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Discussion Forum

 

Feel free to comment on anything that we have published recently or add to existing discussions. We won’t assume that you want us to consider comments posted here for publication in the Journal; please let us know if you want us to do so. Letters we are unable to print in the Journal may be posted here instead (see Writing for the BJGP for letter submission guidelines).

 

 

What you said in 2010

 

Date: 23 Dec 2010
Topic: Response to ‘Sustainable medicine: good for the environment, good for people’
Comments by: James LaBouchardiere, Dorset County Hospital, Dorchester

 

I was reading your editorial regarding sustainable medicine1 with interest, as I was unable to attend the conference earlier in the year. I agree entirely that sustainability needs to be high on the agenda for the development of our profession, and there is much that we can do, both individually and as part of our practice or trust, to reduce our carbon footprint.

 

However, I was disappointed to see that the focus was purely on the carbon economy and the effects of global warming. I feel that it is equally important to consider the resources that we use and – more often than not – throw away. Every day, I am amazed at the amount of paper, cardboard, and plastic thrown in the bins and incinerated in the hospital in which I work. It was only last month that I learned of a colleague in my trust trying to instigate a recycling scheme. Unfortunately, it looks like the scheme was ‘thrown out’ before it saw the light of day, as the trust managers were concerned about the clinical space the additional recycling bins will require.

 

Oil and trees aside, there are many drugs and investigations which we use in western medicine without a second thought as to where the raw materials come from. How many of us have thought about what would happen if we ran out of radioactive iridium or cobalt for our X-rays and CT scanners? While it is unlikely to happen at any point in my career (even as I write this as a lowly ST1) it has been suggested that we have access to less than 100 years worth of useful medical-grade radioactive material. There are other examples of trace elements that we are consuming with abandon. We should not forget that with dwindling supplies come increasing costs to the end user.

 

Many people would simply argue that we would, probably, invent new technologies to skirt the issue before shortages become a problem. This misses the point. Most drugs we prescribe and most tests we order will have an environmental impact. Whether or not the resources we use are in imminent danger of running out, we would all do well to think about what we use, and for the sake of the environment – and the NHS budget – limit their use where we can.
 
At the very least let’s get the managers to put out some recycling bins.
 

Reference
1. Thompson T, Ballard T. Sustainable medicine: good for the environment, good for people. Br J Gen Pract 2011: 61(582): 3-4.

 

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Date: 23 Dec 2010

Topic: ECGs in transient loss of consciousness
Comments by: James Cave
 
Rogers and O'Flynn reporting in the BJGP on the new guidance for TLoC suggest that the biggest challenge for practices will be the requirement that all patients have an ECG. Too right.

 

As an ex-choir boy and now GP I have seen and experienced my fair share of faints. I would want to better understand what doing ECGs on all these people is going to achieve and be clear that NICE has explored the unexpected consequences of using a poorly discriminative tool such as an ECG on the normal population.

 

NICE would have been bolder and done patients a service if they had allowed faints, properly investigated by history from bystander and patient, to be treated for what they are: part of growing up.

 

Reference

1. Rogers G, O'Flynn N. NICE guideline: transient loss of consciousness (blackouts) in adults and young people. Br J Gen Pract  2011; 61 (582): 40-42.

 

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Submitted: 20 Dec 2010
Topic: Primary health care and global health
Comments by: Francesco Carelli, Professsor Family Medicine, University of Milan, EURACT Director of Communications

 

According to Jan De Maeseneer and Marc Twagirumukiza,1 when primary health care integrates public health approaches, for example through community oriented primary care, it may contribute to achievement of the Millennium Development Goals.
   
The discipline of family medicine plays an important role in the choice between the horizontal (personal- and community-oriented care) versus vertical (disease-oriented) approach in health care, and this is increasingly important in developing countries.                         

 

The ‘Declaration of Alma-Ata’ defined health as a ‘complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity’ and stated that the access to basic health services was a fundamental human right. The model adopted to provide healthcare services was ‘primary health care’. This means universal, community-based preventive and curative services, with a great community involvement.

 

Two really important documents have tried to make these ideals a practical reality for patients. The WONCA Europe Definition has set out the range of skills required to practise the kind of primary health care envisaged in the Alma Ata declaration. The EURACT Educational Agenda seeks to equip future generations of doctors in the same way.2

 

A shift was made, which is characteristic for family medicine, from patient to person, from treatment to care giving. Treatment thus becomes more of a social process; attention is given to circumstances, such as diseases affecting children, older people, and women. Of course, these tasks are determined to a considerable extent by the healthcare system in which family doctors work and by the changing needs and demands of the patients. Family practice has always proved to be very good at adapting and responding to changing needs and demands of patients, more so than hospital doctors. 

 

If we want to promote health and well-being by applying health promotion and disease prevention strategies appropriately, we could use a comprehensive approach that is often in contrast with the specialist approach in treating each problem separately.

In this way, EURACT is promoting high levels for teaching and learning health promotion, looking for mandatory specific training, and undergraduate curriculum, and early exposure to clinical experiences within the primary care setting and clear selection for teachers and practices.

 

We must now organise, worldwide, an approach to global health implementing a social model truly consistent with human nature and its needs. Putting forward such a model entails a significant educational-training dimension, which ought to foster the interaction between healthcare providers and patients and between the different professionals involved in the treatment and care who intend to work for the good of the single person and the community.

 

Also here EURACT takes strong consideration of the community orientation. This is because family doctors have a responsibility for the community in which they work and must understand the potentials and limitations of the community.

To be able to do so, they need to learn in the basic curriculum and in the vocational training the interrelationships between health and social care, the impact of poverty, ethnicity, inequalities, the structure of the health care systems in which they live, and in which they work.3


References
1. De Maeseneer J, Twagirumukiza M. The contribution of primary health care to global care. Br J Gen Pract 2010; 60 (581): 875-876.
2. The European Definition of General Practice/Family Medicine, WONCA Europe, London, 2002. http://www.woncaeurope.org/. (accessed 18 Jan 2011).
3. EURACT Educational Agenda http://www.euract.org/ (accessed 18 Jan 2011).

 

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Date: 19 Dec 2010

Topic: Response to: 'Self-monitoring to ... improve hypertension'
Comments by: R Fields
 
I am an ordinary GP, with no research experience, trying to get a message from papers like this.1 One thing that is often quoted is that blood pressure goals are achieved in at most 40% of patients and this hasn't improved in 40 years.

