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E-cigs, Prehabilitation before surgery, Hospital safety

Why vaping is dividing public health experts causing a polarised split; prehabilitation before cancer surgery and the benefits of preparing for an operation; plus can hospital safety be compared to lessons learnt from the aviation industry?

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28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4

 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH – Programme 11.

 

TX:  19.03.19  2100–2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Hello.  Coming up today:  Hospital safety – Margaret McCartney has an issue with recent comparisons between the NHS and the aviation industry.  And surgery – we are all familiar with the idea of Rehabilitation to help people get back on their feet quicker, but why wait until after the operation?  Prehabilitation is the latest development, and it’s having a big impact on recovery, even in patients with cancers.

 

Clip

It’s obviously my body, cancer’s happened to me and if I can do something to help myself to get over it, I’m prepared to do whatever it takes really to still be here.

 

I find it quite fascinating the something as simple as this, which is getting patients ready for surgery has actually improved post-operative outcomes.  And I often think back and think it’s not anything like laparoscopic surgery or robotic surgery that’s done that but it’s just getting patients ready from a physical and mental point of view.

 

Porter

More from the team behind that surgical prehab programme later.  But first, e-cigs and vaping.  While the number of smokers in the UK has fallen by nearly a fifth over the last five years, the number who vape is at an all-time high.  And it’s a trend that has not been lost on the big cigarette manufacturers – British American Tobacco, Philip Morris and Imperial Tobacco all now produce e–cigs of one type or another.

 

But while the falling smoking rate is exciting public health experts, the burgeoning growth of vaping has divided them.  So, what’s responsible for the split?

 

Marcus Munafo is Professor of Biological Psychology at the University of Bristol.

 

Munafo

Well a few years ago e-cigarettes came on to the market and really took everyone by surprise in terms of how rapidly they grew in popularity and how many people were using them.  And it’s brought to light this difference of opinion, essentially, in terms of two broad positions that different people hold.  Either that e-cigarettes are generally a good thing, they help people to stop smoking, they’re substantially less harmful than tobacco products and therefore they can reduce the harms associated with tobacco use.  Or, that they’re broadly a bad thing because they’re another addictive product which could act as a gateway to tobacco use and could allow the tobacco industry to reinvent itself and continue marketing addictive products to the general population across the world.

 

Porter

And what determines which group experts sit in?

 

Munafo

Well this is the really interesting thing because of course all of these people have access to the same evidence, the same data, so it’s really a matter of how we interpret that evidence.  And the thing that I think people sometimes lose sight of is that although scientists are meant to be impartial, disinterested and so on, the reality, of course, is that scientists are human too and therefore subject to the same kinds of bias in their thinking that all of us are.  Now our training is meant to protect us against that but it can only go so far.  And people can find it difficult to admit that they were wrong or to change their position on something, it’s very rare that we have an argument with someone and at the end of that argument the other person says – oh you were right all this time, I’m so glad you’ve pointed that out to me – it’s just not how people think and scientists are the same.  They tend to hold positions and find it difficult to shift those positions because they’re human. 

 

So, to some extent, what it boils down to, are just our feelings about the core issues which are really not about evidence, so much as our perspective on whether or not, for example, being addicted to nicotine or using nicotine in the absence of other substantial harms is problematic in itself.  And so, it becomes, at some level, about values as much as it does about evidence.

 

Porter

What about people’s roles?  I can imagine, for instance, if you’re a clinician and you’re working at the coalface, dealing with smokers, that you might see e-cigarettes as a good thing, as a tool to get them off.  Whereas perhaps if you’re at the research end of public health you’re more worried about perhaps new people coming in to nicotine addiction through vaping.

 

Munafo

I think there’s something in that.  I don’t know of any systematic attempt to survey that, if you like, but my sense is that you do get some people who have spent their careers, for example, trying to push back against the tobacco industry’s attempts to prevent tobacco control legislation being implemented and so on and they see the tobacco industry as the problem, if you like, and therefore the thing that they need to counter.  And because the tobacco industry has been buying up some e-cigarette companies, they treat the two as related, if you like, and they see e-cigarettes as some kind of perhaps trojan horse for the tobacco industry to reintroduce itself into mainstream debate around what’s acceptable in society.  On the other hand, you have some people who have worked with smokers directly, helping them to stop smoking and they see the benefit of e-cigarettes in helping those people to stop smoking.  So, I think, personal experiences and the perspective that that provides one with can be part of this.

