A valuable lesson in ‘less is more’ from a Dutch patient

A few weeks ago one of my patients, Eva, asked about the treatment of urinary tract infections. In the course of our conversation I mentioned that in Australia antibiotics are recommended.

Eva had symptoms of a bladder infection and was after a diagnosis, but preferred not to take antibiotics. She was Dutch and said that cystitis in the Netherlands is often initially managed without antibiotics.

We decided to look it up (it has been a while since I practised in my birth country) and I googled the website of the Dutch College of General Practitioners. I had a feeling Eva was correct, as it was Dutch research that concluded middle ear infections can often be treated without antibiotics. The Netherlands, Norway and Iceland also top the charts when it comes to lowest rates of resistance to antibiotics.

Since 1989 the Dutch GP College has developed about one hundred independent, evidence-based guidelines for conditions managed in primary care. It didn’t take long to find the guideline on urinary tract infections, published in 2013.

Indeed, the document stated (freely translated from Dutch):

“Cystitis in healthy, non-pregnant women can be self-limiting. Leaving cystitis untreated seldom leads to bacterial tissue invasion.

But what is the risk of complications, like a kidney infection, I wanted to know after reading the advice to Eva (who didn’t look surprised at all).

“Apparently it is not very high, doctor,” she answered.

In the endnotes of the guideline I found a reference to two studies, indicating that pyelonephritis in non-immunocompromised, healthy women is rare, with no statistically significant difference in the occurrence of pyelonephritis between antibiotic treatment groups (0 tot 0,15%) and placebo groups (0,4 tot 2,6%).

The document further contained instructions about what to discuss with patients:

“The GP discusses the option of watchful waiting (drinking plenty of fluids and painkillers if needed) and delayed prescribing. The patient can then decide to start antibiotics if symptoms persist or worsen.

Some evidence indicates that, without treatment, 25–42% of uncomplicated urinary tract infections in women resolve spontaneously.

Eva was right about the Dutch approach. In healthy people with uncomplicated infections the Dutch College of GPs recommends consideration of no antibiotics.

Are the Dutch unhappy about a health system that often advises against antibiotics? My patient certainly didn’t seem to be. She was relieved when we decided not to treat her urinary tract infection with antibiotics.

The answer appears to be no. For years the Netherlands has led the Euro Health Consumer Index, which measures patient satisfaction with healthcare systems in Europe – including outcomes, access to healthcare and medications.

On the Choosing Wisely Australia website I found one sentence on the topic: “The management of urinary tract infections (UTIs) is changing, although it can still include antibiotics.” Lack of systematically reviewed placebo randomised trials seems to be a key factor for Australia.

Eva’s urinary tract infection cleared up without antibiotics.

I recommend sensible use of local clinical practice guidelines and treatment recommendations. Always seek timely advice from your doctor regarding any medical condition you may have, including urinary tract infections. For privacy reasons the name and details of the patient have been altered.

Recognising the difference between normal and abnormal

“Would you mind if the medical student examines you as well?” It’s a common phrase in our practice (usually mentioning the medical student’s name too) and the common response from patients is positive. “Yes of course, we’ve all got to learn, don’t we?”

Although they prefer to see diseases, I also try to expose students to as many variants of normal as possible. Normal skin, normal heart sounds, normal ear drums, normal eyes, normal breathing sounds. Interestingly, ‘normal’ has a scale too – there is a wide variety.

Most students love to listen to the fascinating stories patients bring to the consulting room. They appreciate the opportunity to practise their skills on real patients – but it’s not always spectacular.

When the next person comes in with a similar problem I can see the facial expression of the student: why examine all these normal body parts? But I’ve known this patient for a while and there’s something not quite right. The patient and I both suspect it, but the medical student hasn’t picked it up yet because ‘abnormal’ is sometimes only evident when measured against normal.

“Can you feel this?” I ask, “Compare it to the patients we saw earlier.” The student tries again and eyes light up. When they learn the many presentations of normal, students become better at recognising significant deviations from normal.

Defining normality and abnormality can be challenging, even for experienced clinicians. Being able to make the call that something is a variant of normal is as valuable as identifying abnormal findings.

