sp. <i>brisa</i>) ‘north-east wind’ (though, according to Cotgrave, brize also occurs in Fr. (in Rabelais a 1550) = <i>bize, bise</i> ‘north wind’). Cf. also It. <i>brezza</i> ‘cold wind bringing mist or frost’ (Florio), Milanese <i>brisa</i> ‘cool wind from the north’ (Diez). Cotgrave’s <i>brize</i> = <i>bize</i>, supports the suggestion of Diez, that the word was orig. a variant of <i>bisa</i>, <i>bise</i> ‘north east wind’. On the Atlantic sea-board of the West Indies and Spanish Main, <i>briza</i> acquired the transferred senses of ‘north-east trade-wind’, and ‘fresh wind from the sea’, in which it was adopted by the English navigators of the 16th c. The further extension to ‘gentle fresh wind’ generally, is English; <b>cf. the actual F.</b> <i>brise</i> (in the Dict. of the Academy only since 1762).]<br /> <br />
† 1. orig. A north or north-east wind; spec. applied within the tropics to the NE. trade-wind.<br />
<b>1565-8b</b>9 Hawkins’ 2nd Voy. in Arb. Garner V. 121 The ordinary brise taking us, which is the north-east wind.<br />
<b>1595</b> Raleigh Disc. Guiana in Hakluyt Voy. (1600) III. 661 Against the brize and eastern wind.<br />
<b>1604</b> E. G[rimston] D’Acosta’s Hist. Indies iii. iv. 128 In that Zone..the Easterly windes (which they call Brises) do raine.<br />
a1618 Raleigh Apol. 19 When the Easterly wind or Breeses are kept off by some High Mountaines.<br />
<b>1626</b> Bacon Sylva §398 The great Brizes which the motion of the Air in great Circles..produceth.<br />
<b>1685</b> Phil. Trans. XV. 1148 There are continual Eastern winds under the line which they call Brises.<br />
<b>1706</b> Phillips, Brizes, or rather Breezes, certain Winds, which the motion of the Air in great circles doth produce, refrigerating those that live under the line.<br />
† 2. a. The cool wind that blows from the sea by day on tropical coasts. (This was on the Atlantic sea-board of tropical America an east or north-east wind, i.e. a breeze in sense 1; thence the name was extended to the ‘sea-breeze’ from any point of the compass.) Obs. exc. as in b.<br />
<b>1614</b> Raleigh Hist. World i. iii. §8 These hottest regions of the World..are..refreshed with a daily Gale of Easternly Wind (which the Spaniards call the Brize).<br />
<b>a1618</b> — Inv. Shipping 39 Southerly winds (the Brises of our Clymate) thrust them..into the Kings ports.<br />
<b>1627</b> Capt. Smith Seaman’s Gram. x. 46 A Breze is a wind blowes out of the Sea, and commonly in faire weather beginneth about nine in the morning.<br />
<b>1628</b> Digby Voy. Medit. 38 Intending to goe in in the morning with the brize.<br />
<b>1665</b> G. Havers P. della Valle’s Trav. E. Ind. 373 Sending a breeze, or breath, or small gale of wind daily.<br />
<b>1696</b> Phillips, Breez, a fresh gale of wind blowing off the Sea by day.<br />
<b>1839</b> Thirlwall Greece II. 307 A strong breeze which regularly blew up the channel at a certain time of the day.<br />
b. Extended to include the counter-current of air that blows from the land by night; hence sea-breeze and land-breeze.<br />
<b>a1700</b> Dryden (J.) From land a gentle breeze arose by night.<br />
<b>1706</b> in Phillips.<br />
<b>1731</b> Bailey II, Breez, a fresh gale of wind blowing from the sea or land alternately for some certain hours of the day or night only sensible near the coast.<br />
<b>1782</b> Cowper Loss Royal George 9 A land-breeze shook the shrouds.<br />
<b>1832</b> Macaulay Armada 31 The freshening breeze of eve unfurled that banner’s massy fold.<br />
3. a. A gentle or light wind: a breeze is generally understood to be a lighter current of air than a wind, as a wind is lighter than a gale. ‘Among seamen usually synonymous with wind in general’ (Smyth Sailor’s Word-bk.).<br />
<b>1626</b> Capt. Smith Accid. Yng. Seamen 17 A calme, a brese, a fresh gaile.<br />
