OK, a few stories about screening.
The biggest story to hit the UK was when screening errors at Kent and Canterbury Hospital led to the deaths of eight women and 90,000 women were recalled for further tests.
Not surprisingly, after that, screening procedures were tightened up somewhat. ‘Quality’ crept into screening bigtime. Actually it didn’t creep, it jumped in and screamed across the stage.
When I first took over responsibility for cancer services, I was told screening was included. Big difference in health authority terms, none to the public. But basically, screening is regarded as a public health function, ie something to keep people healthy. Cancer services are about treating people who are sick.
‘You’ll be chair of the quality assurance group,’ said one colleague. Knowingly, and sniggered.
I didn’t even get to the first meeting of ‘MY’ group. I was busy writing the Millennium Plan for Year 2000 and couldn’t spare the time. I had, however, recently acquired a seconded assistant – a medic gaining public health experience – so I cheerfully sent him to cover for me.
It was only afterwards that he told me what an interesting experience it had been for him because he had never chaired a meeting before in his life.
I finally made the next meeting. I guess the group wasn’t too happy that I had skipped the first one. They also weren’t too happy that for more than 12 months my authority had been promising them a newsletter that had never materialised. Ah! a gift horse. Newsletter? Get that one whacked out in no time. Even if one director, a secretary and a public health consultant had failed to do it. See, journalists do have some advantages.
At the end of that first meeting, one of the consultant surgeons said to me, and I still remember his words to this day: ‘I am right, aren’t I? You aren’t a clinician.’ Well, so what. Two clinicans hadn’t produced the frigging newsletter that they were all clamouring for so they weren’t much use. And secondly, there were so many clinicians around the table that there were more points of view than you could poke a speculum into.
I think I gave the polite and restrained (for me) response of: ‘No, I’m not. We are lucky to have plenty of intelligent clinicians around the table with a lot of knowledge and experience. It’s my job as a manager to pull that together and use it in the interests of improving the service.’ Or some such similar crap. This guy was no walkover. He had more than one of my female colleagues in tears and was rude and insulting to them. He was well known for being sexist and arrogant, and old-fashioned. He didn’t try it on with me any more.
In fact, when he moaned about the preponderance of vegetarian food available for our lunches – which people had said they preferred – I arranged a carnivorous banquet for him but he didn’t turn up. I received grovelling apologies however and no further complaints about the food. I should say that I also represented our organisation at his leaving do. He wasn’t a bad guy, in fact I would say he was good if you stood up to him. He also took the time to show me around his clinic one afternoon so that I had a better understanding of the work he did. I liked him.
Bit of background. My district included two hospitals with laboratories where the smears were tested, and the same hospitals also had colposcopy clinics where women went for an even nastier procedure than a smear. We had a totally separate admin department that organised the invitations and result letters. Then there were all the hundreds of GPs, and community clinics, the GUM clinic, blah blah. Oh, and health promotion, I always forget that one. All this lot were on my cheerful little group.
To add spice to the mix, one lab was also used by another authority, and that authority had different procedures to ours. Gah!!
The minor first disaster was learning that in spite of all our new quality assurance procedures, the shared lab had discovered some poor reporting of smears and hadn’t bothered to tell either me, or my colleague in the other authority about this. Whose neck is on the block? Theirs – and – OURS, as guardians of the screening programme. So much for joint working together.
But when the other lab had a problem – they did tell me. I probably wished they hadn’t. I had to call a serious incident procedure. The lab had totally missed a smear that wasn’t just borderline, or abnormal. It showed cancerous cells on the slide.
This is probably the point at which to say, that screening slides of cervical smears was a hellish boring job that was badly paid. Invariably as local technicians qualified, they were poached for a few more quid by a local lab. I would never dream of blaming the technician for missing something. Or even the cytopathologist that double checked it. It was just not an easy job.
For me though, the very worst experience was one that didn’t happen – hopefully. A colleague was in charge of registering local homes, some of which included people who had disabilities.
There was a problem in a home with someone who didn’t want a smear. Did my colleague come and ask me what the local policy was? Of course not. ( A few personal power political games possibly in play here). She went happily off to ask a MALE public health doctor who knew jack shit nada about the work of our group. ‘Sedate her,’ he said authoritatively and arrogantly. ‘She needs a smear.’