With the appropriate safety nets in place, it can prevent angst, misdiagnosis, overtesting, overdiagnosis and overtreatment.

Online therapy? It works.

Mental health care is not accessible to everyone. It’s a fact that less than fifty percent of people who need treatment actually get it. But access to an internet connection is available to most people. So it makes sense to offer more health services online.

Although the opinions are divided about Dr Google, health experts now agree on one thing: internet therapy for many mental health problems works.

5 benefits

E-mental health is a broad term used for mental health services delivered via internet programs, telehealth, mobile phone applications and websites. There are five benefits:

  1. It can be accessed anytime and anywhere
  2. There are no or low costs to patients
  3. It fills service gaps
  4. It reduces wait lists
  5. It’s cost-effective to the health system.

Some patient groups will benefit less from online therapy, such as people with complex or severe mental illness, personality disorders, substance dependence, or people who have a higher risk of self-harm or suicide and need urgent clinical management.

Who is it for?

E-mental health probably works best for people at risk of illness or people with mild to moderate symptoms. It is used in many ways including first-line treatment and relapse prevention. Evidence shows that it can be as effective as face-to-face therapy. Using the services in combination with regular visits to a doctor is ideal.

If you want to know what e-mental health services are available and how reliable they are, click here (free registration). The site uses a smiley system to show how much evidence there is that a service works.

More information and free e-mental health training for health professionals can be found here. The RACGP has published a handy e-mental guide for GPs.

Have a look at the video as well. Before you use any of the online services it is recommended to check the terms and conditions so you know what happens with the personal information you provide.

Sources:

Your GP and Dr Google: a good team

Many of us use Google to look up health information. Even doctors google. I often use the search engine to show my patients for example images of anatomy or skin problems. As more people become tech-savvy and websites get better, I expect that Dr Google will be even more popular in the near future.

A study published in the Australian Family Physician in 2014 found that 63 percent of patients accessed the internet in the previous month; 28 percent had sought health information online; and 17 percent had obtained information related to problems addressed during a GP visit.

The challenge is of course to find reliable information. To help differentiate the good from the bad, have a look at this post: 6 warning signs that online health information may be unreliable.

It is recommended to check with a health practitioner that the information is applicable to you. Your doctor may be able to recommend some good resources too.

5 questions to ask your doctor (before you get any test or treatment)

The National Prescribing Service (NPS) has made an interesting list of 5 questions patients should ask their doctors. The aim is to be well informed about the benefits and potential harm before you undergo medical tests, treatments, and procedures.

I think the list is useful and I’d encourage people to ask these questions. At the same time I suspect I will not be able to answer all the questions. For example, I don’t know the costs of all available tests, and the exact risks of certain interventions is something I may have to look up.

I have been told NPS is planning to develop resources for doctors so they can better help their patients with these queries. This would indeed be helpful. But in the meantime, feel free to ask! I hope it will lead to less unnecessary interventions.

Here are the 5 questions to ask your doctor before you get any test, treatment, or procedure:

5 questions NPS

Source: Choosing Wisely Australia

Spotlight on wellness warriors: What you need to know

“Hope is the physician of each misery” ~ Irish proverb.

I understand the power of hope in life & death, but sometimes it comes at a cost. It is painful to see that some of my sickest cancer patients are paying large sums of money to practitioners in the wellness industry who claim they have found a miracle cure. Glamorous and healthy looking health gurus attract mass online followings by selling a dream. Many of these wellness warriors are modern-day snake oil salesmen. The suitcase filled with dubious cures has been replaced by commercial websites, Facebook pages and YouTube accounts.

Jessica Ainscough

Jessica Ainscough was a self-proclaimed wellness warrior. She self-administered daily coffee enemas and took vitamin supplements to beat cancer. She started chemotherapy, but eventually declined it, as well as other conventional treatments like surgery and radiation, which she called the ‘slash, poison and burn method’. Although many of her followers thought her alternative approach was successful, she lost her battle and sadly died at the age of thirty.

The fact that she tried complementary therapies in itself is not surprising, as many people in her situation would do the same. The problem is that Ainscough was very good at selling unproven products to cure cancer, for example by claiming the methods ‘starved cancer cells’.