 

Does this really mean what it seems to say, or could it mean that blood pressure control isn't ideal in 60% of patients and could it also be that far more people are being treated now than 40 years ago due to a higher detection rate? This would alter the picture from "no progress" to "progress but more needs to be done".

 

Regarding the self monitoring I assume that the patients were also on anti-hypertensive medication otherwise just taking your own blood pressure would be a means of lowering it. I don't think you discussed why self monitoring might lower blood pressure but presumably it motivates the patient in terms of taking medication and making dietary and other lifestyle changes as well as putting the patient on the same side as the clinician in trying to achieve target blood pressure. I suppose it is possible that it lowers clinic blood pressure because patients understand how to relax which would just make clinic blood pressure closer to "true" blood pressure.

 

From the point of view of a "simple" GP like myself perhaps there were too many interventions investigated in one paper so that a quick read which is all that most GPs manage can be confusing and not deliver a clear message.

 

In the introduction the second sentence seems to say that hypertension is preventable by blood pressure reduction when I think it should say stroke etc is preventable.

 

Reference

1. Glynn L, Murphy A, Smith SM, Schroeder K, Fahey T. Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review. Br J Gen Pract  2010; 60 (581): e476-e488. View abstract

 

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Date: 7 Dec 2010

Topic: Full skin examinations and malignant melanoma

Comments by: Arif Aslam, Burnley, Lancashire

 

The incidence of malignant melanoma (MM) continues to increase worldwide. In the UK it is estimated that 10-15 per 100 000 people are affected. Survival has increased dramatically highlighting the importance of early detection.1 The aim of the audit was to analyse how many patients, who were referred under the 2-week rule, underwent a full skin examination by their referring clinician, and how many were told they were being referred for suspected cancer under this rule. This retrospective questionnaire survey looked at the total number of histologically confirmed MMs in a large district general hospital in the UK over the 12-month period of 2009. There were a total of 41 patients in whom MM was confirmed by a pathologist with the Breslow thickness ranging from 0.2-4.3mm.

 

Only six out of the 41 patients (14.6%) recall undergoing a full skin examination by their GP or nurse practitioner at the time of referral. Thirteen out of the 41 patients (31.7%) were aware they were being referred under the 2-week rule suspected cancer pathway. This highlights that GPs are not performing enough full skin examinations when presented with an evolving skin lesion that is subsequently referred as a suspected cancer. A full skin examination can reveal other worrying lesions too.

 

GPs are highly trained in communication and specialist consultation skills; however, in this survey the majority of patients were not aware they were being referred with a suspected cancer. Many patients often expressed their surprise and satisfaction at being seen so quickly but did not appreciate not knowing why. It could be argued that telling a patient could create added anxiety but it beneficial as it can reduce the number of people who fail to attend appointments, and knowing that you are being referred to a dermatologist for diagnosis and treatment could also alleviate anxiety.

 

More GPs should consider carrying out a full skin examination when referring a patient to dermatology under the 2-week rule and should always attempt to provide a full explanation as to why they will be seen so quickly.

 

Reference

1. Rivers JK, Wulkan S. The case for early detection of melanoma. J Cutan Med Surg 2010; 14(1): 24-29.

 

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Date: 19 Sep 2010

Topic: Response to ‘The predictive value of cancer symptoms in primary care’

Comments by: Trisha Greenhalgh 

 

Kevin Barraclough’s excellent piece on early symptoms of cancer1 had a misleading title. The issue is not so much ‘The predictive value of cancer symptoms in primary care’ as ‘The value of non-specific symptoms in primary care in predicting cancer’.  As the article makes clear, and as we all know, early symptoms that could be cancer usually aren't.

 

We should of course be reflecting on, and justifying, our gut feelings more. The last middle-aged patient I saw with newly diagnosed type 2 diabetes who engendered a feeling of surprise in me (no family history, non-obese, active) turned out to have carcinoma of the pancreas.  I still have the request form for a CT scan of the abdomen which was returned from the hospital stamped ‘not indicated’.

 

One aspect of gut feeling in possibly-cancer symptoms, which I suspect would be borne out by a prospective study, is persistence. Symptoms that come and go tend to be benign whereas unremitting ones are more likely to be malignant. A few more hypotheses like this could give us the makings of a useful prospective cohort study. 

 

Reference

1. Barraclough K. The predictive value of cancer symptoms in primary care. Br J Gen Pract  2010; 60 (578): 639-640. View title page

 

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Date: 3 Sept 2010

Topic: Response to 'GP commissioning consortia'

Comments by: Dr C Pelton, Ludlow

 

Dr Elegbe raises an issue that, despite the threat of dilution of our profession, cannot be ignored in the face of escalating demand and likely financial cuts in the future.1 If we are serious about commissioning, we should investigate every option. So why not nurse anaesthetists as well as physician assistants? In the US, nurses provide safe cost-effective routine anaesthesia in one of the most litigious societies in the world. Founded in 1931, perhaps we could learn something from The American Society of Nurse Anesthetists.

 

Reference

1. Elegbe O. GP commissioning consortia: is there a role for physician assistants in routine care? Br J Gen Pract 2010: 60(578) 704-705. View title page

 

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Date: 2 Sept 2010

Topic: Epidemiologists and GPs: a lot to learn from each other

Comments by: Dr Luis Ayerbe, Clinical Research Fellow, Department of Primary Care and Public Health Sciences, King's College London; Locum General Practitioner, South East Essex PCT

 

A year ago I left my job as a full-time GP to work as an epidemiologist in an academic department with limited clinical commitments. Since then I have had the opportunity to see how much epidemiology and primary care can complement each other and how well they may go together into a professional career. As a GP I brought into the department my direct experience on disease reality. I know how medical problems not only affect physiological parameters but patients’ daily lives. I am also aware of doctors’ and patients’ personal and professional attitudes towards these problems. My background in primary care just makes epidemiological research more focused on real patients’ needs.  As an epidemiologist I have gained a different perspective over diseases. Getting to know the distribution of health determinants in the population has also improved my clinical work. Many clinical and research questions arising from every day medical practice have their answers in the epidemiology of the disease. Epidemiology and general practice is certainly a good professional combination.


