Friday, October 03, 2014


I am a medical doctor practising emergency medicine and a member of PPS. I have been a PPS member since graduation in 1995. 

In June 2013 I found myself unable to walk and so consequently unable to work. My diagnosis was delayed until March 2014 and PPS refused to pay my sickness claim because the evidence was  "contradictory".

If you are interested in reading the full story you can do so here.

If you are a PPS member and you have sickness and disability cover and you believe you will be covered if your diagnosis is delayed or you are misdiagnosed  you are mistaken because PPS Will Not Pay You! You will see your savings disappear and you will find yourself selling off sundry items because of a lack of income.

PPS has broken faith with me. So, I am understandably biased, but this is a consequence of direct experience.

Friday, July 25, 2014

Prevention is not a medical paradigm

Pharmaceutical Pinball
Pharmaceutical Pinball (Photo credit: DES Daughter)
Healthcare will not ever be about prevention. It is cogent to say that the economics of cure are unsustainable, but healthcare is not about helmets and seatbelts, or electric lighting or piped water or soap or ....

No-one gets paid to prevent anything. Insurers get paid to mitigate risk not eliminate it. So, too, do pharmaceutical companies. And sin taxes are essentially  risk premiums - that is insurance products and bad ones at that, priced by political calculus rather than actuarial coefficients.

Modern Healthcare

Healthcare used to be about local experience and anecdote, then about science, then economics. Now it is about politics.

As the science has gotten better it has also become unmanageably complex.

Wednesday, July 02, 2014

Cognitive Bias

"When we attempt to understand past events, we implicitly test the hypotheses or rules we use both to interpret and to anticipate the world around us. If, in hindsight, we systematically underestimate the surprises that the past held and holds for us, we are subjecting those hypotheses to inordinately weak tests and, presumably, finding little reason to change them."


Tuesday, July 01, 2014

ED Attendances by Age

E. Hassen, R. Bhalla 
Accident and Emergency Department 
Correspondence to E. Hassen; email doctor@drhassencom. 

There is a dearth of epidemiological research into paediatric attendances at Emergency Departments in the UK. This study looks at all types of ED attendances by children at a single site through one year. 

Data and methods: 
Routine data on all attendances by children aged 1-15 years were available (period: 1 January 2005 to 31 December 2005). The data were analysed by time of year (weekly) for each age cohort. 

Attendances peaked at age 2 and decreased for each cohort to a minimum at age 8 before rising again to age 15. For all ages attendances were higher for males compared to females. For the year, paediatric attendances peaked in week 28 as did total ED attendances. However, as a proportion of the total, paediatric attendances peaked in week 27. 

This study has shown that paediatric attendances at our ED are activity dependant, age sex and population dependant. There is considerable variation in ED attendance rates across the country with many factors responsible and few published comprehensive audits to guide planning. It is to be hoped that others will answer the same questions as a basis for further much needed research in Emergency Medicine. 

Abbreviations: ED, emergency department 
Keywords: children; emergency department; epidemiology; paediatric 

There is a dearth of epidemiological research into paediatric attendances at Emergency 
Departments in the UK. Most Emergency Medicine research in the UK has looked at types of injuries although several have looked at all types of ED attendance. Only one 
study has looked at the epidemiology of ED attendances specifically. This latter study found that most attendances were due to injuries and that these varied by age and location and that the variations were not stable across sites. More information is needed from more sites for longer periods through the country in addition to the sentinel sites 
monitored by the DTI given the contingent and complex causes of ED attendances. 

The lack of research in Emergency Medicine is due to the fact that this is a new 
speciality, that Emergency Medicine lacks political capital, that no dedicated funding 
exists for Emergency Medicine research, that no dedicated organisation is responsible for 
Emergency Medicine research, that Emergency Medicine practitioners have an action 
focus rather than a research focus and that Emergency Departments are under-resourced 
for service provision without the ability to do research. The Joint Statement on Children’s 
Attendances at Accident & Emergency Departments was published in 1999 with its most important references from 1985. The Care Group Workforce Team Recommendations 2003 Report did not deal with Emergency Medicine. The most recent numbers published for NHS Direct referrals to Emergency Departments were for 1999-2000, the first year that NHS Direct was operating. 