Ainscough completed an online course at the Institute for Integrative Nutrition in New York, and according to the Australian newspaper, she said it had taught her how to organically attract ‘an amazing tribe’ of people who trusted her.

Via her blog she offered a ‘lifestyle transformation guide’ for just under $1000. She also sold cosmetics and other products. It appears her business model was profitable, as she wrote on her blog: “I earned six figures within a year of completing B-School and have doubled my income every year since.” Ainscough later denied claiming that she had cured herself.

Oncologist Dr Ranjana Srivastava is concerned about these health scams. “There is a legitimate role for a variety of complementary therapies such as yoga, meditation, mindfulness, a balanced diet and moderate exercise,” she says in this article. “The problem arises when the generic multivitamin tablet from the chemist morphs into weekly intravenous injections costing $1000 a shot. Or when the notion of cleansing the body of toxins is exploited with sham diets and enemas that land patients in the very hospitals they are determined to avoid.”

Belle Gibson

Yet, most people don’t seem to be bothered by the modern-day snake oil merchants. I suspect that is because their fantastic stories appeal to our yearning for inspiration and herbal cures. What’s more appealing than trying the same remedy that miraculously cured someone we know? Understandably many cancer patients are desperate, especially when conventional treatments have side effects or are not effective anymore. But it is desperation that makes people vulnerable to dishonest gurus and wellness warriors.

What upsets us most is when the wellness warriors lie about their own health problems – like Belle Gibson.

Gibson’s approach was very similar to Jessica Ainscough’s. She claimed to have cancer and promoted a range of alternative cures to treat cancer. Her wellness and nutrition app ‘The Whole Pantry’ was a best-seller. Unfortunately Gibson never had cancer, and journalists found out she failed to deliver on promised donations to charity.

“What enrages us all,” says psychiatrist Dr Helen Schulz in this blog post, “is those who don’t have any training in health, who deceive the public for overt secondary gain (financial) and delay others from getting help until it’s too late.”

Mainstream medicine

In many ways doctors and other registered health professionals are the opposites of wellness warriors. By law we are restricted in the way we promote and advertise our services. We don’t sell personal health stories, we often have to bring bad news, we don’t always give our patients what they want, we can’t promise total cure, our treatments may have side effects and often we are unable to offer a cure at all.

No wonder lifestyle coaches and health gurus attract large tribes. But, if homeopathy, vitamins and coffee enemas would cure cancer and other maladies, I’d be the first to prescribe it.

3 simple tips

I’m not saying that the wellness industry as a whole is unreliable. I’m also not saying to stay away from complementary therapies. But Ainscough and Gibson are not the first and won’t be the last as the wellness industry is not regulated in the way mainstream medicine is.

To avoid disappointment, please remember:

  • Magic cures don’t exist
  • Think twice before you pay large sums
  • Talk to your specialist or GP before you make a decision.

Stay safe.

Doctor, do I have to stay on these medications?

This is the first article in the ‘Blogging on Demand’ series. If you have a topic you want me to blog about, feel free to send an email, contact me via social media or leave a comment below. Jen Morris picked the topic of this post. She tweeted me saying: “I’d love a GP view on polypharmacy, deprescribing & importance of reviewing and stopping treatment, not just continuing indefinitely.”

I really like this topic. I’ll explain why. It’s fair to say I have a love-hate relationship with medications. They can do a lot of good, but also cause misery. Prescribing drugs is a bit like cooking, and getting the balance of the different ingredients right an art: Use too little and your dinner guests are unimpressed, use too much and it becomes unpalatable.

There are many guidelines in medicine informing us when to use which ingredients, but unlike cooking books, they never tell when a dish should be taken out of the oven, or, in other words, when to stop treatment. This is odd, especially as patients often rightly ask: “Doctor, do I have to stay on these medications for the rest of my life?”

Here is a summary of the why, when and how to stop long-term medications – based on the limited amount of evidence available. For more information I refer to the sources mentioned below.

#1: Why stop medications?