 

Porter

So, what you’re saying is, that these two groups might look at exactly the same data, indeed they are looking at exactly the same data, but they’re using it to confirm their own belief.  It’s a sort of vested academic interest.

 

Munafo

It is but I think it’s worth pointing out that these aren’t necessarily conscious processes, so they’re not actively going into a data set necessarily and saying how can I draw conclusions from this that support my agenda, if you like, or my preconceptions.  It’s much more subtle than that, they’re much more unconscious than that.  I mean financial vested interests, financial conflicts of interest are well known in the biomedical literature to be problematic and so we have to disclose those now in the research that we do in the publications that we write and so on, and rightly so.  But these cognitive conflicts of interest, these cognitive biases are much more difficult to tackle because they’re less obvious, we’re not even necessarily ourselves aware of the biases that we’re bringing to our interpretation.  And they’re harder to make explicit, they’re harder to write down because of that.

 

Porter

Marcus, why does this matter because surely it’s a good thing if we’ve got two opposing groups looking at the same data, in that whatever plan forward comes out of it it’ll be a sort of combination of the two, is it not a better plan of action as a result of that compromise?

 

Munafo

I think that would be the case if there was evidence that the two sides were really engaged in a healthy debate trying to get to the heart of the matter, if you like.  Now there are obviously many people who are trying to do that but there’s an extent to which, I think, the debate has become so polarised that we lost that middle ground.  And it does matter because we need to understand whether or not, for example, there are any unintended consequences of allowing e-cigarettes on to the market.  One of the concerns, which is a justifiable concern, is that young people will get their hands on electronic cigarettes and may start using those and that could serve as a gateway to then using tobacco products, cigarettes, which are dramatically more harmful.  And if that’s happening then we might be negating any benefits of e-cigarettes helping people to stop smoking because they’re also encouraging young people to start smoking. 

 

Now the problem is that the evidence for a link between vaping and smoking amongst young people is all observational, it’s correlational, which means that we can’t confidently claim that there’s a cause and effect relationship.  But what you’re seeing is that across this divide, on the one side, you have those who are interpreting these correlational data as implying a cause and effect relationship and therefore indicating that we should be concerned about that pathway from vaping to smoking.  And on the other side, others interpreting the same data as not necessarily reflecting that because there could be other factors contributing to that correlation, like the fact that young people who are inclined to try things are going to try e-cigarettes and going to try cigarettes but that doesn’t mean that the two are causally connected, if you like.  And understanding that is really important for informing public policy but to reach that middle ground, that you mentioned, that balanced position, does require healthy debate where we genuinely engage with the nuances around these arguments and accept the possibility that we might be wrong.  And when you bring very strong feelings to those discussions it can be difficult to move your position.

 

Porter

Professor Marcus Munafo.

 

Now I am sure you’ve all heard of rehab, but what about prehab?

 

Prehabilitation is a hot topic in the world of surgery at the moment and rightly so.  It makes sense that an operation – and recovery afterwards – might go smoother with a bit of preparation aimed at improving a patient’s physical and mental condition.  Why wouldn’t someone waiting months for a new hip or knee not use that time to lose any excess weight, strengthen their leg muscles and improve their diet and fitness to boost their odds of trouble-free surgery and a quicker recovery?

 

But what about people who need urgent life-saving surgery for cancer?  Well prehab is being used to help them too – as I discovered when I met the team behind the PREPARE programme at St Mary’ Hospital in London.  It was set up by nurse specialist Venetia Wynter Blyth.

 

Blyth

I worked in cancer for many years and I felt that the preoperative preparation was really directed towards what was wrong with the patient, as opposed to what we can do to optimise people.  So, if somebody was getting ready for surgery, you’d look at whether or not they have any lung problems, whether they have any heart problems, not what can we do to improve this.  And many of our patients have preoperative chemotherapy and it felt to me like there was a missed opportunity, it felt that we had this great big swathe of time and how can we use that to our advantage.

