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Sometimes you find articles in the medical literature that make you sit up, take notice and think. From somebody who has to read a few hundred of these every year may I suggest that this does not happen a lot. Nevertheless Anstee, McPherson and Day’s “How big a problem is non-alcoholic fatty liver disease?” really makes you sit up and ponder about the potential public health implications of something that has only been registering on the fringes of my brain.
Non-alcoholic fatty liver disease is pretty much what it says on the tin: triggered by insulin resistance, obesity or type 2 diabetes (which of course often happen all at once) the architecture of the liver changes. Instead of hard working liver cells the liver develops fatty streaks that are later being replaced by other connective tissue (fibrosis) and ultimately by scar tissue (cirrhosis). A liver significantly changed by scar tissue can not work properly and this can end in liver failure (and make liver cancer much more likely).
So how big a problem is this?
Let’s quote the article:
“Estimates vary between populations, but one large European study found NAFLD in 94% of obese patients (body mass index (kg/m2) >30), 67% of overweight patients (>25), and 25% of normal weight patients. The overall prevalence of NAFLD in people with type 2 diabetes ranges from 40% to 70%. With the advent of increasingly sedentary lifestyles and changing dietary patterns, the prevalence of obesity and insulin resistance have increased and NAFLD has rapidly become the most common cause of abnormal liver biochemistry in many developed countries”
So, let’s do some maths: According to Diabetes UK, ca 2.2 million people in the UK have diabetes (most of them Type 2). If the numbers from the articles are correct, that’s more than 1.5 million (as you have to factor in the considerate amount of obese people who have not yet been diagnosed with diabetes). Circa 5% of these develop end stage liver disease. That’s about 75000 patients. And of course with a risk profile like this, you’re much more likely to develop cardiovascular problems (double, actually).
That’s a lot of lives that potentially could be saved by weightloss and exercise.
Because that’s pretty much the only thing you can do.
 The Medical Protection Society has just announced that they are concerned about the impact of the tsunami of guidelines that is currently flooding GPs. During October alone 15 guidelines aimed at GPs were released, all often more than 100 pages long. I have no idea who finds the time to read all of them, but I do know that the Royal College of General Practioners’ Essential Knowledge Updates programme does offer a bit of relief. We check all important articles, studies, guidelines and position papers and let our editorial board choose which studies are the most appropriate for our frontline GPs and present them in a compact format.
I am obviously biased, but I still think it’s the bees’ knees and the best way to keep up to date. Staying up to date improves patients’ safety, reduces GPs’ unmet educational needs and maked revalidation and appraisal much easier.
What’s not to like?
The Guardian reported on the weekend that complaints against GPs have increased by 20%. I checked with the GMC, and according to their report they received 4171 complaints in 2009. At 300 million gp consultations per year that number should probably be kept in perspective.
I have the honour to be the clinical lead for one of the most successful continuous professional development programs for doctors on the internet. Essential Knowledge Updates now attracts the majority of members of the Royal College of General Practitioners. The hosting platform we decided on is the brillant Moodle, an extraordinary versatile e-learning platform that works very well for us, as it is easy to administer and easy to host. So this year I attended Moodle Moot UK 2011, the curiously named conference for Moodle users in the UK to find out a bit more how the rest of the community is using this impressive tool. Unfortunately the whole thing was a bit of a mixed bag. First problem was that the different breakout sessions had talks that just didn’t match: If one session would start with an excellent introduction on how to teach Moodle to hesitant late adopters, the next talk would be on the rather specialised art of setting up GCSE exams on it. Or session would start with a presentation on referencing tools and end in the black art of implementation of content across different different learning environments. So half of the audience would scratch their heads after half the session or have to leave noisily to the a room in which more appropriate content was being presented.
Another problem was keynotes: Why it might hugely rewarding for the few teachers in the audience to have some chap talking about his achievement at his college, the majority of paying customers might have preferred something Moodle related (which was one of the most frequent suggestions during a feedback session).
So, dear Moodle Moot UK organisers, here is my wishlist for next year’s conference:
- Publish the abstracts of the talks in advance
- The breakout sessions need to be thematically ordered
- Moodle relevant content for the keynote sessions
- Better catering (both the catering during the day and especially at the evening session was pretty, er, basic)
- Don’t host the conference in the most expensive city in Europe
- Start the conference with a ‘Getting to know you’ session
- Moodle Moot is not a teacher conference
Apart from that, everything was lovely. Especially the weather.
In a recent article in the much loved British Journal of General Practice, Bill Irish and Fiona Patterson* remind us that selection into GP training is based on the results of the assessment of six key priorities, which include empathy, communication, integrity, clinical expertise, problem solving and resilience.
I would propose the evaluation should look a little bit like this:
- Empathy: Is the trainee able to emphasise with his/her colleagues’ wish to let the trainee do all the homevisits?
- Communication: Is the trainee able to communicate effectively that he/she would prefer not to do all the evening surgeries?
