Covid is testing our diagnostic rationale
Despite the many grumbles about our much-loved health service, it has excelled itself over the past 20 years in reducing fivefold the average waiting time for hospital treatment – down from 18 months to 18 weeks. Predictably, the constraints imposed by the Covid plague have – as the president of the Royal College of Surgeons puts it – “taken a wrecking ball to these waiting-time targets”.
Hence the recent ruling that doctors should reassess on an individual basis the reasons for a hospital referral, so as to prioritise those most in need. This might seem a bit harsh, but the principle has its merits, as Covid has highlighted the scale of inappropriate or unnecessary medical interventions.
Thus the early months of the pandemic confirmed the impression that many children attending casualty do not require emergency care. The figures for the small minority needing urgent treatment or admission have remained stable, but overall attendance rates fell by more than a half. Similar doubts apply to the rationale for the massive upswing in recent times, almost tenfold, in the number of invasive investigations without any parallel increase in the prevalence of the medical conditions for which they are indicated.
The “steep decline” in the numbers attending hospital, it is suggested in the British Medical Journal, “offers a rare opportunity to analyse a natural experiment in less medical care – the avoidance of tests, diagnoses and treatment that would have caused more harm than good”.
A daily dose cure
The gut, as recently reported in this column, is particularly vulnerable to the adverse effects of drugs, causing abdominal pain and diarrhoea that may persist for many years until the connection is made. “I have had regular bouts of watery diarrhoea since being diagnosed with type 2 diabetes 35 years ago and which I was led to believe was due to diverticulosis,” writes one gentleman. He was recently advised to halve the dose of his blood sugar lowering drug metformin. “That was six weeks ago, since when my bowel movements have become perfectly normal.”
Another readily treatable cause of persistent diarrhoea, again too often overlooked, is “bile acid malabsorption”, where the bile acids secreted by the liver irritate the gut. This is a frequent “side effect” of operations to remove the gallbladder in those with gallstones (cholecystectomy) and is the underlying factor in a third of patients with irritable bowel syndrome. In Britain, thousands of people may be afflicted with one or other of these conditions – curable with a daily dose of the bile acid sequestrant (Questran) that neutralises the bile acids in the gut.
The eyebrows have it
The censoring of facial expressions with mask wearing has drawn attention to the role of the eyebrows in conveying a wide range of feelings and emotions – notably the
Facial recognition: we are relying on eyebrows to read others’ moods
“eyebrow flash” as a formal friendly greeting, commended recently on The Telegraph’s letters page. Their movement certainly reinforces the tenor of a conversation, down and inward (a frown) indicating anger or disappointment, a sudden upward jerk, surprise or quizzicality. This latter movement, it has been observed, is particularly expressive when conversing in sign language, recasting a declarative hand-signed statement (a walk in the park) as a question (a walk in the park?).
The subliminal expressive significance of eyebrow movement is, if paradoxically, most apparent when the muscles are paralysed – as following a cosmetic Botox injection to smooth out forehead wrinkles. “It was very disconcerting that my friend could not raise or lower her eyebrows,” writes one woman, “I could no longer accurately infer her mood and had instead to rely on other cues.”
It confirmed that many children attending casualty do not require emergency care