 

Porter

So, the standard, to put it simply, was that these people might be having months of chemotherapy, during which they were becoming deconditioned, they were becoming weaker and less ready for surgery?

 

Blyth

Exactly, so, when I first started working in cancer, many years ago, we would tell somebody they had a cancer diagnosis and we would never address the lifestyle habits.  And actually, what they were doing was they were potentially causing themselves more harm by not taking control of what they can do to actually improve their outcomes.  And I think that’s what people don’t realise, it’s not just about what we can do for people but actually there should be a reciprocal relationship, there should be a symbiosis and it should be us working together as a team.

 

Porter

It’s not just the patients that you need to convince, it’s the doctors, the surgeons as well…

 

Blyth

Yes.

 

Porter

…what sort of response did you get initially from them?

 

Blyth

Honestly?  I mean they were a little bit cynical.  I think it’s changing the paradigm.

 

Moorthy

My name is Krishna Moorthy and I’m a consultant surgeon and I specialise in cancers of the oesophagus and the stomach.  To be honest with you I was a bit sceptical.  These cancer operations are associated with a very high complication rate, a very prolonged recovery – it takes sometimes a year to two years to recover from a big cancer operation – and the hospital stay obviously is very long.  As a surgeon, you know, you think of doing minimally invasive surgery, you try and give very good painkillers, you get physiotherapists involved in the hospital but I just couldn’t change the complication rates and I could not change the hospital stay.  And then, Venetia introduced this programme and both me and my colleague we started noticing the pneumonia rates coming down from 50% to 20%.  We saw our patients were more activated, more motivated, more engaged, they were keen to leave the hospital.  While three years ago they wanted to stay as long as possible because it felt like they’d been hit by a bus. 

 

I remember five years ago we would make snapshot decisions and say this patient’s not fit for chemo so take them to surgery directly or this patient’s not fit for surgery at all.  Now the language is put the patient in the programme and let’s see how the patient does. 

 

Porter

So, as a surgeon, would you consider delaying an operation in somebody that the prehab team didn’t think was quite ready?

 

Moorthy

So, that’s happened a few times.  So, there have been a few patients who had a lot of fatigue on chemotherapy, their physical fitness has deteriorated.  Those are the people who, five years ago, we would have said, you know what, the chemotherapy’s taken a severe toll on them and they’re not fit for surgery anymore.  In those cases, we’ve said – no, actually, let’s see how they do on the programme now that the chemotherapy’s finished.  We wait for them to improve their physical conditioning again, to come back to baseline and then we think they’re ready for surgery.  Otherwise, in the past…

 

Porter

They’d have missed out completely.

 

Moorthy

… they would have missed out completely.  And they’ve actually gone on to have surgery and doing well now.

 

Brett

My name is Dominic Brett.  I was diagnosed with oesophageal cancer.  It was Christmas 2014.  And I had just a little bit of pain just at the top of my stomach.  I went to see the doctor.  He said, it’s Christmas time, it’s probably just overeating and over drinking, come back and see me in a couple of weeks.  I went back to see him.  So, he said, take some of these tablets, again, come back and see me in a couple of weeks.  So, again the pain hadn’t quite gone away and he said then, I remember very well, he said – it could be cancer.  And the pain, it was just like a dull ache really, so I kind of knew something was wrong.  Food was getting a little bit stuck.

 

Porter

Having difficulty swallowing?

 

Brett

Yeah, a little bit.  Took me for an endoscopy and then that’s when they found it.

 

Porter

You’re being very matter of fact about it now but…

 

Brett

It was a real shock.  I tried to avoid looking on the internet, as you always do.  I had chemotherapy.  It actually spread to my neck.  And that’s really when I was told that potentially surgery might not be the option, it must just be palliative care.  And that’s when it really hit home, I remember that very well, I’d just turned 40 and to be told that it was inoperable, that wasn’t really what you wanted to hear.

 

Porter

They could control it or slow it down but they couldn’t cure it effectively.

