Slow Medicine

I recently began working in a new Mackay medical practice started by Dr Nicole Higgins called Health on Central.  And when I say new I mean new. Last time I visited the building it was to buy some screws as it had previously been a hardware shop. Sadly, competition from the mega hardware supermarkets down the road meant the the business became unsustainable and it closed down. Turning a gutted hardware store into a multioffice medical clinic was an adventure I’m sure she will tell you.

The clinic still has an industrial look about it, big windows bring in natural light, a living plant wall, a bench from an old train station and dining table in the middle of the waiting room.

Because the clinic is new, I get to spend 30 minutes with patients and this really has opened my eyes to a different way of practicing medicine. I felt I had time to listen to patients story. Studies have shown that a patient is interrupted at between 12 and 23 seconds after starting their story. Obviously this interruption may mean vital information may be lost and it can make the consultation longer. The silence of the doctor is a neglected tool in building rapport. They are many papers which focus on improving doctor -patient communication. Dr David Dugdale wrote Time and the Patient–Physician Relationship in 1999 which is a good starting point for those seeking to improve the efficiency of time spent in consultation. Dr Simon Morgan, who tried to teach me General Practice up in the NT, wrote this a paper on consultation skill tips for new GP registrars.

Dr Nicole recently exclaimed “Slow Medicine” in a GPDU post, and I thought that sounds like a really good idea. I have a slow cooker at home and I can use it to make wonderfully richly flavoured food. As I discovered Slow Medicine is not a new concept. Dr Alberto Dolaro an Italian cardiologist, wrote about in 2002. It is said he was inspired by the rising Slow Food movement, a reaction to Macdonalds in the culinary heart of Italy. His paper’s abstract describes his ideas,

In clinical practice, hyperactivity is often unnecessary. Adopting a strategy of “slow medicine” may be more rewarding in many situations. Such an approach would allow health professionals and particularly doctors and nurses, to have a sufficiently long time to evaluate the personal, familial and social problems of patients extensively, to reduce anxiety whilst waiting for non urgent diagnostic and therapeutic procedures, to evaluate new methods and technologies carefully, to prevent premature dismissals from hospital and finally to offer an adequate emotional support to the terminal patients and their families.

This goes beyond the drive to improve efficiency in the consultation. The movement focusing less on the time but more on the relationship between doctor and patient, the connections made and our shared humanity. The Slow Medicine has been aligned with the Choosing Wisely movement which aims to educate both doctors and patients that quality of healthcare can be achieved by eliminating unnecessary and sometimes harmful tests, treatments, and procedures. Yes less tests can be better for you.

If you are interested in reading more opinions and thoughts on Slow Medicine here are a few links.

Direct to the source but you will have to rely on google translator if you don’t speak Italian. Slow Medicine Society.

I love the snail logo and their Manifesto which is available in English.

Sobria, Rispettossa, Giusta

Measured, Respectful, Equitable

And if you speak Portuguese have a look at the Brazilian version of Slow Medicine.

If Slow Is Good For Food, Why Not Medicine?

I’m so glad I don’t work in an eight minute medicine world!

For the Very Old, a Dose of ‘Slow Medicine’

I think it is not just important for older patients, I think all ages will benefit.

This paper discussed the pressures those who practice Slow medicine may face.

Dr Michael Finklestein is a strong proponent for slow medicine you can read his thought on his website and his Huffingtonpost articles.

As he says

“In our fast-paced world, we often look for quick-fix solutions to our health challenges, not realizing that these “solutions” in fact may contribute to our problems. Most health challenges are the result of an imbalance in our bodies and lives, and most quick-fix solutions actually exacerbate these imbalances. If, instead, we take a Slow Medicine approach – identifying the root cause of our health challenges, then creating a thoughtful, step-by-step, and long-term response to it – we effectively bring ourselves back into balance.”

If you are interested in benefiting from Slow Medicine, the next time you book an appointment with your doctor, ask how long you get for a standard appointment, and if you think you deserve more than 8, 12 or 15 minutes, ask for a double or even a triple slot, it may make for a less time-stressed appointment.

And, finally I’m sorry if I am running late one day, someone maybe needing my slow care!

Doc, those new tablets just aren’t working so good….

Conversation overheard by the consulting room fly

“Hi Mr Brown, what have you done today?”

“Oh not much Doc, those new tablets you gave me for my back aren’t working as good as my last lot”

Hmmm, checking the prescription record and seeing no change in the medication.

“I haven’t changed your tables for a while, what happening?”

