Are doctors chopping off legs willy nilly in Jamaica?
Who is to blame? Patients, doctors or the system?Sunday, November 22, 2020
Ernest Madu and Paul Edwards
Last week in our column, we discussed the issue of amputations in Jamaica and how we have earned the unenviable title as the amputation capital of the world.
We discussed the proximate causes of amputation in Jamaica and proffered practical solutions. We pointed out main culprits that likely lead to critical limb ischemia and possibly amputation and recommended measures to address those. We discussed lower extremity infections in diabetic patients as well as poor circulation otherwise referred to as peripheral artery disease (PAD).
While the data on the prevalence of PAD in Jamaica is not well established, we can extrapolate from the US data and estimate the number of patients in Jamaica living with PAD. There are 8.5 million Americans with PAD. We estimate that there may be as many as 75,000 Jamaicans or more living with PAD. It is the third most common obstructive vascular disease after heart disease (coronary artery disease) and stroke.
Since our article appeared, we have received many messages in response to the article. We are delighted that the article has engendered a much-needed dialogue on how we deal with an important health problem that affects thousands of our citizens. In response to the article, we had the opportunity to participate in a radio interview a few days ago hosted by Dionne Jackson Miller on Beyond the Headlines on Radio Jamaica 94 FM.
It was a fascinating session with Dr Madu, chairman, Heart Institue of the Caribbean (HIC); Dr Roberts, consultant surgeon, Kingston Public Hospital (KPH) and Dr Taylor, cardiothoracic surgeon. Jackson Miller kicked off the discussion by expressing the opinion that after reading various articles on the subject of amputations in Jamaica that she did not get the impression that doctors chop off legs “willy nilly” in Jamaica. This viewpoint was supported by all panellists but what remains irrefutable is that our number of amputations are way too high for comfort.
Willy nilly is both an adverb and adjective and defined as an event occurring “without direction or planning; haphazardly, whether desired or not ”.
As Dr Roberts emphasised during the interview, based on his experience at KPH, most patients with lower extremity infections or vascular disease present to the hospital very late with severe complications leaving no other option but amputations. While we can agree that these amputations may have become medically necessary, we must confront the sobering reality and determine the structural fault lines that lead to these late presentations and resolve them. In other words, how did willy meet nilly?
Who is at fault? Doctors, patients or systems?
As we pointed out in our article last week, we know the factors that put patients at risk for limb amputation. We know that diabetes and PAD may lead to complications including limb amputation. We also know that once a limb is amputated, the risk of premature death is greatly increased and may reach eight out of 10 dying within five years depending on which limb has been amputated. We know that we can significantly reduce the complication rates and risk of limb amputations by diligently addressing the risks; better management and control of diabetes, treating cholesterol and blood pressure to target, avoiding smoking and better management of foot infections especially in diabetics.
As Dr Taylor reiterated, we must do a better job at screening, detection/diagnosis, and early treatment. Why then are we not doing that? Dr Roberts highlighted the issue of education and health literacy for both the patients and practitioners. Physician education is critical at the frontlines before the patients develop complications and end up on the surgeon's table.
Recognising that we are not doing as well as we should be doing is a starting point to solution. The truth is that we are all at fault. Patients are presenting late because many times, they are not well informed of the risks and issues to quicky attend to. Doctors are not doing a great job with screening to detect disease early and intervene.
We are also not as diligent as we should be with following proven guidelines and strategies in managing patients. There are system issues that complicate the problems. Many patients do not have access to appropriate care in a timely manner. Many are unable to afford appropriate or adequate care and so delay diagnosis and treatment until it is late, and amputation is the only option. This is a system failure and needs to be addressed in a systemic context.
Public or private patient? What is the difference?
There is no denying the fact that most patients seeking care in the private sector tend to be more educated and wealthier than most patients seeking care in the public sector. It is also likely that more patients seeking care in the private sector, because of their higher comparable level of education, may be more health literate than the average patient seeking care in the public sector.
It is not surprising therefore that more complications and ultimately more amputations tend to occur among public sector patients. Our position, however, is that we should address this problem in the context of the “Jamaican Patient”, not public or private patient.
Jackson Miller posed a question during the radio interview regarding difficulty in managing patients in the public sector given that the patients see different doctors each time and so no doctor really “owns” the care of the patient. While that might seem like a problem on the face of it, it really should not be an issue if we follow established guidelines and audit what we do to ensure compliance and conformance with standards.
Checking the A1C of diabetic patients to ensure adequate glucose control should not be contingent on which doctor is seeing the patient. Checking the cholesterol and blood pressure and treating them appropriately should not be contingent on which doctor is seeing the patient. Checking the peripheral pulses and referring the patient for a Vascular Profile, especially in diabetic patients and individuals with known risk factors should be done routinely and should not be dependent on which doctor is seeing the patient.
If we are committed to doing the right things, we should do them both in the public and private sector. We should employ one standard of care to ensure appropriate quality is delivered to the Jamaican Patient whether in the public or private sector. We must provide the necessary resources to accomplish that, hold ourselves accountable to deliver on quality care, educate and enlighten practitioners and patients so that we understand why we do what we do.
Do we need a national programme on amputation prevention?
In the Beyond the Headlines interview, it was suggested that a national programme on amputation prevention could be created to deal with the matter. While this sounds reasonable, it is difficult to see how this can be successfully implemented without addressing other fundamental frictions in the health care delivery ecosystem.
Most amputations can be avoided if we successfully manage diabetes. We would advocate a more aggressive approach to the management of diabetes including a more focused and vigorous screening and detection of potential complications of diabetes including poor circulation and infection. This can be readily accomplished by implementing and monitoring compliance with established standards and guidelines within the existing health care system.
A national health literacy campaign focused on atherosclerosis (including coronary artery disease, stroke and PAD) would have a significantly better return on investment. The health literacy campaign on atherosclerosis should be targeted at patients, health care providers, third party payers, and policymakers. The society must understand the social, economic, and health care consequences from poorly managed diabetes and atherosclerosis.
It is a good thing that the dialogue is taking place. We know that we can do better. Let us do better.
Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are Consultant Cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital
Dr Madu is a main TED Speaker whose TED talk has been translated into 19 languages, seen, and shared by more than 500,000 viewers. He has received the Distinguished Cardiologist Award, the highest award from the American College of Cardiology and has been named among the 100 most influential people in health care and among the 30 most influential in Public Health. Dr Madu is also a recipient of the Global Health Champion Award from the University of Pennsylvania.
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