Treating Obesity

Happy Halloween! The clocks go back this weekend so it's also the start of winter - officially. Had no idea what to write about this week, a medical student was accused of being behind the plot to blow up a plane bound for the US, I heard on the radio that they're hoping to invent an alternative to the contraceptive pill which involves rubbing cream into your thighs, and David Nutt has announced that alcohol is more dangerous than heroin (albeit on a population scale).

An article in the Sunday Times this weekend highloghted the ongoing debate over availability of drugs and the catch phrase 'post-code lottery'. The headline read 'Call for Banned Obesity Drugs Re-Think'. There have been calls in Scotland for the NHS to re-instate treatments for obesity despite evidence of the risks involved which include 'heart problems and depression'. In January the NHS chose to withdraw Sibutramine from the market, a drug which causes early satiety and can reduce food consumption by up to 20%. There is a growing feeling that relatively safe drugs are being withdrawn from the market because obesity is viewed differently to other disabling diseases without consideration for the physical, mental and social consequences of the condition. A whopping 10,500 people in Scotland are estimated to be on a daily treatment for obesity. Ribonamant was another anti-obesity drug withdrawn from the market in 2008 due to increased risks of suicide, and Orlistat which prevents fat absorption has unpleasant gastric side effects.

In the BMJ this week, the headline article was about surgery for obesity. NICE and SIGN have now published guidelines recommending bariatric surgery for specific groups of patients however many are still unable to gain access to treatment. NICE guidelines recomment bariatric surgery for patients with a BMI of greater than 40. A Cochrane review found that surgery was more effective than conventional management. the question that remains is should we be offering more bariatric surgery than is available at present? The surgery comes with its risks but the bottom line is that what was once considered an un-necessary and rare form of surgery is more and more becoming a leading treatment for obesity, at a time when obesity is reaching 'pandemic' levels in the UK.

PC Project Patient Meeting

I've just got back today from the European Pachyonychia Congenita (PC) Support Meeting 2010 which was in Edinburgh. I've never been along to a patient support meeting like this before but it was a great experience. The PC Project has now grown from an one person's idea to a worldwide support group for patients affected by the ultra-rare skin disorder. It is a keratin disorder caused by a genetic mutation, inherited as a dominant trait.

The best parts of the meeting were undoubtedly the discussion sessions. Several talks were given which were intended to be the springboard for discussion. It got very emotional at times, particularly in the Sunday morning session, where one of the mothers read out a selection of patient experiences. It was interesting to hear about how many people had lived for many years, some of them almost their whole lives without a diagnosis for their condition. Some had to just 'got on with it' while others were misdiagnosed and poorly managed by their doctors. With a condition as rare as PC, many consultant dermatologists will never have heard of the disease or seen a patient with the condition at all in their professional lives. Patients would often find that their doctors didn't know what their disease was and had to just take the advice they were given, these were the experts after all.

The PC Project enables a bridge to be made between research and clinical practice, now commonly known as 'Translational Medical Research'. It allows the people doing the lab work to find new treatments to meet the people who they are trying to help in an informal setting, and offers the opportunity for the patients to find out first hand about new developments and treatments for their condition. Although the PC Project is small, involving only a few dozen patients in the UK, I think that this kind of model could be applied to informing people about much more common diseases. It works particularly well for PC because most doctors do not know about the disease, therefore meeting the experts is really required for patients to have an understanding of the disease.

The whole experience was very rewarding, and it was great to put a human face to the name 'PC'. It puts some of the work that I did during my BMSc into perspective and gave me the chance to meet some of the people who may one day be receiving the benefits of all of the hard work that's gone into PC up until now.

October Reading Week

Spending the week in Kendal in the Lake District with Amy. Finally submitted my answers to the Foundation Application today, great to get them out of the way. Looking forward to enjoying the rest of the week, then its the second Glasgow clinical SSC, this time in Dermatology.

These doctors must have a low workload...

This made me laugh....Medic Guide: These doctors must have a low workload...

Treatment for Infertility and Latest News

This is the proposed logo for the project being worked on at the moment "The Scottish Universities Medical Journal" which I'm hoping will be developed over the forthcoming year with input from all of the medical schools in Scotland.

This week in the press was the awarding of the Nobel Prize for Medicine this year to Robert Edwards, the man credited with the discovery of in-vitro fertilisation. This treatment has helped over 4 million babies to be born around the world and now in the UK accounts for 2-3% of all new births. Although the process has been criticised from many religious groups, such as the Vatican, there is no doubt about the benefit this technology has been of to the huge numbers of couples every year who are infertile. It has been 32 years now since the first 'test-tube' baby was born in the UK and since then there has been a staggering increase in new developments, such as the development of intra-cytoplasmic sperm injection (ICSI) and pre-implantation genetic diagnosis.

Other topics which have been covered in the news have particularly relevant to me personally over the last couple of weeks. The most pressing is the news that there will be a shortage of foundation jobs for applicants this year. The waste of time, money and talent for any graduating doctor to be without a post next August seems pretty awful, particularly with the application process currently used. It seems that in the next few years an exam style application will be introduced whereby all applicants must complete the form within a set, short time period.

The new government is soon to introduce the true extent of the spending cuts which have dominated the headlines this year. News today is that students may be facing a 100% increase in tuition fees (certainly in England) and/or a new graduate tax. If this is brought in, it will hit students hard and I think many will drop out of university as a result. Medical students in particular (who take on longer, more intensive degrees and have less time for part-time work) will surely be the worst affected. Bringing in higher fees certainly goes against all of the work which the BMA has done in the past 5 or 10 years to broaden access to medicine. The next few weeks will be very interesting to see what happens and the reaction which will be taken to the proposed cuts.

Sunday 3rd October

Today marks the start of the Commonwealth Games in Delhi and I'm looking forward to watching as many of the events as I can over the next couple of weeks.

I read an interesting ethical article today with the title "Should you ever lie to your patients?" based on the 2007 article in the BMJ titled 'Can deceiving patients ever be morally acceptable?'
The author argues that in certain instances it may be alright to deceive patients. The example given is one where a patient is about to undergo surgery where their chance of survival is low, less than 50%, and asks the anaesthetist "Is everything going to be alright?". Should the anaesthetist in this situation tell the truth?

One argument is that you should never lie to patients and I agree with this message. Trust is a core element of the doctor - patient relationship and any form of deceit will fundamentally undermine this relationship. Lying to the patient would deny them of their autonomy, their 'right to know'. Should we always tell patients the truth, no matter how grim the outlook may be? Another option would be to take an evasive approach 'We'll do our best'. This however risks arousing suspicion and further upset the patient. Lying in this situation could be argued to be the most helpful due to compassionate reasons.

The obvious answer to this problem is that as with many ethical dilemmas, there is no right or wrong answer. Lying to patients is wrong and should not be done in any circumstances, however there may be situations where it may be in the patient's best interests not to know the whole truth and it may be more compassionate not to disclose information that could harm the patient (non-maleficence).