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Date: 25 Aug 2010

Topic: Response to 'Clinical burden and health service challenges of chronic heart failure'

Comments by: Hasnain Dalal, GP, The Three Spires Medical Practice, Truro and Hon Clinical Lecturer, Peninsula Medical School (Primary Care), Truro

 

Richard Hobbs' Mackenzie lecture reviewing the management of chronic heart failure1 is a welcome update but omits any reference to the benefits of cardiac rehabilitation. In the same issue of the BJGP, Roger Boyle and colleagues point out that in heart failure: ‘only a minority of patients have access to cardiac rehabilitation’, and conclude by promoting the value of cardiac rehabilitation.2

 

The latest guidance from the National Institute for Health and Clinical Excellence, covering aetiology, prevention, diagnosis and therapeutic interventions in heart failure includes a whole section on the evidence base for cardiac rehabilitation.3 Similar guidelines from the American College of Cardiology, the American Heart Association, and European Society of Cardiology all recommend cardiac rehabilitation as a safe and effective intervention for people with heart failure. Despite this, the review by Hobbs1 and another recent one in the BMJ4 have ignored cardiac rehabilitation a point acknowledged in the BMJ.5

 

An editorial in the BJGP highlighted the lack of knowledge on cardiac rehabilitation and suggested how primary care could engage with hospital services to improve the uptake of cardiac rehabilitation.6 Evidence from a recent Cochrane Review shows that in chronic heart failure, cardiac rehabilitation not only improves health related quality of life but reduces heart failure related hospital readmissions.7 The latter is an important outcome given the current focus on reducing costs within the NHS.

 

Ironically, Roger Boyle as the National Director for the Heart Disease and Stroke Vascular Programme is keen on increasing the uptake of cardiac rehabilitation and was the joint recipient of The Mackenzie Medal - awarded earlier this year by the British Cardiovascular Society for outstanding contributions to British cardiology.

 

References

1. Hobbs FDR. Clinical burden and health service challenges of chronic heart failure. Br J Gen Pract 2010; 60(577): 611-615. View title page

2. Boyle R, Field S, Sparrow N, Howe A, Rafi I. Cardiovascular disease beyond the QOF. Br J Gen Pract 2010; 60(577): 558-560. View title page

3. National Institute for Health and Clinical Excellence. CG108 Chronic heart failure: full guideline. London: NICE, 2010. http://guidance.nice.org.uk/CG108/Guidance (accessed 16 Sept 2010).

4. Arroll B, Doughty R, Andersen V. Investigation and management of congestive heart failure. BMJ 2010; 341: c3657.

5. Dalal H, Austin J, Davis R, et al; on behalf of REACH HF. Don't forget rehabilitation. BMJ 2010; 341: c4286.

6. Bethell HJN, Lewin RJP, Dalal HM. Cardiac rehabilitaion: it works so why isn't it done? Br J Gen Pract 2008; 58(555) 677-679. View title page

7. Davies EJ, Moxham T, Rees K, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail 2010; 12(7): 706-715.

 

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Date: 23 Aug 2010

Topic: Primary care academics submitted to RAE 2008

Comments by: Frank Sullivan, Dundee; Tony Kendrick, Southampton; Frances Mair, Glasgow

 

In the Research Assessment Exercise of 2008 (RAE2008) 147 whole time equivalent staff were submitted to Unit of Assessment eight (UoA8- Primary Care and Community Based Clinical Subjects) from 14 universities.1 The heads of department (HoD) of the Society for Academic Primary Care considered that this was likely to represent a significant under-estimate of the size of the primary care research community. They resolved to ask each HoD to provide the information to estimate the overall size of the primary care submission to RAE.

 

All SAPC heads of department were asked by email to identify the number of primary care academic whole time equivalents submitted to any UoA8 panel from their university. Reminders were sent after 3-4 weeks and a further reminder to non-respondents after a similar period. Clarification was provided in response to queries that the definition of a PC academic was ‘someone who is primarily conducting PC research and was submitted to RAE2008’.

 

The total numbers (WTE) of primary care researchers was 246.1 representing 99.1 more than were submitted to UoA8 So 60% of primary care academics were submitted to the panel assessing primary care. TPC academics were submitted across a total of 12 different units of assessment with Health Services Research (48.4), Epidemiology and Public Health(10.8) and Social Policy (10.4) comprising the other largest units of assessment. The figure below demonstrates the wide variation in total numbers submitted by universities from 1-24. Those submitting to UoA8 tended to have a larger number of PC research active staff submitted overall.

 

The data confirm the extent of under-representation of PC researchers in RAE2008 and the wide diversity of fields in which PC researchers undertake high quality research.2 It should be noted that these data are self reported (except those publicly available on the RAE website) and that some HoDs were uncertain about whether to categorise some colleagues as primary care researchers. Most primary care groups are still relatively small and need investment to progress to the development of 'critical mass', from universities as well as the NIHR and other funders. The consultation process for the Research Excellence Framework in 2014 suggests primary care will be assessed with Health Services Research, Epidemiology and Public Health as a subpanel of Clinical Medicine.3 Primary care research has long been considered an interdisciplinary subject and it may prove detrimental to its development if its broad range is not recognised in the arrangements for REF.

 

References

1. RAE 2008 Results for Primary Care and Other Community Based Clinical Subjects http://www.rae.ac.uk/results/qualityProfile.aspx?id=8&type=uoa last accessed 23.8.10

2. Research in general practice: bringing innovation into patient care. Academy of Medical Sciences London 2009 http://www.acmedsci.ac.uk/p101puid163.html last accessed 23.8.10

3. Reserach Excellence Framework http://www.hefce.ac.uk/research/ref/ last accessed 23.8.10

 

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Date: 14 Aug 2010

Topic: Response to 'Let's take a vote on revalidation'

Comments by: R Champ

 

Daniel Edgcumbe discussed the 'elephant in the room' questioning the validity of the charade that is revalidation.1 I support his call for a vote. The chasm between jobbing GPs and College gowns has grown ever larger; the gowns see an excellent opportunity in revalidation for self promotion and self importance. It will be interesting to see how they will attempt to block this call for a vote.

 

Reference

1. Edgcumbe D. Let's take a vote on revalidation. Br J Gen Pract 2010; 60(576): 537. View article 

 

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Date: 14 Aug 2010

Topic: Obesity: when prevention is much better than treatment

Comments by: Anonymous

 

I experimented on myself over many years and found the following conclusions. We are what we consume: food, information, environment. Obesity is caused by eating the wrong brands, at the wrong time, in the wrong sequence.

