Monthly Archives: March 2015

Supersize supermodels: which way do they tip the scales?

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

For years there has been deep concern about the dangers to health of girls and young women aspiring to the figures of ‘size zero’ models. How odd then that the signing of a morbidly obese model to a top modelling agency was heralded by many in the press as a triumph despite the vast array of health issues associated with obesity.

Tess Holliday, the size 24 model in question, is a champion of the ‘body positive’ campaign which aims to destigmatise obesity and challenge conventional perceptions of beauty. In many ways this it to be applauded. There is no doubt that obese individuals are widely stigmatised and there is much evidence that the stigma attached to obesity is a major barrier to people seeking help for weight loss and for achieving their weight loss goals¹.  It has even been argued that, as medical practitioners, destigmatising obesity is part of our duty of non-maleficence².

Yet many people would counter that models such as Tess Holliday feed into the increasing normalisation of high BMI. Being overweight or obese in the UK has already become so normal that the majority of adults in the UK who fall into these categories do not recognise that they have a weight problem³. Not recognising the problem is of course a huge hindrance to tackling it.

So where does this leave Ms Holliday? On the one hand she is helping to break down the stigma that causes such difficulty in promoting weight loss, on the other hand she normalises a dangerous health condition.

This is the quandary we all face day to day when we deal with overweight patients. How does one strike the balance between re-affirming a positive self-image and instilling a healthy fear of a condition that demands treatment? How do you make someone feel good enough about themselves to be motivated to change, and yet convince them that the change is necessary?

There is another danger in the debate concerning plus size models. Each time a model such as Tess Holliday makes the headlines the argument surrounding obesity regresses to one of aesthetics and vanity which trivialises an issue that is a major problem both for individuals and our nation as a while. This detracts from the important public health messages. The more normal obesity becomes the harder it will be to bring home the importance of preventing and treating it.

Underlying all this is one further big question. Why does our fashion industry feel compelled to swing between the extremes of dangerously underweight models and dangerously overweight models? It seems to me that between size zero and size twenty four there are at least ten healthier dress sizes. Are there not enough beautiful women to be found amongst them? Is it not possible to re-normalise a healthy weight?

Perhaps, as doctors, there is only so much we can do. For many people issues of vanity will always trump issues of health and it is not till healthy is seen as beautiful that we will begin to win this battle.

References

1 Brewis AA (2014) Stigma and the perpetuation of obesity. Soc Sci Med 2014 Oct; 118:152-8

2.  Abu-Odeh D (2014) Fat Stigma and public health: a theoretical framework and ethical analysis. Kennedy Inst Ethics J 2014 Sep;24(3):247-65.

3. Johnson et al (2014) Do weight perceptions among obese adults in Great Britain match clinical definitions? Analysis of cross-sectional surveys from 2007 and 2012. BMJ Open 2014 Nov 13;4(11)

Essential law for GPs: discussing treatment risks

IMG_9619 copyAdam Sandell is a GP in Cumbria, and a barrister at Matrix Chambers.

A Supreme Court judgment last week changed the law about the discussions we need to have with patients about the risks posed by treatment. “Doctor knows best” has just suffered another stroke.

The busy-doctor version: We must discuss with patients any material risks involved in proposed treatment, as well as reasonable alternative approaches. A risk is ‘material’ if the patient is likely to attach significance to it. Ask yourself whether knowing about the risk might alter the patient’s decision: if so, tell the patient about it.

If you’re more interested: Remember the Bolam test? Bolam’s the case about breaching your duty of care. You’re not negligent if you act in accordance with a practice accepted as proper by a responsible body of medical opinion, so long as the practice isn’t nuts.

Until now, Bolam was how the courts determined what we have to tell our patients about the risks of treatment. You didn’t have to discuss a particular risk if there were other suitably-qualified doctors who wouldn’t have done so.

That’s been changed by Montgomery, a Supreme Court case last week.

Mrs Montgomery was small, diabetic and pregnant with a large baby. Her obstetrician didn’t normally warn such women of the risk of shoulder dystocia because she believed the risk of serious harm to be small, and she thought that discussing that risk would result in women deciding to have caesareans when it wasn’t in their interests to do so. Shoulder dystocia occurred during Mrs Montgomery’s distressing vaginal delivery, and her baby was born with severe disabilities.

Things have changed, said the Supreme Court.

“Patients are now widely regarded as persons holding rights, rather than as the passive recipients of the care of the medical profession. They are also widely treated as consumers exercising choices. … The idea that patients were medically uninformed and incapable of understanding medical matters was always a questionable generalisation.”