“Those new green tablets for my back pain, well they don’t work as good as the white ones. Hang on I’ve got those tablets in my pocket.”

Living in a world where there is supposedly generic equivalence I wondered if Mr Brown was inadvertently taking the wrong tablet. After all the TGA website suggests,

“A generic prescription medicine works in the same way as the existing medicine. What matters is the active ingredient, which is the same in the generic brands and the existing brand.”

Mr Brown handed over a packet of tablets which contained exactly the same medication as the one prescribed. Except that the brand I prescribed was indeed white and these were green.

Can the colour of tablet really affect how a patient may perceive its effectiveness?

Well yes it would seem!

Delving in to the BMJ from 1970, a trial in 48 patients with anxiety found that changing the colour of oxazepam tablets from red to yellow to green affected the response to the medication. Anxiety symptoms responded better to green and depressive symptoms responded better to yellow. Adverse effects were found not to be colour related. Unfortunate for the authors, despite the trend statistical significance was not achieved.

The colour of a placebo tablet has been found to influence patient’s perception of effect. an earlier study from 1962, revealed that the “maximum” placebo effect was obtained when the patients were given a placebo of the preferred color and the least effect obtained with the non-preferred color.

A more recent Dutch study found  perceived action of coloured drugs showed that red, yellow, and orange are associated with a stimulant effect, while blue and green are related to a tranquillising effect. It has been found that red stimulants work better than blue.   707cbd96c92af08d2c6bcec1af06c708

There has also been found a difference in efficacy between tablet and capsule of the same medication and shape and size of tablets.

Strange creatures aren’t we.

“Well Mr Brown, what i think you need to do it have a chat with your pharmacist and make sure you stick to the brand which you think works better.”

A What rush?

<<Rant Alert>>

Thanks TGA

It would seem the TGA would now like Australian doctors speak more like our cousins across the Pacific Ocean in America, that is. There is a updated list of the politically correct names we should all now be using for a select group of drugs. https://www.tga.gov.au/updating-medicine-ingredient-names-list-affected-ingredients. I know these are really the International Nonproprietary Names but it seems that most of the names are being changes to what Americans call their drugs rather than what generations of Australian doctors have called them.

 

adrenaline 6adrenaline 9adrenaline 3 adreanline 3

Adrenaline shall now be called epinephrine. the sight of a white pointer rushing at you on a small yellow kayak, the feeling as you catch a 100 foot wave or jump from a perfectly good plane  or a solid mountain top, or as you touch 300kph in top gear will now forevermore be an EPINEPHRINE RUSH. Doesn’t really sound the same does it?

Noradrenaline, the alpha receptor specialist, likewise shall be known as norepinephine. Must venlafaxine now be called a serotonin, “norepinephrenergic” reuptake inhibitor? Maybe the Americans were getting confused with North American Aerospace Defense Command when someone called for a box of Norad?

Amethocaine my old friend, a sight for a sore eye, now is tetracaine but it may be better if you have four eyes.

Apparently amphoterin gains a “B”. Not sure what happened to amphotericin A. Maybe the “B” is for better.

All the phenobarbitones are now phenobarbitals but that just doesn’t sound right, too aggressive, these drugs are supposed to be more sedate. Amylobarbital, barbital, secbarbital, nembutal (well that one seems to have snuck in for a while), thiopental…

There are few changes that just seem stupid. Where am I to put methylrosanilinium chloride? Oh, if you told me it was crystal violet then maybe I’d  have a better idea.

I will not be moving the “u” and writing an “o” in frusemide. Just to make that clear. It’s like calling my best mate “Buroce”, sorry Bruce I’m not making fun of you it just won’t happen.

Maybe I can drop the “e” from eformetrol, it might make it sound less rude.

Lignocaine remains lignocaine in my mind and you can put that lidocaine and epinephrine right back and give me what I asked for sister!

There are bunch of other changes which just confuse me like dosulepin instead of dothiepin.

There is a list of minor changes too. Such as we are now supposed to drop the “y” in amoxycillin an change it to a “i”. Also pericyazine become periciazine. Surely there are enough vowels in there already, give the consonants a go please. And of course, son’t forget about the “ph” in cephalexin, cephamandole, cephazolin, cephalothin…..  I see even Wikipedia still call this group cephalosporins. Okay a couple with the “f” have already settled into our local formulary …. ceftriaxone, ceftazidime, and cefotetan….

Its not just antibiotics that loose the ph its also Phytic acid becomes fytic acid. I guess it goes the way of telephone, physiotherapy, phallus, physics and farmaceuticals. Dammed its happened already. Mooo

We loose the “o” in oestrogen and all its cousins like oestradiol and oestriol. It is a word rooted in the latin word oestrus.  Bit like orthopaedic, paediatric and gynaecology…..