 

I tested this hypothesis by switching brands (of the same compound e.g wheat from the right brand to the wrong ones). Within a few days (three to five) of switching to the wrong brands I started to experience the following symptoms: these start with a distended abdomen, increased flatulence, sensation of weakness in the lower back, posture starts to droop due to lower back muscle weakness and carrying excess waste in the intestines, irritable bowls (two three days of constipation followed by a loose watery discharge with slight abdominal pain, followed by another two/three days of constipation and the cycle repeats), waist line starts to increase, meat/muscles start to feel limp, muscle tone reduces, fat deposits start to increase starting around the abdomen. All these symptoms start to appear within 2 to 3 weeks of switching to the wrong brand.

 

I have found that the wrong brands share some common characteristics (the right brands are actively sourced to ensure that they do not have these characteristics). These are:

  1. Genetic modification
  2. Use of artificial/synthetic/human-made chemicals
  3. And this a very subtle one wrong terroir characteristics (time dependent), e.g right now most English terroir is 'limp' hence so is the grain, e.g wheat grown in England has the same characteristic. The Swiss terroir is solid and the grain has a core strength.

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Date: 12 Aug 2010-09

Topic: Response to White Paper: a framework for survival

Comments by: Francesco Carelli, Professor of Family Medicine, University of Milan

 

I agree with Roger Jones when he writes that this White Paper seems to be restructuring the system while ignoring the funding crisis.1 All western societies now have to find alternative ways to pay for health, being conscious of the impact on state pension provision. I think that this new White Paper will attract widespread interest in European countries, mainly Italy where the NHS configuration is so similar. In Italy, there is a real problem for primary care is conflict with secondary care: the gatekeeper's role is daily in danger and to be defended with great difficulties in every sense. This White Paper seems not to take in to proper consideration this relationship.

 

Roger Jones indicates many requirements in such aspects: one is accountability across localities, undertaken by primary and secondary care working together. So, instead of the 500 GP commissioning consortia, would it not be better to think again about the Liberal Democrat’s local health boards as a more practical and territorial way for the better relationship and reorganisation?

 

References

1. Jones R. The White Paper: a framework for survival? Br J Gen Pract 2010; 60(578): 635-636. View title page

 

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Date: 11 Aug 2010

Topic: Response to 'Type 2 diabetes and dog walking'

Comments by: Geoffrey Woodcock MA, PhD, Honorary Senior Fellow, University of Liverpool

 

I read the paper on type 2 diabetes and dog walking1 with great interest. As one who has personal experience of being treated for type 2 diabetes, I would confirm their proposition that a bias towards the stress on dietary, rather than exercise, regimes by health professionals exists. In contrast, my earlier experience of rehabilitation for cardiac conditions, gave greater weight to appropriate physical activity. (Additional support to the medical staff being given, in the first case, by dieticians and, in the second, by physiotherapists which might have influenced this bias). In the treatment of my heart condition I was fortunate that my GP was a member of a local NHS scheme which, in addition to walking and cycling, suggested that patients should sample tai chi and aqua aerobics classes with a view to continuing involvement.

 

The article emphasises the need for motivating long-term and sustained physical activity. Both tai chi and aqua aerobics can provide group support. These activities, I later found, can be also used as a part of type 2 diabetes treatment for both weight loss and increased metabolic rates, though they were not specifically suggested as complementary to a strict dietary regime. Alternatively, at a personal level, I can concur that there is also a need for long-term motivational support for suitable individual exercise programmes.

 

The researchers highlight, in their conclusions, the usefulness of dog exercising in promoting a regular walking regime. In this connection, it is important that an appropriate breed of dog should be ‘adopted’ for speedy and sustained walking for an appropriate distance. A dog, in addition to providing a ‘conscience incentive’, also is also a helpful aid to the ‘legitimisation’ of walking when otherwise solo activity, particularly by men, has been known to become the basis of unnecessary suspicion.

 

The study’s findings are important in lending weight to the need for health professionals to emphasise the importance of physical activity as much as diet in the treatment of Type 2 diabetes. Professor Steve Field’s timely article in the Observer Don’t take offence if we lecture you on how to stay alive and healthy (Comment: The Observer 08.08.10) has also brought the need to sustain motivation towards the adoption of a healthy diet and exercise to a wider public.  

 

Reference

1. Peel E, Douglas M, Parry O, Lawton J. Type 2 diabetes and dog walking: patients longitudinal perspectives about implementing and sustaining physical activity. Br J Gen Pract 2010; 60 (577): 570-577. View abstract

 

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Date: 3 Aug 2010

Topic: Response to 'Type 2 diabetes and dog walking'

Comments by: David Church, GP, Machynlleth, Town Councillor, Tywyn, Meirionydd, and Assistant Regional Surgeon, North Wales

 

The fitness benefits of dog-walking are thoroughly examined in Peel and colleagues' article in the August issue of the BJGP,1 but two aspects that were not included could be highlighted. The first is that that dog-walking can have an adverse effect on the general amount of walking of the population, the second is an un-envisaged problem with dog-ownership affecting health service provision.

 

To start with the latter, it impacts noticeably on my working practice most days. We have a number of patients who live alone, except for their pet. What happens when they need to be admitted to hospital? A budgie can be picked up and transported readily to a friend's house where it will receive food, water, and social interaction for a short holiday. A cat or fish can be fed by a friendly neighbour, and will look after itself otherwise. (Indeed many cats will actually claim 'ownership rights of several households!) A dog needs to be fed/watered, but also requires very substantial socio-emotional interaction.

 

So how, you may ask, can dog-walking inhibit general population walking? Well this is a problem I hear complaints about regularly in my role as a Town Councillor. The dog-walkers are so inconsiderate to the other inhabitants in leaving piles of faeces all over the streets and pavements, that other people (including some other dog-owners) are put off walking anywhere by the smell, and the mess when they get it onto their shoes, clothes, carpets. In some localities the physical behaviour of the dogs is also a disincentive: people, especially children, can become frightened of dogs, especially those that are big, fast, loud, or just bite at the ankles, to the extent they avoid walking out.

 

The editorial for the issue2 mentioned people being more wiling to walk on safe streets. Please can we have our safe streets back again, free from fear of attack by dogs (especially small children and the elderly), and free from risks of blindness from Toxocara canis, echinococcus, Hydatid disease, and the ever present smell and threat of offensive deposits on the footwear and household floors!