<b>1762</b> Falconer Shipwr. i. 350 The lesser sails that court a gentle breeze.<br />
<b>1798</b> Coleridge Anc. Mar. ii. v, The breezes blew, the white foam flew.<br />
<b>1863</b> C. St. John Nat. Hist. Moray vii. 167 The breeze was gentle, but sufficient to take us merrily over.<br />
b. Slang phrases: to hit, split or take the breeze: to depart; to get (have) or put the breeze up: to get or put the wind up (see wind n.1 10 b).<br />
<b>1910</b> ‘O. Henry’ Whirligigs xiv. 168 We got to be hittin’ the breeze.<br />
<b>1925</b> Fraser & Gibbons Soldier & Sailor Words 35 Breeze up, to have the: to be nervous, to have the ‘wind up’.<br />
<b>1931</b> Runyon Guys & Dolls (1932) 29 And with this she takes the breeze and I return to the other room.<br />
<b>1934</b> D. L. Sayers Nine Tailors iii. 279 He got a vertical breeze up.<br />
<b>1948</b> D. Ballantyne Cunninghams 89 She was only making out she hadn’t seen you so’s you wouldn’t get the breeze up.<br />
<b>1951</b> J. B. Priestley Fest. Farbridge 296 Put the breeze up me.<br />
<b>1959</b> I. & P. Opie Lore & Lang. Schoolch. x. 193 Expressions inviting a person’s departure, for instance:..sling your hook, split the breeze, [etc.].<br />
4. fig.<br />
a. A disturbance, quarrel, ‘row’. colloq.<br />
<b>1785</b> Grose Dict. Vulgar Tongue, To kick up a breeze, to breed a disturbance.<br />
<b>1803</b> Wellington Let. in Gurw. Disp. II. 367 The cession would create a breeze in the Konkan.<br />
<b>1811</b> — ibid. VII. 320 There was an old breeze between General — and —.<br />
<b>1837</b> Marryat Dog-Fiend i. xv. (L.), Jemmy, who expected a breeze, told his wife to behave herself quietly.<br />
<b>1865</b> Sat. Rev. 28 Jan. 119 ‘Don’t be angry, we’ve had our breeze. Shake hands.’<br />
b. A breath of news, whisper, rumour. colloq.<br />
<b>1879</b> Stevenson Trav. Cevennes 215 There came a breeze that Spirit Séguier was near at hand.<br />
<b>1884</b> Denver (Colorado) Tribune Aug., Give us a breeze on the subject.<br />
c. slang. Something easy to achieve, handle, etc. orig. U.S.<br />
<b>1928</b> G. H. Ruth Babe Ruth’s Own Bk. Baseball 299 Breeze, an easy chance.<br />
<b>1958</b> M. Dickens Man Overboard ix. 136 This will be a breeze for you.<br />
<b>1962</b> S. Carpenter in Into Orbit 75 All in all, the test was a breeze.<br />
5. Comb., as breeze-borne, -like, -shaken, -swept, -wooing, adjs.<br />
<b>1805</b> J. Grahame Sabbath, On the distant cairn the watch~man’s ear Caught doubtfully at times the breeze-borne note.<br />
<b>1798</b> Coleridge Day-Dream ii. 5 A soft and breeze-like feeling.<br />
<b>1802</b> Wordsw. To H.C., The breeze-like motion.<br />
<b>1742</b> Young Nt. Th. ii. 300 Fate..hair-hung, breeze-shaken, o’er the gulph A moment trembles.<br />
<b>1872</b> Calverley Fly Leaves 4 Lingers on, till stars unnumber’d Tremble in the breeze-swept tarn.<br />
<b>1894</b> G. Bell Safar Nameh 48 On the threshold of his breeze-swept dwelling.<br />
<b>c1830</b> J. H. Green Morn. Invit. Child 22 The bee hums of heather and *breeze-wooing hill.<br /></p> http://www.parhasard.net/entry/2021/02/08/00:21/COVID-19, negative nasopharyngeal swab, clinical positivity.COVID-19, negative nasopharyngeal swab, clinical positivity.2021-02-07T23:21:31Z<p>
I was in the interesting situation over the last few days of dealing with a
patient with a recent hospital admission (discharged two weeks previously in
the context of a distinct clinical problem), brought in by ambulance with a
decreased level of consciousness, dyspnoea, and bilateral pneumonia on chest
X-ray, CURB-65 of five. With our pre-test probabilities as they are, he
almost certainly has COVID-19, and he improved dramatically on Airvo®
treatment (high-flow nasal cannula), after iv dexamethasone, iv antibiotics,
and a failed trial of CPAP. His nasopharyngeal swab was negative for