Research shows that elderly people often feel better after their medication is discontinued. One study found that only 2% of the medications had to be restarted because the original symptoms reoccurred. This suggests that many people take medications unnecessarily.

It is estimated that up to 30% of hospital admissions for elderly patients are related to the medications they take. Reviewing the medication list periodically is therefore important, for example after the annual home medication review by the pharmacist.

#2: When to consider stopping

There may be good reasons why, after review, it is better to continue long-term medications. But there are 5 circumstances when stopping should be considered:

  1. A patient is taking multiple (more than 4) drugs
  2. An adverse drug reaction is suspected
  3. The drug doesn’t work (anymore)
  4. A patient experiences falls or cognitive decline
  5. The condition of the patient improves or worsens dramatically.

 #3: How to stop

Deprescribing can be done safely, but is not without risks. Withdrawal symptoms, rebound syndromes and reappearance of the original symptoms may occur. Medication withdrawal should be undertaken in consultation with a doctor.

The literature suggests different methods, but I particularly like the following simple 5-step approach:

  1. Prepare: Always consider the option of deprescribing at the start of a therapy, in case it is required later on.
  2. Recognise the need to stop: are any of the above mentioned 5 circumstances applicable?
  3. Prioritise one drug at a time to stop.
  4. Wean, especially benzodiazepines, opioids, beta blockers, corticosteroids, and levodopa.
  5. Monitor: Look out for withdrawal symptoms, discontinuation and rebound syndromes, reoccurrence of illness, falls, and changes in cognition and quality of life.

Research into deprescribing has mainly been done in elderly people taking multiple drugs. I believe it is not unreasonable to apply the same principles to younger people, even if they are on a smaller amount of long-term medications.

I always find it extremely satisfying if we manage to cut the number or dose of someone’s medications – and most patients seem to be equally pleased. Less is sometimes more.

Thanks to Jen Morris for the topic suggestion.

6 warning signs that online health information may be unreliable

If you are using Dr Google to find information about a health problem – like most people do – you will come across unreliable information. Here are 6 warning signs that will help you stay clear from quackery sites.

Information may simply be outdated or incomplete. But sometimes it is deliberately incorrect or manipulated, for example to make you buy something. How to differentiate between the good and the bad? (I admit, this is not always easy).

#1: The site wants to sell something

If a website is trying to sell a product, the information provided may not be objective. Be careful if the site is:

  • Showing lots of advertisements or testimonials, difficult to distinguish from the website content
  • Offering a free trial, money back guarantee or special offer
  • Using phrases or words like: Recommended by doctors, used by professionals, scientifically proven, patented technology, or guaranteed results.

A site may not explain that its main purpose is to sell something. Stay clear if it sounds too good to be true, for example if the website is promising you a miracle or magic cure, amazing results, or a new, quick or easy way to fix your health problem.

#2: It is not clear who makes the claims

Always check if a trustworthy health professional or professional organisation is providing the online information, like the Royal Australian College of General Practitioners or Physicians, the Australian Medical Association, the Consumer Health Forum of Australia or the National Prescribing Service.

Are links to original sources or scientific research provided? Missing or insufficient information may be a clue that a website is not reliable. Websites carrying the HON Code or HealthInsite logos are usually reliable.

#3: The website is out-of-date

Always check how old the information is. Has the website recently been updated? If the information is more than 2-3 years old it’s best to look for a different source of information – or talk to a health professional.

#4: The site has a less reliable domain

Trustworthy health websites contain the domains .gov, .org or .edu, indicating that the information comes from the government, a not for profit organisation or a university.

This doesn’t mean that other websites are always unreliable, but it’s good to find out who is sponsoring or paying for a commercial website (.com or .com.au) before relying on the information. You particularly want to know if the information favors the sponsor.

Websites written by a single person are less reliable than websites run by professional organisations. Yes, that includes this blog (I just shot myself in the foot, didn’t I?)

#5: You have landed on Wikipedia

Wikipedia scores high in search engines so it’s easy to arrive at a Wikipedia page. As much as I like Wikipedia, one study showed that it may contain errors.

#6: The site is requesting your information

Reliable health information is freely available online (at no cost), so there is no need to give a website your details, like your email address. If you must submit personal information, check what will happen with your details first.