Emergency Medicine is still an orphan speciality and needs research that proves the 
growing workload and the effectiveness (clinical, social and financial) of Emergency 
Departments. Towards that end we contribute this study. 
This study looks at all types of ED attendance at one hospital to report on the use of the 
Emergency Department by children to see how these vary by age, sex and season. 


The Study Hospital is a district general hospital in North East Wales serving a 
population of 250,000. It is situated on the outskirts of the town (pop 70,000), 
which is near the Welsh/English border in North Wales. The catchment area extends 
beyond the county to include patients from Flintshire, Powys, south 
Gwynedd, as well as some from Cheshire, the Wirral and Shropshire. 

The Emergency Departments is fully computerised and records information on every 
attendance made. Data on all new ED attendances by children aged under 16 years of age 
were available for the period 1 January 2005 to 31 December 2005 (12,443 records). 


In 2005 ED attendances peaked at age 2 and then decreased to a minimum at age 8 before rising again. For all attendances the peak was reached in week 28, which was also the week in which paediatric attendances peaked; however, as a proportion paediatric 
attendances peaked in week 27. For all ages males presented more frequently than 
females with the smallest difference at age 2 and the largest difference at age 12. 

We have an advantage compared to the fragmented health services sector in America: 
most accidents and emergencies in the UK are dealt with by the NHS in the Accident & Emergency Department. Centralised data collection, analysis and dissemination are 
possible. We hope it happens; soon. 

We would like to thank the ED staff at the Study Hospital 


Funding: None. 
 Competing interests: none declared 


1. Downing, A, Rudge, G. A study of childhood attendance at emergency 
departments in the West Midlands region. Emerg Med J 2006 23: 391-393. 

2. Scuffham, P, Chaplin, S, Legood, R. Incidence and costs of unintentional falls in 
older people in the United Kingdom. J Epidemiol Community Health 2003 57: 

3. Accident & Emergency Services for Children: Report of A Multidisciplinary 
Working Party. RCPCH. June 1999. 

4. Long Term Conditions Care Group Workforce Teams Recommendations - 2003 
Report to the Workforce Numbers Advisory Board. DHHRD Care Group 
Workforce Teams. Nov 2003. 

5. Outcomes of calls to NHS Direct, 1999-00: Social Trends 31. DoH 2002. (Last accessed 20 June 2006). 

6. Helen Cooper, Chris Smaje, Sara Arber. Use of health services by children and 
young people according to ethnicity and social class: secondary analysis of a 
national survey. BMJ 1998; 317:1047-1051. 

7. MacFaul R and Werneke U. Recent Trends in hospital use by children in England. 
Arch Dis Child 2001; 85:203207. 

8. Emergency Care for Children: Growing Pains (2006). Board on Health Care 
Services. 2006. 

Saturday, October 12, 2013

Not there yet....

Our efforts at healthcare are aimed at returning people to pleasurable, productive lives. But in determining who receives what healthcare we only terminally consider quality of life. Elsewise the healthcare available and provided depends very much on geography. 

Further in those quality of life assessments people do not expressly consider pleasure, but rather an absence of pain, the ability to eat, to mobilise, to socialise and to sleep. These activities are intrinsically pleasurable but not necessarily so and where they are pleasurable the pleasure is variable.

As far as productivity is concerned, assessments are necessarily retrospective. In disease, treatment seeks to return one to a premorbid state, but such states are never calibrated and so we rely on our very fallible memories to decide whether or not we function as we did before. So, treatment aims to return the capacity for productivity, but no-one would argue that someone who has gone through three cycles of chemotherapy has the same intellectual capacity as previously. The same could be said of someone who has recovered from a serious heart attack or stroke even if such recovery seems remarkably complete. The point here being that all serious illness and the chemicals and procedures we use to return human bodies to functional status have costs in intellectual performance. I know that the activities of daily living do not need or demand a towering intellect but it is nevertheless true that such towers lose both breadth and height in serious illness. Most times irrecoverably so.

I say all this because despite the remarkable and dramatic strides that the technologies of healthcare have made, contemporary healthcare remains very crude in it's diagnostics and it's treatments. We know that we will be able to do better but we are far from implanted cybernetics and designer babies.