Tioguanine, etacrynic acid, beclometasone  and indometacin all seem to be missing a “h” Do the INN committee members have something about touching the tongue to their toot?

Its wong I tell you all wong. See you need that extra consonant otherwise you’ll be making fun of all sorts of people.

Give me Paraffin – soft white any day over soft white paraffin.

Enough….read the list. As I read through the list I wonder how many TGA committee meetings in Canberra it took to devise this list. Or was someone bored one Friday afternoon. No new drugs to approve, hey let’s change some names?

Yep Thanks TGA for surrendering to all things America, sorry INN.

At least we bought a French submarine…. Hopefully they will be launched with a nice bottle of Australian Champagne oops sparkling white, preferably from the Clare or Barossa valley.

Oh by the way, we are still apparently permitted to call paracetamol, well paracetamol. So shove that non-INN acetaminophen suppository up your bum America.

<<Rant Over>>

How do I choose a new drug?

I wonder whether I choose a new drug in the same way I picked my new car_DSC9496-001.

The car buying process involved a lots of research, a bit of procrastination and then some negotiation.

Reading several months of Wheels, Top Gear & Car & Driver

Like reading the MJA/BMJ/NEJM

Reading Carsguide & Caradvice websites

The 6 Minute and Australian Doctor equivalent

Watched Youtube reviews and forums like VW Watercooled Australia to get the gossip on reliability and after sales service

Not sure if there is any medical equivalent, maybe GPDU

Then I did talk with a salesperson

The Drug Rep

And went for test drive

No real equivalent experience here. It isn’t really appropriate to ask for a sample of Targin to see how it helps my chronic pain, or shoot up Saxenda for a month to see if I loose weight.


So should I use drug reps as my primary source of information about new drugs?

Should I even see drug reps?

There is certainly support out there if I do go down this path. There are doctors out there who already say no to drug representatives.  http://www.nofreelunch.org/ and http://noadvertisingplease.org/

Dr Brett Montgomery has written on the subject here  https://theconversation.com/why-i-dont-see-drug-reps-a-gps-take-on-big-pharma-spruiking-32435

Dr Ben Goldacre has blogged on his BadScience website and written on the influence of pharmaceutical companies on drug utilisation.  After eventually making it through Bad Pharma I felt a little pessimistic about the whole process. It’s a bit like House of God, essential junior doctor reading.

A list of problems include

  • Missing clinical data which the rep probably doesn’t know about either
  • Positive paper publication bias
  • Ghost writers instead of academics
  • No decent independent head to head studies, so what if me2 is better than placebo is it better than the first drug?
  • Kick backs to medical journals
  • Half blind public agencies
  • Statistical manipulations and sub- subgroups analysis
  • Glossed over serious adverse effects. “The risk of thyroid cancer with Saxenda is over rated!” or “No that only happens in beagles”
  • Glossy brochures and advertising in journals.
  • Pushy drug reps and their inducements – which do seem limited to lunch rather than international flights these days.
  • Leaving behind drug samples as starter packs
  • Subsidising patients support groups and turning them into pharmaceutical lobby groups
  • Product familiarisation campaigns
  • Breaking news on popular media dressed up as “news” stories
  • Chatting in the ear of the clinic nurses, who also look after the sample cupboard. I wonder if any rep has suggested that the oppositions product be pushed to the back or even in the bin?
  • Paying specialists to “educate” GPs
  • Creating a “disease” to sell a product, eg fibanserin for a woman’s poor libido

As a health professional am I impervious to drug rep propaganda. I think the evidence suggests NO.

A few hints include the average sales force expenditure for pharmaceutical companies is $875 million annually and that is just in the USA. Being Australian, I am of course more skeptical and cynical but even so it has been estimated that in 2012 $30 million was spent by pharmaceutical companies trying to persuade doctors to use their product. I think it safe to assume no one would spend that kind of money if there wasn’t some return.

I think I can say that drug are not evil and may be a source of information but they need to handled with care.

Where are you putting that Mars Bar?

mars2

I saw a recent suggestion that rectal administration of a chocolate bar could be used to reverse hypoglycaemia in a patient who was unable to take anything orally.

This led to a range of comments from colleagues mostly of surprise. There were the suggestions that maybe a Poly Woffle has a better likeness to a stool. I helpfully hinted that the wrapper needs to be removed first.