 

References

1. Peel E, Douglas M, Parry O, Lawton J. Type 2 diabetes and dog walking: patients longitudinal perspectives about implementing and sustaining physical activity. Br J Gen Pract 2010; 60 (577): 570-577. View abstract

2. Davies P, Garbutt G. The exercise prescription, Br J Gen Pract 2010; 60 (577): 555-556. View title page

 

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Date: 27 July 2010

Topic: Response to 'Letters on Managing chronic kidney disease'

Comments by: Mark Brady and Donal O

 

We were interested and grateful to receive the comments from Drs Cave1 and Tisi2 in response to our editorial.3 Firstly, we fully accept that the lead-time for the introduction of eGFR reporting to primary care was much too short and should have been accompanied by better, structured education. We know their views are shared by a number of nephrologists, in addition to colleagues in primary care, and it is important to have an open debate about the evidence, and where that, and their consequences.

 

The term chronic kidney disease (CKD) was coined in 2001 by the international kidney community owing to the confusion and harm resulting from earlier terms such as renal insufficiency, impaired kidney function, uraemia etc. The publication of an internationally agreed staging system has enabled much better communication between clinicians and with the public, and aims to address the wide variability in management and outcomes for patients with all forms of kidney disease. Such variations are extremely costly, both to individuals and the system, accompanied by a lack of awareness or suitable mechanisms to capture those affected, not least because of the inadequacies of serum creatinine in isolation as a marker of renal function.

 

The introduction of eGFR (estimated glomerular filtration rate) is a clear improvement in those not acutely unwell, with work continually ongoing to develop more accurate methods of assessing renal function. Efforts continue to be made to improve the staging system, with NICE guidance introducing stages 3a and 3b,4 and using proteinuria to stratify further.

 

Regarding terminology, it is important to note that CKD is an umbrella term, representing a heterogeneous group of patients, of which the vast majority have CKD as part of vascular disease pathology, suffering cardiovascular morbidity and death, never reaching end stage renal failure. The pathology for such patients is similar to coronary heart disease, peripheral vascular disease etc all carrying the same suffix.

 

There was and remains a need to raise awareness, not only for the majority described, but also for those with systemic disorders affecting the kidneys, rare primary renal diseases, or those reaching end stage disease from vascular pathology. Although these patients are rare ~0.07% population), their renal replacement therapy costs alone represent 2% of the £130 billion NHS budget. As a result, early identification is a key challenge for primary and secondary care. Simple urinalysis and blood tests can identify those at greatest risk for cardiovascular disease, those with rare renal disorders, and those likely to need dialysis in the short or long-term.

 

For those with moderate levels of renal impairment (CKD 3a) we agree it is a challenge to communicate the term CKD, the need for altered lifestyle, more focused cardiovascular disease and medicines management without undue psychological burden. Statins are beneficial in such patients,5,6 possibly highlighting commonality with other vascular diseases, but not in those with advanced kidney disease on dialysis, where the pathology relates in part to alterations in cardiac structure, sympathetic activity, and vessel calcification.

 

We are not advocating screening. NICE guidelines suggest those in whom renal function should be assessed, with many CKD patients identified following incidental findings in primary and secondary care. The NICE calculated costs for checking eGFR and proteinuria in those indicated per 100,000 population are £32,000, whereas postponing just one dialysis year for one patient saves at least £25,000. It is also pertinent to consider individuals as well as populations, e.g. younger patients with early CKD (3a) and proteinuria are at significant risk of premature vascular events and advanced kidney disease.

 

There is evidence for slowing the progression of decline in renal function and reducing cardiovascular events in diabetic, non-diabetic, hypertensive, and non-hypertensive patients with angiotensin system antagonists. Number needed to treat (NNT) to prevent death in CKD patients with diabetes, with ACE inhibitor therapy, is 28,7 comparable to statin therapy for prevention of cardiovascular disease for those with a 20% 10 year cardiovascular disease risk in the general population (NNT 33).8 The heterogeneous nature of CKD means a study to establish a true NNT for all patients with CKD has not yet been conducted.

 

Therefore, as we move forward, a register of all those currently assessed as having CKD should help to tell us which patients should remain on a register, those in need of more intensive management, practical and effective blood pressure targets etc. Importantly, we are already seeing a reduction in the percentage of late presentations to nephrology (presenting 90 days or less prior to commencing dialysis). We feel it is too soon to know the true benefits of early CKD identification, Quality and Outcomes Framework registers, and subsequent care using the principals and systems of chronic disease management.

 

We are always looking to improve our knowledge and devote our attention to those who need it most, in the right place defining who that is, changing what we do, learning from primary and secondary care, sharing our views, is part of that process. Studies repeatedly show that primary care manages to balance the interests and needs of their patients better and more cost effectively than other forms of healthcare delivery and we hope that the vast majority of CKD patients will be cared for in a similar manner.

 

References

1. Cave JAH. Managing chronic kidney disease. Br J Gen Pract 2010; 60(576): 532. View title page

2. Tisi R. Managing chronic kidney disease. Br J Gen Pract 2010; 60(576): 532. View title page

3. Brady M, ODonoghue D. The role of primary care in managing chronic kidney disease. Br J Gen Pract 2010; 60 (575): 396-397. View title page

4. National Institute for Health and Clinical Excellence (NICE), Clinical Guideline (CG73) Early identification and management of chronic kidney disease in adults in primary and secondary care. www.nice.org.uk/Guidance/CG73

5. Tonelli M, Isles C, Curhan GC et al. Effect of pravastatin on cardiovascular events in people with chronic kidney disease. Circulation 2004; 110: 1557

6. Strippoli GFM, Navaneethan SD, Johnson D, Perkovic V, Pellegrini F, Nicolucci A, et al. Effects of statins in patients with chronic kidney disease: meta-analysis and meta-regression of randomised controlled trials. BMJ 2008, 336: 645-651

7. Strippoli GFM, Bonifati C, Craig M, Navaneethan SD, Craig JC. Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease. Cochrane Database of Systematic Reviews 2006; 4: CD006257.

8. Hippisley-Cox J, Coupland C. Unintended effects of statins in men and women in England and Wales: population based cohort study using the QResearch database BMJ 2010; 340: c219

 

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Date: 11 Jul 2010
Topic: Response to ‘Protecting generalism’
Comments by: R Fields
 
Joanne Reeve's article about the difference between interpretative medicine and disease centred medicine1 should be contrasted with Ian McKelvey's article in the same edition giving a framework for the 10 minute consultation which is the standard required for the nMRCGP.2

 

I am sure both authors are on the same side and understand the need to get to the bottom of the problem as it affects the patient, but also the doctor's need to get on with the job of dealing with lots of patients.