 

Brett

So, it was then, it was sort of discussing it with my surgeon and we said yeah, we’ll go for it.  We didn’t really have an option.

 

Blyth

Once we know that somebody’s going to have surgery – so this programme is very much focused on people who are going down to the surgical pathway – they come to a prehabilitation clinic and that consists of an exercise specialist, it consists of a nurse specialist – so myself – and a dietician.  So, we can sort of tease out any potential lifestyle habits that may cause them harm in the long term and try it flip it around on its head.  So, there’s a term that we use called the teachable moments and the teachable moment is a time when somebody is most amenable to make the lifestyle change and it happens to be, for example, when somebody’s told they have a cancer, that could be a threat to their mortality, and that’s when they are likely potentially to make a change for the better.  So, it’s how we take that moment and instead of just saying to someone – right off you go, go home, take it easy – we very much – I become quite a sort of tough matron and say right actually this is what you can do, this is how you can change your outcomes and it’s about getting the family onboard, that’s so important, cancer doesn’t just affect the person, it affects so many people in their sphere as well.

 

Brett

I was 39 when I was diagnosed, I’d got a wife and two young children and it was the last thing on my mind.

 

Porter

Big operation.  Tell me exactly what was done.

 

Brett

So, it was approximately 11 hours or so.  They go in through your back to remove your oesophagus, removed one of my ribs – which I found out later on.

 

Moorthy

The surgery is a very long operation because it consists of three stages.  You first have to approach the oesophagus and the tumour from the chest, so you have to go between the ribs, make a cut at the back between the ribs, then you’ve got to turn the patient over and that whole process with all the tubes and the lines that turning over, itself, takes about half an hour.  Then you make an incision in the abdomen, you’ve got then to mobilise the stomach, convert the stomach into a long tube.  And then the neck bit I took the assistance of one of my very senior neck surgeons because Dominic had to have all the lymph glands in the neck cleared as well.  And then you remove the whole oesophagus, you pull the new stomach tube up and you join it to the remaining oesophagus in the neck.

 

Brett

So, I actually had two surgeons.

 

Porter

Not surprising it took 11 hours.  So, how did you prepare for that?

 

Brett

To start with they said you want to be as active as you possibly can be.  And I’d just go out walking, I wasn’t working, so I had to buy some new shoes and I was out there walking three or four hours a day.  And then I came to see the surgical team and that’s when you met the exercise specialist and it’s more of a tailored programme.

 

Blyth

So, if somebody’s sedentary I’m not going to say to them right, I want you to go and run five miles a day, I will say to them or the exercise specialist will say actually, it’s about making little tiny incremental changes so that we’re gradually kind of building you up.  So, it’s because it’s tailored, because it’s personalised that really makes a big difference.  So, we’re not making a huge leap from zero to 100 overnight.

 

Porter

And looking at the programme here at the moment how long would a typical patient be on the programme for?

 

Blyth

So, I’d say most of our patients have chemotherapy and radiotherapy before they have surgery.  So, I’d say the average length of time is 12 weeks.  But some of our patients will go straight to surgery, so the shortest period of time would be two weeks.

 

Porter

And you can do something in two weeks effectively?

 

Blyth

I think definitely.

 

Moorthy

There’s a lot of research coming out now that says that even two weeks of a prehabilitation programme can accrue all the benefits of the programme.  A lot of cancer surgery is nowadays preceded by a course of chemotherapy and chemoradiotherapy, just like Dominic had.  Now in those three months patients are just lying around, in fact may use the term they are being affected by the side effects of chemotherapy – they experience extreme fatigue, and they’re not doing very much.  And the key here is to utilise those three months to try and there’s a lot of evidence swear by exercise even reduces the side effects of chemotherapy, exercise reduces fatigue.  So, you utilise those three months to start getting them fit and that’s what our data shows as well, that in those three months while you would have expected their quality of life to go down, you would have expected their physical fitness to go down, despite the fact they’re on chemotherapy we can maintain all that in those three months. 

 

But on the other hand, there also needs to be a balance between operating too early and waiting for too long.  The readiness of surgery is more important than the timing of surgery. 

