What can a woodpecker teach health system managers?

Bismillah,  alhamdulillah: Yesterday I had the opportunity to see a program on how motorcycle helmets are being redesigned from studying woodpeckers. A good motorcycle helmet is able to reduce the impact force on the head during an accident. It does so by combining a rigid outer surface with a soft flexible inner foam. This slows the impact slightly and makes a potentially fatal collision into a survivable one. Is it possible to make even better helmets for the future?
That’s where the humble woodpecker has something to teach us. It hits the side of a solid tree 22 times a second and exposes itself to a force greater than 1200 g and yet remains unharmed. 

Scientists have thus turned to the woodpecker to try and understand how it manages to survive such brutal force. What they have noted is that the woodpecker has four layers of alternating but complimentary structures. A rigid yet flexible beak, an elastic layer which wraps around the brain, a thin fluid filled space which absorbs vibration and a spongy bone between the brain and the bone. Each layer helps dissipate the forces and results in a miraculous design.

So what has this got to do with doctors and health system management? The elaborate structure that the woodpecker is blessed with has one aim. To protect its most valuable asset – its brain. The brain being a neural structure does all the thinking but suffers from vulnerability to shock and sudden changes in speed.

In a health system the most vital asset are the health professionals who work in it and have the task of seeing patients on a day to day basis. Doctors and nurses are like the central nervous system in this regard. This soft and vulnerable structure exists in a body called the health system. If the health system is flexible and well designed, looks after the needs of its ‘brain’ and does everything to dissipate stress  then it can become like the remarkable woodpecker in its efficiency. If on the other hand the health system is rigid and succeeds in transmitting outside pressure to its brain the consequences are unpalatable.

Health system managers need to be empowered and reminded to introduce flexibility in the system at every level. An endless stream of patient initiatives and jumping hurdles within inelastic short time periods will not result in the organic growth of quality but with an increasingly frustrated and punch drunk work force. 

Accrediting agencies,  such as the Joint Commission International and Accreditation Canada International, have the ability to promote this aspect of health system improvement and promote change by setting standards for flexibility of management and standards for protected accreditation awareness time for front line staff. 


The importance of a smile

Bismillah,  alhamdulillah: a documentary from the BBC on the effect of illicit drugs on dentition. One of the dentists in the program, who runs a clinic for illicit drug users in the USA,  gives the basic pathophysiology of the severe dental decay. Most users of illicit drugs get a very dry mouth,  the lack of saliva leads to overgrowth of plaque and further damage to teeth. The thirst pushes the users to consuming more sugary drinks and this is turn makes the whole situation worse.

Part of trying to rehabilitate drug users is to try and help them get back to work. One of the key things to getting a job – that many of us may take for granted – is a smile at a job interview. For this group of patients the severe loss of dentition puts them at a huge disadvantage.
Have a listen …

Drugs and the Dentist
Duration: 26:51
Published: Tue, 11 Oct 2016 03:00:00 +0000
URL: http://open.live.bbc.co.uk/mediaselector/5/redir/version/2.0/mediaset/audio-nondrm-download-low/proto/http/vpid/p04bmp2h.mp3

Drugs like crystal meth and opiates wreck the teeth as well as the mind. In America, more than just about any country, good teeth are a sign of success and so dentists like Dr Bob Carter are helping f…

Head to head – Should all GPs be NHS employees?

Bismillah, alhamdulillah: With the changes in the economic prospects of the UK following the results of the Brexit and other unpredictable global financial winds, what is the future of General Practice or Family Medicine in the UK? This is a three way discussion on the pros and cons and future direction of family medicine in the UK.  The sad conclusion was that most GPs will eventually become NHS employees and the idyllic picture of small to medium size practices run as businesses will be a thing of the nostalgic past.

There are many factors for this change.  One that was identified was the way patient demand and expectation has changed over time. The following question illustrates this: when patients are asked the question: ‘Do you wish to see the doctor of your choice in a few days or any doctor within a day’? The response of the majority is the latter. 

This is an example of the age old rule of economists, time discounting. The value of something further in the future diminishes the further away it is. If people are offered 10 dollars now or 20 dollars in a week the vast majority choose the 10 now, over the 20 next week. 

In the long run those who wait are richer and better off but our desire for quick gratification has resulted in prioritising our long term health over our short term desire to be seen. Most doctors will agree that waiting a few more days to see the doctor who is most familiar with a patient’s case – in the long run – is the best option. This naturally excludes problems of a critical nature and that need to be solved in a very short time period. 

It is a pity that though the long term costs and outcomes of good health care have been well studied and reported on by the late Professor Barbrara Starfield and others in the field. One of the key findings has always been continuity of care. Yet, we still ignore the findings and are pandering to quick wins and slowly undermining the long term quality of the once excellent health system in the UK.

