Let's Concentrate on Dehydration
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comment‘ We medicalise normal physiology (and a large ‘ proportion of NHS staff) to little benefit NO HOLDS BARRED Margaret McCartney Let’s concentrate on dehydration emember—healthy whose nancial pro t and pile of plastic pee is to , to empties are fuelled by the fear that, if we you must hydrate!” So aren’t running clear urine, something is goes a rhyming couplet inherently wrong with us. “R from the Think Kidneys The bottom line is this: where’s the website, the online presence of the evidence that telling people to monitor Transforming Participation in Chronic the colour of their urine and saying that Kidney Disease programme. It comes they’re in a pathological state results in with a colour chart, not unlike those better health outcomes? Common sense available in shops selling paint, ranging in medicine needs evidence—because we from the o -white shade (good) to frequently, and with good intentions, get shade , which I’d describe as orange it wrong, even while seeming sensible. with a hint of rust (severely dehydrated). Then there are “sick day rules.” These are a Scottish I suspect that the normal colour of most doctors’ pee Patient Safety initiative for patients to have a credit when at work—if they get to the loo at all—will range card sized infographic advising them to stop using from “dehydrated” to “severely dehydrated” (that is, angiotensin converting enzyme (ACE) inhibitors, from mellow yellow to that classic dark orange). But anti-in ammatories, and diuretics during intercurrent is this actually pathological? Dehydration is surely by illness, to prevent acute kidney injury. This sounded de nition pathological and would need blood tests to very sensible when it was initiated a couple of years determine it: a physiological adjustment of our renal ago. However, my initial support has wavered because output shouldn’t be classed as dehydration but as a body no good evidence shows that this will improve mortality that needs uid to continue functioning normally. or morbidity. Human physiology is amazing: drink more, and I should have asked for better evidence rst. A" er we pee out more urine; drink less, and our kidneys all, we thought that steroids would help head injury, concentrate it. This ballet is orchestrated through our that caring for a simulation baby would reduce osmoreceptors and baroreceptors, by antidiuretic, teenage pregnancy, and that vertebroplasty would angiotensin, and aldosterone hormones, and by the treat painful osteoporotic fractures, when they did sensation of thirst, which everyone remembers from nothing of the sort. tutorials in medical school. So, when does physiology The human body is mainly incredible. Professional become pathology? intervention needs evidence. Can we please have free All sorts of considerations apply when people have a access to tap water and the time to drink it—but also a speci c diagnosis, are ill, or are in hospital and cannot proper randomised controlled trial of well intentioned respond to the natural call of thirst. They may need help safety initiatives before they’re rolled out? to drink, or they may be on deliberate uid restrictions. Margaret McCartney is a general practitioner , Glasgow But we medicalise normal physiology (and a large [email protected] proportion of NHS sta ) to little bene t. We must also Follow Margaret on Twitter, @mgtmccartney think of those poor people in the bottled water industry, Cite this as: BMJ !"#$;%&':j()(! the bmj | 21 October 2017 105 ETHICS MAN Daniel Sokol Lessons fromthe frontline Lawsuits are miserable for doctor defendants but can lead to better, safer practice n the summer of I was sitting in an Oxford cafe with a professor of medical ethics. I had just nished a masters degree Iin the history of medicine and, intrigued by the dubious conduct of some doctors in the past, was has been an outlet for those lessons. Do not skip or for interview panels, whether they contemplating a career in medical Here are further re! ections from the rush through are selecting medical students or ethics. “What do you want to do?” past two months. surgical consultants, should be: does this asked the professor. “I want to help I represented a medical student checklists. person have insight? doctors,” I replied. And so started my in a tness to practise hearing. The Do not stray Cosmetic surgery journey in medical ethics. chief concern was his lack of insight beyond the Fi een years later, now working as into his rudeness towards others. scope of On occasion I advise on cosmetic a barrister, I sue doctors. Insight can be de ned as the ability surgery cases. I attended a course on the original The way to reconcile these two to understand intellectually and the topic last month, in which the facts is that lawsuits, though emotionally why a behaviour is consent case study, a ctitious one blending miserable a