Thursday, October 10, 2013

Vignettes: Emotional Contagion

A daughter wrote a letter of complaint, essentially about my lack of empathy. I was reminded of this reading The Managed Heart which discusses the work of feeling and feeling rules.

The daughter brought her mother to A&E on a Monday, which is almost always busy, because she had fallen and sustained several gruesome looking soft tissue injuries, most dramatically of her face. This happened early on Saturday morning after she had been out drinking on Friday night.

There was some urgency to attend to her because her husband was dying, literally, in a palliative care facility due to a metastatic brain malignancy and they wanted to be with him for his last few hours. All understandable.

Being the conscientious doctor that I am, I reviewed her previous attendance records and found that she had been discharged the afternoon previous after a thorough assessment, including CT scans of her brain and cervical spine, and a lengthy period of observation.

So, after introducing myself and acknowledging that she was being seen immediately because of her husband's pending death, I asked, "Why have you come back today?" Quite reasonable I think considering that she had been discharged less than 24 hours earlier.

It turns out that she had been drinking excessively because of her husband's health problems; that she had fallen down drunk and then lost consciousness on a public road, from whence an ambulance brought her to A&E. When she was well enough, in the department, she was asked, as per protocol, who to contact regarding her admission. She listed her daughter as next of kin but refused to have her contacted. She refused again at discharge, declaring a preference for a taxi hire. She did not want her daughter to know that she had been admitted to hospital for more than 24 hours because of injuries sustained due to acute alcohol poisoning.

So, her daughter who had last seen her a week before was entirely unaware of the events of that weekend. Concerned and already grieving for her father she brought her mother in for treatment.

I examined the mother and found nothing substantially different from the afternoon before and explained that the injuries looked much worse than they were and that once the swelling resolved - another three or four days - things would look considerably better.

During this conversation the daughter had burst into tears. And I had failed to acknowledge her obvious distress. In explanation, it was the first anniversary of my father's death and managing my own grief without expressing it at work was already hard work without the additional stress of her emotional contagion.

And I did not believe that I owed her an exposition of my own loss or it's expression. It was not my fault that their family dynamics had become so dysfunctional under the stress of her father's dying and her mother's inability to cope and her lack of sibling support.

She was angry and guilty and afraid and anxious and quite overwhelmed. I know.

Neither her mother nor her father were legitimate targets and so she took the time to write a letter about my lack of human feeling, which lack was particularly egregious given my profession.

I wrote a letter of apology for my perceived lack of expressed empathy and/or sympathy. It said nothing about my own grief and the work of managing it. And it very deliberately said nothing about the communication failures within their family.

Patients, their relations and their friends pay lip service to the humanity of doctors and nurses without accepting the frailties that lead to such failures of communication as I have described.

Knowing is never enough. We all fail sometimes....

Monday, October 07, 2013

Vignettes, An Introduction?

I work in the Emergency Department. It used to be called Casualty, but, of course, very little of what comes through the doors has anything to do with significant trauma. Having said that, I work in Wales, but I trained in South Africa and the same is not true of that sunny, gorgeous land.

Emergencies in South Africa very rarely involve strokes or heart attacks or sudden incapacitating palpitations. They certainly do not involve panic attacks. Or major depressive episodes with suicidal ideation. I am not entirely convinced that either of the last two constitute emergencies. I may just be biased especially considering that there are about 8.45 deaths per 100000 people per year in the UK due to suicide and depressed people present to hospital very frequently thinking about suicide but not actively planning it.

I am not insensitive. You will probably disagree. I do think that statistics are important in resource allocation. Utilities. QALYs. Numbers.

This is not, however, intended to be about numbers; or at least not to any significant extent. This is intended to be a series of vignettes.

I have been encouraged to write. And activity is generally inconducive to depression, especially brief reactive episodes.

So, this is a beginning. It is telling that it begins with depression, but circumstances being what they are, it is understandable.

Sunday, November 04, 2012


Health care rationing must necessarily fail, given that clinicians primary responsibilities are towards their patients, which means that costs must be discounted at the point of care.