All of this is potentially good news for the private sector and community medicine. If they can succeed and target the patients who value continuity of care there is a market in the community sector awaiting them. They will have to convince their customers of the value of continuity of care and sell it – not as a unified medical record – but as something far greater. 

It is a pity that the UK model of family medicine which combined business entrepreneurship and continuity of care and managed to bring this to the masses is playing out its final scenes.

Have a listen…
Head to head – Should all GPs be NHS employees?
The BMJ Podcast
Duration: 16:48
Published: Fri, 07 Oct 2016 15:44:30 +0000
URL: http://feeds.bmj.com/~r/bmj/podcasts/~5/k4GTmjZHOk4/286590794-bmjgroup-head-to-head-should-all-gps-be-nhs-employees.mp3

Independent contractor status creates unnecessary stress, argues Azeem Majeed, GP partner and professor of primary care at Imperial College London.

Laurence Buckman, GP partner and former head of the…

What is EDACS? 

Bismillah,  alhamdulillah: that was the question on my mind as I heard of this score to safely rule out ischemic heart disease within  2 hours! My mind wandered back to the days of hospital medicine and 6 hour Troponins. 2 hours sounded good and it piqued my interest. 

Increasingly ER work is being farmed out to family doctors and primary health care centres. With the diminishing costs of fast lab work – it will probably not be too long before someone decides that chest pain of uncertain cause and with stable patients should be worked up more fully at the first point of contact rather than a busy or overworked ER department.

The article being reviewed was recently published in the BMJ and the abstract is given below. You can try out the EDACS score at Mdcalc here.


External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP).

Flaws D1Than M2Scheuermeyer FX3Christenson J4Boychuk B5Greenslade JH6Aldous S7Hammett CJ8Parsonage WA8,Deely JM9Pickering JW10Cullen L6.

Author information



The emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP) facilitates low-risk ED chest pain patients early to outpatient investigation. We aimed to validate this rule in a North American population.


We performed a retrospective validation of the EDACS-ADP using 763 chest pain patients who presented to St Paul’s Hospital, Vancouver, Canada, between June 2000 and January 2003. Patients were classified as low risk if they had an EDACS <16, no new ischaemia on ECG and non-elevated serial 0-hour and 2-hour cardiac troponin concentrations. The primary outcome was the number of patients who had a predetermined major adverse cardiac event (MACE) at 30 days after presentation.


Of the 763 patients, 317 (41.6%) were classified as low risk by the EDACS-ADP. The sensitivity, specificity, negative predictive value and positive predictive value of the EDACS-ADP for 30-day MACE were 100% (95% CI 94.2% to 100%), 46.4% (95% CI 42.6% to 50.2%), 100% (95% CI 98.5% to 100.0%) and 17.5% (95% CI 14.1% to 21.3%), respectively.


This study validated the EDACS-ADP in a novel context and supports its safe use in a North American population. It confirms that EDACS-ADP can facilitate progression to early outpatient investigation in up to 40% of ED chest pain patients within 2 hours.

Is walking on a treadmill as good as walking outside?

Bismillah alhamdulillah: very nice interview with the olympic level athlete and cardiologist Dr Paul Thompson on what exercise to recommend to patients. Some take home points:

  • 30 minutes walking per day
  • Recommend every day to get 5/6 days
  • Jogging 15 minutes/day
  • Walking outside = walking on a treadmill with a 1-2% incline because of air resistance!
  • Cycling on a stationary bike is pretty poor.
  • Don’t forget to keep strengthening your muscles as many people are outliving their muscle strength. 
  • Lovely last thought from the interviewer who remembered her mentor’s thought: ‘I wish our lives were like batteries, they run on full power right to the end and then give up very quickly’

Have a listen and keep moving! 

Walking the Path to Health
Medscape Family Medicine Podcast
Duration: 15:00
Published: Tue, 20 Sep 2016 12:35:28 EDT
URL: http://bi.medscape.com/pi/editorial/studio/audio/2016/core/868795.mp3

Dr Henry Black speaks with cardiologist Paul Thompson on how the best exercise practices are often the simplest

The diabetes race – the turtle of fasting glucose v the hare of HbA1c?

The power of a well drawn Venn diagram to show how a diagnostic criteria can change the number of people diagnosed as diabetic.