 

Although Ian McKelvey is talking about GPs in training, the emphasis on time is likely to fit a disease centred model better than the person centred model of interpretive medicine.

 

Taking 20 minutes for a consultation should not be a sign of poor time management when this extra time may be needed especially when the ground shifts from physical symptoms to psychosocial issues. In this respect, two 10 minute consultations a week apart may not achieve the breakthrough that can be reached in a longer consultation.
 
References
1. Reeve J. Protecting generalism: moving on from evidence-based medicine? Br J Gen Pract 2010; 60 (576): 521-523. View abstract
2. McKelvey I. The consultation hill: a new model to aid teaching consultation skills. Br J Gen Pract 2010; 60 (576): 538-540. View title information

 

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Date: 5 Jul 2010
Topic: Homeopathy and a response to ‘Protecting generalism’
Comments by: Andrew Sikorski, Belmont Surgery, Wadhurst, East Sussex
 
It has been recommended in some quarters for homeopathy to be axed from the NHS1 for alleged lack of evidence – although having critically surveyed the data it can be seen there is scientific evidence proving homeopathy has a greater effect than placebo.2 Why not put selective serotonin reuptake inhibitors (SSRIs) on a shelf labelled PLACEBO, as there is hard scientific evidence this is how effective they are in anything other than severe depression?3

 

The saving to the NHS would be colossal versus a paltry sum for removing NHS homeopathic provision. The only problem with people taking ‘smarties’ for their low mood might be an increase in national obesity as we currently seem to put away heroic quantities of dubiously effective and costly SSRIs. Fortunately, homeopathy lacks the potential of harmful side effects which clinical evidence confirms is opposite to the case with SSRIs.

 

Homeopathy is cheap, has been shown to help patients, even those who have attended numerous hospital specialist out-patient appointments to no avail, has minimal side-effects, and it is popular.4 The current issue of the BJGP contains an article questioning the universal application of evidenced-based medicine in community healthcare5 and contains a plethora of examples6,7,8 indicating why a blinkered, uniquely scientific approach to healthcare is likely to fail, no matter how much taxpayers’ money is spent on it. Please read it in conjunction with the current BMJ.9 Protectionist posturing by ‘scientism’10 is against patients’ best interests.

It’s time for new thinking in healthcare. A cheap, honest and effective example, from which we can learn to provide effective primary care in the UK, already exists in Cuba.11


References
1. Cohen D. BMA meeting: BMA representatives vote to ban homoeopathy from the NHS. BMJ 2010; 340: c3513.
2. The Research Evidence Base for Homeopathy. http://www.britishhomeopathic.org/export/sites/bha_site/research/evidencesummary.pdf (accessed 5 Jul 2010).
3. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010; 303(1): 47–53. http://jama.ama-assn.org/cgi/content/abstract/303/1/47 (accessed 5 Jul 2010).
4. Spence DS, Thompson EA, Barron SJ. Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study. J Altern Complement Med 2005; 11(5): 793–798.
5. Reeve J. Protecting generalism: moving on from evidence-based medicine? Br J Gen Pract 2010; 60 (576): 521-523. View abstract
6. de Kare-Silver N. Training for change. Br J Gen Pract 2010; 60(576): 542–543.
7. Fraser S. The Wizard, the gatekeeper and the watchman. Br J Gen Pract 2010; 60(576): 544–545.
8. Lamb A. The generalist solutionist. Br J Gen Pract 2010; 60(576): 546–547.
9. BMJ. 1 July 2010; 341(7762).
10. Milgrom LR. ANH Feature: Beware scientism’s onward march! Surrey: Alliance for Natural Health, 2010. http://www.anh-europe.org/news/anh-feature-beware-scientism%e2%80%99s-onward-march (accessed 5 Jul 2010).
11. Primary Health Care in Cuba: The Other Revolution (ISBN: 0742566358 / 0-7425-6635-8).


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Date: 2 Jul 2010
Topic: Response to ‘Protecting generalism’
Comments by: Dr Charlotte Paterson
 
Thank you to Joanne Reeve for a novel approach to quality of knowledge use in generalist practice and for the concept of interpretive medicine.1 I think this shift away from the application of EBM decision making to the generation of individualised knowledge could be very significant, though as you point out, turning it into a quality marker for general practice will require considerable research.

 

One tool that may be useful in this research programme is the brief individualised outcome measure Measure Yourself Medical Outcome Profile (MYMOP), which was designed for multidisciplinary primary care.2 MYMOP has been used extensively in practice-based service evaluations and has the advantage that the patient nominates their main problem as well as scoring its severity, alongside their general wellbeing. This makes it applicable to all symptomatic problems presenting in primary care and in complex situations it helps to focus treatment and outcome measurement onto the problem which the patient perceives as most important. It is freely available, along with instructions, references and FAQ, at: http://sites.pcmd.ac.uk/mymop/

 

References
1. Reeve J. Protecting generalism: moving on from evidence-based medicine? Br J Gen Pract 2010; 60 (576): 521-523. View abstract
2. Paterson C. Measuring outcome in primary care: a patient-generated measure, MYMOP, compared to the SF-36 health survey. BMJ 1996; 312:1016-1020.
 
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Date: 23 Jun 2010
Topic: Japanese prisoner of war patients
Comments by: Dr Simon B N Thompson, Consultant, Royal Courts of Justice Expert Witness, and Programme Leader, MSc Clinical Programme, Bournemouth University, UK

 

Increasingly, I have seen a number of English patients who were ex-POWs from Japanese camps. They are intriguing because of the apparent delay in onset of post-traumatic stress disorder (PTSD).
    
During World War II there were over 140,000 prisoners in Japanese camps (Kakodate, Sendai, Tokyo, Nagoya, Hiroshima, Fukuoda, Osaka), Taiwan, Singapore, other Japanese-occupied countries. Camps housed military personnel and civilians who had been in the East before the outbreak of war. The Geneva Convention was ignored and rules included frequent punishments. One in 3 died from starvation, work, punishments, or diseases for which there were no medicines.
    