COVID-19 (and it was correctly done, I was in the room as it happened), and
I write this post to document that the man had a urea of about 48 mmol/litre
(about 7 times the upper limit of normal) and was dry as a bone, with skin
flaking and dry mucous membranes. From my assessment, the reason the
nasopharyngeal swab was negative was because the man was secreting nothing
at all from his upper airway, because he had little to no fluid to help with
that secretion process, as is not shocking with a severe acute kidney
injury.</p> http://www.parhasard.net/entry/2020/04/07/19:43/Free Kirk o Scotland (1843—1900)Free Kirk o Scotland (1843—1900)2020-04-07T17:43:30Z<p><a href="https://en.wikipedia.org/wiki/Free_Church_of_Scotland_(1843%E2%80%931900)">https://en.m.wikipedia.org/wiki/Free Church of Scotland (1843—1900)</a></p>
<p><blockquote><i>“The first task of the new church was to provide income for
her initial 500 ministers and places of worship for her people. As she
aspired to be the national church of the Scottish people, she set herself
the ambitious task of establishing a presence in every parish in Scotland
(except in the Highlands, where FC ministers were initially in short
supply.) Sometimes land owners were less than helpful such as at Strontian,
where the church took to a boat.”</i></blockquote> <p>An individual I used
to know well grew up speaking a Turkic language in Iran, together with good
Persian. Neither of those have grammatical gender, something that contrasts
with classical Arabic and with many European languages. This person was very
much on board with the idea that languages either had grammatical gender or
did not, and was very irritated by the standard English-language habit of
referring to ships as ‘she’ and the less standard habit of referring to
individual vehicles as ‘she’.</p></p>
<p>The above paragraph describing the circumstances of one of the presbyterian
churches seems calculated to enrage my acquaintance. As a non-Scottish
English speaker, it is only remotely comfortable to read for me because of
my German, and I would be irritated if the gender differed from that of
Kirche in German. I write this entry to document my surprise at this sort of
consistent use of grammatical gender for the word church in English.</p> http://www.parhasard.net/entry/2018/12/06/00:35/RCEM Learning Podcast.RCEM Learning Podcast.2018-12-05T23:35:13Z<p>
I worked as <a href="https://en.wikipedia.org/wiki/Senior_house_officer">an
SHO</a> in the <a href="https://www.mater.ie">Mater</a> Emergency Department in
Dublin from July 2014 when <a href="https://twitter.com/andyneill">Andy
Neill</a> was a registrar there, and my thinking then was ‘this man is clearly
great as a doctor, I am glad of any input from him on almost any presentation,
my one concern is not to overload him with questions, I’d prefer him not to
burn out while I’m here.’</p>
<p>The Irish secondary care system is, let me phrase this diplomatically, uneven,
and when I was working as an SHO in non-central-Dublin hospitals the guidance
from registrars was of limited benefit to the patient or to either of the
doctors. There was no whisper of this situation from Andy, and from most of
the registrars in MMUH.</p>
<p>The correct specialty (in terms of benefit to patients and long-term quality
of life for the doctor) for most of the doctors most of the time in the
Republic is General Practice. And so I applied for the training scheme, and
have been in Donegal since July of 2015; I thoroughly recommend the Donegal
Specialist Training Scheme in General Practice, I have spoken at length with
trainees across the Republic and the North about their schemes, and in terms
of almost anything objective, the Donegal scheme comes out best.</p>
<p>But; the first specialty I worked in post-intern-year, early 2013, was