Bismillah,  alhamdulillah: Sometimes a picture is worth a thousand words. This Venn diagram nicely illustrates how changing the diagnostic criteria for diabetes will affect the epidemiology of diabetes. A new set of patients will fall under the label of diabetes and some old timers will loose the label. The sceptics might note that overall the number of diagnosed diabetics will go up significantly and pharmaceutical sales of medication will no doubt reflect that. As a clinician who sees significant variability and mismatch between fasting glucose and HbA1c, especially in the Middle East, I sit firmly in the old timers camp and rely on the older more pathophysiologically consistent diagnostic criteria. I am sure the debate between experts over the issue has not ended. I have three thoughts that come to mind if the HbA1c is adopted:

  1. If we accept HbAc as a diagnostic criteria what should we say to patients who had a HbA1c >6.5% but a normal FG who then manage to normalise their HbA1c through lifestyle changes. Did the lifestyle prevent diabetes or cure it? If we are consistent we should surely say – cure. Great news we have discovered a cure for diabetes! Indeed the pen is mightier than the sword.
  2. Will clinicians behave in a paternalistic way and start to hunt for diabetes by any criteria? Instead of relying on a single criteria could this, coupled with the falling cost of tests and Health Information Systems offering ‘one click ordering’, result in more than one test done at a time. Will we have a rule-in or a rule-out attitude? I suspect a rule-in one is where doctors tend to head for. We will then have the ability to increase the incidence of diabetes from 9.1% of the population to 19.9% of the population. A small step for doctors, a giant leap for mankind.
  3. No one seems to talk about the clinical value of the extra diagnoses over a period of time. A patient who is diabetic by HbA1c but not by fasting glucose today, and is truly destined to have diabetes will eventually have both criteria being positive after a period of time. What is that period of time? Is the earlier diagnosis clinically significant rather than statistically significant? Do we have long term studies that have tracked these two populations from pre-diagnosis and onwards?

My gut feeling is that the race between HbA1c and fasting glucose sounds like the old turtle and hare race story: at the end of the day the slower predictable turtle of fasting glucose will win over the faster but unpredictable hare.

The Venn diagram was taken from the following article:

Focus: HbA1c and postprandial glucose: should they be used as diagnostic criteria or only for monitoring glycemic control?

What happens when you can’t put your socks on? 

Bismillah,  alhamdulillah: a frequent question that our patients with hip and knee pain may ask their health care providers is should I have a hip or knee replacement? This BMJ podcast gives a patient’s view of having a total hip replacement for a fellow medic who was very wary of surgery. He had tried all the conservative therapies first. But the advise his orthopaedic doctor gave him stuck in his mind: ‘Do the operation when you are ready. When you can’t put your socks on – you are ready.’

Have a listen…

Having hip osteoarthritis
The BMJ Podcast
Duration: 12:40
Published: Fri, 08 Jul 2016 16:25:01 +0000
URL: http://feeds.bmj.com/~r/bmj/podcasts/~5/B7OJFOiqaNs/272759006-bmjgroup-having-hip-osteoarthritis.mp3

2.46 million people in England have osteoarthritis of the hip, and many of those go on to eventually have a hip replacement – which is now widely considered one of the most commonly performed and successful operation. 

Are clinical examinations evidence based and relevant in today’s modern  world of medicine?

Bismillah,  alhamdulillah: well to a non medic this question is probably a no brainer,  the answer must surely be yes. But hang on, what do most doctors in most consultations across the world – especially at the end? They order tests to help them work out what is going on. Why not just speed the process up and do the tests before you meet the doctor?

Well there are many good reasons why that is not a good choice. But one reason why this thought exists is that there is a zeitgeist that has taken hold of doctors, fuelled by  technology that the clinical exam is not really that useful. The efficacy of the standard clinical exam is minimal and it doesn’t help much as we rely on technology as the final arbiter in diagnosis. This is what this discussion  in the BMJ podcast talks about with Prof. Andrew Elder who was commissioned by the BMJ to seek out the evidence base of clinical exams. His findings run against the technology zeitgeist and reassuringly support the classical position  as taught in medical schools throughout the world.

Have a listen.

Evidence for examination
The BMJ Podcast
Duration: 15:45
Published: Tue, 16 Aug 2016 15:24:50 +0000
URL: http://feeds.bmj.com/~r/bmj/podcasts/~5/JjaUBG59cU4/278510894-bmjgroup-evidence-for-examination.mp3

You may have spent hours practicing for your examination exams, but how evidence based are the techniques taught?

Andrew Elder, a professor at the University of Edinburgh, and author of the clinical …

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Is this outrageous or a masterly business move?

Bismillah, alhamdulillah: Who should we blame for the obesity ‘smoke and mirrors’? The canny sugar industry or the human foibles of academics? Or society for not paying academics well and leaving them vulnerable to such practices?  After the Tobacco Legacy Documents this article does not come as a surprise and I wonder what will be written in the next 50 years about other well marketed ‘health’ interventions or should we call them deflections?  

How the Sugar Industry Shifted Blame to Fat – NYTimes.com