Use of rectal chocolate bars seemed a little strange but not directly counter intuitively. As a pharmacist, I had the joy of preparing suppositories albeit for my undergraduate manufacturing examination, where a pass required a homogeneous and perfectly contoured little bullet. Suppositories have a long history of medicinal uses, although in the Australian context they are not always a popular choice.

But a chocolate bar!

Mars bars contain Milk Chocolate 40%,  Nougat 33% and Caramel 27%. Specific ingredients are Sugar, Glucose Syrup (Sources include Wheat), Milk Solids, Vegetable Fat, Cocoa Butter, Cocoa Mass, Barley Malt Extract, Cocoa Powder, Emulsifier (Soy Lecithin), Salt , Egg White, Natural Flavour (Vanilla Extract). A 36 gram bar gives you 20.8 grams of sugar and 6.2 grams of fat, and reassuringly 0.5g of fibre. There is some glucose in it and that is what we need to reverse hypoglycaemia. Sucrose will do the same but it first needs to broken down to glucose and fructose by the enzyme, sucrase. Sucrase, unfortunately lives in the brush border of the small bowel not the rectum. This kind of makes sense given that the food goes into the mouth and waste comes out of the rectum and from an evolutionary perspective it is best to absorb the good stuff higher up in the bowel after it has passed the taste bud test.

The upper part of the rectum drains into the superior mesenteric vein which drains into the liver via the portal vein. The middle and inferior rectal veins in contrast drain the lower part of the rectum and venous blood is returned to the systemic circulation via the inferior vena cava and thus avoids hepatic first pass metabolism by the liver. So use of some drugs as a suppository has an advantage, although potentially toxicity is increased as liver metabolism is bypassed.

Drugs aside, is their any evidence for benefit from per rectum glucose?

Long, Geiger and Kenny published in Metabolism in 1967 a small study following radiolabelled glucose infused per rectum compared to intravenously. They showed that if you killed of gut flora with neomycin, then the expired radiolabelled CO2 following rectal administration was diminished greatly. They suggested rectally absorption of glucose was minimal and the CO2 expired was due to the effect of gut flora.

In 1984, Aman and Wranne published a small study using six diabetic children as in their words “volunteers” in Acta Paediat Scand. The title kind of gives away their findings “Treatment of Hypoglycemia in Diabetes: Failure of Absorption of Glucose through Rectal Mucosa” The authors gave their “volunteered” children aged 5 yo 10 years old, their normal insulin dose, half a serve of breakfast then exercised them to ensure hypoglyaemia. They were sent to bed and given a dose of 30% glucose solution via a rectal tube. One of the children’s glucose was 1.4mmmol/L and they were so worried that child got intravenous glucose leaving just five subjects. Two more were given milk, leaving just three subjects. One child who got 100ml of the solution up the bum, managed after an hour to get a blood sugar rise from 1.8 to 2.4 mmol/L and I suspect still symptomatic. Anal leakage was also an a problem. Aman and Wranne quite reasonably suggested that “For the unconscious hypoglycemic child, glucose intravenously or glucagon by injection is still necessary.”

A letter published in 1985 in Diabetes care by Attval, Lager and Smith used healthy volunteers, thankfully a little older and better able to consent to having tubes pushed up their bums. In this case a dose of glucose 1g/kg was dissolved in water and inserted. The mean maximal increase in serum glucose was 19%, compared to 64% per oral. The time to that increase rectally was 30 to 40 minutes after administration. Oral peak was at 20 minutes.

For historical purposes only Tallerman published a study On the rectal absorption of glucose in Quarterly Journal of Medicine in 1920. He noted the change was slow. Interestingly this was done  prior to Banting and Best introducing insulin into clinical medicine in 1922.

Interestingly, glucagon which I would normal inject in severe hypoglycaemia, has been studied by Parker etal in a suppository form and it works quite well. Unfortunately, and possibly thankfully for me and my patients, it is only available in Australia in an injectable form.

Is there an alternative for an unconscious hypoglycaemic patient?

Yes, you can given parenteral glucagon if available. And you can place glucose into the mouth. A New Zealand study by Harris et al published in the Lancet in 2013 in neonates showed that a 40% glucose gel was effective as reversing hypoglyacemia.  The gel was massaged into the buccal cavity and the babe encouraged to feed. The use of the gel was more effective than feeding alone. Now this doesn’t exactly transfer to the unconscious adult. There is the issue of teeth to contend with. But there is evidence that there are glucose transporters within the the oral cavity.

