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Women's Health Watch

edited by Sandra Coney

 

Selected articles from Women's Health Watch newsletters in September 2000

Contents

Issue 54, September 2000

All fired up over Fahey

Sandra Coney investigates actions being taken by medical groups in the wake of the Morgan Fahey case

In Auckland Feminist Action activists have stuck up posters around the city warning women that doctors should be listed among those who rape. It's men who know you who rape, the posters say. New Zealand Medical Association chair, Dr Pippa MacKay, is disappointed. The posters, she said, would incite distrust.
The case of Dr Morgan Fahey has incited diverse responses and health professional groups are struggling to work out how to respond.
The concept of 'chaperons' has been dusted off and proposed as an answer, but this has not won universal support. 'Mystery shoppers' to trap abusive doctors was proposed by the Medical Council of New Zealand, but got the thumbs down from women's groups, and from GPs, 55% of whom voted against it in a IMS Health New Zealand Doctor poll.
Dr Fahey, a senior Christchurch GP and one-time deputy-mayor of the city, was convicted of 13 charges of sexual abuse of patients, including sexual violation and rape, going back 34 years. A number of complainants were Ansett flight attendants who were required to see Fahey for their medicals. They complained that Fahey required them to undress and groped their breasts. Women told their supervisors, but little occured. In 1991 the flight attendants were told they could have a female chaperon with them when they saw Fahey.
Other cases involved patients who visited Fahey where he worked at the Shirley Medical Centre.
The case came to light after a 20/20 TV expose, where an ex-patient confronted Fahey with a hidden camera. Although Fahey finally pleased guilty, for months he vehemently denied the charges. One of the most disturbing aspects of the case for women members of the public, was that all.
his colleagues gave him the benefit of the doubt, and that women's concerns were disbelieved.
Now the Medical Council, New Zealand Medical Association and the Royal New Zealand College of General Practitioners are all working on policies on doctors who abuse.
The Medical Council says its 1994 policy 'Trust in the doctor/patient relationship' which adopted a zero tolerance approach, is now out-of-date as it was devised under the old Medical Practitioners Act, a new act having been passed in 1996. The Fahey case has been a wake-up call.
'The Fahey case has prompted us to carry out a wider review of policies and processes,' says the Medical Council's Sue Ineson.
The council has had meetings with doctors in Christchurch and with a range of women's groups, who were invited to come up with strategies they would want.
And the council has employed an evaluator, Clare Bear, charged with devising an evaluation plan on 'sexual boundaries' to go to the next council meeting. The document will be used to go out and consult. Bear has to assess current policies, look at similar programmes in overseas medical boards, suggest options for improvement and change and consult with interest groups in the health sector and wider community.

Chaperons - an idea whose time is gone

Chaperons have been promoted as a quick fix but even a casual perusal of the Fahey and other similar cases shows inadequacies. Proponents say a chaperon should be present whenever a male doctor offers a woman an intimate examination, or a woman could bring a friend.
But Fahey's abuse was not confined to gynaecological examinations. He intimately touched Ansett women during routine medicals. The earlier case of an ear, nose and throat surgeon from Dunedin, is another case in point. He groped his patients' breasts and penetrated one woman's vagina with his finger. He said he was testing their glands.
Abusing doctors frequently seek positions where there is a power imbalance, such as vetting applicants for jobs, people needing approval of an ACC claim, or children or women in institutions, such as homes, prisons or mental institutions, so that women are less likely to complain.
There are issues of privacy for women, who may not want a stranger &endash; the receptionist or practice nurse &endash; or even their friend, as an audience to an intimate examination. What if the examination is because the woman suspects she may be pregnant, has a vaginal discharge or painful sex. For busy working women, it would be practically difficult to arrange for a friend to accompany medical consultations.
Chaperons are being pushed by the New Zealand Medical Association, even though chair Pippa MacKay acknowledges patients have said the offer of a chaperon implies distrust or could give offence.
Some doctors have even maintained that a doctor could insist on a chaperon, but Pippa MacKay points out that while patients have right under the Code of Rights to have someone present, doctors have no right to insist. If a patient refuses a chaperon, she says, 'the doctor's right then is to refuse to conduct the consultation or examination'.
The NZMA has issued a 'Chaperons' statement and suggests the following notice could be posted in the waiting room:

