Dr. James Manos (MD)
April 1, 2023
Improving healthcare systems worldwide
Image (free to use): The entrance to the Arthur South Day Procedure Unit at the Norfolk and Norwich University Hospital taken the user FrancisTyers (January 11, 2006). Uploaded by the user: FrancisTyers (commons Wiki). Source: Wikipedia. Link: https://commons.wikimedia.org/wiki/File:NHS_NNUH_entrance.jpg
You may also read my text Emergency Medicine: Suggestions for improvement
Contents
a) Overview
b) Recommendations
a) OVERVIEW
Several issues that arose during the coronavirus pandemic
You may read my article on Covid-19: Did governments handle the pandemic effectively?
Is there an ideal healthcare system?
No. I think an ideal system globally does not exist as all have flaws. Some healthcare systems are good, such as in Sweden, Taiwan, Australia, Germany, and Canada, but they still have problems, most importantly, funding. For example, in March 2016, junior doctors in the UK went on strike, complaining about pay cuts and exhausting working hours. In many Western countries, problems still show that healthcare systems are not flawless.
In the UK, a junior doctor is paid only 25,000 pounds annually, nearly 32,400 dollars! With this meager income, a junior doctor had to pay numerous obligations, such as renting a costly (nearly 1,000 dollars) small apartment in London. In the British National Health Service (NHS), things are predicted to deteriorate, as it is financially unsustainable, and some speak even about its (semi)privatization, as in the USA!
In Australia, the healthcare system is satisfactory. Still, I cannot forget the 7 hours my grandmother said she spent in the emergency department (ER) in a Sydney hospital until a doctor examined her! My grandmother was carried there after falling from the chair while hanging the curtains. Although that occurred many years ago, it is not something negligible.
Is the American healthcare system the best?
No, the U.S. healthcare system is not the best. The American healthcare system is semi-private. It is manipulated by insurance companies, and only patients who can afford financially can access better healthcare, including expensive imaging tests. In the past, patients in American hospitals who did not have money to pay were dumped from the hospitals!
Two cases show that the USA's Emergency Medical System (EMS) is not optimal. On May 25, 2020, in Minneapolis, a police officer with his knee choked to death a black man! A video released a couple of months later shows that in the above murder, the paramedics delayed confirming the cardiac arrest and defibrillating the victim immediately. It was a police officer who started CPR inside the ambulance while the paramedics neglected to begin the ALS (or at least the BLS) protocol immediately. You may watch the shocking video at https://www.youtube.com/watch?v=VhwxGzYU2ts&t=1453s and https://www.youtube.com/watch?v=NjKjaCvXdf4&bpctr=1598737360 and https://www.youtube.com/watch?v=YPEJwoXsKy4
A similar event happened on July 17, 2014, with a black man in New York who died when a police officer ''restricted'' him with a chokehold. Similarly, although the black man was in cardiac arrest, the raw video does not show any immediate on-scene resuscitation, such as CPR and, if shockable rhythm, defibrillation by the paramedics. Ironically, the priority of the police officers was to pass handcuffs to the man who was already in cardiac arrest rather than performing chest compressions before the ambulance arrives! You may watch the full raw footage at https://www.youtube.com/watch?v=24PAhUhnACo and https://www.youtube.com/watch?v=z0j-7L094d0
The above videos not only show police brutality in the USA but also that the healthcare system is not as perfect as many think, as the paramedics failed even on the basics!
Is the British healthcare system (NHS) the best?
No, the British National Health Service (NHS) is not the best either! After the COVID-19 crisis, it is on the verge of collapse! It will probably become private! The waiting surgery and hospital care lists in the UK are long, and the system is unsatisfactory despite the myriad of theoretical standards. Other systems, such as Sweden, Taiwan, Australia, and Canada, are much better.
We always think that whatever is American is the best. This is not the case in real life, at least in medical care. For instance, healthcare in trauma, surgery (especially spine surgery), and neurology in Germany are excellent. Also, research in Germany, especially neuroscience research at the Max Planck Institute, is promising.
The following video shows an alleged medical negligence case resulting in a woman's death during an operation. You may watch the video at https://www.youtube.com/watch?v=VndU2zap_Rg The video shows that things are not such ideal as we presume!
In the UK, there are myriad standards that the system supposedly has and expects from its personnel. However, the problem is the lack of citizens' rating of the system. So, despite these standards, their practical implementation is an issue. Undoubtedly, the NHS is problematic. Brexit and the coronavirus pandemic are expected to make matters worse.
The NHS is not flawless, as some wrongly believe. There are many cases of negligence that show that it malfunctions. When I visited London some years ago, a student said that when he was transferred to the emergency department suffering from a seizure, he was not assessed with a CT scan, although it was his first fit. I guess it was not cost-effective! Cost-effectiveness was also a reason for not offering life-saving interferon to patients with multiple sclerosis. Another case was of a friend who told me that some years ago, his schoolmate waited with a broken arm in the emergency department of a hospital for more than an hour to be seen by a doctor.
Recently, a trainer orthopedist in an ATLS course who had worked as a registrar in the UK said that when a patient suffered a cardiac arrest, he called an anesthetist to intubate him. But the anesthetist was at the theater for an operation while the second anesthetist was on-call at home! Hopefully, he arrived fast as his house was nearby. But in an arrest, time is life, so even the short delay was significant!
The most significant drawback of the NHS is the long waiting list for operations and exams that makes many British people travel abroad for surgery! A British friend whose wife was pregnant found it easier and faster to travel to Greece, where his wife did all the pregnancy preventive tests for free!
I also recall a documentary about an old UK man who visited the ER suffering from mesenteric ischemia. Although this is fatal unless treated surgically, he was excluded from surgery ought to various medical conditions (including epilepsy), i.e., comorbidities. Of course, he died. However, in this case, the patient had no choice but surgery, as no surgery condemned him to death. Things here are complicated, as many surgeons are assessed for their mortality rate and would avoid operations with a high mortality risk! But it should be the patient who should come first, not the statistics!
Are English medical books the best?
Many English books or Kindle editions, such as the Oxford Handbooks and Harrison's Principles of Internal Medicine, are exceptionally good. But they are not flawless. You may read my review of the Oxford Handbooks at Medical Oxford Handbooks (Oxford University Press): My Review & Remarks The article was initially an email to them that they never replied to, so I decided to post it publicly on my blog!
However, other than the British and American bibliography is also good. For instance, a healthcare professional may find excellent German anatomy (such as the book of Heinz Feneis), neurology (such as Peter Duss), and surgery books.
Does a perfect health system exist worldwide?
No, I am not aware of any perfect system. In the US, the current populist president threatens to revoke the ''Obamacare'' in which the system becomes less dependent on insurance companies while the state funds the uninsured patients previously dumped from the hospitals! Even in the UK, the NHS (National Health Service) has many problems, with the most significant related to its funding. A considerable problem is that many posts, covered mostly by international doctors, are service instead of training. Hence, they are not educational, approved by a Dean, but we have a service type of doctor like an employee.
Additionally, the fact that the population in Western countries is becoming older means that there is less working-age population to pay for the healthcare and pensions themselves and the existing pensioners. Consequently, healthcare has less money to work efficiently. The expensive immunotherapy drugs deteriorated the national health system funding problem, as each injection cost is estimated at least 500 dollars/ Euros.
Are the NHS in the UK and Medicare in the US the best healthcare systems?
It is doubtful whether the NHS in the UK and Medicare in the US are the best healthcare systems. I am not sure if they are even satisfying! The question is, who does the rating? The evaluation of a healthcare system should be performed by independent international authorities, such as the World Health Organization (WHO), rather than local such as NICE in the UK.
Regarding the National Health Service (NHS) in the UK, although its myriads of ‘standards,’ it has many flaws, such as the long waiting lists for surgeries, as well as the fact that most foreign doctors run the system offering service instead of sustaining official (having the educational and Dean’s approval) training. Another significant issue is the recent underfunding of the system, which worsened after Brexit. Already the wages and working conditions of junior doctors have caused frustration!
According to Public Health England’s annual health profile, British women have the lowest life expectancy in Europe at birth, at 83 years! The longevity in the UK is ranked 17th out of 28 European Union (EU) nations! Women born in England can expect, on average, to spend 19.3 years, 23 percent of their lives, in poor health! Statistics for men in the UK are slightly better.
According to Public Health England’s annual health profile, British women have the lowest life expectancy in Europe at birth, at 83 years! The longevity in the UK is ranked 17th out of 28 European Union (EU) nations! Women born in England can expect, on average, to spend 19.3 years, 23 percent of their lives, in poor health! Statistics for men in the UK are slightly better.
Regarding the US, the Medicare system is manipulated by the insurance companies that always aim at spending less money on the patients’ treatment. This tactic negatively affects their health when important lab and imaging tests and interventions are omitted! Additionally, before the ‘Obama Care’ in 2010, uninsured patients had no access to the healthcare system, while those treated for emergencies were dumped from the hospital after recuperation! US resident doctors (not specialists) are also said to be treated like slaves!
The latest statistics in the US show, as in the UK, that the figures are unsatisfactory. Americans' new average life expectancy is 78.7 years, ranking the US behind other developed nations and 1.5 years lower than the Organization for Economic Cooperation and Development (OECD) average life expectancy of 80.3!
The latest statistics in the US show, as in the UK, that the figures are unsatisfactory. Americans' new average life expectancy is 78.7 years, ranking the US behind other developed nations and 1.5 years lower than the Organization for Economic Cooperation and Development (OECD) average life expectancy of 80.3!
Private vs. Public Healthcare system
There is controversy over the ideal system; some argue that it should be public, while others insist it should be private. In the US, contrary to common belief, the Medicare system is a public-private partnership, while the decisions to pay claims are made by private companies! Contrary, in the UK, the NHS is public. Both systems have flaws, most importantly, their funding. The overpopulation in Britain and the increased demand to treat senior citizens with infirmities have brought the NHS system to its knees. Things in the UK are getting worse, as the waiting lists for visiting a specialist and surgery are often so long that a patient may seek another European hospital with a shorter waiting list.
On the other side of the Atlantic, in the US, before Obamacare, uninsured patients were dumped from hospitals after receiving first aid! Statistics show that healthcare expenditure in the US is the highest compared to other countries. However, a substantial proportion of the population, including children and the impoverished, are uninsured or ''under-insured''! For example, this may be an individual's choice to work without insurance in a job or as a freelancer, with the former being illegal and the latter a reckless choice that the uninsured will understand eventually when they become old or if an unexpected illness or injury comes.
Putting it all together, an ideal system is between private and public, with cooperation in receiving patients and undertaking lab and imaging exams.
Private vs. Public healthcare: Which system is to the benefit of the patient?
Let us imagine a patient who suffers from a medical problem and is hospitalized. The patient will be treated well in a public hospital, but when the hospital is overcrowded, less attention may be paid, and earlier discharge may occur, as every available bed is valuable! Suppose the patient needs to be hospitalized in an ICU (intensive care unit). In that case, specific criteria may exclude them, such as extreme age, ominous prognosis, if the illness is incurable, etc.
