Archive | August, 2013

2 is worse than 1

24 Aug

Medical students (and by extension doctors and then their patients) are taught that Type 1 Diabetes is worse than Type 2. Turns out, at least some of the time, that’s wrong.

Type 1 diabetes – also called Insulin Dependant diabetes or “juvenile onset diabetes” – is what young kids get. They develop antibodies which attach their own pancreas, the insulin-producing cells stop working, they produce no insulin and they get very sick. Before the discovery of insulin in 1921, Type 1 diabetes was an early death sentence. Now, it commits the patient to a lifetime of sugar testing and insulin injections.

Type 2 diabetes – Non-Insulin Dependant diabetes or “adult onset diabetes” – is classically associated with overweight, inactive middle-aged patients. In fact we see a wide variety of people with Type 2 diabetes and not all fit that mould, but it is true that lack of exercise and excess weight do make the likelihood of developing diabetes much greater. However there is probably also a gene which makes the condition more likely, though not inevitable, in many patients.

With the progressive increase in obesity in society we are seeing increasing numbers of diabetics, and in particular Type 2 diabetes at younger and younger ages. Whereas even a generation ago, we never saw Type 2 diabetes in teenagers or children, now about 1/3 of kids who develop diabetes have type 2.

Frighteningly – and against traditional teachings – it turns out Type 2 is much more dangerous in kids than Type 1. Research at Royal Prince Alfred Hospital in Sydney shows the death rate for teens with adult-type diabetes is double that of those with juvenile-onset diabetes. They also develop more severe complications, develop them sooner and do so even if their sugar control after diagnosis is the same as the Type 1 patients.

There are lots of theories as to why that might be – perhaps the genetic predisposition that allowed Type 2 diabetes to develop might be the cause of the complications, or perhaps the lifestyle issues which triggered the diabetes are the cause.

In any event, the study (care.diabetesjournals.org/content/early/2013/07/09/dc12-2455.abstract) noted that most treatment offered to adults with diabetes (particular types of cholesterol and blood pressure medications) are not normally given to kids because most research excludes children from drug trials. But something needs to be done to help these kids. And foremost, is trying to prevent diabetes in the first place.

Whilst we can’t do anything about the genetic factors, it’s critical for parents, doctors and society at large to look at the lifestyle choices and behaviours that may cause diabetes and that can be altered to improve our kids overall health.

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Regular reaps rewards

19 Aug

One of the great frustrations of general practice is the paperwork. Forms for everything!

And one of the greatest contributors to paperwork is a little tool called “care plans”.

Care plans were a cute idea introduced about 10 years ago. The theory was that doctors who were doing hours of unpaid work coordinating care and mapping out treatment plans for patients with multiple complex conditions would be rewarded by paying them additional sums for completing paperwork. The idea was that by just filling in a form in addition to usual care for the patient, the doctors could then claim (significant) sums for the work they were already doing. The advantage for the patient was that they would be given a clear, written outline of their health needs and goals and a formal plan of how to get there. There was also the carrot of Medicare subsidising up to 5 visits per year with various allied health providers who would help manage the conditions identified in the plan.

Whenever there is money to be made, someone will abuse the system. There are certainly some doctors and practices that see care plans as their major revenue stream and generate dozens of the things daily. Those practices do very well financially though we wonder whether either the patients or the taxpayer is getting any value for the dollars being spent.

And many doctors have queried the value of care plans at all. The care plan is often just paperwork – does it actually change the patients treatment or the outcomes?

Turns out … it does. This weeks Medical Journal of Australia has an article that shows patients with diabetes who have a care plan – and have it reviewed at least twice a year – have small but significant improvements in their sugar levels, weight and cholesterol. Patients without care plans and those with care plans that were not reviewed regularly did not benefit as much.

Care plans can be annoying – they involve reams of printing and often several visits to the doctor. But there is the benefit of the visits to allied health practitioners that Medicare will subsidise or fund; the reassurance of a formal up-to-date summary of your condition being prepared; the knowledge that having a care plan does result in better health outcomes … and the satisfaction of knowing that your doctor will be well rewarded for having worked hard!

We’re from the government …. we have no idea how to help you

18 Aug

The promise of a personal medical record accessible to everyone involved in a patient’s health care sounds like a wonderful idea. And if the system actually worked – it would be! Tests wouldn’t be duplicated, hospitals would know the full list of diseases that the GP was treating and GPs would know all the medication changes that hospitals and specialists instigated.

Of course the more complex a system, the bigger the chances that something will go wrong. So the development of the PCEHR (Personally Controlled Electronic Health Record) was always going to be difficult. Medical groups were worried whether the information on the file would be accurate; IT experts were worried about whether the security levels would be robust enough; consumer groups wanted patients to be able to control who could and couldn’t have access to any aspect of the record.

The danger with a asking a committee to design a horse is that you end up with something that looks like a camel. Although the government invested close to a billion dollars developing the PCEHR system, nobody involved has been really happy with the outcome. Several hundred-thousand people have registered to enrol in the system but in fact less than 5000 GP-written health care summaries have been created across Australia.

