Health tsars: more
like Peter the
Great than Ivan
the Terrible

In 1999 the Department of
Health appointed the first of
nine health tsars to help

shape a variety of services
from primary care to cancer,
heart disease, and services for
children and older people.
This was the first time
clinicians could direct change
at a national level from a
department of the
government. Five years down
the line Burke (p 126) asked
them to summarise their
achievements and other
people to assess their work. In
an accompanying editorial
Burns (p 117), the former
cancer tsar for Scotland, tells
us what it takes to be a tsar: be
open to ideas and have money
to spend, but also be ready to
take jealousy and hostility
from some of your colleagues.

Editor’s choice
Doctors mangled by “justice”
This morning I spent three hours in the chambers of
a Queen’s Counsel. It was like a stage set. The open
fire crackled. The view over the 18th century lawns
was magnificent. The room was lined with leather
bound reports from the appeal courts of the 1890s. It
was impossible not to be impressed by the forensic
precision of the lawyers’ minds, and we all had a
lovely time. But many doctors’ experiences of the
law are nothing like this Georgian arcadia but rather
a brutal mangling. I’ve read of two such cases this
week.

The first was in JAMA and described the case of a
family physician in an American academic centre who
saw a 53 year old man for the “routine physical” that
is common in the United States but uncommon in
Britain (2004;291:15-6). The physician and patient
discussed the possibility of measuring the man’s
prostate specific antigen. The easy thing would have
been to simply order the test. Instead, the physician
opted for the modern model of patient partnership.
He explained the pluses and minuses of the test, and
the fully informed patient decided against. Three
years later the physician was sued because the patient
had developed metastatic prostate cancer and died.
The physician was exonerated, but his academic
programme is liable for a million dollars.

This story is likely to strike terror into many
doctors. “This could easily have happened to me,”
might be the first thought. “It’s so unjust” might be a
second: “The doctor goes to all this trouble, practising
medicine in the way we teach now—and still gets
screwed.” Then there are the implications for practice
across the United States. Many patients—often
prompted by the media—are asking to have their
prostate specific antigen measured. Will doctors
discuss with them the risks and benefits of the
procedure—or will they simply suggest that the patient
has the test?

The “villain” in my second story is less the law
and more the media. The Daily Mail last week carried
the headline “The killer doctor back working in
hospital” with a picture of the doctor (7 January, p 5).
The doctor had been found guilty of manslaughter
for failing to diagnose a knee infection that
complicated surgery and led to the death of a young
man. “He escaped a jail term after his barrister
pleaded that his career was in ruins,” reports the
newspaper; and he was not struck off by the General
Medical Council.

The doctor has now been re-employed in a
training position, greatly upsetting the father of the
young man who died. “I don’t think,” says the father,
“there is any normal human being in this country
who would say this is right.” To suggest that anybody
who thought it was right—including the courts, the
GMC, and the employing authorities—are not
“normal human being[s]” may be strong, but it’s
understandable and excusable in a bereaved father.
What is inexcusable is to report the story in a national
newspaper.

Richard Smith editor rsmith@bmj.com

POEM*
Earlier mobilisation improves pneumonia
outcomes
Question Does early mobilisation improve outcomes in
patients with community-acquired pneumonia?

Synopsis Everyone looks healthier sitting up, don’t they?
Previous studies of myocardial infarction and orthopaedic
procedures have shown improved outcomes with early
mobilisation. These researchers applied that thinking to
hospitalised patients with community acquired pneumonia.
Patients (n = 458) admitted to 17 general medical units were
randomised by medical unit to early mobilisation (encouraged
to get into an upright position for at least 20 minutes during
the first 24 hours of hospitalisation, with progressively
increased mobilisation thereafter) or usual care. A large variety
of variables and outcomes were measured, but the primary
outcome was length of stay. Groups were similar at baseline;
approximately 25% were younger than 50 years and 25% were
older than 80 years. Most received their antibiotics within eight
hours. The mean length of stay was lower for the early
mobilisation group (5.8 v 6.9 days; 95% confidence interval 0
to 2.2). The results were stratified by the pneumonia severity
index (PSI) score, where I is the lowest severity (what were they
doing in the hospital in the first place?) and V is the highest
severity. The greatest difference in length of stay occurred
among the 86 patients with an intermediate PSI score of III
(4.9 v 7.4 days; 0.2 to 5.0), and the authors speculate that
patients who were less sick were going to get better quickly
whether they were lying down, sitting up, or standing on their
head, while those who were most sick were less likely to benefit
from this simple intervention. There was no difference between
groups in the risk of death or readmission.

Bottom line Early mobilisation, beginning by having patients
sit up for at least 20 minutes in the first 24 hours after
admission, reduces the length of stay for patients with
community acquired pneumonia.

Level of evidence 1b (see www.infopoems.com/resources/
levels.html). Individual randomised controlled trials (with
narrow confidence intervals).
Mundy LM, Leet TL, Darst K, et al. Early mobilization of patients hospitalized
with community-acquired pneumonia. Chest 2003;124:883-9.

©infoPOEMs 1992-2003 www.infoPOEMs.com/informationmastery.cfm

* Patient-Oriented Evidence that Matters. See editorial (BMJ 2002;325:983)

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