 

So, I think we try to change the paradigm here a little bit, we’re trying to look for is this patient ready for surgery and by that I mean is this patient at a point physically, mentally, nutritionally to have the operation because we may find that if we operate on a lot of people too early, yes we may get the cancer out early but then we face all the consequences of complications, prolonged hospital stay and prolonged recovery.  So, it’s finding that balance.

 

Porter

Looking at the impact here, from a hard-nosed evidence point of view, what sort of impact has the programme had?

 

Moorthy

So, for example, we’ve reduced our complication rates quite significantly, we’ve reduced our hospital stay but I think the most important thing is what really matters to patients, not to hospitals and doctors, hospital stay, complications matter, but I think what really matters to patients is quality of life.  And our data also shows that patients can maintain their quality of life despite undergoing serious treatments like chemotherapy and surgery.  And our data also shows that our patients are actually fitter and stronger a year after surgery than when they first saw us and they sustain this behaviour change that was instilled before the surgery – they sustain it in the postoperative period as well.

 

Blyth

I do think we need to start thinking very carefully about how we assess people because actually we can do more harm than good, if you operate on somebody who’s not ready for surgery as opposed to somebody who really is in a position to have the surgery and recover quicker and get back home.

 

Porter

What sort of parameters are you using to measure them?

 

Blyth

So, for their anxiety and psychological wellbeing we look at anxiety and depression scores.  From a nutritional perspective we look at weight and grip strength and we develop this programme with patients and they said to us – look, we don’t want to come back every week to the hospital is there any way that we can monitor them at home.  So, we would follow them up over the telephone and we call these weekly touchpoints, where we call them up and we set them specific goals.

 

Porter

And what sort of proportion need geeing up?

 

Blyth

I’d say 70% of people actually really do take the ball and run.  We also give people Fitbits, so we can remotely track their progress as well and people love that, they like being able to take control of their own progress.

 

Porter

Because you must get some super-fit patients, I mean they arrive at the prehab and they’re already running or have been running up till recently 30 miles a week or something and presumably they’re pretty well ready, aren’t they?

 

Blyth

Well, it’s interesting you say that because actually we did have somebody who was really fit, phenomenally fit, they were a rower but their anxiety levels were actually really quite high.  Because they had a cancer diagnosis there was a threat to their physical function, it had a knock-on effect on their anxiety.  And that’s why prehab has to be holistic, it has to look at mind and body, you just can’t separate mind and body.  And yes, you’re absolutely right, it’s what a lot of people say to me, is Venetia, they’re physically fit, they’re ready but then I would perhaps just probe them a little bit and say well actually let’s look at them in different way, let’s look at how they’re feeling from a psychological perspective because absolutely that’s just as important.

 

Brett

Give or take three and a half years afterwards and I feel absolutely fantastic.

 

Porter

How are you getting on with your stomach being hitched up into your chest, do you notice any difference?

 

Brett

You wouldn’t know at all.

 

Porter

You look well.

 

Brett

Thank you very much. 

 

Porter

Because you could be forgiven, having been through four cycles of chemotherapy, being told you’ve got this major surgery coming up, you’re waiting a couple of months, that actually you just do nothing, sit at home, not working, vegging and getting out of shape. 

 

Brett

Yeah, absolutely, you could quite easily feel sorry for yourself.  I remember two or three days after surgery literally marching up and down the corridor and the physio was saying it’s fantastic really.

 

Porter

Did it help you psychologically preparing?

 

Brett

Absolutely it did.  It’s obviously my body, cancer’s happened to me, it’s one of those things, it may have been my fault that I got it and if I can do something to help myself to get over it and to help my family then I’m prepared to do whatever it takes really to still be here.

 

Porter

Dominic Brett.  And there is more information on the PREPARE programme that he undertook before surgery on the Inside Health page of the Radio 4 website.  Where you can also find details of how to subscribe to our weekly podcast in case you missed anything.

 

We would like to hear what you think of prehab and any other item that piqued your interest this series.  As well anything you think we should be looking at over the summer. You can email insidehealth@bbc.co.uk or tweet me @drmarkporter

 

It has been a terrible month for the aviation industry with Boeing having to ground part of its fleet following the Ethiopian Airlines crash.  But, recent events aside, the industry does have an enviable safety record.  Indeed, it is often said that the NHS could learn a lot from airlines – a comparison that makes Margaret McCartney uncomfortable.