Suppose the same patient is hospitalized in a private hospital and can afford to pay his or her expenses without the interference of a private insurance company. In that case, the patient can receive optimal treatment in a well-organized private hospital with more skilled doctors (mostly specialists), and ICU admission criteria may be less strict! However, in case the private hospital's expenses are paid by a private insurance company, then healthcare may be suboptimal, as the insurance company will cut many expenses that are not always unnecessary. That means the patient will receive at least the basics. However, depriving the patient of the expensive lab and imaging tests or access to the ICU (in which the daily cost is huge, for example, it may be $ 3,000 per day) may affect the outcome.
As mentioned above, the ideal system may be between a private and a public healthcare system. But as public or private insurance is associated with pensions and healthcare, things are more complicated, and since the population is aging, it may become unsustainable!
Are there any satisfying Western healthcare systems?
I am unsure if there are any satisfying Western healthcare systems, as the problem is who does the rating, i.e., whether it is independent. Countries such as Scandinavia, Canada, Australia, and New Zealand allocate public funds from taxation to finance their national health system to which everyone has free access. These countries have succeeded in providing satisfying effective healthcare for their citizens, not theoretically as in the UK, which has myriads of standards. In contrast, the system still has many problems, with funding being the most important.
Which are the two most important causes that hamper Western healthcare systems? Was migration to Europe a practical solution?
The most noble cause that hampers all the Western healthcare systems is the aging of the population! The population in most Western countries is aging. As a result, more money is spent on treating various diseases of the pensioners, and less money is collected from the insurance of the working population that shrinks! The problem of aging came to solve the myriads of migrants who were encouraged to migrate to Europe, where labor and skilled technicians are needed desperately, especially in Germany, as the local population is composed mostly of senior citizens! Of course, uncontrolled immigration in Europe had negative ramifications, such as an extra burden for the healthcare system.
Another significant cause that impedes the effectiveness of the healthcare systems is the excessive cost of the new drugs, referring primarily to immunotherapy drugs with usually a minimum value of 500 dollars for each injection! Moreover, the first gene therapies have an enormous cost, 1 to 2$ million per dose! Stem cell therapies are also extravagant. The fact that the aging population deteriorates things further as the cost of novel treatments is extraordinarily high and unsustainable for most healthcare systems to offer treatment options to a society in which senior citizens outnumber the working-age population, meaning that the number of people who need treatment is increasing!
Should doctors be assessed with an appraisal and revalidation system?
Should complaints against doctors be made easier by clicking an option on the General Medical Council's webpage?
This system has efficiently worked in the UK and should be an example for all countries. But the way that anyone can easily make a complaint by merely clicking the option on the General Medical Council may make doctors practice ''defensive medicine'' with an additional cost of unnecessary lab or imaging exams and interventions, even surgeries!
Should emergency medicine doctors in the emergency room (ER) and ambulance paramedics be assessed?
Yes, they should, as they should be controlled and assessed if they perform their job correctly, as guidelines, algorithms, and protocols say. Perhaps, surveillance and body cameras (like the ones the American police officers carry) could be used for this assessment, but I think most will not agree with this. Doctors are already assessed in some countries, such as the UK. However, in many countries, paramedics are usually not assessed. You may watch the above on ''Is the American healthcare system the best?'' the videos in which the paramedics in the USA failed even on the basics!
Procedures that can be performed by nurses
Often doctors do jobs that can be done by nurses. For instance, in German hospitals, I was informed by a colleague that the intravenous (IV) line placement for fluid administration is performed by doctors, not nurses, contrary to the UK and the US, where nurses (and paramedics) have advanced responsibilities that in many other countries are held by doctors! In the US, for example, nurses in the ER do an excellent job, while paramedics often offer advanced medical procedures.
That means that in many countries, doctors waste their time on procedures nurses can perform. Additionally, in many countries, senior doctors are on-call at their homes during non-working hours (including afternoons, nights, and weekends). That means that a non-specialist doctor may deal with a medical situation that may be unskilled and inexperienced.
Compliance with working time directives
A widespread issue is that doctors may work overtime in many countries that do not follow working directives, sometimes doing extra work at the end, for instance, to complete medical notes. Of course, they are not paid for these extra hours. In many European countries, the EWTD (European working time directive) is violated, and often doctors are exhausted from their extra shifts and the exhausting working hours without a break or minimal breaks. Apparently, this renders them vulnerable to making mistakes).
Competition
Competition for a medical post is extremely high, and the classic example that comes first to my mind is the UK, where there may even be some hundred applications for a single hospital post. In the last decade, competition has increased dramatically from international doctors, and this was aggravated by the migration surge towards Europe, referring to migrants from Europe (such as from the Balkans and Southern Europe) or migrants coming from countries outside Europe, such as from the Middle East, Asia, Africa, and even from South America!
So, foreign doctors participate as well in the reckless competition for the available hospital posts that, in this way, they become international! The abundance of applicants has consequently covered all the available vacancies, while recently, most vacancies appeal to higher-level doctors, specialists, and consultants. This is most striking in the UK.
Training (vs.) Service posts: wasting time on irrelevant non-training posts until obtaining a specialty!
A problem common in the UK is that most posts are not educational and Dean-approved but are service posts and consequently do not count in the estimation of the training years for completing a specialty! Most of the vacancies in the UK are LAS (locum appointment for Service) rather than LAT (locum appointment for Training). There is controversy over this matter, as some claim it is better not to have service posts, as all posts should be training. Doctors need training. There is controversy over the fact that posts that are not educational and Dean-approved do not count toward the overall period of medical practice. Some believe that regardless of service or training, all working years should count as a specializing period.
Most NHS medical posts in the UK are service posts (as if working in a supermarket), so they do not have the educational and Dean's approval as training posts! So, even if the hospital says they have a training aspect, it may or may not be a training post officially! That means that many doctors in the UK work in various service posts that are often irrelevant to the specialty they wish to practice. For instance, a doctor wanting to specialize in gastroenterology may practice medicine at various clinics, such as the emergency department, as most vacancies are clinical and require experienced doctors even at the Foundation Year 2 level! Thus, a doctor in the UK may spend an overall 7 - 10 years to become a specialist, while in other countries, it may take only 5 to 6 years for most specialties!
Four-month contract, underpayment, and costly accommodation!
Another problem in the NHS of the UK is that most contracts are for four months to a maximum of one year. That means that usually, after four months, a doctor must change hospitals or reapply to the same one! Consequently, the medical training period is interrupted every 4 months until the adjustment to a new hospital.
Additionally, many junior doctors complain that their wages in the UK remain low, despite their strikes. But even for higher levels, the salary is not satisfactory concerning the highest salaries in other Western countries or even the Middle East (such as in Dubai). Also considerable is the excessive cost of living in the UK, especially in London, where someone may pay nearly 1,000 dollars monthly to live in a small apartment! Contrary, in the US, accommodation is more affordable to medics, while some may reduce the cost by living with a roommate.
Overqualified doctors for junior posts!
The extreme number of international applicants in countries such as the UK means that many vacancies, even those involving junior doctors, are covered by overqualified doctors, even specialists! Qualifications such as MRCP exams and sustained experience are often desirable for posts referred to junior doctors, but they should not, as these are higher-level qualifications!
A striking example that came to my attention was a service post (LAS) of Foundation Year 1 in general surgery in the UK that asked a trainee with clinical skills such as venipuncture, insertion of central lines, peritoneal drains, etc. These skills, of course, are extreme for a junior doctor on a foundation year one level. Regarding Foundation Year 1 posts, some vacancies require previous NHS (British National Health Service) experience. However, these posts apply to medical interns who are about to practice in hospitals without clinical experience! The number of doctors who apply for a post is high, especially from India, Pakistan, and Southeastern Europe. Notwithstanding, vacancies often ask for previous hospital working experience, even for junior posts!
A striking example that came to my attention was a service post (LAS) of Foundation Year 1 in general surgery in the UK that asked a trainee with clinical skills such as venipuncture, insertion of central lines, peritoneal drains, etc. These skills, of course, are extreme for a junior doctor on a foundation year one level. Regarding Foundation Year 1 posts, some vacancies require previous NHS (British National Health Service) experience. However, these posts apply to medical interns who are about to practice in hospitals without clinical experience! The number of doctors who apply for a post is high, especially from India, Pakistan, and Southeastern Europe. Notwithstanding, vacancies often ask for previous hospital working experience, even for junior posts!
All the above are related to the abundance of international doctors who apply for medical positions worldwide. Hence, hospitals are happy to use overqualified doctors for low-grade medical jobs, usually service posts, as the educational and Dean-approved training posts are the minority!
The low wages of the medical staff and the unpaid overtime!
In most developing countries, as well as in many developed countries, doctors, especially those of low levels regarding specialization, are paid low wages while working overtime is often unpaid even in developed countries, and this is a kind of exploitation! The salary of the medical professionals working in hospitals should be satisfactory. Otherwise, without a financial incentive, doctors feel frustrated, and their performance remains low.
In the UK, a junior doctor is paid only 25,000 pounds annually, nearly 32,400 dollars! With this meager income, a junior doctor should pay numerous obligations, such as paying nearly 1,000 dollars to rent a small apartment in London. In the British National Health Service (NHS), things are predicted to deteriorate, as it is financially unsustainable, and some speak even about its (semi)privatization, as in the USA!
In the last years, there has been a massive wave of medics from developing countries and even from developed countries (such as from Southern and Eastern Europe) who make applications aiming to work in developed countries such as in Southern and Central Europe and North America where they seek better wages in advanced health systems.
In the UK, a junior doctor is paid only 25,000 pounds annually, nearly 32,400 dollars! With this meager income, a junior doctor should pay numerous obligations, such as paying nearly 1,000 dollars to rent a small apartment in London. In the British National Health Service (NHS), things are predicted to deteriorate, as it is financially unsustainable, and some speak even about its (semi)privatization, as in the USA!
In the last years, there has been a massive wave of medics from developing countries and even from developed countries (such as from Southern and Eastern Europe) who make applications aiming to work in developed countries such as in Southern and Central Europe and North America where they seek better wages in advanced health systems.
Doctors wearing casual clothes!
In the UK, you can see doctors without white coats or scrubs (like those surgeons wear). They simply carry a label with their name! Obviously, it is not for the benefit of the doctor's sanitation to wear casual clothes. A white coat protects the physician as well as the patient. So, from my perspective, wearing casual clothes with only an ID tag signifying that a person is a doctor is unacceptable regarding contaminant disease protection. In the ER, at least an apron should be used for protection.
They removed the lab (white) coat in the UK in 2007. But there are no convincing reasons for not wearing scrubs that are amazingly comfortable, speaking from my own experience! The UK has banned crocks (hospital-comfortable open shoes) since 2011!
Bank doctors!