airs, can lead to better, wrong. Without this ability, learning the stories of several patients, was a safer practice. But this only occurs if is sti! ed and poor practise goes schoolteacher who underwent breast lessons are learnt, and this column unchecked. A compulsory question augmentation. ACUTE PERSPECTIVE David Oliver ChallengingthevictimnarrativearoundNHSdoctors In July, I posted some tweets arguing If more doctors really are feeling of nite public resources, as well as that doctors still have public respect, this way it may damage recruitment, pressure from a range of stakeholders high professional status, secure and morale, and retention and reduce well beyond medical professionals, relatively well paid careers, and a engagement in medical leadership not least from patients and voters. great deal of hard power and so and patient advocacy, with Doctors will never get everything we in! uence. I said doctors shouldn’t consequences for patient care. want or call every shot. It’s the same describe themselves as hapless, In any case, none of these for the military, police, re service, impotent victims of the state. Plenty examples proves that the profession prisons, and schools. of doctors agreed with me. And In a politically is powerless or has earned victim Pay? The whole public sector has plenty disagreed vehemently. accountable status. Feelings run high and taken an austerity hit. We do better Years of below-in! ation pay rises, system, shouldn’t be dismissed, but I’d than most and have relatively more the mistreatment of whistleblowers, doctors will challenge the hyperbole. security, career progression, pension and the government’s demoralising never get to NHS doctors work in a tax entitlements, and paid leave. attitude to junior doctors during last call every shot funded, politically accountable Public respect? Doctors and the year’s contract stand-o were all cited system—a principle that most of NHS still repeatedly top polls about as evidence of our disempowerment. us still strongly support. But this trust in professionals, despite some They certainly contribute to doctors’ comes with consequences. As a horribly disrespectful attitudes we sense of being less in! uential than public service the NHS is in! uenced can all encounter. Online reaction to we once were—or were expecting to by macroeconomics, government TV hospital documentaries has been be when we entered training. allocation, and trade-o s in the use incredibly supportive—o en awed. 106 21 October 2017 | the bmj During the operation one of the In the knee case the surgeon said implants was dropped and, with no nothing about the mishap to the BMJ OPINION Mary McCarthy spare implant available, the surgeon patient until she asked some weeks decided to insert two larger ones. later. She was distraught and lost It’stimeforGPsto The operation was a success, but the faith in the surgeon. The lesson: be berecognisedasthe patient was distraught. So obvious honest when you make a mistake, specialiststheyare was the change that she became the however daunting the prospect. You For many years general practitioners have been butt of teenage jokes at her school, will be surprised how o" en patients arguing that they are specialists in general practice fell into depression, and quit. forgive. Remember also the legal duty and want to be recognised as such. of candour. Many see their European colleagues recognised Nickel allergy Finally, last weekend I had as specialists in family medicine: out of EU Coincidentally, the next week the misfortune of attending an states recognise general practice as a specialty. In fact, I received a new case involving emergency walk-in centre with an eye European GPs are surprised to find that the UK, which a patient who underwent a knee problem. Sitting there, I witnessed the is widely regarded as the founder of modern general replacement operation. She was depressing sight of sick and injured practice, does not acknowledge its own GPs as expert allergic to nickel and had asked for a people walking in, some propped up specialists. nickel-free product. In the operation against a worried helper, others with And it’s not just in Europe. Australia, Canada, and the surgeon removed the old knee, bloodied tissues packed into their the US also recognise the specialty. A Canadian doctor once told me that in his country consultants opened the packet for the new knee, noses, and others pale as ghosts. were considered “doctors of restricted scope of and to his horror discovered that it They looked so despondent that the practice,” whereas GPs were “doctors of unrestricted contained nickel. Faced with a large very experience sunk my spirits. scope of practice.” defect cavity, he thought he had no When my turn came, the doctor was The GMC—despite having two registers, one for choice but to implant the knee. The cheerful, diagnosed conjunctivitis in specialists and one patient developed complications.