Emergency Medicine. And, well, I really enjoyed it. I enjoyed how general it
was, I enjoyed randomly having to deal with an Afghan refugee where my Persian
was of some use, knowing that <span lang="fa">نقرس</span> is gout was of
actual help to the patient, I enjoyed managing patients well through French
without issue when the triage nurse in Blanchardstown (closest hospital to the
airport!) was worried about the need for an interpreter but hadn’t actually
organised an interpreter on triage. I even enjoyed that anyone who had put up
with the fourteen hour wait was actually sick enough to need to be in
hospital, and so I knew how to manage them from my intern year! I didn’t know
much about sprained ankles or migraines, but I did manage to learn it.</p>
<p>And I still like it. Five years later, I am still consistently seeing ED
patients a proportion of the week and enjoying it, there is no prospect of me
stopping ED work in the medium term. I’m not doing it in Dublin, but that is
mainly a constraint of my registration rather than an explicit choice.</p>
<p>Which is a roundabout way of saying I listen to the <a
href="https://www.rcemlearning.co.uk/foamed/december-2018/">RCEM Learning</a>
podcast because I enjoy it and it is relevant to my day-to-day work. I write
this post today because I now contend that <i>it is a high point of human
learning.</i></p>
<p>I attended some local teaching in Donegal yesterday from a medical specialist,
about one of her areas of interest and the appropriate management and approach
to referral; and it reminded me of how <b>bad</b> medical teaching can be. She
used data from the US population that differed importantly from the Irish
population to make decisions; she appeared to have no insight into the
day-to-day pattern of presentations to GPs in general and how her
recommendations would impact on her clinic numbers, when making a presentation
to GPs in large part advertising her service; practicality and pragmatism were
at no point involved in the presentation. It was as bad an experience as any
of the bad presentations involved in my experience of Computer Science
lecturers, and those fellows had the <a
href="https://en.wikipedia.org/wiki/Theory_of_mind">theory of mind</a> of a
four-year-old <a href="https://en.wikipedia.org/wiki/Sheldon_Cooper">Sheldon
Cooper.</a></p>
<p>Nothing like the above ever happens with the RCEM Learning podcast, of which
Andy is the backbone. Doctors’ weaknesses of understanding are usually with
formal statistics; the RCEM Learning podcast gets this right
consistently. Practicality and pragmatism are front and centre. The variation
in speakers, from the UK to ourselves to Australia, a little bit the US
(certainly not a massive cultural variation, but a big variation in how health
care systems are funded and how the associated incentives play out), mean that
the decision-making cul-de-sacs that give bad outcomes for economic reasons
are mentioned as avoidable.</p>
<p>I listen to lots of North American podcasts relevant to Emergency Medicine,
and they’re great, much better than our medical specialist above. RCEM
Learning still edges in front of all of those I listen to. If you are a doctor
who drives and has anything to do with Emergency Medicine (whether working in
it, taking referrals from it, or making referrals to it), make your car handle
podcasts in some way, and listen to the <a
href="https://www.rcemlearning.co.uk/foamed/december-2018/">RCEM Learning</a>.
podcast when it comes out. You will make better decisions, you will have a
better understanding of the decisions made when you refer, and you may
incidentally start <a
href="https://groups.google.com/d/msg/sci.lang/zGDF7a2BRWk/tTNN37KowvsJ">rhyming
‘now’ with the French word for ‘eye’,</a> which will be entertaining for
everyone.</p>