Well, Mr Arrogant Public Health Consultant, it is basically not your decision. Simple as that. It wasn’t then and it isn’t now. Do not force a woman with disabilities to undergo an invasive test that she clearly doesn’t want. Sedating her? Hey date rape doctors here we go.
Finally I’ll finish with a comment dear to my heart. It’s hardly surprising that patient information has always been one of my priorities. I could never understand why medics, nurses (usually left to nurses of course) and every other clinican in the health service, always thought they could write well, because they couldn’t, it wasn’t their job to write – theirs to diagnose and treat.
When I discovered that GPs were sending out info and letters, as well as our computerised admin centre sending out similar-but-not-quite-the-same info to our resident female population, I asked a colleague to conduct an audit. By which I mean, asking all the local surgeries to send in their patient info stuff so that we could share best practice, aka tell the ones who are writing rubbish to STOP DOING THAT. Because that was what I wanted at the end of the day.
And what was worrying about the results? GPs were writing out to the women on their list and telling them, basically, that if they didn’t attend for a smear they would get cancer. Now that was not only misleading, it was a downright lie, and only served to perpetuate disinformation.
I wonder why women are ill-informed about cervical smears?
What next? Patient consent perhaps?
roughseasinthemed
Clouds moving in 
Wow, roughseas – hair-raising. “Sedate her”, and the attitude that she’ll get cancer unless she comes for a smear. Yes, that’s the kind of arrogance we’re dealing with in the “forced vaccines” crowd. And yes, I have a few personal stories about that kind of arrogance, and yes too, about sloppy workmanship in the labs. In the private lab I was eventually asked to check all the juniors and some of my colleagues. I had a colleague double-checking me, too. And mix-ups did happen – luckily they were all blocked in time, before the results could go out. Blocked, fixed and sometimes re-sampled.
I guess cytogenetics is less boring than screening for cell morphology etc. It’s as poorly paid though. So few people stick around to become senior analysts. Most wander off – in South Africa, mainly into different careers. Marketing, estate agent, or whatever.
I love your highly professional journalistic style. Have to say, it’s true, everyone in the medical field who knows how to hold a pen thinks they can write. They simply don’t respect another profession enough to understand it is a profession too.
Following this logic, every farmer ought to have the same kind of arrogance, because food is even more essential to our survival than health care.
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Analytically, I don’t agree with screening. I think it uses vast resources that could be better spent. Even years back we discussed the unnecessary recall of women when their last two or three smears had been negative. But the herd is programmed to think it promotes good health, not helped by irresponsible doctors telling women it prevents cancer. Groan. To voluntarily leave the programme you had to write in and have your request ‘approved’ by the director of public health. Or, as I did, you could just ignore the invitations. Except when I was talking to my arrogant sexist GP, he threatened to not give me the Pill prescription if I didn’t go for a smear. His wife, (also a GP) talked him out of that. But really. Refusing to provide contraception unless I went for a non-compulsory smear?
Intellectually, I really enjoyed screening. It was interesting, and my clinical colleagues in both breast and cervical, were great. One of the easiest PR moves was to visit the departments. Staff were really pleased to show you round and explain what happened. One said ‘can’t remember anyone from the health authority visiting before’. A total win. Trip out for me, interesting, helped me understand the process better, and improved working relationships. We put in a bid to get a national pilot for the new screening technique and won that, so it was a great boost for the whole team.
Even the top consultants were double checked in the lab. One of the advantages about the pilot was that using a brush not a speculum meant clearer readings. Lost track of it now of course, but it was quite exciting. Everyone was so committed, no-one moaned about extra work. Whenever it was newsletter time, they would always produce something for me, I’d write one or two pieces and edit, layout and publish the rest. Writing a newsletter on cervical screening is very different to blogging! I guess one of the skills we learn in journalism is to adapt the writing style for the subject and market. I did get annoyed that everyone expected me to write everything and edit their work, yet still not have decent status or more bucks. That’s why I moved out of PR and media work to take on a clinical responsibility. But that also gave me the clout to be able to start influencing things much more 🙂 and continue the writing as well.
I’m stuck when I don’t write. When I take a break from editing, I write.
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His wife, (also a GP) talked him out of that. YAY Girl Power!