The new trend in the UK is the post of 'bank doctors.' No, they are not related to banks and finance! They are doctors who 'land with their parachutes' whenever and if needed ('when and if') to cover somebody's days off or leaves or in case a doctor is necessary for a specific clinic. So, these doctors do not have a particular residence, which raises the concern that a doctor comes to work in a hospital unfamiliar to them. The bank post may also be without a contract, meaning the doctor can be easily fired!
Skype pre-interview or direct live interview?
When someone who has applied for a vacancy in countries such as the UK is called for an interview, it is prudent to ask for a video call pre-interview, usually via Skype. This choice will prevent the applicant from wastefully spending money to travel to the UK and learning at the interview that they do not meet the elevated expectations of the hospital, as most posts are covered by overqualified international doctors with sustained experience.
Vacancies for UK hospitals (application forms): Please tell me your ethnic origin, religion, and sexual orientation?
The GMC (General Medical Council) asks the same to enroll as a doctor in the UK. For this article, I called the GMC and asked them why they asked so, and they replied that they do it for statistical reasons to register the diversity. They assured me that this information was confidential. However, I still have not realized the necessity of asking these kinds of questions in the application form for a hospital post. My consideration is especially how an employer will assess this information. Apparently, this information is given to protect applicants from discrimination. But, from my perspective, this should be obvious to everyone, regardless of providing or not this information.
Difficult exams and certifications
Certifications, such as the MRCP (and FRCS for surgeons) in the UK, make things difficult for someone who wishes to complete a specialty and become a consultant. In the US and Canada, the USMLEs (steps 1, 2 & 3) tests are mandatory for someone who wishes to study medicine there. These difficult exams discourage many international students who want to live the American dream.
In the UK, most posts ask for NHS (National Health Service) experience; many ask applicants to have passed the MRCP test (it has fees). Moreover, in the UK, the GMC (General Medical Council) needs, in some cases, the PLAB test, while for proof of English language proficiency, they need an exceedingly high overall score of 7.5 and a minimum of seven on each of the four modules of the IELTS exams to enroll non-native speakers. However, I think this is challenging to achieve in ''writing part 2,'' i.e., the essay! Generally, in academics, even for post-graduate studies applications, an IELTS overall score of 7.5 is high, as they are happy with a lower score such as 6. Surprisingly, the GMC does not recognize the American TOEFL exams, as if in the USA, they are speaking Chinese!
In Australia, there are also exams that an international student needs to pass. The clinical and MCQ exams, the recommended books to read for the exams, as well as the online portfolio of the applicant are costly. The cost to start specializing as a doctor in Australia may reach 5,000 dollars. Additionally, the system has a mandatory one-year clinical practice in Australia. It was something like a rural service in the past, but vacancies can be found everywhere, even in a large city. The Australian Medical Council, apart from IELTS, recognizes TOEFL (IBT), but it needs an extremely high mark on writing. It should be mentioned that the British and Australians have created the IELTS test, which explains why they prefer their exams to TOEFL or other international exams.
According to the above, the widespread belief that Western hospitals in the US and Australia have easy access to international students is a misconception, as they all have ambitious standards to work there.
Different units of measurement and different generics!
Regarding units of measurement (weights and measures), there is a global discrepancy as they differ between countries, and many countries, such as the US and the UK, have different units from other countries. For example, they measure pressure on kPa (kilopascals) and not mmHg; length to feet and inches and not m (meters) and cm (centimeters); weight as pounds (or stones in the UK) or oz (ounce) and not kg (kilograms), etc. Two examples are the partial (arterial) pressure of oxygen (PaO2) and the blood glucose concentration. In the UK, they are measured in kPa and mmol/L, respectively, while in other countries, they are measured in mmHg and mg/dl, respectively.
Unfortunately, although international units exist, there is no consensus for using them worldwide, as many countries stubbornly use their units. In medicine, this is a problem for biochemistry values that may differ between countries. For example, some countries measure a substance as mEq/L while others as mmol/L or mg/dl.
Another discrepancy is with the name of generics. For instance, acetaminophen, epinephrine (epi), and furosemide in the US are called paracetamol, adrenaline, and frusemide in the UK! This may cause confusion, especially to ''international doctors''!
It is obvious that units of measurement should be common globally, and the international system (SI) is suggested. Similarly, generic names should be the same everywhere.
Unfortunately, although international units exist, there is no consensus for using them worldwide, as many countries stubbornly use their units. In medicine, this is a problem for biochemistry values that may differ between countries. For example, some countries measure a substance as mEq/L while others as mmol/L or mg/dl.
Another discrepancy is with the name of generics. For instance, acetaminophen, epinephrine (epi), and furosemide in the US are called paracetamol, adrenaline, and frusemide in the UK! This may cause confusion, especially to ''international doctors''!
It is obvious that units of measurement should be common globally, and the international system (SI) is suggested. Similarly, generic names should be the same everywhere.
Official recommendations vs. anecdotal information or biased articles!
Today's huge problem is that many parents deprive their children of vaccination. This is already considered a form of abuse in some countries, and parents may face legal action. Unbelievably, many people today believe the nonsense they read on the internet or trust the opinion of an actor or celebrity who is not an expert. Vaccination is valuable in disease prevention. The most striking example was the measles mumps and rubella (MMR) combined vaccine that some accused of causing autism. This was never proven scientifically.
However, the first report was not anecdotal or from a celebrity but was published in 1998 in the scientific magazine ''The Lancet''! However, the official organizations found the study biased and unethical. Consequently, it was revoked 12 years later! For further details, you may visit Lancet retracts 12-year-old article linking autism to MMR vaccines
The main issue here is that not only laypeople but also some doctors take into consideration a single study, even if it is of low value, for assorted reasons such as statistical flaws, low sample, no placebo/ control group, short duration, in vitro rather than in vivo, conflict of interest, bias, etc. So, people, especially doctors, should only trust recommendations by official medical organizations and keep in mind that a single study says nothing. More reliable may be a Cochrane review and metanalysis that first assesses the quality of the relevant studies and then concludes if therapy is effective or if a medical condition is associated with something. Journalists are often interested in selling their stories, so they may find a published study striking, but as mentioned, a single study may be worthless and misleading! Hence, it is prudent to seek the official recommendations of medical organizations. But through time, these changes. For example, in the past, doctors prevented people from eating eggs with a limit of 3 eggs per week, while recently, they have said that it is OK to eat one every day for all but hyperlipidemic patients!
Cost-effectiveness!
Nowadays, cost-effectiveness is mandatory as the health systems have already been brought to their knees because of the aging population. They struggle to provide expensive drugs, especially immunotherapy and gene therapy. However, this should not be done at the expense of the patient's safety. An example was the controversy over depriving British patients of interferon for Multiple Sclerosis in the NHS, while in other European countries, it was widely used. A recent example is the new expensive meningitis group B vaccine that many health systems cannot afford, so families purchase it at their own expense. Briefly, cost-effectiveness should always be sought, but we should keep in mind that in medicine, humans come first, not the economy!
The need for international guidelines rather than local ones!
Nowadays, it is unacceptable for every country to have its own guidelines. Often hospitals have their own protocols, even in the same country! I once met a student in London who said he visited a hospital with a first-time episode of seizures. I asked them if they had performed a CT, and he replied negatively. However, a CT and MRI may reveal an epileptogenic lesion in nearly 30 percent of patients with a first-ever seizure. In any case, weighing cost-effectiveness may sometimes be detrimental!
Another example is the controversy mentioned above over depriving British patients of interferon for Multiple Sclerosis in the NHS, while in other European countries, it has been widely used. A third example is that for cardiac arrest or arrhythmia, someone may read the guidelines of the UK Resuscitation Council, the European Resuscitation Council, and the ACLS of the American Heart Association. Often, instructions from different medical associations may differ.
These three examples show the necessity for international guidelines, algorithms, and protocols after a global consensus and to avoid discrepancies between countries and between hospitals in the same country!
Following international guidelines, algorithms, and protocols
A critical problem is that there is no consensus on issuing international protocols that could be published by the WHO (World Health Organization). Consequently, there is a discrepancy regarding this issue, as many countries have their own guidelines, algorithms, and protocols. There is confusion about who is right and whose recommendations are correct or evidence-based!
An example of the discrepancy between different countries is, regarding advanced life support, the ALS (advanced life support) of the ERC (European Resuscitation Council) in Europe (although the UK has its own resuscitation council and its rules), and the ACLS protocols of the American Heart Association (AHA) in the US. Another example regarding trauma (injury) is the ATLS (advanced trauma life support) of the American College of Surgeons (ACS) and the ETC (European Trauma Course) in Europe.
All the above courses have differences that may be significant. For instance, the Americans say that on an unwitnessed arrest, the rescuer should perform one and a half to 3 min of CPR before defibrillation (electric shock). Contrary, the Europeans say that in case of a shockable rhythm in a cardiac (heart) arrest, immediate defibrillation is required!
Often, on the internet, someone may find many algorithms from various reliable sites (such as Medscape and UpToDate) for the same medical problem, such as the diagnostic approach of pulmonary embolism or dealing with an adrenal mass accidentally found on a CT or diagnostic in amenorrhea or tachyarrhythmia (fast heart rate) or osteoporosis treatment, etc.
As there are no international guidelines, algorithms, and protocols, we can speak about a Babel regarding units of measurements and instructions, protocols, and algorithms, such as the Biblical Tower, where people could not communicate as they spoke different languages! Thus, there is a dissimilarity between medical practices worldwide.
In some countries, the medics still use the obsolete precordial thump on a witnessed cardiac arrest from ventricular arrhythmia, but others find it meaningless. Even drugs differ between countries. For example, in the US, they may use beryllium. Still, other countries prefer amiodarone as an antiarrhythmic (although it may decrease blood pressure and cause thyroid problems) or use esmolol (fast-acting) or flecainide.
Also, in some countries, they use lorazepam as a sedative or for convulsions, while in others, they use diazepam (Valium(R)); or may use ketamine as an anesthetic in emergencies (although it may cause hallucinations and dissociation, it is helpful in case of asthma while some may use it in pediatric emergencies) while others don't.
Additionally, in some countries, they use denosumab for osteoporosis while others prefer the less expensive older bisphosphonates; or may use warfarin as a blood thinner for stroke prevention in case of an arrhythmia called atrial fibrillation or DVT (deep vein thrombosis)/ thrombophilia while others use modern drugs such as rivaroxaban or dabigatran.
Even in blood malignancies, US guidelines do not have an age limit for a receiver of bone marrow transplantation, but Europeans do. Another example of a discrepancy is analgesics (painkilling medication) that in some countries are avoided in emergencies, including surgical cases (such as acute abdominal pain), to prevent covering the symptoms or because they have not the experience to administer analgesia or are afraid of respiratory compromise by the opioids.