So doctors must now take reasonable care to ensure that patients are aware of any material risks involved in any treatment, and of any reasonable alternative treatments. And this means discussion with patients, not bombarding them with technical information.

Note the words any material risk. What risks are ‘material’? Anything that a reasonable patient in the same situation would ‘attach significance to’, or that you know or should know your patient would attach significance to. That must mean anything that the patient would want to know at the time or that, if she knew it, might result in her making a different decision.

One caveat is that we can withhold information from patients when we reasonably believe that disclosing it would be seriously detrimental to their health. But this will be rare, and probably needs careful consideration, discussion with colleagues, and documenting. In another case the Court of Appeal has distinguished between discussions that may cause some distress and those that are likely to cause physical or psychological harm. The possibility that a patient may find a topic distressing won’t usually justify withholding important information from her.

Comment: While Montgomery was about treatment, it must apply to investigations too, and to decisions not to investigate or treat.

If this feels like a load of extra work, try turning it around. How would you feel if you discovered you’d not been told about treatment risk when, if you had been told about it, you might have chosen a different treatment, or might have decided not to have the treatment?

For GPs, the two risks we most often need to be discussing with patients are probably potential harms from medication, and the risks of decisions not to investigate things, perhaps particularly with more elderly patients. If you’re not discussing the risk of dependence when you prescribe gabapentin or pregabalin, or are opting for a wait-and-see approach with a frail, elderly patient who might have cancer without discussing your thinking with her, you may need to think again.

We’re going to have to get used to discussing things with patients that have gone undiscussed in the past. And, if the courts are a little ahead of the medical profession on this, I’m glad about that. As a patient, I’d want to know: in fact, I’d feel entitled to know. That right is what the Supreme Court has recognised.

The elephant in the room: how are we going to fund the NHS?

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

Last weekend The Times published a leading article which described the financial straitjacket in which the NHS finds itself, and suggested that the additional funding required to keep the service going should be found from sources outside general taxation. I wrote a letter supporting this view, pointing out that other healthcare systems, with perfectly respectable health outcomes, some better than ours, work on a combination or some variation of co-payment and insurance mechanisms. none of which, importantly, equate to privatisation.

I described this discussion as an elephant in the room – something that no one really wants to talk about and certainly won’t talk about in the run-up to the general election. I concluded by saying that I hoped the next government has the courage and gumption to bring into the open a discussion that everyone knows needs to take place, and which must take place if we are to preserve a national health service.

Extra money is going to be needed because the NHS is going to become increasingly expensive and there is going to be ever greater competition for money among government departments. A few years ago John Appleby, the chief economist at the Kings Fund, described three funding scenarios for the NHS – tepid, cold and arctic – and these three funding futures are reflected in Simon Stevens’ Five Year Forward View. Note that none of them are “comfortable” or “balmy”. It doesn’t require much detective work to read between some of the lines of this document to discern a lack of absolute certainty of the affordability of a publicly funded health system in the future. New models of integrated care may or may not turn out to be more cost-effective, but the NHS does not have a strong record on cost containment.

In my response to the Times leader I used the phrase “Those more able to pay for healthcare simply pay more”, and I don’t think that this is a bad mantra for the future of health funding in this country. It is consistent with social justice and I understand that there is some opinion poll evidence that it would not be an unpopular direction of travel for more affluent citizens. I think we have to tread carefully around the “free at the point of need” slogan – the NHS was never free – and we certainly would not wish to introduce a system in which health care providers need to see the colour of your money before treating you. It has been often said that the decency of a society can be judged by the way that it treats its most vulnerable and needy citizens. Requiring that the more fortunate members of our society make a greater contribution to the costs of health care could help to ensure that their less fortunate fellows continue to receive the care that they need.

NHS and astrology: GP with a special interest in witchcraft

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

When MP and member of the health select committee David Treddinick suggested that the NHS should offer astrology to its patients he was widely ridiculed. To me it seemed wildly unfair that this man was so heavily criticised for expressing his personal views. Although he has no experience in healthcare provision, and although he holds beliefs that are almost universally disparaged, I see this as absolutely no reason why he shouldn’t hold a position on the most influential health committee in the House of Commons. If I believed in earthly politics he is exactly the kind of man I would vote for.