'Patients have the right to a third party being present during consultations if they wish. The doctor may be able to provide a suitable person, for example, the practice nurse.
Doctors may also require that a mutually acceptable third party may be present during intimate examinations, and in some other situations, and may refuse to conduct such a consultation if the patient refuses consent.
In threatening situations the difficulties may be such that these requirements have to be waived.'

A bizarre feature of the Fahey aftermath is that the issue of chaperons is primarily about doctors' fears of false complaints.
The NZMA's new 'Chaperons' statement begins:

'In an increasingly litigious society, it is important that doctors protect themselves as far as possible against unjustified complaint. Doctors are particularly vulnerable when conducting internal or other intimate examinations...'

The association has even developed an 'Informed consent for a chaperon' form, for having a chaperon and not having a chaperon (with the patient required to give 'reasons'). This is to be signed by the patient, chaperon, and doctor.
Who's protecting who from whom? Although the Fahey case featured a doctor's abuse of women, the chaperon is presented as a way that doctors can reduce the risk of false complaints against themselves.
Despite being asked, the Medical Council of New Zealand can produce no statistics as to how often these occur.
In New Zealand Doctor, lawyer Gaeline Phipps, a solicitor for the Medical Protection Society, advised doctors to routinely offer chaperons to create 'a safe defence position for yourself if a subsequent allegation is made'. She believes in the aftermath of the Fahey case, women may have 'heightened suspicions or be more sensitive than usual'.
Phipps says that 90% of patients decline a chaperon, but doesn't consider that this might mean it is unacceptable to patients. Instead, she says this high refusal rate ensures that the practice won't be expensive.
Phipps advocates offering a chaperon at all consultations, not just those involving intimate exams. She also advises that doctors have a panic button to call a nurse quickly in case a patient comes on to the doctor or gets upset.

Women want prevention

Cindy Carmichael of The Health Alternatives for Women says that at the Christchurch meeting, women's groups didn't identify chaperons as a strategy at all. 'They didn't see that as making a difference,' says Carmicheal. Along with other women's groups around New Zealand, the Christchurch women took a much broader view.
'We came with some strategies to make it easier for women to complain, such as a Medical Council phone number in the Christchurch telephone book, 'how to com-plain' notices in doctors' waiting rooms and wide publicity, but we also wanted doctors to be more proactive about this issue.'
'It is all very well to make it easier for women to complain, but doctors need to take more responsibility. Doctors need to change,' she says, noting that the medical community in Christchurch has been very quiet since the Fahey case.
'They feel betrayed by Morgan Fahey, that it's made women distrust them.'
The women want a process that would attempt to weed out unsuitable doctors before they even start their training. She believes medical schools are reluctant to deal with the issue, pointing to the replacement of a community-led process that dealt with the issue with a course in 'professional development'.
'They need to work out how you pick out these doctors before they start. They should cover what is sexual abuse in the first year and teach young doctors to deal with situations where they might feel attracted to a patient.'
Both Sue Ineson and Pippa MacKay think more work needs to be done with overseas doctors, who may not appreciate the cultural mores of New Zealand, although that was clearly not the case with Dr Fahey.
According to MacKay, 'We are getting people here who have no training in New Zealand culture and habits. This puts some stress and risk in the doctor/patient relation-ship.There was one case where an overseas doctor said that where he came from it was appropriate to touch women's breasts in the way he had.'
This was the case of Dr Ramesh Nayar and it provides a reminder of how poorly medical authorities have dealt with cases involving sexual abuse of women. In 1999, the Medical Council found him guilty of disgraceful conduct for fondling the breasts of a patient three times in 1994 and 1995. But he was only fined and ordered to be chaperoned, whereas the normal penalty would be suspension or being struck off. The Council said it had taken into account several factors, including his ethnic background, in deciding the penalty. Two other women complained of similar behaviour with Dr Nayar, but the charges were not proven. At the time Dr MacKay called the decision 'astonishing'.
The Medical Council now says it is looking at including in examinations for New Zealand registration, questions about cultural appropriateness and the status of women.