However, other countries find it cruel to let the patient suffer from pain. They pay attention to analgesia in emergencies, including trauma & orthopedics, and pediatrics (related to children). Another example in many countries is that they have no antidotes for poisons such as cyanide poisoning (a common cause is smoke inhalation from burning plastics or bitter almonds consumption or some drugs). Moreover, emergency medicine as a separate specialty does not exist even in developed countries such as Greece. In many developing and some developing countries, the Emergency Department and the clinics (during the afternoon, night, and weekend) work mainly with specializing doctors, often unsupervised, while TRIAGE (case sorting) does not exist.
Unsatisfactory wages
In many countries, wages have always been low or lower than in the past. A satisfactory salary should consider the cost of living in expensive cities as, for example, in London, most money goes to house rent and taxes. On the other hand, medicine has lost the prestige it used to have in the past because there are plenty of available doctors now. However, it is more prudent for health systems to pay more attention to the quality of the doctors rather than their quantity, as medical education worldwide remains unsatisfactory, and evidence-based medicine is still an issue in many countries, even developed, where medicine is still practiced empirically.
The lack of a second medical opinion and avoidance of surgeries in the elderly!
Often people diagnosed with cancer or another severe disease, acute or chronic, do not seek a second medical opinion as either they neglect it or rely on and trust the first and single medical advice.
Senior patients also have the right to a second opinion regardless of age, especially for life-threatening conditions. This is especially important when urgent or elective surgery is excluded. Otherwise, we can speak about a subtle form of euthanasia! I recall a documentary about an old UK man who visited the ER suffering from mesenteric ischemia. Although this is fatal unless treated surgically, he was excluded from surgery ought to various medical conditions (including epilepsy), i.e., comorbidities. Of course, he died. However, in this case, the patient had no choice but surgery, as no surgery condemned him to death. Things here are complicated, as many surgeons are assessed for their mortality rate and would avoid operations with a high mortality risk! But it should be the patient who should come first, not the statistics!
I once asked a Southern European surgeon who works in the NHS if the elderly with cancer are treated as in his country. He replied that a surgeon in the UK might be reluctant to bring a senior citizen into the operating room. However, in other countries, surgeons may be less reluctant! From my perspective as a medic, a relatively good cardiovascular condition and the lack of severe comorbidities are conditions that the elderly should not be excluded from surgery. Cardiovascular health should be investigated with ECG, Echocardiography, and pulmonary function tests, especially FEV1.
That is especially important for life-threatening diseases such as cancer and CABG (coronary artery bypass) for heart problems. Of course, the patient will take the mortality risk. But the problem here is that if the mortality ratio of each surgery is documented, a surgeon will not be happy if a senior patient dies. Consequently, surgeons will discourage or refuse operations in elderly patients who otherwise are fit for surgery. That is a shortcoming of reporting mortality rates in operations.
Heart attack, stroke & cardiovascular disease risk factors
Cardiovascular (heart attack) or cerebrovascular (stroke) disease are the leading causes of death after mid-age. However, most of the modifiable risk factors for these diseases are preventable. The modifiable cardiovascular disease (CVD) risk factors related to coronary artery disease (CAD) and stroke include: tobacco use (smoking), hypertension (high blood pressure), dyslipidemia (increased blood fats such as cholesterol and triglycerides), diabetes mellitus (elevated blood sugar), a diet rich in saturated fats and carbohydrates, being overweight or obese, heart failure and left ventricular dysfunction, specific behavior (being competitive or combative or feeling overly stressful, as most people do) and sedentary lifestyle (lack of physical activity as the youth whose only exercise is texting and posting on their social media), depression, increased blood fibrinogen (which is a factor of blood clotting), increased blood homocysteine (congenital with premature atheromatosis or from decreased intake of vitamin B12, B6, and folic acid).
Most people neglect to control the modifiable risk factors for cardiovascular disease that may lead to myocardial infarction (heart attack), cerebrovascular accident (stroke), and also on peripheral artery disease (PAD). Many people continue to eat junk food and do not mind if lipids (such as cholesterol) will obstruct their arteries, causing a heart attack. Most people never or rarely check their blood pressure, another risk factor for stroke and heart attack. Other hypertensive people (with high blood pressure) or dyslipidemia (high blood fats such as cholesterol & triglycerides) continue eating salt and junk food rich in ‘trans’ fat, respectively. Most people have a sedentary life and never or rarely exercise.
Unfortunately, many people do not mind at all modifying their risk factors such as cutting smoking, eating a healthy diet (deficient in fats, sugar, and salt), reducing their weight (if obese or overweight), regularly exercising (such as to go for jogging), control their blood pressure (the most important is to avoid salt) and blood sugar levels, etc.
Many, if not most, people modify their risk factors only after a severe disease such as a heart attack. However, this severe disease (e.g., heart attack) may often present with sudden cardiac death (SCD)! But apparently, SCD could be prevented merely by controlling the modifiable risk factors such as high blood lipid levels (with a statin drug or a plant sterol if not so high) or high blood pressure (avoiding salt, losing weight if obese, and taking an antihypertensive drug if it remains high).
Hippocrates (c. 460 – c. 370 BC), the father of medicine, used to say that ‘prevention is better than treatment.’ Today, even though many sophisticated medical tests exist (lab or imaging tests), people neglect to modify their risk factors and prevent cardiovascular diseases. Many people do not even do regular medical blood checkups.
Unsupervised practice and lack of immediate help when needed!
The unsupervised practice of doctors who are not specialty registrars or consultants (i.e., are non-specialist doctors) is, in many countries, even developed, a significant problem, and this is especially important when the unsupervised medic is on duty and has a shift. Additionally, when non-senior doctors are on duty, and a senior doctor is on-call at home, they do not have immediate support in a complicated case when they need it.
Sometimes, senior doctors discourage lower-grade doctors from consulting them regarding problems they deal with, which is unacceptable. Unsupervised practice and unavailable immediate (and not through a phone line) provision of information by an experienced doctor are vital issues that compromise a patient's safety and proper handling of any medical problem.
The need for innovative technology
Most hospitals worldwide, even in the West, lack innovative technology such as DaVinci robotics, telemetry, PET-CT, functional MRI, VATS, laryngoscope with a camera, etc. Innovation is essential today, and currently, there is a development of sophisticated software that will assist in the Chest X-ray (CXR) interpretation as well as in the diagnosis of various conditions using diagnostical algorithms. Most hospitals do not use battery-powered cardiopulmonary resuscitation devices, such as LUCAS and AutoPulse (TM), that perform cardiac compressions. These are important, as the central issue in cardiopulmonary resuscitation is the inferior quality of chest compressions in cardiac arrest.
Innovative technology may also be used educationally with virtual anatomy and surgical procedures using computer 3D images (with ''joysticks'' for surgery) and synthetic cadavers in the gross anatomy class!
Black humor and posting medical cases on social media
The unsupervised practice of doctors who are not specialty registrars or consultants (i.e., are non-specialist doctors) is, in many countries, even developed, a significant problem, and this is especially important when the unsupervised medic is on duty and has a shift. Additionally, when non-senior doctors are on duty, and a senior doctor is on-call at home, they do not have immediate support in a complicated case when they need it.
Sometimes, senior doctors discourage lower-grade doctors from consulting them regarding problems they deal with, which is unacceptable. Unsupervised practice and unavailable immediate (and not through a phone line) provision of information by an experienced doctor are vital issues that compromise a patient's safety and proper handling of any medical problem.
The need for innovative technology
Most hospitals worldwide, even in the West, lack innovative technology such as DaVinci robotics, telemetry, PET-CT, functional MRI, VATS, laryngoscope with a camera, etc. Innovation is essential today, and currently, there is a development of sophisticated software that will assist in the Chest X-ray (CXR) interpretation as well as in the diagnosis of various conditions using diagnostical algorithms. Most hospitals do not use battery-powered cardiopulmonary resuscitation devices, such as LUCAS and AutoPulse (TM), that perform cardiac compressions. These are important, as the central issue in cardiopulmonary resuscitation is the inferior quality of chest compressions in cardiac arrest.
Innovative technology may also be used educationally with virtual anatomy and surgical procedures using computer 3D images (with ''joysticks'' for surgery) and synthetic cadavers in the gross anatomy class!
Black humor and posting medical cases on social media
Black humor is more prevalent in the USA with expressions such as ''man vs. car,'' etc. It is unacceptable. Another problem is posting a medical case on social media for various reasons. For example, a nurse was fired for posting an ER photo on Instagram with the caption ''#Man vs 6train,'' for a man hit by an NYC subway train. You may read the story at Nurse Firing Highlights Hazards of Social Media in Hospitals
b) RECOMMENDATIONS
i) Emergencies
ii) General
ii) General
i) Emergencies
I have published a particular text Emergency medicine system: suggestions for improvement worldwide
How to deal with emergencies, including sudden cardiac arrest (SCA)
It is unacceptable that many people today do not know how to perform CPR (cardiopulmonary resuscitation) to resuscitate a victim with a cardiac arrest but wait for the ambulance, which may delay. After all, in the case of a cardiac arrest without resuscitation, the deadline to avoid permanent brain damage is only 10 minutes from the arrest! Commonly ambulances may arrive on the scene in more than 10 min. Moreover, most people do not know how to perform the Heimlich maneuver to resuscitate a victim from choking. It is disappointing that contemporary people know to use complicated devices (including their smartphones and tablets) but do not know CPR and know how to use an automated external defibrillator (AED ) in the community to perform an electric shock to save the life of someone in a cardiac arrest. But even if they knew this, there are not enough AEDs distributed in the community! But first, prices of AED need to be reduced (medical devices were always overcharged) so that every building has its own AED. We must consider that a cheap AED may cost about one thousand dollars, which is not so costly for someone who spends nearly the same amount on an iPhone smartphone!
It is unacceptable that many people today do not know how to perform CPR (cardiopulmonary resuscitation) to resuscitate a victim with a cardiac arrest but wait for the ambulance, which may delay. After all, in the case of a cardiac arrest without resuscitation, the deadline to avoid permanent brain damage is only 10 minutes from the arrest! Commonly ambulances may arrive on the scene in more than 10 min. Moreover, most people do not know how to perform the Heimlich maneuver to resuscitate a victim from choking. It is disappointing that contemporary people know to use complicated devices (including their smartphones and tablets) but do not know CPR and know how to use an automated external defibrillator (AED ) in the community to perform an electric shock to save the life of someone in a cardiac arrest. But even if they knew this, there are not enough AEDs distributed in the community! But first, prices of AED need to be reduced (medical devices were always overcharged) so that every building has its own AED. We must consider that a cheap AED may cost about one thousand dollars, which is not so costly for someone who spends nearly the same amount on an iPhone smartphone!
Every building should have its AED, and volunteers should be skilled in using it. In Italy, in a small city, a group of volunteers uses their cars to reach and resuscitate victims of cardiac arrest using AED and CPR. It is crucial to teach first aid lessons in high schools. It is unacceptable for students to learn mathematics, science, and other complicated lessons but not to learn how to perform CPR and use an AED. First Aid class should include CPR on adults, children, and infants, using AED, and managing choking on infants and adults. Moreover, the government should distribute AEDs in the community in busy public places such as malls, schools, crowded beaches, airports, etc.