So in conclusion, and without any obvious evidence, I think hypoglycaemic bottoms are safe from chocolate bars and squirting glucose into the mouth seems a more reasonable approach if intravenous access is not readily available. Honey which contains up to 35% glucose would be a useful substitute. Except in neonates of course, because of the risk of botulism.

BEACH GONE, DARKNESS RETURNS.

Haven’t posted on my blog for a while but think that I should resurrect it.

A recent media release got my attention…

From the Family Medicine Research Centre.  University of Sydney 11 April 2016

The current contract with Australian Government Department of Health (DoH) for a partial contribution to the costs of the BEACH (Bettering the Evaluation and Care of Health) program finishes on 30th June 2016.

We have been informed that there will be no further funding from DoH for the BEACH program.

BEACH has always struggled to gain sufficient funds each year. However, this notification comes when we also have a large shortfall in funding coming from other organisations such as NGOs and pharmaceutical companies, due to closure of many Government instrumentalities and authorities, and the heavy squeeze on pharmaceutical companies’ profits, resulting from changes to the PBS.

We therefore have no choice but to close the BEACH program. This will leave Australia with no valid, reliable and independent source of data about activities in general practice.

We also have no funds available to produce the annual BEACH report and the ‘decade of Australian general practice activity’ report for this year. Officially, the program will close on the 30th of June, after contracted deliverables to the DoH and other funding organisations are complete. We are committed to supporting the GPs who are currently participating in the study, and will ensure that they are able to complete the study and receive their quality improvement points. However, we cannot support any more GPs to start the study given the short timeframe involved.

The BEACH team wishes to thank all the organisations who have supported BEACH over the last 18 years, in any capacity.

Most importantly we thank the 11,000+ GPs throughout Australia who have participated one or more times in the program, making a big contribution and generously giving their time to do so.

BEACH has been the only continuous national study of general practice in the world which relies on random samples of GPs, links management actions to the exact problem being managed, and provides extensive measurement of prevalence of diseases, multimorbidity and adverse medication events (to name just a few subjects of the many SAND sub-studies conducted in the BEACH program).

Without the GPs, we would not have had the data to report.

Without BEACH there will be very little reliable, independent national information about GP clinical activity in the future.

This loss of BEACH data turns off a light on General Practice in Australia, returning us the dark ages. We will now have to depend upon the muddies waters of government data which may be spun for political gain. And half-arsed efforts by groups like the Gratton Institute who recently wrote a report on chronic disease care in Australia and suggested

“Ineffective management of heart disease, asthma, diabetes and other chronic diseases costs the Australian health system more than $320 million each year in avoidable hospital admissions”

Closure of BEACH program after 18 years.

If you would like to know more about Beach contact Professor Helena Britt
Tel: +612 9845 8150  Mob +61 411 197 938

helena.britt@sydney.edu.au
Director, Family Medicine Research Centre, University of Sydney .

Looking for a new challenge?

Rural GP (Obstetrics)

We are looking for a VR GP with obstetrics to join our team at the Kangaroo Island Medical Clinic.

The KI Medical Clinic is located in Kingscote on Kangaroo Island, SA’s ecotourism jewel.  Although located in an RA4 Area, the Island is only 25 mins to Adelaide by plane and offers a great lifestyle – surfing, fishing, kayaking, bushwalking, wildlife and fine food and wine experiences.   Kangaroo Island has a resident population of approx. 4,600, with more than 150,000 tourist visitors each year.

The clinic is currently staffed by 6 GP’s (who also provide emergency on-call services to the KI Health Service), supported by 2 practice nurses, a practice manager and administration team, all with a commitment to providing high quality care to our patients.

The clinic is involved with medical student education through Flinder’s University and registrar teaching.

At this boutique rural practice, we can offer:

  • A 3-4 day working week
  • Up to 8 weeks annual/up-skilling leave for associates
  • Rural retention allowance and relocation incentives are available
  • A dynamic and supportive practice team
  • Combine the opportunity to practise your emergency and procedural medicine skills with a great lifestyle in the perfect location

Essential requirements:

  • FACRRM or FRACGP
  • Adv Dip Obstetrics
  • Emergency medicine experience

For more information please contact our Practice Manager, Genevieve Willson on 08 8553 2037 or at practice.manager@kimedical.com.au; or to see more of what Kangaroo Island and the KI Medical Clinic have to offer, visit https://www.youtube.com/watch?v=RGpy3W-EPYM.

 

 

 

Genevieve Clark
Practice Manager

 

64 Murray St

Kingscote SA 5223

Ph: 8553 2037

Fax: 8553 2437

genevieve.clark@kimedical.com.au