Recently, I saw Mr P, in his 80s, happily married of 50 years with three children and several grandchildren. He was fairly quiet, mild-mannered but had periods of low mood going for long walks to ‘walk it off’. Increasingly, he was prone to fits of anger. A minor car accident had made him wildly admonish the driver to the embarrassment of his passenger wife. This signalled the beginning of a worrying new trait in which he showed more apparently ‘aggressive’ outbursts.
    
Typical DSM-IV1 PTSD criteria signs were noted: nightmares, ‘night sweats’, and flashbacks. However, only now was any connection made with his distant and difficult past. Over time with cognitive behavioural therapy, he confronted his past and the meaning behind his actions. Re-interpreting events, he found eventual solace in his eldest grandchildren showing great interest in recording events he described using a tape recorder.
    
I suspect the symptoms of many ex-POWs remain unrecognised because of subtle or masked symptoms2 or only surface because of another trauma, as in the case of this patient’s minor road traffic accident. There will be many more patients coming through from the recent Iraqi conflicts. As professional, we need to be aware of the multi-faceted problems associated with PTSD symptoms.

 

References
1. DSM-IV. Diagnostic & Statistical Manual of Mental Disorders. 4th edition, Arlington, USA: American Psychiatric Association, 1984.
2. Thompson SBN. Dementia and Memory: A Handbook for Students and Professionals, Aldershot: Ashgate, 2006.

 

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Date: 19 Jun 2010
Topic: GP Commissioning
Comments by: Clare Gerada

 

General practitioners are being encouraged to lead commissioing and a new White Paper will be published soon setting out what structures and function the new commissioning groups will have. The College believes that GPs needs to come together in Federations - which are provider units from which the Commissioning Boards can commission services. GPs must start to think about the roles they wish to have - be that sitting on the top table helping to design and implement stratergy; helping to redesign services with the twin role of improving quality and reducing cost; and finally bringing in innovation - which is where GPs excel
I would welcome your thoughts.
Clare Gerada, RCGP Chair Elect
 

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Date: 13 Jun 2010
Topic: Authors' response regarding ‘Hypertension in Pakistan: time to take some serious action’

Comments by: Fahad Saleem, Mohamed Azmi Ahmad Hassali, and Asrul Akmal Shafie, Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia.

 

We truly appreciate the response by Dr Newmark about our recent letter1 and would like to clarify a few points raised by him. First, he expressed his concerns about our credibility and authority to suggest recommendations for healthcare issues in Pakistan, based on our affiliation with a Malaysian university. For all of our readers’ information, the first author of our letter is a qualified practising clinical pharmacist from Pakistan and currently is affiliated with the Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences at Universiti Sains Malaysia for his PhD studies. As a pharmacist in the ground work, Mr Fahad is well versed with the situation in Pakistan to a great extent, especially to the region in which he is currently practising (Balochistan).

 

Second, Dr Newmark has also argued that our recommendations are merely based on western treatment guidelines and are not suitable for application in Pakistan. Based on the authors’ current observation of recent practice in Pakistan, we are afraid that he missed the point that things had changed positively over the last few years. There are now adoptions of a number of standard international guidelines in practice, such as the Joint National Committee, British Society of Hypertension Management, European Society of Cardiology, and Canadian Hypertension Education Program, the employment of more foreign trained doctors, and an increasing awareness of evidence-based practice by practitioners and national health authorities.

 

The initial letter that we wrote was to highlight the issues related to non-adherence and poor knowledge towards hypertension and, as practising pharmacists, to develop or at least discuss a mechanism to improve the condition. The word ‘pharmacist’ is relatively new to the people, and the profession is still struggling to be recognised by the healthcare team and institution. Therefore, it was stressed in the letter that interprofessional roles have to be strengthened and the pharmacist must work out of traditional domains of dispensing and supply, and start looking ahead for further responsibilities in patient care.

 

The letter had nothing to do with the treatment guidelines, the manner of how hypertension is treated, or to discuss singular versus multiple-risk factors. It was an effort to promote the role of pharmacists that will be beneficial for all. We are quite sure that if the new system is implemented and the pharmacist is ready to be moulded into a new shape, practical application of these ideas can be achieved even in the least developed areas of Pakistan. It’s better to try than to sit and wait for a miracle to happen.

 

DOI: 10.3399/bjgp10X515151

 

Reference
1. Saleem F, Dua JS, Hassali AA, Shafie AA. Hypertension in Pakistan: time to take some serious action. Br J Gen Pract 2010; 60(575): 449-450. View title page

 

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Date: 8 Jun 2010
Topic: Response to ‘Hypertension in Pakistan: time to take some serious action’

Comments by: Jim Newmark, Salaried GP for Asylum Seekers, Refugees, and Homeless, Bevan House Primary Care Centre, Bradford.

I am concerned about this long letter.1 I find it odd and I do not understand why it was accepted for publication. There are two reasons for this concern. Firstly, I find it simplistic in its acceptance of the usefulness of screening for a single risk factor (hypertension) and secondly, I am suspicious of the authors’ motives in writing.

 

I have lived and worked for a number of years in Pakistan, and have ongoing connections with the country. Part of my role was in diabetes management, but I very rapidly became disillusioned with regard to treatment recommendations that are based on a developed country model. On my desktop I have, with the permission of Cambridge University (http://www.dtu.ox.ac.uk/Outcomesmodel), the UKPDS Outcomes Model programme that was acquired in order to do some research to prove that which I already know. We all do really. That is, for the vast majority of the population, the recommendation to buy expensive pharmaceutical preparations over many years in order to, largely theoretically, save a few months of life or morbidity, does not take into consideration informed consent.

 

The true cost of implementation of this recommendation is to deprive individuals and families of essentials such as food, shelter, and schooling. Advice from professionals to act in this way is often treated with a respect that is simply not deserved and this when there is no axe to grind. This is true in nations that are considered developed, and even more so in countries that are less fortunate and for which the profit motive in selling pharmaceuticals direct to the public is much less hidden.

 

With regard to my other concern, I was interested to see that the address of your correspondents is the department of Pharmaceutical Sciences in a university in Malaysia. This is at least honest, but it does not reassure me about their objectivity. Intriguingly, Balochistan is one of the least developed areas of Pakistan and in this context I really cannot see how the practical application of their ideas can be remotely achieved.