Courses in hospitals and the community on Basic life support (BLS), CPR (Cardiopulmonary resuscitation), using an AEA (automated external defibrillator) & performing the Heimlich maneuver
The ambulance service could organize courses for citizens to teach them BLS (Basic Life Support) focusing on cardiopulmonary resuscitation (CPR), the use of an automated external defibrillator (AED) in cardiac arrest, as well as dealing with choking in adults (Heimlich maneuver) and infants. In these seminars, dummies are used for practicing BLS.
AEDs (automated external defibrillators) in critical points in the community
AEDs (automated external defibrillators) should be dispersed in the community at key points such as crowded places, for instance, museums, airports, and malls. From my perspective, every building should have its defibrillator. Its cost has decreased lately and will drop further if mass production occurs. I just searched eBay and found that the cheapest used AED costs only $294 (254 euros), less expensive than the latest iPhone, which costs 800 - 1,000 dollars! The cheapest unused AED costs $1200 (1037 euros), slightly costlier than the most recent iPhone!
All hospitals should use battery-powered cardiopulmonary resuscitation devices, such as LUCAS and AutoPulse (TM), that perform cardiac compressions. These are important, as the central issue in cardiopulmonary resuscitation is the inadequate quality of chest compressions in cardiac arrest. I think these devices should also be in the community, public places, and AEDs (automated external defibrillators).
Emergency medicine courses for doctors and nurses
It is necessary for all medical and nursing personnel to be trained in BLS (Basic Life Support), including cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED; heart ‘shock’ device), as well as the treatment of choking in adults (Heimlich maneuver) and infants. In all hospital clinics, an automatic external defibrillator and an 'Ambu' type bag mask with a reservoir should be available in an emergency, including cardiac arrest. Health professionals (including doctors and nurses) must know how to use them. BLS & using AED courses can be organized by the ambulance system (EMS) and the hospital's anesthesiology department. The basic life support (BLS) seminar should be mandatory for all doctors and nurses and annually repeated, as all the medical and nursing staff should be familiar with CPR and the use of an automated external defibrillator (AED), to know how to deal with a cardiac arrest inside or outside the hospital.
Hospitals and health centers should organize emergency medicine seminars and courses for all medical and nursing staff, especially those dealing with emergencies. In case of emergency, all clinics should know how to effectively give rescue breaths with an ‘Abu’ type bag mask. A self-inflating bag with a reservoir can be connected to an oxygen cylinder to give 90% - 100% Oxygen. This is far more than the 30% oxygen, which gives a simple face mask. An oropharyngeal airway is also useful to prevent the tongue from obstructing the airway and establish the airway’s patency. The ‘Venturi-type oxygen mask is also used to administrate a specific percentage of oxygen.
Courses and seminars on emergencies are necessary for staff (doctors and nurses) working in the emergency department (ED) in hospitals and district health centers to become familiar with resuscitation equipment and medications and know all the algorithms for resuscitation.
Emergency medicine courses for emergency department (ED) doctors and nurses
The emergency department (ED) of hospitals and health centers should regularly organize seminars for the resuscitation of emergencies such as endotracheal (ET) intubation, laryngeal mask placement, ventilation with bag-mask with reservoir, defibrillation in arrest, cardioversion of life-threatening tachyarrhythmias, treatment of severe bradycardia, heart attack, and stroke diagnosis, immobilization of injured, ABCDEs assessment on trauma, etc. The emergency seminars should involve adults (seminars ALS, ACLS), children (seminars APLS, EPLS), and trauma (seminars ATLS, PHTLS, and ATCN for nurses). Training may include a variety of these courses.
Which are the emergency medicine courses?
The official emergency medicine courses are:
• BLS (Basic Life Support) for all doctors and nurses. This seminar also applies to the public. It includes cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED), as well as the treatment of choking in adults (Heimlich maneuver) and infants.
• ALS (Advanced Life Support) / ACLS (Advanced Cardiac Life Support) and AMLS (Advanced Medical Life Support) for doctors dealing with emergencies (such as emergency and acute medicine doctors) and nurses involved in emergencies.
• Airway, ECG (electrocardiogram) & pharmacology (drug administration) courses are additional courses for emergencies.
• Airway, ECG (electrocardiogram) & pharmacology (drug administration) courses are additional courses for emergencies.
• GEMS (Geriatric Education for Emergency Medical Services) for geriatric (elderly) patients (most of the patients in hospitals).
• APLS (Advanced Pediatric Life Support) / EPLS (European Pediatric Life Support), NLS (Neonatal / Newborn Life Support) for emergency medicine doctors, pediatricians, and nurses involved in emergencies on children. It should be mentioned that many medical facilities have no specialized emergency rooms and specialists, or emergency pediatricians, for children, but an emergency medicine doctor treats pediatric cases in addition to adults. There is also a course called ALS (Advanced Life Support) – PEPP (Pediatric Education for Pre-hospital Professionals) for prehospital professionals.
• ATLS (Advanced Trauma Life Support), ETC (European Trauma Course), and ATT (Assessment & Treatment of Trauma) for those dealing with trauma.
• ATCN (advanced trauma care for nurses) for nurses occupied with trauma.
• PHTLS (Pre-Hospital Trauma Life Support) for ambulance rescuers (paramedics).
• ALSO (Advanced Life Support in Obstetrics) for obstetricians and those involved in emergencies that may face an obstetric emergency.
The ED (emergency department) of hospitals and health centers should regularly organize courses for resuscitation in emergencies based on the above seminars.
These seminars must be repeated after at least four years (but they may be repeated earlier). However, the clinics may frequently organize lessons based on these seminars. Medical and nursing staff involved in emergencies should be familiar with emergency algorithms.
The ED (emergency department) of hospitals and health centers should regularly organize courses for resuscitation in emergencies based on the above seminars.
These seminars must be repeated after at least four years (but they may be repeated earlier). However, the clinics may frequently organize lessons based on these seminars. Medical and nursing staff involved in emergencies should be familiar with emergency algorithms.
Incidents of mass destruction
Cases of mass destruction require the organization of the available emergency services. The triage on the scene must be done by a specific doctor who should not be tempted to treat the patients but only to triage which patient needs immediate resuscitation. Separate team leaders are required for the police, the fire brigade, and the ambulance service. A specific individual should coordinate the resuscitation as a chief officer. Receiving hospitals should be informed to employ all their personnel (those in their homes should be called immediately, regardless of whether they are or are not on-call). Other hospitals should be employed if a receiving hospital’s facilities are saturated.
Cases of mass destruction require the organization of the available emergency services. The triage on the scene must be done by a specific doctor who should not be tempted to treat the patients but only to triage which patient needs immediate resuscitation. Separate team leaders are required for the police, the fire brigade, and the ambulance service. A specific individual should coordinate the resuscitation as a chief officer. Receiving hospitals should be informed to employ all their personnel (those in their homes should be called immediately, regardless of whether they are or are not on-call). Other hospitals should be employed if a receiving hospital’s facilities are saturated.
Ambulance drones!
An ambulance takes an average of 10 minutes to get to the scene of an accident. This time is too late for help in some cases, such as severe bleeding or cardiac arrest. In the Netherlands, they created ambulance drones carrying a defibrillator that can be used in case of cardiac arrest, where it arrives very fast, faster than an ambulance! You may watch the video at https://www.youtube.com/watch?v=y-rEI4bezWc Other ambulance drones resemble an ambulance called Emergency Doctor Drone (EDD). You may watch the video at https://www.youtube.com/watch?v=lhsiGmdOa5s
An ambulance takes an average of 10 minutes to get to the scene of an accident. This time is too late for help in some cases, such as severe bleeding or cardiac arrest. In the Netherlands, they created ambulance drones carrying a defibrillator that can be used in case of cardiac arrest, where it arrives very fast, faster than an ambulance! You may watch the video at https://www.youtube.com/watch?v=y-rEI4bezWc Other ambulance drones resemble an ambulance called Emergency Doctor Drone (EDD). You may watch the video at https://www.youtube.com/watch?v=lhsiGmdOa5s
ii) General recommendations
The need for international guidelines rather than local ones!
Nowadays, it is unacceptable for every country to have its own guidelines. Often hospitals have their own protocols, even in the same country! An example is cardiac arrest or arrhythmia. Someone may read the guidelines of the UK Resuscitation Council, the European Resuscitation Council, and the ACLS of the American Heart Association. Often, instructions from different medical associations may differ.
The necessity for international guidelines, algorithms, and protocols after a global consensus is apparent. With international protocols, discrepancies between countries, and even hospitals in the same country, will be avoided!
The institution of general practitioner (GP)/ family doctor
Many countries, such as the UK, have the essential institution of general practitioner (GP)/ family doctor (family physician; the word ‘physician’ in the US English means doctor). The family doctor is the cornerstone of the system as it facilitates patients' access to a general practitioner (GP) in their district for free as the state pays the GP. Importantly, a GP gives medications, or when the incident is urgent (as the ambulance system handles emergencies) or needs further investigation, the GP refers the patient to the hospital for further treatment and writes a referral note for the receiving doctors. The general practitioner may even visit a patient at home or at an emergency scene, but this may occur at extra cost.
In the UK, all specialties are ‘house’ officers working inside the hospital, while the GP usually practices medicine privately in the community. GP's role is essential for the system, specifically in sorting the cases and providing the necessary treatment immediately or referring the patient to a hospital for further or definite care. That is of immense importance, as with the institution of the GP/ family doctor, the emergency department (ED) of hospitals and medical centers are not congested by patients complaining of minor health problems that otherwise could be treated by a GP at the surgery (doctor's office in the UK).
The need for international medical protocols, directives, guidelines & algorithms
As mentioned above, internationally agreed medical protocols, directives, guidelines, and algorithms do not exist. Consequently, often there is confusion and discrepancy on which algorithms, guidelines, protocols, or directives are better. Things are complicated as several medical associations and organizations publish their guidelines and protocols. From my perspective, the World Health Organization (WHO) can issue international medical protocols, directives, guidelines, and algorithms. There should be an international consensus regarding these guidelines and not the unacceptable condition of various medical associations to publish guidelines that vary in different countries. These guidelines should be updated annually or earlier when needed.
Intentional Guidelines, algorithms, and protocols are needed for diagnostic procedures, risk classification (e.g., for stroke or pulmonary embolism/ DVT), and treatment, including drug treatment and emergency medicine algorithms. It is unacceptable for each country to have its own protocols that sometimes are more than one, such as the stroke deficit scale in the US that may include the Canadian, NIH, and Cincinnati stroke scales (the Cincinnati is pre-hospital). Another example is the Wells and the Revised Geneva Scores, both for pulmonary embolism risk assessment.