How to tell on buddies

An allied issue exercising the minds of professional associations is how to encourage other doctors to raise their suspicions about a colleague with authorities. According to Pippa MacKay, 'Some doctors knew from their patients about Morgan Fahey, but the patients didn't want to complain. There are things that doctors can do.'
But this raises the question of doctors' attitudes to such behaviour. There was hot debate in the pages of the New Zealand Medical Journal when the Medical Council of New Zealand released its 1994 policy on 'Trust in the Doctor/patient relationship'. This takes a zero-tolerance approach, but New Zealand doctors have been much more ambivalent.
A 1993 poll of 400 New Zealand GPs by Alex Thomson found that two-thirds of doctors admitted having sexual feelings for their patients. Four out of five thought sex with a former patient was acceptable and 37% thought dating a current patient was alright. 10% said genital sex was alright in some circumstances.
A 1998 study of GPs, also published in the New Zealand Medical Journal, asked doctors what they would do if they discovered a new patient had has sexual contact with a previous doctor. One-third said they would 'do nothing' and only 47% thought it would be mandatory to report a colleague currently having sexual contact with a patient.
Dr Frances McClure says the Royal New Zealand College of GPs is encouraging all doctors to take action over suspected sexual abuse.
'We're saying to all doctors, if you have concerns about your own behaviour, self-report to the Sick Doctors' Association. If you are worried about another doctor's behaviour, report it to them.'

The reluctant complainant

The college has also been pursuing what can be done about patients who have been abused but do not want to make a complaint. Meetings have been held with Ron Paterson, Health Commissioner, to discuss whether a process could be based in his office.
Kim Bannister of the college reports a possible process: 'Ron Paterson promoted the idea that when a person doesn't want to lay a complaint, the next step is to get the person to talk through the process with a sensitive patient advocate, with no obligation to take it any further. The intention is that once the person has discussed it, they might cope with making a proper complaint.
The college is considering the possibility of a 'dossier of anonymous reports', similar to a Doctors' Hot or Cold File, that could be kept at the Com-missioner's office, that 'might alert you to a problem if more reports came in'.
'There is a problem in that the Commissioner can't take action unless he can specify who made the complaint,' says Bannister.
The college has also discussed whether a colleague could be sent to confront a doctor if abuse is suspected, although not all council members agree with this tactic.
Kim Bannister says the topic is one members have 'spent a lot of time anguishing over at council level somewhat endlessly.'
'If criminal conduct is suspected, that approach would not be appropriate,' says Bannister, 'it would be a matter for police or a statutory authority. But if it is inappropriate behaviour causing offence, a colleague or colleagues could discuss it. We haven't sorted it out.'

Editorial - Here we go again

Sandra Coney comments on three major planks of the Labour Government's health reforms

Labour is well down the track with its health reforms. The three major planks of its new approach have been released.

  • New Zealand Health Strategy

This sets high level direction for the sector. There is a return to a focus on improving health status and a population approach. Labour's'Closing the Gaps' strategy is embodied in the emphasis on reducing health disparities with particular attention to Maori and Pacific health. Goals are set for the health sector and ten priority areas identified. These include reducing smoking, improving nutrition and the level of physical activity, reducing suicides, minimising harm caused by alcohol, reducing the incidence and impact of cancer, cardiovascular disease and diabetes, improving oral health, reducing violence and improving access to child health and immunisation.