I do see the sense in screening. Though I’d make it a bit more specific, only target the higher risk groups (e.g. women who carry the carcinogenic HPV strains). Now here’s a funny question – why do only women get injected against HPV? Where’s herd immunity now? Isn’t it the men that carry and spread it? (Not that I’d want my son Gardasil-damaged either, after reading a number of mere anecdotes.)
A friend of mine is a breast-cancer survivor, thanks to it being diagnosed early – not because of a mammogram but because she hurt her breast carrying a heavy piece of equipment. Me – I don’t go for checkups. Guess I’m a bit of a fatalist in that respect.
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Screening is not cost effective, however you look at it. Where is the value in screening a white middle class woman, who does not have affairs and neither does her husband, every few years? And they are the ones who take up the screening call. Why screen younger women for breast cancer when the readings can be false and when the incidence/mortality rates are higher for older women?
The HPV one is interesting. As I remember, and I am totally going on memory now, only a couple of HPV strains were carcinogenic, and they were the ones to look for. Most HPV was pretty harmless in the scheme of things. A bit like a lot of prostate cancer.
You know the answer to that. The clinical one is that women get cervical cancer, men don’t. The political answer is, well, fill in that one yourself.
Breast cancer. I had surgeons tearing out their hair trying to prove that early diagnosis makes no difference. And while I agreed with them, try telling a woman who has just been diagnosed that waiting a few months for treatment makes no difference. Clinical studies v mental health doesn’t always do it.
I’ll end this one with lead time bias. I’ve written about it on here, but if I try to find it I’ll lose this comment!
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You mean, it makes no difference to the prognosis how early breast cancer is diagnosed? Is that not within certain limitations as the cancer is slow to progress from stage 1 to 2 and 3 but fast from 3 to 4? I always thought (what we were all told) that the earlier you diagnose a tumour the more likely it will still be operable. The logic is sound – does the evidence point in the opposite direction?
Yes there are only a few (could be it was 2, I’m too lazy to look up the email now) strains of HPV that cause cervical cancer, both ironically asymptomatic infections (not the type that causes warts). But even they cause cancer only in a limited proportion of infected women. Mostly the immune system deals with them. Between pap smears and Gardasil I guess the pap smears are to be preferred (Dr bro told me that screening picks up almost all cases). The way I’d go about it is to test for the virus after “exposure” (e.g. in recently-active teenagers). If it is present, then, well, pap smears I guess. You don’t do a pregnancy test either if you haven’t been “exposed”.
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Early stage cancer – depending on the type – no. Stages 3-4 of any cancer you are bending down and kissing your arse anyway. I had to tell my dad because the old age doc knew less than me about cancer 😦 Geriatrician. Knew stuff all about cancer. I ended up telling her over the ‘phone what stage I figured my dad’s cancer was – three, I reckoned, maybe four, but it was going on limited info.
Back to breast. And my link to lead time bias. You will not die of breast cancer if you are not treated immediately. Simple as that. If you have an invasive cancer then the situation is different. But neither is dependent upon timing.
The point is not whether it is operable, rather that waiting doesn’t increase the risk factor. Again, depending on the type of cancer. My consultant radiologists didn’t freak much, but when they encountered the invasive ones…
I am sure it was two too(!) HPVs. Two numbers that were the key ones. I knew them, now I don’t.
I think the big issue with cervical is blurring testing for STD and cancerous cells. In a way HPV has made that distinction worse.
Lead time bias…
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First, arrogance is RARELY an attractive trait in a man — unless it’s exquisitely done in the Stephen Colbert genre of course where you can’t stop laughing 😉 — and it can easily be redirected into humble confidence IF the man so chooses. That’s glaring to me first off.
Last, one of my highest historical icon of humble, firm, stoic, intelligence for me to model… is Mahatma Gandhi. He even had a great sense of humor, although given his era in life, in was likely unable to be enjoyed as much as it should’ve been. I love that man. I only hope that another one is born into this world…and many others for that matter!
Many more male medical doctors, EMT’s, etc, would be of MORE benefit to their patients and the world if they exhibited Gandhi-like qualities.
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It’s all about the power politics of the work environment, and I never did play the suck-arse game well.
There are a lot of people, primarily men in my experience, who like to put you down to see how react. Other arseholes just get a kick out of being ignorant and destroying someone’s selfesteem. It’s like the old negotiations about money. You know you have to ask for more than you are offered to show you have character. Or something. All. Too. Boring.
Medics. Don’t start me on them.
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