- Integrity: Is the trainee able to withstand the offer of a free pen from a drug rep?
- Clinical Expertise: Is the trainee able to diagnose a bout of D+V two weeks after it happened to produce a backdated Med3?
- Problem Solving: Is the trainee able to placate the senior partner after inadvertently taking his favourite tea cup?
- Resilience: Is the trainee capable to see forty patients a day and still attend her local deanery’s CPD events.
If the trainee successfully takes these hurdles, a glorious career as a GP is likely assured.
*Irish B, Patterson F: Selecting general practice specialty trainees: where next? BJGP 2010; 60; 849-852
So here I am, on my way back from Harogate, the location for this year’s RCGP conference. There was plenty to learn, experience and take in. Both sessions on Evidence Based Medicine (EBM) encouraged me to continue using the Computer as a diagnostic and decision-aiding tool within and outside the consultation. Using sites like pubmed or Essential Knowledge Updates to check on the latest evidence or treatment regime reduces not only prescribing errors but also avoids falling into the trap of continuing to use treaments that have no evidence for their use in certain settings (e.g. Gabapentin vs Pregabalin in neuropathic pain).
It was good to hear so much excellent feedback on the Essential Knowledge Updates and I am genuinely excited to see the project undergo an extensive evaluation exercise and have it prodded from all sides. I am sure we will have a great paper to present at the next conference and EKU will come out of this even better than it is already.
I am genuinely sad to see Steve Field go. He was such a proactive and trend setting leader of our profession. Instead of only responding to the latest catastrophy he pulled his shirt sleeves up and launched himself into the dirty world of health politics like a Wostock rocket and fought for the progress in the profession through one meeting after another. It’s going to be interesting to see how Claire Gerada will tackle the challenges that we are facing in these exciting and uncertain times of the White Paper and she will be able to follow Steve’s example of continuously setting the agenda instead of just reponding to it.
I wish her luck.
The NHS in London is currently in a bit of a pickle. It is aware that money will be tight in the future (with most of governmental spending these days seemingly necessary to save the Royal Bank of Scotland), so together with those friendly efficiency creaters from McKinsey it has started to look where it could make some savings. One of their ideas would be to ‘reduce the unit cost in the non-acute sector’ by ‘radical measures in staff utilisation (66%), appointment times (33% reduction in PC[primary care]) and prescribing costs (10%-15%)’ (link here: Strategic Planning Guidance 2009 10 appendix1 HfL affordability assumptions).
Now, I am sure that we all approve of reduction in prescribing costs and utilising staff better, but I do take umbrage with the suggestion to reduce my consultation times. Most days I have a 3 hour surgery in the morning and the evening. In each 3 hour block I’ll see about 18-20 patients, most of them about 10 minutes each. You could argue that 10 minutes isn’t much for the complexity of primary care medicine, and you would likely have a point, but after a long time coming, ten minutes has been the norm for consultations in general practice. Of course, neither doctor nor patient get the full ten minutes, as the clock doesn’t start when the patient sits down in front of the doctor, having taken his or her coat off. No, the clock starts when the doctor calls the patient from the waiting room. Depending on disability or injury, the way from the waiting room to the consulation room can be a long and slow one, so by the time the patient arrives, a third of the consultation might already be over. If patient and doctor are staisfied at the end of the consultation that everything is sorted, a plan is in place, concerns discussed, the doctor still has to meticulously document everything that happened within the consultation. Only then the next patient can be called in.
This shows you two things:
- how immensely important good timekeeping is within general practice (imagine a 5 minute overlap for the first 17 patients in a 3 hour surgery: that would mean an 85 minutes wait for the patient who had an appointment at the end of the surgery).
- how absolutely impossible it would be to reduce consultation times to 7 minutes. Experience shows that the only thing this results in is decreased satisfaction for both patient and doctor and an increased rate of referrals, as your GP has less time to sort things out on a primary care level.
As unnecessary referrals are a terribly expensive way to conduct medicine, the NHS in London is likely to pay more for their scheme to reduce consultation time. Nevertheless, that’s what happens if you invite consultants like McKinsey who have no interest beyond the obvious cost savings and are not interested in either the consequences or the ‘soft’ (i.e. relational) side of medicine.
The NHS London insists this plan was widely consulted on.
Ah.
For the past 20 years people who ought to know better have been bashfully embracing one evidence free treatment after another, for fear that refusing to do so would make them seem reactionary old fuddy duddies. But hope is never dead. In this instance it springs from rather an unlikely source: the Royal College of Physicians.
This is the spirited introduction of an article by Nigel Hawkes in last week’s BMJ and he certainly doesn’t pull his punches:
And it is difficult not to feel a certain sympathy with the herbalists. With respect to modern medicine they occupy the same relation as alchemists do to chemists, astrologers to astronomers, or the Arts and Crafts movement to IKEA—historical anomalies that are almost (but not quite) touching in their rejection of modernity.