There is a strong emphasis on involving consumers and communities in planning and decision-making about health.

  • New Zealand Public Health and Disability Bill

This outlines the structural framework for the sector. Twenty-one health boards will be responsible for the health of their area. Health boards are crown entities, not com-panies, each will have up to 11 members, 7 elected three-yearly, 4 appointed by the Minister of Health. Each board must have at least two Maori members.

Boards will have three committees: Health Improvement, Disability Support, and Hospital Governance. Members do not need to be board members and the committees can have delegated authority. Boards are to have a population focus and'working within allocated resources' must consider the needs of their populations and work to improve health. Boards can deliver services themselves or contract with others.

The Crown partnership with Maori must be reflected in the workings of the board and the relationships they establish with mana whenua in their districts. They must foster capacity building among Maori providers.

  • Primary Health Care Strategy

This establishes Primary Care Organisations (PCOs) that are to deliver services for enroled populations. They must address the health needs of their populations and reduce health disparities. They are to deliver on DHB plans. PCOs will be capitated or bulk-funded and are expected to include communities in their governance.

Where does it take us?

There is a great deal of idealism and some naivety built into these new arrangements. New Zealand's health sector has become highly commercialised and competitive after ten years of the market model. The change is culture may be irreparable, but certainly there is nothing in the new model to prevent the commercial ethos continuing to predominate. Annette King seems to think there has been a change in consciousness - a'sea-change' she has called it, but it is of course convenient for providers to be diplomatic while they position themselves to make the most they can from the new changes.

The new model was recently described to me by a Treasury official as'more of an internal market' than National's and he is right. The extreme devolution of the model will encourage all sorts of varying arrangements to be struck by boards. The funder/provider split survives at a lower level and contracting into the private sector is facilitated by the change. In many ways the DHBs are like the Health Maintenance Organisations that were promoted in Choices for Health Care in 1986 and Unshackling the Hospitals (Gibbs Report) in 1988. John Marwick, one of the three authors of the former review, is now at a high level in the Ministry of Health and shepherding through the PCO model.

The ability to delegate authority to non-elected committees of boards who need not have board members raises the distinct prospect of provider capture, particularly of the Health Improvement Committee by GPs. Despite the new name, this is still popularly referred to as the Primary Care Committee.

Getting from A to B

The NZHS sets public health goals but does not provide a public health strategy to deliver them. The expected mechanism seems to be GPs through PCOs. A reduction in health disparities will not be delivered by GPs. Such laudible goals will only be achieved by tackling some very big picture issues that will require coordination across sectors and the engagement of communities in the task. GPs have little experience at doing this.

General practice on which PCOs are based is still business-oriented. This is seen in the way GPs always cry out for more money every time they're asked to do a little extra in improving the way the health system is run. The new direction is welcomed by many of them because GPs incomes are dropping, and capitation provides more security of income and the opportunity to profit from surpluses.

Mrs King seems to have been persuaded by the models documented by Professor Laurence Malcolm, particularly the so-called'third-sector' providers of Health Care Aotearoa. This very small section of providers - union clinics, Pacific providers, and so on - bring a social awareness and commitment to their particular client group but it is a very different ethos from mainstream general practice.

Can Maori providers do better? Possibly, but they too cannot perform miracles when so much health disparity is caused by factors much larger than the model of care. And there are worrying trends of US managed care-type organisations signing'heads of agreement' with iwi providers.

From a consumer perspective, the prospect of greater engagement with the sector will vary greatly from DHB to DHB and PCO to PCO. As Hospital and Health Services (HHSs) prepare their transitional plans they have engaged consumers to varying degrees from a little to not at all. Perhaps the best tactic is to build relationships with newly appointed board members. There was generally a high calibre of persons appointed. This may be a more effective route for dialogue over the future.

The New Zealand Public Health and Disability Bill is open for submissions until 22 September.