To the best of my knowledge I am the only GP in the country who has a specialist interest in witchcraft. When I realised that my surgery stood at the intersection of two particularly propitious ley lines I could feel the Wicca spirits practically insisting that I undertake some rigorous further training in spell casting, crystal healing and blind optimism. Once my training was complete I began offering the service to my patients and, I must admit, I have now almost entirely moved away from traditional general practice.

It is easy to deride a service like mine as ‘hocus pocus’ but I have a long waiting list full of free thinking individuals. My patients include those clear minded people who know that the Illuminati are suppressing the truth that vitamins will cure cancer so that big pharma can continue to make money from pointless ‘medicines’, or other people who can see that the childhood vaccination programme is merely a fiendish government plot to stop our children dying.

Fortunately my waiting list is oddly self regulating. Curiously many of my patients seem to pass over to the next world despite my attentive ministrations. Whilst many in modern medicine would see the death of a patient as something of a failure, I tend to think of it as a referral onto secondary care. In fact, once my patients have passed over, I am able to hand their care over to my in house psychic who continues to soothe their chakras in the afterlife. Unfortunately a small fee has to be charged for this service.

This is supposed to be the era of evidence based medicine so how is it possible that the medical establishment wilfully ignores the evidence that thousands and thousands of people are willing to pay good money for these services? I may not have a double blinded, placebo controlled, randomised trial providing an evidence base for my treatments but I do have a pretty strong sense that there is more to this life than we currently understand and surely that is evidence enough to justify some NHS expenditure into the area?

So I applaud David Treddinick for his ideas and I am grateful that we still have strong input from politicians into our health service. Without it how would MPs be able to give a voice to people like myself at the highest levels of government and influence health policy accordingly? How else would we ever make the NHS provide such services as my own?

May the spirit of the mother goddess be with you all.

NHS and astrology: a morning zodiac clinic

Camera 360Tim Senior trained as a GP in Sheffield, and now works in Aboriginal and Torres Strait Islander Health in Australia. He is a Scorpio, whatever that means. He can be found tweeting from @timsenior

News reaches us from the UK Health Select Committee that one of their members has suggested that there’s a simple solution to the woes of the NHS in the UK: astrology.

Now, I’m as sceptical as the next doctor about how stars thousands of light-years away from Earth, that, with the trick of parallax error, suggested vague shapes to ancestors entertaining themselves on dark nights can influence the progress of little Maisy’s appendicitis.

That was before a recent clinic.  I saw just twelve patients…

The first patient was Michael Aries. “I feel a bit sheepish coming to see you,” he told me. He spoke for quite a while, but the story was quite woolly. I’m still not really sure what he wanted.

Darren Taurus told me that he’d been violently sick for the last few days, but was fine now, and needed a certificate for missing work for the last few days. I couldn’t disprove it, but I suspected it was all bull.

Maria Gemini brought her new (and very cute) babies, Christine and Sonia. They were doing well now, but at birth one looked big and healthy, the other small and pale. They’d probably never know about their twin-to-twin transfusion syndrome.

Melanie Cancer told me she was very unwell, and thought she might be about to die. We talked around this, neither of us wanting to mention the C-word… until I realised I’d misunderstood, and she was having to deal with a nasty case of crabs.

Bill Leo was a rather large man coming to see me with his young son, who said nothing but stared aggressively at me without blinking throughout the consultation. “The mane problem,” said the father, “is that school says he roars aggressively at the other children.”

“Ummm…,” I said, swallowing.

“He’s not aggressive. He’s a pussy cat at home. I think it’s just his pride….”

Theresa Virgo was an elderly nun, looking a little confused about a letter she had received from the practice. I had to check the guidelines before reassuring her that, no, on consideration she didn’t actually need to come for a PAP test.

Susanna Libra just had a scaly rash

Peter Scorpio had pancreatitis. I went through the causes in the textbook in my head, and the only one possible was the most memorable – a scorpion sting.

Jimmy Sagittarius had shooting pains in his chest, and had come clutching his X-Rays. The radiologist had helped me out with the diagnosis by putting a large arrow through his ribs.

Frank Capricorn was next. “You know what gets my goat?” he told me. ”The Nanny state. How the government think they can interfere with what I eat. Or drink.”

“Or smoke,” I added.

“Yes, well,” he said. “That too….” He paused. I raised my eyebrows. I could sense there was a “Butt…” coming.

Mitchell Aquarius was carrying quite a lot of water due to his congestive cardiac failure. His ankle oedema and his ascites were certainly a non-traditional, but highly effective way of bearing liquid, I thought to myself.

Penelope Pisces was Susanna Libra’s sister and had a similar rash. Perhaps it wasn’t just any old rash, but icthyosis.