All hospitals should follow the updated international protocols, directives, guidelines, and algorithms in daily medical practice. An essential advantage of international guidelines is that less money is wasted on useless lab or image examinations performed primarily by unskilled doctors or expensive drugs that can be substituted by cheaper as it is the effect that counts.
The knowledge of how to read a study
Many published studies are biased. An example is when a medication is studied by the pharmaceutical (drug) company that produces it, is interested in manufacturing it, or in case a study is sponsored. On the other hand, many studies are poorly designed. For instance, their sample may be small (e.g., it is different from enrolling five subjects than 5,000 subjects), and they may have statistical flaws or inadequate information regarding statistical methods and results. Also, they may not be placebo-controlled or double-blind, or randomized controlled. Also, a meta-analysis may involve just a few RCTs (randomized controlled trials), so it is impossible to reach a safe conclusion. Moreover, a study may have a short duration, influencing the results. Follow–up is also a critical issue.
As many studies are poorly designed, before considering a study, we first need to assess its quality and credibility. A Cochrane meta-analysis includes well-designed studies, and the Cochrane database (containing meta-analyses) is especially important for applying 'evidence-based medicine' (EBM). A systematic review assesses a specific topic, for instance, if glucosamine sulfate, a dietary supplement, helps patients with knee osteoarthritis.
Then, with an overview of the results of the studies included and considering matters such as the statistics or other quality flaws, Cochrane’s reviewers end up to a safe conclusion. This may be direct (e.g., that a specific drug helps or not in a particular disease) or may just be that better or more extensive studies are needed, or that the available data is insufficient regarding the number of included RCTs or their quality, to lead to a safe conclusion, so more research is needed. The Cochrane database on the published meta-analyses of various medical issues includes simple language abstracts so lay people can read them.
For Cochrane meta-analyses, you may visit http://www.cochranelibrary.com/ and http://cochranelibrary-wiley.com/cochranelibrary/search
Evidence-based medicine (EBM)
Today 'evidence-based medicine' (EBM) is the prevailing medical trend. EBM requires scientific evidence, as empirical or anecdotal knowledge is inappropriate to justify a clinical practice. It is essential to know if there is scientific proof concerning the effectiveness of a drug or a medical procedure. EBM is based on systematic reviews and meta-analyses of the available published trials. These are also available online, such as PubMed.
Evidence-Based Medicine analyzes several randomized controlled trials (RTCs) included in meta-analyses, such as the ones that the Cochrane database publishes, that lead to a safe conclusion about if a specific medical approach helps a disease. Consequently, Evidence-Based Medicine (EBM) aims to apply the best available evidence gained from the scientific method to clinical decision-making. It seeks to assess the strength of evidence of the risks and benefits of a treatment or lack of treatment as well as diagnostic tests. EBM helps clinicians to understand whether a procedure will do better than harm.
''First, do no harm,' quotes the Hippocratic oath explicitly! Evidence quality can be assessed based on the source type from meta-analyses, systematic reviews of triple-blind, randomized, placebo-controlled clinical trials, and other factors, including statistical validity, clinical relevance, currency, and peer-review acceptance.
EBM seeks to clarify those parts of medical practice that are, in principle, subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment.
For evidence-based medicine, you may visit https://en.wikipedia.org/wiki/Evidence-based_medicine
Evidence-Based Medicine categories
According to the US Preventive Service Task Force, Evidence-Based Medicine recommendations can be categorized into the following categories:
· Level A: good scientific evidence suggests that the clinical service's benefits substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients.
· Level B: there is at least good scientific evidence suggesting that the benefits of the clinical service outweigh the potential risks. Clinicians should discuss the service with eligible patients.
· Level C: there is at least good scientific evidence suggesting that there are benefits provided by the clinical facility. However, balancing benefits and risks is too close to make general recommendations. Clinicians need not offer it unless there are individual considerations.
· Level D: there is at least good scientific evidence suggesting that the risks of the clinical service outweigh the potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.
· Level I: scientific evidence is lacking, has poor quality, or is conflicting, so the risk against benefits balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.
The importance of databases, such as ‘‘Cochrane,’ that publish meta-analyses on several medical issues
Regarding this topic, all the available randomized controlled trials (RCTs) that are double (or triple)-blind and placebo-controlled are included. Two reviewers assess the available studies and decide which will be incorporated based on particular ‘inclusion criteria.’ Cochrane also evaluates the statistics of the studies for statistical flaws. The quality of the included studies (including sample, duration, follow–up, etc.) is valued.
The importance of databases, such as ‘‘Cochrane,’ that publish meta-analyses on several medical issues
Regarding this topic, all the available randomized controlled trials (RCTs) that are double (or triple)-blind and placebo-controlled are included. Two reviewers assess the available studies and decide which will be incorporated based on particular ‘inclusion criteria.’ Cochrane also evaluates the statistics of the studies for statistical flaws. The quality of the included studies (including sample, duration, follow–up, etc.) is valued.
For the Cochrane database (that has meta-analyses), you may visit http://www.cochranelibrary.com/ and http://cochranelibrary-wiley.com/cochranelibrary/search
Medical education in medical schools and training hospitals
Furthermore, the evaluation of medical school professors is essential. Otherwise, the education system will remain at a low level. It is also crucial that med-school professors use modern ways of presenting their lessons or courses. For example, in some countries, even developed ones, some professors use old-fashioned transparency rather than using, for instance, PowerPoint (R) to write the lesson and with the aid of a video projector to project images like cinema in which videos, such as of surgery, can be added.
Another suggestion is that med-school students and training resident doctors should participate in presentations, medical seminars, courses, conferences, and workshops. Everything important, such as a BLS (basic life support) annual course, should be mandatory and regularly provided by the medical school and the hospitals.
The need for sufficient medical education
The education of medical school students and resident doctors (interns), along with theoretical, should be practical, including rotation in all clinics and active participation in medical procedures such as taking arterial blood gases (ABGs), placing an IV line, and controlling drip rate, performing venipuncture to take blood for lab tests, etc. This training must be supervised, and of course, the supervising senior doctors need to record the competence and performance of each student or resident doctor and the skills that the student or intern learns.
I have published a particular text about improving the emergency medical system.
The training of resident doctors/ interns must be supervised, and their supervising senior doctors should keep a record of the skills and competence of each doctor who should have created a portfolio.
Senior doctors should be present during their shifts and not just on-call from their homes, as usually occurs in most countries. When present, they can deal with a severe case and not leave alone a junior or unskilled doctor to undertake it without consultation or with only advice on the phone. For example, it is unacceptable for an emergency such as a cardiac arrest to be dealt with only by specializing doctors rather than experienced senior doctors in advanced life support (ALS). Unskilled doctors should not deal alone with cases, including emergencies, which are not competent and skilled to cope with.
Supervised hospital training of resident doctors by senior doctors
The training of resident doctors/ interns must be supervised, and their supervising senior doctors should keep a record of the skills and competence of each doctor that should have created a portfolio. It is also necessary for the system to have a specific hierarchy in medicine so that junior doctors do not handle patients unsupervised but have guidance and, when needed, ask for the help of senior doctors. It is of vital importance to encourage junior or inexperienced doctors in a specific situation or procedure doctors, to ask for the help of a competent colleague, such as a senior on-call doctor, in case of an urgent incident or an emergency or when a junior doctor is or feels that is not skilled to take up.
The presence of on-duty senior doctors on their shifts as being on-call compromises patients’ safety
Senior on-call doctors keen to help the duty doctors
It is also necessary for the system to have a specific hierarchy in medicine so that junior doctors do not handle patients unsupervised but have guidance and, when needed, ask for the help of a senior doctor, at least over the phone.
It is of vital importance to encourage junior or inexperienced doctors in a specific situation or procedure doctors, to ask for the help of a competent colleague, such as a senior on-call doctor, in case of an urgent incident or an emergency or when a junior doctor is or feels that is not skilled to take up. It is to the benefit of the patient's healthcare when senior on-call doctors do not discourage the on-duty doctors from asking them for advice; otherwise, when they are reluctant or rude, this may affect the patient's treatment and cause unnecessary malpractice.
It is also important, to my mind, for on-call doctors to stay in the hospital so that they are immediately available in case of an emergency rather than being on-call at home. Obviously, examining the patient is different than hearing the story over the phone!
Teamwork and team-leading skills
Teamwork and team-leading skills are crucial, although often neglected, especially in developing countries. It is imperative for emergencies to be managed by the emergency medical team (EMT) coordinated by a team leader. Teamwork is vital in all clinics of the hospital and should be encouraged by the senior doctors as it ensures that medical interventions are performed faster and safer.
To familiarize and train doctors with teamwork, they should be assigned to group projects regarding a presentation on a topic of their clinical interest after reviewing the literature. At least three presentations annually are probably sufficient.
The need to create and comply with international directives related to the working conditions of the medical and paramedical personnel
The EWTD (European Working Time Directive) is the European Directive that the member countries of the European Union (EU) are obligated to follow (but I am not sure if they all do). It describes no more than 48 hours of work per week and also includes 11 hours of continuous rest in 24 hours, 24 hours uninterrupted rest per week or 48 hours in 2 weeks, 20-minute break at work over 6 hours, 1-month leave, and finally maximum working 8 hours in 24 hours for night work.
The EWTD was introduced so that doctors would not work as slaves and not make mistakes because of fatigue. At the same time, it is apparent that extra or overtime work that doctors undertake must be paid, while doctors should not do more shifts than the EWTD has as the maximum.
For EWTD, you may visit http://en.wikipedia.org/wiki/Working_Time_Directive
The continuous assessment of the medical staff
Over the last few years in the UK, a system of continuous assessment, appraisal, and revalidation of doctors is mandatory to exercise the medical profession. Also, every doctor has a portfolio.
It is beneficial for the doctors working in a hospital or privately to have their performance regularly assessed by senior doctors. This appraisal should include their competence to cope with medical emergencies; their prudence to seek assistance from senior doctors in severe cases in which they do not have the expertise to deal; their effectiveness in teamwork; their eagerness to attend on a regular basis conferences, courses, and medical seminars; and their willingness to updating their medical knowledge by reading medical books, journals, and articles on the internet and participating in research and presentations. If the assessment is negative, senior attending doctors need to improve the doctor's skills. However, in the case of relapse, the license to practice will be temporarily or permanently revoked.
Nurses with medical duties!
Patients in Sweden can call the Health Center to discuss their medical complaints. There they talk to the on-call nurse who, with the help of algorithms, gives self-care tips so that fifty percent of those who call eventually sit at home and become well on their own!
After a brief collaboration with a doctor, many who eventually visit the Health Center are first examined by a nurse who treats non-severe cases, such as uncomplicated tonsillitis or Urinary Tract Infection (UTI). Nurses even do ear cleaning from wax, while they may specialize in chronic diseases such as diabetes mellitus, hypertension, and asthma. The last may also do spirometry (pulmonary function test). Nurses are also responsible for childhood vaccinations.