Ethics of ethics committees in the spotlight

The Gisborne Inquiry has raised questions about the conduct of ethics committees at a time when their future placement and working rules are under review.

Are ethics committees obstructing necessary research projects? Or are they simply carrying out their designated role to protect research participants? The Gisborne cervical cancer inquiry has highlighted this debate, with researchers criticising regional ethics committees for delaying important research on cervical cancer because of their misguided interpretation of privacy issues, and ethics committees taking umbrage and leaping to their own defence. Professor David Skegg from Otago University told the inquiry about difficulties getting access to information held on the Cancer Registry and the cervical screening register. Two projects have been stopped in their tracks.

Answering questions in Gisborne
To provide information so that the Gisborne inquiry could answer its term of reference regarding whether there was under-reporting of smears in the Gisborne area, the researchers had ap-proached the local Tairawhiti Regional Ethics Committee to get permission to carry out a retrospective study of cases of invasive cancer in the Gisborne area. They proposed to study the records of the 42 women in the area who had developed cervical cancer from 1990 (This number has subsequently in-creased to 61 women). They records were held on the National Cervical Screening Register, and by GPs and hospitals.

Were they having smears at all? Were their smears misread? Were there problems about the way their treatment had been managed? A review of the screening histories of these women would throw light on why they had cancer.

However the Tairawhiti committee told the researchers they would have to obtain written consent from all the women in the study, a directive which Professor Skegg argued would jeopardise the results because unless they were able to study all the women, the results would be incomplete. Some women have died and others may not be traceable.

Roadblocks at the national level
A proposed national audit of cases of cervical cancer, part of the much-delayed evaluation of the National Cervical Screening Programme, had also not gained Otago Ethics Committee approval after eight months, according to Professor Skegg.

In this case the researchers sought access to the names of women held on the National Cancer Registry. The Registry's protocol says that researchers must have ethics committee approval to access names it holds. The researchers then planned to go through the women's GPs to discuss approaching them, either by letter from the researchers or sometimes by the GPs. This method has been used before for studies of prostate cancer and breast cancer with no objections from people approached.

No, said the Otago committee. Instead it said that the Cancer Registry should write a letter to the women on Registry letterhead, inviting them to take part.

Ethics committees bite back
The chair of chairs of regional committees Sharron Cole is surprised that ethics committees became the'bad guys' at the Gisborne inquiry. Newspaper articles accused ethics committees of having unfettered powers and operating under sets of principles that are not understood.

ŒThe ethics committees were doing exactly what they were set up to do which is to safeguard the welfare of the individual. Our National Standard and the Helsinki declaration state that it is not alright to sacrifice the wellbeing of the individual for the greater good.'

There is always going to be tension with researchers who believe ethics committees are preventing important public research going ahead, according to Ms Cole. However she says that the committees have not stopped the research going ahead. In the Otago case, the ethics committee said the Cancer Registry should make the first approach to women.

The researchers argue that this is not appropriate and the Cancer Registry agrees. It says it doesn't write to people and isn't set up to do so. Problems of women who have died or moved would also exist.

At the inquiry, Sandra Coney for Women's Health Action, said that as people were not routinely told their data was mandatorily entered on the Cancer Registry, most would not know.'Women might not respond to a letter from a strange agency, or they might interpret it to mean they had something to worry about.'

Women were promised when they joined the programme that it would be regularly evaluated. It was critical for all women in the programme that this occurred.

Researchers complaints
Clearly there is growing discontent among some medical researchers about aspects of ethics committee decision making. A recent survey of medical researchers, reported in the New Zealand Medical Journal, showed many researchers were critical of the quality of advice from ethics committees. Concerns about lack of information about decisions and committees' assessment of risks and benefits, scientific validity and cultural appropriateness were raised by the researchers surveyed. Study author Associate Professor Charlotte Paul, who is also part of the group wanting to carry out the national audit, believes there should be more scientific expertise on committees.