I have to admit that I am a bit ambivalent about the whole alternative medicine shindig. My motto is normally: ‘As long as it doesn’t harm you and you’re enjoying yourself and you’re not becoming poor in the process’, I don’t mind what people do with their money, and if they have fun sitting half an hour chatting with a chrystaltherapist, a reflexologist, a homeopath or a herbalist, that’s fine. As long they’re not being harmed financially, physiologically or emotionally.
I nevertheless get cranky when people come to me asking about therapies they have read about on the internet or sold by ‘friends’ and spent a large amount of money on and that have no evidence of it working (or worse, evidence of harming people). Unfortunately this happens a lot, and in the age of the internet even more than it used to.
Which brings us elegantly (or less so) to the nub of the problem: evidence. When I prescribe a drug to a patient, I have a clear idea about the latest evidence on its efficacy. Meta-analyses, reviews, double blind,placebo controlled studies do help to guide my prescribing finger.
Unfortunately there is no evidence out there whether it is helpful to put an opal or a quartz in your belly button when you have the runs, apart from auntie Agatha telling you the man who put that green stone in there was very nice and the everything was better after three days.
With other words: before you spend a lot of money on things that are likely not to work, check with your doctor. You always do your research before you by a new TV, so why not do the same for your health.
Hi all,
I would like to warmly recommend a feature from today’s Gaurdian. Deborah Orr, the former ‘Independent’ columnist, has produced an excellent account of the daily reality for mental health professionals and the clients they are caring for in the community. Well informed, sympathetic to the subject and well researched, this is an excellent piece of journalism and should be read by everyone with an interest in community mental health.
Pleas click here.
So the Department of Health released the second annual report of its Cancer Reform Strategy. Entitled ‘Achieving local implementation’, it highlights the stark variation in cancer detection and survival across England. Without fail, the GP bashing started immediately. The Sun quoted Katherine Murphy, director of the Patients’ Association:
“Patients will sometimes tell us that they had been going to see their GP for six to nine months with, say, a pain in their stomach and were told to go to the pharmacy and buy an over-the-counter medicine (and later are found to have cancer).”
In a time honoured strategy, General Practitioners are usually the first to face the wrath of the national media. Nevertheless, there are a few more variables to be accounted for before a successful early cancer diagnosis can be made and it’s not all down to the GP to make it happen. First of all, the patient must tell his or her GP about the new and worrying symptoms he or she might have. While this may sound obvious, there are a couple of reasons why this might not happen. A good example is the comparatively low percentage of men seeing their GP with early red flag symptoms and often presenting in the later stages of a medical problems (1).
Another reason often cited is patients who ’didn’t want to bother the doctor’. I normally tell these that I’d rather be seeing them a once more than necessary before we miss anything important. And by the way: we’re not ‘bothered’ by our patients. The reason that we’re sitting in the chair in the surgery, seeing forty patients a day is because we chose to do so. If I would be bothered seeing patients I would have chosen a different specialty (without naming one in particular, of course. But as you can imagine, there are a couple of specialties where you can reduce patient contact to a minimum) than General Practice. If you can’t stand the presence of your own patients, then you’re definitely in the wrong job.
So before making a diagnosis, the doctor has to know about the symptoms. When the General Practitioner then hears about the worrying complaint it is likely that he will request investigations (bloods, xrays, ultrasound, etc) or will refer directly to a specialist. If the complaints are classic red flag symptoms it is highly unlikely that any GP will be ignoring these and telling the patient to go to the pharmacy. That doesn’t necessary mean that GPs never get it wrong, but I’d wager the number is neglectable in these circumstances. But more frequently there are times when the symptoms just aren’t classic red flags. In fact they might be completely unspecific. In that case it is up to the individual practitioner to either investigate, refer or just wait for a week or two. This is the often quoted ‘Management of Uncertainty’ and is at the heart of General Practice, as most patients arrive with concerns that just don’t fit in any particular category. Medicine is fuzzy and patients rarely have text book presentations of one particular illness. Hence the management of uncertainty bit. And this is obviously the moment where things can go wrong in General Practice. Managing uncertainty is not easy, and GPs will get it wrong at times, no doubt about that. But I am sure this is due to the nature of General Practice, and exceedingly rare due to a single practitioner .
So let’s say the GP made the appropriate diagnosis and referred the patient. There are still plenty of things that can wrong: the referral might get lost. The appointment letter might get lst in the post. The clinic is cancelled. The Xray machine (MRI/CT-Scanner/USS) is broken. The xray report vanishes. The report from the specialist to the doctor can’t be typed because of staff ilness. And who will then pick up the phone and try to call the various partys? Exactly, it’s the patient’s GP who has a worried patient in his surgery who hasn’t heard anything from the local hospital and will likely sort it out by sweet-talking various members of staff.
So there we have it: before blaming GPs for the failures within the NHS, do consider the other factors that might hinder successful cancer detection and treatment.
Thank you.
—-
1 Ian Banks: No man’s land: men, illness, and the NHS. BMJ. 2001 November 3; 323(7320): 1058–1060
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