 

DOI: 10.3399/bjgp10X515142

 

Reference
1. Saleem F, Dua JS, Hassali AA, Shafie AA. Hypertension in Pakistan: time to take some serious action. Br J Gen Pract 2010; 60(575): 449-450. View title page

 

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Date: 5 Jun 2010
Topic: Response to “GP training ‘schemes’”
Comments by: Natasha Usher
 
I would like to respond to David Church's letter in this month's BJGP.1 While when most of us were doing our training, there was the option of stand alone SHO posts, these have now mainly disappeared. First year SHO posts now known as FY2 are essentially run through posts from FY1. Then they pass into ST1 posts, which are the start of training proper. Competition for training schemes in recent times has been fierce, although slacking off significantly in general practice at the present time.

 

There is very little avenue for anyone to do extra posts as there simply aren't the posts available. This is part of the problem with the current set up, there is little option to change career path or do different things. Whether this will change in future remains to be seen. The only other option is a staff grade post, but many of them require extra experience not necessarily available to a GP trainee.

 

Correct me if I'm wrong, but I would imagine this is part of the driving force behind the change to 5 year training, as well as the fact that there is simply more to know about being a GP than 10 years ago. And remember the huge increase in salaried posts where there may be no senior GP for advice where employment is by private company or in a solely salaried PMS practice.

 

Reference
1. Church D. GP training ‘schemes’. Br J Gen Pract 2010; 60(575): 451-452. View title page online

 

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Date: 21 May 2010
Topic: Response to ‘GPs' opinions on the NHS and HPA response to the first wave of the influenza A/H1N1v pandemic’
Comments by: Tahira Chishti, Academic ST4 GP, Pippa Oakeshott, Reader in General Practice, St George’s, University of London


Caley and colleagues found that West Midlands GPs thought oseltamivir (Tamiflu) was easy for patients to obtain.1 But it is unclear how many patients actually complete the course. Between December 2009 and March 2010 we conducted an audit of patients with suspected swine flu at an inner London practice to see how many actually took a course of oseltamivir and reasons behind their decisions to take or not to take the drugs.

 

Using Population Manager in Emis and key words “swine flu” or “suspected swine flu”, we identified 72 registered patients who may have been prescribed oseltamivir between August and October 2009. Attempts were then made to contact these patients by telephone.

 

The response rate was 50% (36/72). Thirty-three of the 36 patients (92%) said they had been prescribed oseltamivir: 20 by the practice, 12 via the pandemic flu line, and one through the local out-of-hours service. The mean age of these 33 patients was 27 years (range 1 to 79), 45% were female, and 25% were from ethnic minority groups. The majority – 27 patients (82%) – said they had completed the full 5-day course. Four patients took oseltamivir for less than 5 days, and two patients did not take any medication, one because of clinical improvement and one because of fear of side effects. In total, eight patients (24%) experienced symptoms which they attributed to oseltamivir, mainly gastrointestinal symptoms and listlessness or drowsiness.

 

Caley et al identified ease of obtaining anti viral medication as one of the strengths in the ‘professional to professional’ H1N1 response. Our small audit found this was matched by a high (82%) compliance rate in patients at one general practice, suggesting that many patients seem to have trusted the information they received.

 

Reference
1. Caley M, Sidhu K, Shukla R. GPs' opinions on the NHS and HPA response to the first wave of the influenza A/H1N1v pandemic. Br J Gen Pract 2010; 60(573): 283-285. View abstract online

 

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Date: 12 May 2010
Topic: Obesity: when prevention is much better than treatment.
Comments by: Edoardo Cervoni, MD, Central Lancashire PCT NHS

 

I still remember the day when my mother took me to see my GP. It was the year 1975 and I had just started the primary school. That GP was a young and new face; he was a locum.

 

He checked my weight and height, albeit I was presenting with sore throat and no one had asked him to do so. He looked at me and to my mother with perplexed gaze, and then he said: “Your son is obese and he has to eat less and exercise more”.

 

Actually, I had not a clue what obesity was at that time and I just can remember how my mum was upset and how she kept repeating “that word” again and again. She was upset with the locum GP and she spoke about it for a few days. Previously, the principal GP had told her that if I did carry on growing up that way I could have joined the Italian Army by the age of 10. But that consideration, accompanied by a smiling face, was perceived as a compliment rather than a criticism or suggestion to control my bodyweight.

 

Yet, my mum decided that he was worthwhile following the advice of the locum GP despite, to my grandmother’s eyes, I did look still thin (too thin to be precise!). Ever since, there was less pasta in my dishes and more running around after school. Unfortunately, the change also meant that I could see less TV, this meaning one hour per day at the most.

 

I can now understand how that GP was right to say what he said and I’m still thankful to him. Besides my heavy commitment to my studies, I was able to keep fit and even lucky enough to enjoy above average results in several sports. I took pride of looking after my body shape and I suspect my wellbeing and self-confidence did benefit from the adopted lifestyle.

 

When first I moved to the UK in 2002, I was bewildered by the prevalence of obesity. This was mostly a “visual” impression, as rarely I saw it documented in the medical records. Actually, very often I was the first doctor to check the body weight in years, sometime in absolute. Now that there is an obesity register you would expect the situation being under better control, particularly if QOF achievements are excellent, but this is not the case in my experience. I am rather often the first to check body weight, particularly in children and young adults.

 

In a few occasions the patients or their parents left my consulting room upset. Just recently I had to cause upset for being willing to check the body weight of a lady for the first time after 5 years, her BMI being 47 and the problem never acknowledged despite the several co-morbidities and her being just in her late twenties. A well experienced and extremely valid colleague and friend of mine, did later on book an appointment for her to see me as she had abdominal pain and she was asking for a review after having seen him the day before with the same problem. He suggested not mentioning her weight again.

 

I suspect that if we just would introduce annual body weight checks, eventually at the time of the immunizations, making sure that the child does not shift off centile too much, we would have made a big step in the right direction without even having to mention the term obesity.

 

Same applies to the body weight check in adults. Any occasion should be a good occasion, including the review for oral contraception, and it would be at the least sensible to check the body weight anytime a patient has a blood test, so much welcome to most patients as a “health check”.

 

On the bright side, as a rule, the young obese patient, is a potentially rather healthy individual and it should not come as a surprise his disbelief if from “nothing” the stigma of obesity is thrown upon him after a single encounter with a healthcare practitioner.

 

Discussion forum current

Discussion forum 2009

Discussion forum 2008

Discussion forum 2007

Discussion forum 2006

 

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