'In my view you can't separate out the scientific issues. Both lay people and scientists are needed on these committees.' Sandra Coney points out that in the current cases, the approach taken by the ethics committees was not acceptable from a patient point of view.

'Sure, the approach jeopardised the science, but I can't see that proposing a letter from the Cancer Registry stacks up ethically. Working through the GP who knows her is likely to be more acceptable. To me this is far more ethical than firing off letters from unknown people where there is the potential for misinterpretation. A woman receiving it might think something untoward has been discovered about her, or that there is information she has not been told. Is it ethical to send a letter to a woman which is received by relatives because she has died? In the past, relatives have been very upset by such occurrences.'

Coney argues that there is an urgent need to strengthen ethics committees and that an evaluation of their performance is overdue. The committees arose out of the Cartwright Report in 1988 but have been left to their own devices for years.'They were attached to Regional Health Authorities, then the Health Funding Authority, which really doesn't have an interest in how the committees function,' she says.

ŒThe committees have worked assiduously but there is always a danger where there is no external scrutiny or systematic review. Left to their own devices, groups can develop their own culture and territoriality.'

Committees should also be educated more about ethics, according to Associate Professor Paul, although she believes ethics are a major consideration for researchers. The survey of researchers did not reveal any problems with the Privacy Code but privacy issues emerged as a major problem with the proposed studies into cervical screening, she says.

Associate Professor Paul says there are continuing negotiations over the proposed national audit and public debate at this point is probably not helpful.'Everyone is very cross about it.'

Looking for a home
Meanwhile a future home for regional ethics committees remains uncertain. Regional ethics committees are currently funded by the HFA and Ms Cole says a Ministry of Health paper has put forward three options: the committees could be contracted to the Ministry, become sub committees of the Minister of Health or be contracted to District Health Boards.

'Everyone agrees ethics committees must be independent and be seen to fulfil our role under the national standard for ethics committees.'

Ms Cole says feedback from ethics committees chairs shows most members see the Ministry's Consumer Protection Directorate as the best place for regional ethics committees because the Ministry has some institutional knowledge about the history and importance of ethics committees. HFA funding has not proved to be a problem for ethics committee independence, even though the potential for difficulties was present, Ms Cole says.

Ethics committees are concerned going with DHBs could lead to fragmentation, according to Ms Cole. Becoming a sub committee of the Minister means the Minister would make appointments to ethics committees which could then be seen as less independent, she says.

Some consumer groups are dismayed to learn that the future location of ethics committees is being discussed without any public input. Women's Health Action has promoted the idea that the committees should come under the Health and Disability Commissioner.The Commissioner, Ron Paterson, has reservations as he says his office could be seen to be approving research and then investigating any complaints that could arise from the same research. But Sandra Coney says the same objections were raised about patient advocates and resolved.'We would at least like to see the Commissioner's Office examined as one of the options.'

The Ministry of Health says it is neutral about where regional ethics committees sit and the Minister will make the final decision when the final content of the reform legislation is determined but before, or as part of, the disestablishment of the HFA.

A new national committee?
In the new New Zealand Public Health and Disability Bill there is also provision for a new national committee to advise the Minister of Health on ethics. Alternatively the Minister can seek advice from the Health Research Council ethics committee. In the past this advice was available from an ethics committee called NACHDSE but this body was disbanded last year following a review. It is understood NACHDSE was never asked for an opinion.

Standards or guidelines?
In another move, a committee reviewing the National Standard for Ethics Committees, last updated in 1996, has decided the standard should be called a guideline. The chairman of the review committee Colin Feek says the problem is that ethics committees are accredited by the HRC Ethics Committee but there is no statutory authority for this process.

Some ethics committee members have raised fears that downgrading the standard to a guideline could weaken ethics committees but Dr Feek says the move is not intended to alter the way ethics committees function. He says ethics committees will be required to stick to the guidelines through contracts and committees will be audited to ensure they are complying.