In the USA, nurses may have medical duties, especially those working in the emergency room (ER), who have excellent training to help in emergencies. On the other hand, in Germany, nurses may not be involved in procedures such as intravenous (IV) line placement, but they may call a doctor to do this!
Good medical practice and etiquette
Patients in Sweden can call the Health Center to discuss their medical complaints. There they talk to the on-call nurse who, with the help of algorithms, gives self-care tips so that fifty percent of those who call eventually sit at home and become well on their own!
After a brief collaboration with a doctor, many who eventually visit the Health Center are first examined by a nurse who treats non-severe cases, such as uncomplicated tonsillitis or Urinary Tract Infection (UTI). Nurses even do ear cleaning from wax, while they may specialize in chronic diseases such as diabetes mellitus, hypertension, and asthma. The last may also do spirometry (pulmonary function test). Nurses are also responsible for childhood vaccinations.
In the USA, nurses may have medical duties, especially those working in the emergency room (ER), who have excellent training to help in emergencies. On the other hand, in Germany, nurses may not be involved in procedures such as intravenous (IV) line placement, but they may call a doctor to do this!
Good medical practice and etiquette
In the UK, the General Medical Council (GMC) is responsible for all doctors, and there are no separate medical councils in every province as in some countries. Furthermore, in the UK, there are associations for each specialty. The General Medical Council has issued guidelines and directives that all doctors can find online on their site Good medical practice
It is suggested that all countries issue a ''good medical practice'' manual in which many significant issues should be mentioned. These may relate to how doctors should behave to their colleagues, the other staff, and the patients; call a senior doctor when they are (or feel they are) unskilled to cope with; work as a team (teamwork); have empathy for their patients, etc. It is necessary for medical professionals to be polite to the hospital personnel and their patients, not to be manipulative, and never make racial or homophobic or other kinds of discrimination.
Another significant matter is that the patient's interest comes first. According to this, a doctor must notify the General Medical Council if another doctor endangers a patient's life, for instance, by omitting exams or interventions or by deliberately compromising the patient's treatment. This practice is of extreme importance for the patient's best interest, as a cover-up would be unacceptable.
The National Formulary
In the UK, the National Formulary is a list of the medications and, in detail, their indications, contraindications, adverse effects, interactions, and doses. The General Medical Council should give all doctors an annually updated National Formulary paperback without any charge. Alternatively, an online version is a cheaper solution. Otherwise, an excellent site to be informed about the drugs (medicine) is http://www.drugs.com/
The need for all specialties and subspecialties to be available in all countries
In many countries, there is need for new medical specialties such as sports medicine (in some countries it is a subspecialty of orthopedics), general medicine (in some countries the general practitioner is confused with general medicine doctor), podiatry (useful on diabetics and people with recurrent fungal infections such as the athlete’s foot), palliative medicine (in some countries there is a lack of clinical palliative care for the terminally ill), spine surgery (back surgery), sexology ( in some countries it is practiced by urologists as andrology while when causes are functional or psychosomatic then it is practiced by psychiatrists), medical immunology (in some countries it does not exist, but I wonder how children with congenital immunodeficiencies are diagnosed and treated), trauma surgery, social medicine, tropical diseases medicine (extremely important today with the uncontrolled immigration and traveling), space medicine (in Europe they could work at ESA (European Space Agency)), etc.
Another issue is that in some countries, most of the above specialties are the main specialties, whereas, in others, they are subspecialties. For instance, intensive care unit (ICU) medicine in many countries (including the UK) is an independent specialty; in others, it is a subspecialty. Also, in the UK, acute medicine is a separate specialty, covering emergencies but not trauma which is covered by emergency medicine. In other countries, acute and emergency medicine is a subspecialty or does not exist!
Recorded duties for all the hospital personnel, including doctors and nurses
It is crucial that the responsibilities and duties of doctors and nurses working in hospitals and health centers, as well as paramedics in ambulances, be recorded so that everyone knows his/her responsibilities and limitations. The lack of documented duties means that the doctor may do a nurse's job!
Watching doctors undertaking nursing duties is not uncommon in many developing but also in some developed countries such as Germany, where IV (intravenous) lines are placed by doctors, not nurses. In many countries, doctors waste their time doing the work of a nurse, such as venipuncture (taking blood for lab exams; the person who does it is called a phlebotomist), ECG (electrocardiogram), IV-line placement, changing bandages, and removing sutures, etc.
Advanced duties for nurses!
When nurses undertake advanced duties, they spare doctors' time and effort so that they waste their energy more efficiently rather than squandering their time with a menial nursing routine. For instance, in many developed countries, including the US, the emergency nurse takes a short history and records vitals such as blood pressure, pulse, oxygen saturation, and often a finger stick for blood glucose. Additionally, in some countries, skilled nurses may give certain medicines, such as painkillers and some antibiotics.
The shortage in healthcare personnel, including nurses and the lab staff
For the proper functioning of hospitals, they should be covered with all the necessary staff so that the hospitals offer excellent service and the existing personnel do not become exhausted. Uncovered hospital vacancies are a significant problem worldwide, even in developed countries. Many countries have a shortage of nurses and doctors in hospitals and medical centers.
The lack of available beds in Intensive Care Units (ICUs)
Regarding the intensive care units (ICUs), in many countries, especially developing ones, there is a shortage of available ICU beds in many hospitals. At the same time, there are hospitals without an ICU at all or have an ICU, but they lack ICU doctors and specialized nurses. However, the system cannot work effectively without ICUs, especially for critically ill patients. So, the state must create new ICUs in hospitals where they do not exist or are inadequate and recruit specialized medical and nursing staff to work there. In the USA, single rooms can be transformed into ICUs with a respiratory machine and appropriate nursing care.
The shortage of medical equipment and supplies in the hospital (including the laboratories)
In many countries, there is a shortage of medical equipment supplies in the clinics and laboratories that impedes the proper functioning of the hospital. It is essential for hospitals to cover shortages so that the system works efficiently.
The low wages of the medical staff and the unpaid overtime!
In most developing countries, as well as in many developed countries, doctors, especially those of low levels regarding specialization, are paid low wages while working overtime is often unpaid even in developed countries, and this is a kind of exploitation! However, an underpaid doctor is less keen to be efficient and productive. So, it is necessary for doctors' wages to be proportionate to the cost of living. For example, in the UK, a junior doctor is annually paid only 25,000 pounds, nearly 32,400 dollars! With this meager income, a junior doctor should pay his or her numerous obligations, such as paying nearly 1,000 dollars for a small apartment in London!
Doctors' outfit & footwear: scrubs & sneakers!
In the UK, you can see doctors without white coats or scrubs (like those surgeons wear). They simply carry a label with their name! Obviously, it is not for the benefit of the doctor's sanitation to wear casual clothes. They removed the lab (white) coat in the UK in 2007. But there are no convincing reasons for not wearing scrubs that are amazingly comfortable, speaking from my own experience! Someone can choose any color as part of the dress code, such as light blue or light green scrubs for doctors, burgundy (= a dark reddish-purple color, like the color of red wine) scrubs for nurses, and dark blue scrubs for medical assistants.
In the UK, they have banned crocks (rubbery clogs; hospital comfortable open shoes) since 2011! Although crocks do not offer protection and do not support the heel, a better suggestion would be to wear sports shoes (sneakers) with an underfoot cushioning system. As my first degree is in physical therapy, I have always supported wearing sneakers in hospitals that are better for 'rounds.' However, crocks are more comfortable when the medic is inactive.
Healthcare of migrants and uninsured
In the UK, you can see doctors without white coats or scrubs (like those surgeons wear). They simply carry a label with their name! Obviously, it is not for the benefit of the doctor's sanitation to wear casual clothes. They removed the lab (white) coat in the UK in 2007. But there are no convincing reasons for not wearing scrubs that are amazingly comfortable, speaking from my own experience! Someone can choose any color as part of the dress code, such as light blue or light green scrubs for doctors, burgundy (= a dark reddish-purple color, like the color of red wine) scrubs for nurses, and dark blue scrubs for medical assistants.
In the UK, they have banned crocks (rubbery clogs; hospital comfortable open shoes) since 2011! Although crocks do not offer protection and do not support the heel, a better suggestion would be to wear sports shoes (sneakers) with an underfoot cushioning system. As my first degree is in physical therapy, I have always supported wearing sneakers in hospitals that are better for 'rounds.' However, crocks are more comfortable when the medic is inactive.
Healthcare of migrants and uninsured
The problem of illegal migration is significant in developed countries, especially in Europe. In most countries, migrants and refugees enjoy free healthcare services from the National Health System. However, people without insurance have no access to public medical facilities. When this is related to unemployment, and it is not a choice, it is necessary for the extra cost to be paid by the state.
Frauds and corruption in the health system
Corruption in the health system is common, and fraud cases have occasionally been reported worldwide. Corruption, including bribery and fraud, should be punished by the justice system and the General Medical Council. An example may be when a doctor is bribed and favors a specific drug company prescribing its drugs or products, such as cardiology stents and pacemakers or orthopedic materials and grafts, exclusively or when a doctor is bribed to send patients to a particular private clinic for specific lab or imaging tests. Another example is when officers overcharge purchased medical equipment, supplies, or medications.
Corruption is prevalent in the Balkans. In some cases, patients bribe surgeons to take better care of them (it is said that the surgeon also asks a small amount for the anesthesiologist) and slide over the operation waiting list. However, sometimes the patients spontaneously bribe the surgeon without being asked to do so but feel they will be treated better this way! In some cases, it is said that the surgeon instructs the patient to use the emergency service and come to the emergency department (ED) of the hospital to be admitted as an emergency so that surgery can be done as an emergency, although it is not!
Bribing and fraud related to medical professionals should be reported directly to the police as criminal offenses. Also, it should be reported to the general medical council to schedule a disciplinary panel for the offender. Moreover, the health ministry should do its best to eliminate these cases.
To avoid corruption in medical supplies, a centrally directed by the health department and the IRS tax collecting service should record and assess all purchases of supplies of medical equipment from the hospitals so that public money is not stolen on frauds such as overpricing hospital materials or buying them with fraudulent competitions in which the winning company bribes the committee of the hospital responsible for the purchase. This practice is not rare, as a few years ago, there were accusations related to the German company Siemens of corruption in some countries, including Greece.
Medical files database (hospitals & GP)
Nowadays, medical files can be saved on computers, and there is no longer a need to be handwritten! This database should be national, and medical personnel with a PIN and password can access their patients' files. A security system should prevent hackers and others, including insurance companies, from visiting the database. However, some governmental organizations, such as the Health Department and the Driver and Vehicle Licencing Agency (DVLA), may have access.
This database will offer immediate access to the patient's history, lab & imaging exams, and therapy. That is very useful in cases of malingering and patients who continuously visit the ED of the same or other hospitals with similar complaints and cases of abuse. It is also essential to find factitious disorders and people with Munchausen syndrome by proxy who make up or create a medical problem or injury on their child or a person under their care, such as the elderly or an individual with a disability.