 

McCartney

“What can healthcare learn from aviation safety?” reads one headline.  “I am determined to blaze a trail across the world in developing a truly safe healthcare system with an ‘airline’ level of safety.”' said previous health secretary, Jeremy Hunt.

 

And they make me wince.  Though healthcare systems can learn a lot from airline safety, the analogy took off in 2011, when the World Health Organisation had just appointed an envoy for patient safety, Liam Donaldson, who said that the chance of dying due to an error in healthcare was one in 300.  This compared, he said, to a risk of dying in an air crash of about one in 10 million passengers, and he concluded, “It shows that healthcare generally worldwide still has a long way to go.”

 

Ever since, that aeroplane analogy has regularly revisited discussions about patient safety.  But useful is it?  It’s certainly true that the airline industry is a clear example of how to do safety in a regular, systematic way that means routine checks are stuck into work.  And how do they do it?  Defined staffing levels, professionals who have to meet stipulated rest periods, a passenger quota which cannot be exceeded, a standard operating procedure which is run through and ticked every time there is a take-off.  There are back up systems to kick in if the usual ones fail.  Support crew on the ground to advise and assist.  And if something does go wrong, the Air Accidents Investigation Branch has a ‘no blame’ approach, seeking to find out what went wrong and how to put it right so that it does not happen again.

 

Compare and contrast to the NHS: taking off a plane in a hurricane with half the staff missing, travellers standing in the aisle without a seatbelt because there aren’t enough seats, on the way to multiple destinations that you aren’t yet sure of, and without enough fuel to get you very far, all while being told that you need to make more efficiency savings.  Add to that, fear of speaking up and out in a culture that seeks to blame more than explain.  There might be some standard procedures that might fit best into an aviation model of healthcare, but medicine, much of the time, is too messy to fit well.

 

And the bottom line?  Comparing death rates in planes and hospitals isn’t a reasonable comparison.  We go on aeroplanes when we are well, but we go into hospital when we aren’t. A better comparison would be contrasting what happens to patients who are recommended to go into hospital and find out whether they are improved more by being admitted or kept at home.

 

But of course, avoidable errors do happen.  But how often, and what do we do about it?  A couple of years ago a paper came out in the BMJ titled ‘medical error – the third leading cause of death in the US’.  It’s a statistic regularly wheeled out and understandably it’s shocking. But is it true?

 

Well, that study relied on extrapolation, and compared different types of studies, like comparing apples and pears, which required a lot of effectively guesswork.  And these studies have no control group, we can’t tell what would have happened with no medicine at all. 

 

But that still doesn’t mean that medical errors don’t happen.  They do.  But if we want to get better at reducing them, we need clear information about what causes them and what might help.  The action needed to stop an error that happens due to laziness is quite different from stopping an error because someone is being asked to monitor too many patients and fill in too many forms all at once.

 

Probably the best data we have about the extent of error in the NHS is a UK study where trained reviewers examined medical records and made a ‘best judgement’ that around 3.6% of deaths were ‘probably’ preventable – judging that there was a 50% chance that optimal care would have delayed the death.  What we need next is a way of knowing what is needed to reduce errors and some of this is obvious.  For example, despite blood tests being ordered online, the results returned online and being checked by a doctor online, I have no failsafe way of knowing if any have gone missing, each step is separate from the last and not joined up.  We shouldn’t have to wait for a disaster to fix it.

 

Trying to improve means understanding first and we can only do that if we are open about errors.  We need the fact finding, no blame aviation investigation approach.  But if we want to fix the problems we find, we also need to get our facts right, let go of the zombie comparisons and think about the system factors that really do need fixed.

 

Porter

Margaret McCartney.

 

Just time to you about next week’s programme – the last in the current series – when, among other things, we visit a neonatal unit that actively encourages parents to get much more involved in their baby’s care, even if it is all a bit scary because they are premature, tiny, attached to lots of tubes, and on a ventilator. 

 

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