'There is no intention to undermine ethics committees.'

However Ms Cole says guidelines sound very negotiable. The guideline or standard will be released to the health sector for discussion but Ms Cole says the review is taking longer than expected because very complex issues have emerged. She says the Gisborne screening issues have highlighted the problems with definitions of audit and a definition of innovative treatment has also vexed the review team.

'We have to talk to clinicians because there is no point boxing on unless they understand and agree with our definition. We continue to be frustrated by difficulties understanding each other's thinking,' Ms Cole says.

Compensation for women with misread mammograms

Two South Island breast cancer sufferers will receive compensation for medical misadventure after claiming their mammograms were misread by Healthcare Otago. The women, in their sixties, had been left to prove their cases without the benefit of crucial evidence - their mammography files had disappeared. The women had mammograms taken as part of the mobile Otago-Southland breast screening programmes and were assured their results were clear. Within 10 months one woman was forced to undergo radical surgery for a 2.5cm tumour she found herself. The other woman was also treated for a 2cm lump found 20 months after the mammogram. The women's surgeons say the cancers were evident on the mammograms. Despite the fact that the mammograms are missing, ACC says it has to give the women the benefit of the doubt and they would be entitled to lost earnings and medical and travel expenses.
Healthcare Otago says reading mammograms is fraught with difficulty but stringent systems were in place to avoid giving false negatives and false positive results.
Ref: Sunday Star-Times 16 July 2000

Debate over mammography causes confusion

Most women believe mammography screening should start before age 40, according to a United States study. The researchers say there has been confusing and often vitriolic debate in the United States about the value of screening women aged 40 to 49 years and the study aimed to find out how women interpreted this debate.
About half the women surveyed reported being upset by public disagreement among experts and nearly half the women believed the debate was about the costs of screening younger women. The researchers say women did not distinguish between the relatively weak evidence supporting mammography screening for women aged 40 to 49 years and the strong evidence for screening older women. Almost half the women surveyed believed screening would be helpful for women aged 18 to 39 years. The research concludes policy makers must work out how to communicate the evidence about screening
Ref:Arch Intern Med 2000; 160: 1434-40

Urinary incontinence higher after hysterectomy

Women having hysterectomies should be warned about the risks of developing urinary incontinence. A study in the Lancet reports that women who have hyster-ectomies are at least 40 percent more likely to develop urinary incontinence compared to women who do not have the procedure. Women over the age of sixty were 60 percent more likely to become incontinent. The researchers say hysterectomy may damage the pelvic nerves or pelvic support structures and increase the risk of incontinence, although this may not develop for some years after the hysterectomy is carried out. Reasons for the delayed onset of incontinence are unclear but the pattern is similar to that of childbirth where incontinence often occurs five to ten years later.
Ref: Lancet 2000; 356: 535-39

Bone density screening raises questions

Doctors and the public should understand the limitations of the newer peripheral densitometry devices, used to help diagnose osteoporosis. These devices measure bone density at sites like the heel, whereas the major problems caused by osteoporosis are the hip and spine. An editorial in the British Medical Journal says the limitations of measuring bone density at peripheral sites mean there is the potential for misdiagnosis.
One of the main problems is that bone mineral density is not the same throughout the skeleton, raising the risk of misdiagnosis, especially in women under the age of 65 years. More than one site should be measured in younger women to avoid this risk of misclassification.
The article raises concerns about increasing use of the World Health Organisation definition of osteoporosis, which it says was arrived at for research purposes only. Increasingly the WHO definition has been used for the diagnosis of osteoporosis. It says while optimal methods for defining osteoporosis and predicting fracture risks are debated, it is imperative users understand the limitations of the techniques. Portable peripheral densitometry devices should be used in conjunction with other risk factors such as previous fractures and falls.
Ref: BMJ 2000; 321: 396-98