A great example of a computer database is in Taiwan, where all patients have a magnetic card that the doctor can scan and view all the data referring to the patient, such as hospital visits, lab tests, imaging exams (with access to CT and MRI images), and prescriptions. Sweden is another country with a similar database.
In the above database, the GPs will also keep their patients' medical files so that when they need medical help and visit a hospital, the receiving doctor can access these files without calling the GP first. That is especially important in senior patients who take many drugs that cause side or adverse effects and interactions.
Nowadays, medical files can be saved on computers, and there is no longer a need to be handwritten! This database should be national, and medical personnel with a PIN and password can access their patients' files. A security system should prevent hackers and others, including insurance companies, from visiting the database. However, some governmental organizations, such as the Health Department and the Driver and Vehicle Licencing Agency (DVLA), may have access.
This database will offer immediate access to the patient's history, lab & imaging exams, and therapy. That is very useful in cases of malingering and patients who continuously visit the ED of the same or other hospitals with similar complaints and cases of abuse. It is also essential to find factitious disorders and people with Munchausen syndrome by proxy who make up or create a medical problem or injury on their child or a person under their care, such as the elderly or an individual with a disability.
A great example of a computer database is in Taiwan, where all patients have a magnetic card that the doctor can scan and view all the data referring to the patient, such as hospital visits, lab tests, imaging exams (with access to CT and MRI images), and prescriptions. Sweden is another country with a similar database.
In the above database, the GPs will also keep their patients' medical files so that when they need medical help and visit a hospital, the receiving doctor can access these files without calling the GP first. That is especially important in senior patients who take many drugs that cause side or adverse effects and interactions.
Differential diagnosis with the aid of the Internet!
More straightforward differential diagnosis with internet tools is feasible today. There are many online programs with or without a subscription, including https://www.isabelhealthcare.com/ and https://diagnose.kahun.com/
I tried the latter with a mock case of a patient with high blood pressure visiting the ER with sudden chest pain radiating into the back. It concluded with diagnosing aortic dissection as the first probability on the differential, which is also a priority to exclude in real life!
Medic-Alert bracelets & microchips!
Patients with potentially life-threatening diseases, such as diabetes mellitus and a history of allergy/ anaphylaxis, and those taking specific drugs (for example, corticosteroids or blood thinners) should wear a Medic-Alert bracelet that will inform the doctors of the ER (emergency room) for the disease. This is essential in case the patient has confusion or a decreased level of consciousness (LOC) or is in a coma, as well as in case there is no spouse, or relatives, or other people close to the patient that know and can inform the ER for the specific medical condition. A more futuristic suggestion is to contain the medical files in an under-the-skin implantable microchip!
Electronic prescriptions
Electronic online prescriptions are the safest way when prescribing drugs to eliminate any possibility of bribery, with money or ‘sponsored’ trips to medical seminars or ‘gifts’ such as domestic equipment, to favor a specific drug company. Additionally, the use of generic medications is helpful in avoiding costly medicine. However, there is a controversy about the quality of generics from developing countries such as India and developed such as China with questionable standards of safety and control. Many cases have been reported to the FDA, so vigilance is essential for imported drugs from unambiguous sources.
About electronic prescribing, you may visit:
Direct online complaints on the General Medical Council reporting doctors for malpractice
In the UK, the General Medical Council (GMC) has a link for making a direct complaint concerning a doctor to whom someone can report malpractice for several reasons such as inappropriate behavior, discourtesy, physical or psychological abuse, bribery, etc. A complaint against a doctor for misconduct may also be made by a colleague or other hospital staff, such as a nurse.
The doctor against whom there is a complaint is scrutinized by a panel of the disciplinary inquiry board of the General Medical Council. If the evidence is against the reported doctor, they are fired or temporarily dismissed. The UK health system prefers to get rid of bad doctors rather than keep them to continue malpractice! The expulsion of an offending doctor is the duty of the Disciplinary Inquiry Board and should not be seen with sympathy because of being a colleague because of solidarity. This solidarity is common in the Balkans, where fraud and bribery cases were reported, but the general medical council showed unacceptable leniency!
The replacement of the rolling system of hospitals on duty with the operation of all hospitals on 24/7 duty
All hospitals in a large city should be on duty 24/7. It is unacceptable when someone needs immediate medical help and visits the nearest hospital not accepted because that specific day or hour is not on duty.
Smoking in or outside the hospital!
A total ban on smoking in hospitals or the yard is necessary globally, as well as its rigorous implementation! Doctors must not be allowed to smoke in their offices, which must be imposed by the directors of the clinics. Also, the security guards in the hospital should notify patients and relatives who smoke in the hospital wards or the yard. Patients' relatives who do not comply should be dismissed from the hospital. Smoking in hospitals is prevalent in developing countries and in some developed countries, such as the Balkans, where the greatest smokers are the doctors who smoke in their offices!
The presence of the patient’s relatives and friends in the hospital only during visiting hours
A patient's relatives and friends should not be 24/7 with the patient. If the visiting hours are not followed, then the hospital becomes overcrowded. So, relatives and friends should not be allowed to enter the ward unless they come during visiting hours or in an emergency. However, in some countries, the family bonds are often intense, and relatives and friends help a patient psychologically. So, it is suggested that only one relative (partner, sibling, or child) could be allowed to stay continuously with a patient.
Exclusive private nurses with doubtless qualifications or without a license
Regarding private nurses that families in some countries hire, it would be unnecessary if the number of nurses in a medical facility was enough. But in most countries, it is not! Often in hospitals at night, there may be even one or two nurses on each floor! But if the patient or their family feels safer with an extra paid exclusive nurse, this should be done lawfully. The documented evidence (certificate, license, nursing degree, and, if an immigrant, a residence permit) should be handed to the Chief Nurse of the department, who should coordinate the system of private nurses hired by families.
Volunteering in hospitals and interpreters for foreign patients
An excellent idea is for hospitals to organize a volunteering program where volunteers can participate in supporting roles such as collecting laboratory test results, informing visitors, guiding patients, etc. Volunteering already occurs in some developed countries, such as the US. Traditionally, Red Cross volunteers participated voluntarily in hospital duties.
Also, it is necessary for hospitals to have interpreters for foreign patients, including immigrants and refugees, to receive proper treatment. Many developed countries already have interpreters in hospitals.
Preventive medicine
Most people neglect to control the modifiable risk factors for cardiovascular disease that may lead to myocardial infarction (heart attack), cerebrovascular accident (stroke), and on peripheral artery disease (PAD). Many people continue to eat junk food and do not mind if lipids (such as cholesterol) will obstruct their arteries, causing a heart attack. Most people never or rarely check their blood pressure, another risk factor for stroke and heart attack. Other hypertensive people (with high blood pressure) or dyslipidemia (high blood fats such as cholesterol & triglycerides) continue eating salt and junk food rich in ‘trans’ fat, respectively. Most people have a sedentary life and never or rarely exercise.
Most people neglect to control the modifiable risk factors for cardiovascular disease that may lead to myocardial infarction (heart attack), cerebrovascular accident (stroke), and peripheral artery disease (PAD). As cardiovascular disease is the leading cause of death in the West, all countries should have a screening program for cardiovascular disease to identify modifiable risk factors in the general population.
Many types of cancer are also preventable. Contrary to widespread belief, many types of cancer are sporadic without any clear genetic predisposition. Many people expose themselves to carcinogens such as tobacco, alcohol, sunlight (or at least without a high SPF sunblock), etc. However, carcinogens in the environment, our food, and water are so widespread that it is often impossible to avoid them. But we may at least try to avoid the ones that can be prevented, e.g., avoid the above carcinogens; participate in screening medical programs e.g., for breast, rectal, and vaginal cancer.
A common misconception is that enrolling in an anticancer drug trial may be helpful. But it may not, as not only the patients become a ''guinea pig'' exposed to potential (and potent) adverse and side effects of the drug, but they also may belong to the placebo group of the inactive substance! People should be aware of these implications.
Informing surgery candidates about the statistics, including mortality rates, of all surgeons
The right to seek a second medical opinion and the access of the ''fit'' elderly to the operating room (OR)!
Importantly, people diagnosed with cancer or another severe, acute, or chronic disease should always seek a second medical opinion, as many people seek an expert's opinion for minor issues. Still, they may neglect to do so for cancer or leukemia!
Senior patients also have the right to a second opinion regardless of age, especially for life-threatening conditions. This is especially important when urgent or elective surgery is excluded. Otherwise, we can speak about a subtle form of euthanasia!
A surgeon in the UK might be reluctant to bring a senior citizen into the operating room. However, in other countries, surgeons may be less reluctant! From my perspective as a medic, a relatively good cardiovascular condition and the lack of severe comorbidities are conditions that the elderly should not be excluded from surgery. Cardiovascular health should be investigated with ECG, Echocardiography, and pulmonary function tests, especially FEV1.
That is especially important for life-threatening diseases such as cancer and CABG (coronary artery bypass) for heart problems. Of course, the patient will take the mortality risk. But the problem here is that if the mortality ratio of each surgery is documented, a surgeon will not be happy if a senior patient dies. Consequently, surgeons will discourage or refuse operations in elderly patients who otherwise are fit for surgery. That is a shortcoming of reporting mortality rates in operations.
The need for innovative technology
Most hospitals need innovative technology such as DaVinci robotics, telemetry, PET-CT, functional MRI, VATS, and a laryngoscope with a camera. Innovation is essential today, and currently, there is a development of sophisticated software that will assist in the Chest X-ray (CXR) interpretation as well as in the diagnosis of various conditions using diagnostical algorithms. Hospitals should use battery-powered cardiopulmonary resuscitation devices, such as LUCAS and AutoPulse (TM), that perform cardiac compressions. These are important, as the central issue in cardiopulmonary resuscitation is the inadequate quality of chest compressions in cardiac arrest.
Conclusion
Many developing countries need to fundamentally reorganize their National Health System and organize it more efficiently. However, many improvements must be made even in developed countries where many ‘malfunctions’ exist. The reorganization of the National Health Systems needs to focus on a) The better and more comprehensive education of medical students and resident doctors. b) The continuous presence of senior doctors in the hospital to supervise junior doctors so they will not undertake difficult cases alone, without their aid. c) Adopting the British model to make the organization and hierarchy of hospitals appropriate. d) The continuous appraisal and revalidation of public and private doctors e) Implementing a working directive like the European working time directive (EWTD) of 48 hours of work per week in all hospitals. f) The hiring of adequate health personnel, including doctors and nurses, in all hospitals and health centers, so the existing staff will not become exhausted. g) The focus on evidence-based medicine.
Thanks for reading!
Reference:
· http://en.wikipedia.org/wiki/Evidence_based_medicine (Retrieved 1 August 2012)
· Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.
· Evidence-Based Medicine, p. 668 – 669, Longmore M., Wilkinson I.B, Davidson E.D., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 8th edition, 2010.
· Evidence-Based Medicine, p. 489, Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.