Look for the website’s Privacy Policy: this tells you how a website or organisation manages your personal information. You may want to know if your data will be sold or provided to other organisations. A Disclosure Notice informs you if a site receives funding or accepts forms of paid advertising, sponsorship, or paid topic insertions.

More information

A rule of thumb: Don’t rely on one source. Try to find other reliable websites or sources confirming a message or claim about a product or service. Ask an AHPRA-registered doctor or health professional if you’re not sure.

If you would like to know more about finding reliable health information online, have a look at this 16-minute tutorial by the US National Library of Medicine.

Sources:

6 great podcasts for primary care

 

6 great podcasts

Here are six free podcasts made with tender loving care by a variety of people and organisations. I enjoy listening to these online broadcasts because they are relevant to my daily work in general practice. I download the episodes on my iPhone at home when I’m on WiFi – and listen on the way to work.

The first two podcasts are aimed at health professionals and mainstream audience, the others are more suitable for health professionals only. There are many other awesome podcasts out there; if you know of any in particular, please share your tip in the comment section below.

Do you want to know how to set up podcasts or how to get started recording your own? Here is a good explanation by GP Dr Tim Leeuwenburg.

#1: Health Report (ABC)

In-depth quality reports by Norman Swan and other ABC reporters on topics such as breast cancer & screening, contraceptive options other than the pill and science topics like the future of DNA-sequencing. Well put together with often several national and international experts in one episode.

Audience: Mainstream and health professionals. Episode duration: 28 minutes. Download on iTunes

#2: Inside Health (BBC)

Inside Health
Inside Health with UK GP Dr Mark Porter

Great podcast discussing a few topics per episode – with UK GP Dr Mark Porter. Demystifying myths about vitamins, glucosamine, testosterone, statins, e-cigarettes and much more. One episode about the doctor’s gut feeling inspired me to write this blog post.

Audience: Mainstream and health professionals. Episode duration: 28 minutes. Download on iTunes

# 3: Broomedocs Podcast (Dr Casey Parker)

High quality grassroots podcast by Australian GP & ED Doctor Casey Parker. All sorts of topics relevant to general practice and emergency medicine, such as resuscitation techniques, snake bites, vitamin D deficiency, contraception, overdiagnosis and suicide. The podcast could do with a professional iTunes logo to make it stand out on mobile devices amid other podcasts.

Audience: Health professionals. Episode duration: 15-50 minutes. Download on iTunes

#4: Best Science Medicine Podcast – BS without the BS (Dr James MCormack and Dr Michael Allen)

Entertaining Canadian show discussing evidence-based drug therapy. Lots of myth busters and many topics relevant to general practice such as vaccines, osteoporosis and the treatment of common cold.

Audience: Health professionals (GPs). Episode duration: 20-40 minutes. Download on iTunes

#5: Australian Family Physician Audio (RACGP)

Interesting interviews with authors of articles in Australian Family Physician, the journal of the Royal Australian College of General Practitioners. The podcast is a great way to follow the journal if you don’t have the time to read everything, or if you want to hear more from the authors. Episodes are presented by various AFP editors, and include topics like multimorbidity, systemic lupus erythematosus, multiple myeloma, SSRIs & adolescents, and obesity in general practice.

The quality of the recordings varies between episodes. It is occasionally necessary to read the article to gain full understanding of the topic. The podcast needs a professional iTunes logo to make it recognisable on mobile devices amid other podcasts.

Audience: Health professionals (GPs). Episode duration: 10-30 minutes. Download on iTunes

#6: HBR Ideacast (Harvard Business Review)

HBR IdeacastManagement and business skills are not taught sufficiently during the medical training, even though doctors often find themselves in leadership positions. The Harvard Business Review podcast features tips and ideas by inspirational leaders – ready to be implemented at work. Food for thought for business owners and (practice) managers.

Listen to topics like: how to spread excellence when opening another practice, and online training videos for new staff members. Want more tips? Download the free Harvard Business Review management tip of the day app on your phone.