Simply put most GPs don’t trust the system. We are worried about the security, we are worried about the implications of relying on the information in the record when there is no certainty as to who is able to amend notes, and we are worried about the time involved in creating a health summary when Medicare will not fund it as an exercise other than letting us count the time towards a consultation.

A few of our patients have asked our thoughts on PCEHRs and the answer our doctors give is pretty consistent – a good idea that we think has a long way to go before it’s useful and therefore we won’t get involved just yet.

Earlier this week our view was justified when the entire group of clinical leads at NEHTA resigned. NEHTA is the National Electronic Health Transition Authority – a government body that is overseeing the development of electronic, internet and computerised medical records and information. The clinical leads are the doctors who are both providing advice to the Authority on how practitioners want the system to work to best benefit patients and those treating them; and they are the representatives of the Authority whose job is to spread and sell the benefits of the system to doctors throughout the country.

That not just the lead clinician – the highly-respected Dr Mukash Haikerwal – but the ENTIRE group of clinical leads have all resigned because they feel that the concerns of doctors about the usefulness of the system is being completely ignored, endorses our view that the system simply isn’t fit for its intended purpose.

Our practice has always been forward-thinking in the use of technology for medical care. Dr Peter Tribe was one of the first doctors in Victoria to write electronic scripts, and we converted to electronic medical records years before most practices. But we will never adopt a technology just because it’s new.

There is nothing quite as dangerous as “a good idea”.

We love you – but …..

12 Aug

Back in the early 1980s, one of Melbourne’s leading vascular surgeons was famous for harshly criticising his patients for smoking – while puffing away at a cigarette himself during the consultation. When challenged, he replied they were the ones with the problem not him – and that when he had his first heart attack, then he would stop!

Everybody knows that lifestyle is a key element in preventing heart attacks – and even more so if you’ve already had one. Yet recent research by the Baker Institute showed that even after a heart attack, 60% of patients continue on an unhealthy diet, 70% do not exercise regularly, 35% have cholesterol that is too high and more than 10% have not quit smoking. Overall women were worse at changing their lifestyle than men.

Our job as GPs is not just to prescribe drugs, but to help you live a healthier life and we hope to give you the information, knowledge, resources, tools and support you need. But ultimately, it’s up to each of us to be responsible for our own health. If not before we suffer a health catastrophe, then certainly afterwards.

Postscript to the story – apparently the surgeon did end up having a heart attack….but kept smoking. After his second heart attack a few months later he finally quit smoking for good. Proving that even surgeons are capable of learning – eventually.

Whom to believe and what to do?

10 Aug

Readers of our blog will know that one of our favourite sports is to report on every new set of PSA testing guidelines that come our way, if only to show how often they change and contradict each other.

Poking fun at PSA is just too easy. This week two major recommendations regarding the pros and cons of PSA testing were released within 48 hours of each other. And as expected – they contradict each other completely.

The Prostate Cancer World Congress met in Melbourne and released a consensus statement regarding testing. This is the expert opinion from world leaders in the field – primarily urologists. The main points they made were:

– Prostate cancer testing is a separate issue from prostate cancer treatment (finding prostate cancer early does not have to involve surgery. Depending on the PSA and then other tests, it could involve just watching to see how quickly everything develops/evolves.)

– A man in his 40s can have a baseline test to determine future risk.

– For men between 50 and 70, regular PSA reduces the risk of prostate cancer spreading by 30% and decreases the risk of dying by 20%. Older men who are expected to live at least 10 more years will probably also benefit from testing.

Fair enough. The experts have spoken and the logic seems reasonable.

But wait! A couple of days later the Australian National Health and Medical Research Council – the chief scientific research body released its recommendations for PSA testing based on a review of the world research and literature. Their advice is that PSA testing has no discernible impact on the risk of dying of prostate cancer but runs a significant risk of leading to overdiagnosis and overtreatment including significant side effects.

The key points they make are:

If 1000 60-year-old men who have a low-risk of prostate cancer get tested annually for 10 years then:
• Two will avoid dying of prostate cancer before age 85.
• 28 will be diagnosed with prostate cancer as a result of the PSA testing, but many of them would never have has symptoms so their test is finding a disease that actually doesn’t matter
• 87 will undergo unnecessary biopsies and 24 will suffer significant side effects as a result.
• 25 will undergo potentially unnecessary treatment, 7-10 of whom will be left impotent or incontinent as a result.

The full NHMRC report can be read at http://consultations.nhmrc.gov.au/files/consultations/drafts/resources/men4apsatestingreportv03190713.pdf

So there we have it – the latest evidence analysed by up to date experts resulting in completely contradictory advice.

What is a patient to do? What, for that matter, is a GP to do?

The truth is – we’re not sure. By all means, talk to your doctor. And we will do our best to tease out the evidence and discuss the pros and cons with you. But don’t expect us to give a clear-cut answer or definitive advice.

We’re not expert enough to do that.