At the end of the clinic, I just wish there had been a medical student with me, as I’d seen more signs in one clinic than I usually see in a month.

Of course it’s possible I made the whole thing up. Much like real astrology. Sadly, though, I didn’t make up the story about the politician believing astrology would help the NHS. That’s completely strange but true.

Being patient-centred – who are we trying to please?

bjgpApr-2015-65-633-204.jpgPeter Aird is a GP in Bridgwater, Somerset.

This week I’ve received some good news. I’ve been ‘liked’ by the GMC. Well I say liked, I mean of course ‘revalidated’ but it comes to the same thing. I posted a few comments of questionable value on an appraisal website and, lo and behold, I’ve been affirmed by no less an organisation than the GMC.

Yet the experience left me feeling somewhat flat. Curiously, being approved of by a faceless organisation, which demands certain requirements that I must satisfy in order to have their approval bestowed upon me, turns out not to be as fulfilling as I’d hoped. Tragically though, it seems that we are being driven by an ever greater need to be liked. It’s not just Facebook. It is a requirement that we be approved of by various groups – groups that sometimes have diametrically opposed ideas of what it is they want from us.

Take the antibiotic prescribing issue. On one hand we are quite correctly being encouraged to reduce our antibiotic prescribing and being threatened with a reprimand if we do not curtail their inappropriate use. But, on the other hand, we are being judged by how satisfied our patients are by our practice and, despite what patient education programmes try to convey, the idea continues to be held, even by some of the most educated of our patients, that antibiotics are required for minor self-limiting infections. Without them many of our patients won’t be satisfied. One wonders if scientific explanation of the facts will ever be effective in a society that increasingly has dismissed scientific fact in favour of what it feels is right.  Aren’t we all a little like Stewart Lee’s taxi driver who dismisses what he doesn’t want to believe with, ‘Well you can prove anything with facts!’? Leaving aside that particular question though, one thing is certain – it is impossible to satisfy the competing desire of patients who want antibiotics and those who want us to reduce antibiotic prescribing.

Similarly we are being asked to avoid unnecessary admissions to hospital whilst being increasingly criticised for delays in diagnosis and referral. Some have called for a doubling of our referrals to cancer services and starting primary prevention for heart disease at ever lower levels of risk, and yet our referral rates and prescribing practices are under ever more scrutiny.

Who are we going to choose to please?

I wonder if we doctors are particularly vulnerable to the need to being liked. How many of us were the good boys and girls at school who, driven by the desire to please, worked hard for our teachers, didn’t like to disappoint the careers advisor who suggested we tried our hand at medicine, and jumped at the chance of entering a profession which made our parents proud? Not that there’s anything wrong with any of this – it’s just that we may not be the best people to say an appropriate ‘No’ to our patients and risk disappointing them. After all didn’t we go into medicine, first and foremost to help patients – to please them, and not our bureaucratic taskmasters, who we find it equally hard to say no to?

The truth is that one can’t please everybody all the time – and we are fools to try. In a society that constantly and increasingly seeks affirmation it is no wonder that we are overwhelmed by the need to please those with competing desires. Whatever we do is wrong in somebody’s eyes. The incessant double binds threaten, not only our own happiness but also the stability of the whole system. A system already creaking from the overwhelming demand and time limitations that together drive us, perhaps, along the route of least resistance – the route that earns us a ‘like’ most easily – the one that comes from our patients. We may not be proud of it, but haven’t we all issued an antibiotic or renewed a sick note, not entirely appropriately, as we simply did not have the time or energy to do otherwise and out of a desire to please the patient?

Something is going to have to change in regards to the way we behave if things are to improve. We need to be professionals who are in the job, not to be admired, but to do what is necessary. Whisper it quietly, but we are going to have to be less patient-centred in order to be more patient appropriate. We are going to have to be less concerned about doing what our patients want, what they will like us for, and try instead to do, to the best of our ability, what is right. And we are going to have to care less about how we are thought of by our patients – I’m not sure just how valid their opinion always is anyway. On a single day last month I received two pieces of feedback – one accused me of incompetence, the other rated me as unusually astute. So which is it? Well of course it is neither – I am no more awesome than I am useless. I am in fact ordinary – an ordinary GP who, like ordinary GPs up and down the country, knows less cardiology than a cardiologist – but more than my patients. Our patients, our politicians, and we ourselves are going to have to accept this – whether they, or we, ‘like’ it or not.