Audience: Managers & business owners. Episode duration: 10-20 minutes. Download on iTunes

Why doctors don’t ask about your drinking

“It is socially unacceptable to say you’re a heavy drinker, but it is actually socially acceptable to be a heavy drinker.” This interesting quote from a GP came out of a research project by Dr Michael Tam, GP at the School of Public Health and Community Medicine in Sydney. It may explain why GPs feel reluctant to discuss alcohol intake with their patients…

Dr Tam tried to find out why doctors are avoiding the topic. He found the following 3 barriers:

  • Many GPs didn’t want to be seen as moralising or didn’t want to label people with an alcohol problem
  • There was doubt about effective screening tools; what people say may not always reflect their true alcohol intake, so why bother asking
  • GPs were concerned that discussing the topic would affect the relationship with their patients

Dr Tan concluded that routine alcohol screening questionnaires by GPs may not be helpful to detect at-risk drinking.

What do you think needs to happen? Fill out the poll below or leave a comment.

Source: Detection of at-risk drinking – beliefs and attitudes of Australian GPs

Why we vaccinate: amazing figures from Australia

These graphs show what happens to the number of deaths when we start vaccinating.

The red arrow indicates when vaccines were introduced in Australia. The take-home message: vaccines save lives.

Why we vaccinate
Image (click to enlarge): Number of deaths in Australia from diseases now vaccinated against, by decade (1926–2005). Red arrow indicates when vaccine was introduced. Source: The Science of Immunisation: Questions and Answers, Australian Academy of Science.

For more information have a look at the website from the Australian Academy of Science which provides easy-to-understand information that explains the science of immunisation.

2×5 questions you should ask your doctor

There are a 5 simple questions you can ask your doctor about tests and 5 questions about the treatment, to be better informed, and get the outcome you want.

Testing

  1. How certain or uncertain are you about my diagnosis?
  2. Are further tests required?
  3. If so, how good are the tests?
  4. Are there risks or downsides to the tests?
  5. Is testing necessary or are there other options?

Treatment

  1. What treatments options do I have?
  2. How successful is the treatment?
  3. Are there risks attached to the treatment? Eg adverse reactions, interactions with other medications, antibiotic resistance, bleeding, infection.
  4. Is the treatment necessary or are there other options? Eg wait, try lifestyle changes first, do further tests, see another doctor.
  5. Is there anything else I need to know about the treatment? Eg how to administer, when to come back, how to prevent this from happening again.

5 things to remember before a doctor’s visit

It happens regularly: people visit a doctor but have difficulty providing essential details about their health.

Sometimes people incorrectly assume that all information is always at my fingertips. I don’t blame them; the healthcare sector is complicated and going to the doctor is understandably not everybody’s cup of tea.

And in all fairness, it’s not easy to remember when we had our last tetanus vaccination or in which year we were in the local hospital.

I hope the following five tips will help to make the most of your doctor’s visit.

1. Gather information

Write facts down, together with your questions. The doctor may ask a few things such as: when you first noticed the problem, what made it better or worse, and what your main concerns are. Make sure you know what your questions and expectations are.

  • Tip: Feel free to do your research on the Internet and check your findings with the doctor. Remember that online health information may not be applicable to you.

2. Allow enough time

If you want to discuss a complicated issue or a few problems, consider booking a long appointment to avoid running out of time.

3. Ask a friend or family member to join you

Having someone with you is helpful in many ways: to ask questions, to remember what has been discussed, for support and to give you a lift to and from the clinic if you are unwell.

4. Keep a record of all your past and present health problems

This is important. Doctors always need background information about your health. Don’t automatically assume the doctor always has all the required information.

  • Tip: Your own record could include a list of your medical problems, diagnoses, hospital admissions, operations, medications, vaccinations, allergies to or side effects from certain medications, products or food. Outcomes of important tests are always helpful. Keep a paper record or store the information in a safe place on your computer, phone or preferably electronic health record.

5. Never leave things to the last moment

A doctor’s visit just before a holiday trip, or on a Friday afternoon may cause problems – for example if your doctor needs to do more tests or the recommended medications are not available in the pharmacy. Sometimes a last-minute visit is unavoidable but often good planning goes a long way!