Muscular dystrophy: new RCGP emodule on neuromuscular disorders

headshotDr Sheonad Laidlaw is a qualified GP, Chair of the Scottish Council for Muscular Dystrophy UK and has a daughter with spinal muscular atrophy (SMA) type 2.

Recognising and supporting patients with rare and complex neuromuscular conditions presents acute challenges for GPs.  The Royal College of General Practitioners have worked with Muscular Dystrophy UK to produce a new set of online tools to help bridge the gap between primary care and the specialised services available.

More than 60 progressive neuromuscular conditions, affect 70,000 children and adults in the UK. Recognition of neuromuscular conditions is improving, but many patients still experience long delays in diagnosis as early symptoms can be non-specific. Symptoms may include: muscle weakness resulting in difficulty with climbing stairs or lifting heavy objects; muscle stiffness or cramps; or fatigue. If a neuromuscular condition is considered, prompt referral to a neurologist is necessary. After diagnosis GPs, as part of a multi-disciplinary team, are integral in the care of the patient and making prompt referrals to a broad range of local and specialised services. As GPs we will often be the first port of call for a patient and therefore should be confident in managing acute complications as the condition progresses.  Recognition of the psychosocial impact on the condition on the patients and their families is important with a focus on quality of life paramount.

My daughter, who was born in 2009, has spinal muscular atrophy (SMA) type 2. At eleven months I noticed that she wasn’t weight bearing, that she had stopped crawling, and that when waving at people her arm would drift down. I was lucky in that I had contacts at the local Children’s Hospital and my daughter was seen promptly by a neurologist.  The possibility of SMA was not discussed with me until three months later, however, and was confirmed after genetic testing.  The condition is physically disabling and she has been wheelchair dependent since fifteen months old.  She is at risk of life-threatening respiratory infections and has a scoliosis and hip subluxation, but she is cognitively able and bright.  Led by a community paediatrician, my daughter has a range of health professionals involved in her care, including physicians, surgeons, orthotics, physiotherapists, occupational therapists and wheelchair services.  There is no cure for SMA but the right treatment and support is vital to effectively managing the condition.

A typical patient pathway for someone with a neuromuscular condition will include services funded and delivered locally and at specialist tertiary centres. Neuro-respiratory and  Cardiology input and follow-up are essential. Many neuromuscular conditions can weaken respiratory muscles, leaving those affected susceptible to lower respiratory tract infections. When respiratory function deteriorates acutely or chronically, referral for specialist respiratory care, physiotherapy and medical equipment, for example cough assists, is necessary. Heart function may need to be monitored too. For many people any cardiac problems will be slight, but arrhythmias or reduced cardiac function may need pharmacological intervention.

Local neuromuscular specialist teams, which include care advisers, play an important role in liaising between primary and specialist care. However, as the gateway for patients to community services, it is important that GPs and community health professionals have an awareness of where to refer for the day-to-day support this group of patients require. Community rehabilitation services including physiotherapy, occupational therapy, hydrotherapy and wheelchair services are also absolutely vital. Finally, given the progressive nature of these conditions it’s important to be aware of the emotional effects the condition can have. Referring patients and families to support groups, organisations, and social services can help many come to terms with and manage the complexity of their condition.

Muscular Dystrophy UK received a Department of Health funding in 2013 to run Bridging the Gap, a project bringing together patients, clinicians, health professionals, and specialised and local NHS commissioners to improve neuromuscular care for both children and adults. A key aim of this initiative was to increase awareness of neuromuscular disorders among primary healthcare professionals.  The charity has been working closely with expert neuromuscular specialist consultants, physiotherapists, care advisors and GPs and the Royal College of General Practitioners to develop an e-learning training module. This has been designed to help GPs understand the spectrum of genetic neuromuscular disease. This course is concise and informative, easy to use and identifies the key presenting features and management issues for these conditions.  The importance of a holistic assessment of the patient and the family, including their psychosocial care and the recognition of the complexities of being a carer, was an important learning point for me.

An online map of both primary and tertiary neuromuscular services, the ‘Neuromuscular Support Hub’, has also been launched, helping patients and health professionals identify local neuromuscular specialist teams and community rehabilitation facilities that are vital to people living with muscle-wasting conditions. The Hub also contains useful factsheets and information for GPs and other health professionals.

Improving GPs’ knowledge via this module will be vital – not only for spotting the symptoms that can help lead to a quicker diagnosis from a specialist, but to also ensure that GPs play a central part in day to day management of these conditions; linking across to specialist teams when necessary.