Firstly, we’d like to get to know you better. Let’s start with what inspired you to become a physician and to specialise in diabetes management and cardiovascular risk?
I had always planned on becoming a doctor, and when I did a training post in diabetes I enjoyed it, and so decided to choose that as my specialism. Diabetes is a common problem, and it’s a specialty where you can really help people. Obviously there are complications, but often you can really make a difference. Also, there’s quite a broad-base of general medicine work beyond just diabetes which was very attractive to me.
What would you say are the biggest challenges you face as a physician in the UK?
The biggest challenge is the number of patients coming through the door. We have an ageing population so we have more chronic conditions like dementia, Alzheimer’s disease and other degenerative conditions which will drive up the cost of care. That leads to issues with social care because the current social system is not able to cope with the rising demand and sometimes it’s very hard to get a streamlined transition from hospital to primary care.
On the other hand, how have the healthcare services in the UK improved since you started to practise?
Things have improved a lot in the last twenty years. Medical treatment and technology have made significant progress – we have far more evidence to guide our practice and we work with more robust guidelines. Nursing expertise has increased with nurse specialists who have taken on more substantial roles, allowing medics to focus on more complicated patients. Things have to improve with progress, it would be worrying if they didn’t.
As a teaching hospital, we have medical students working alongside us on the wards. The emphasis of their medical education has changed from a focus on didactic teaching to problem based learning and communication skills, rather than a pure emphasis on knowledge. There is a lot more focus on patient-doctor relationships and managing patients holistically, which I think is for the better, and medical training needs to evolve to achieve these goals at undergraduate and postgraduate levels.
How do you see the doctor/patient relationship nowadays? What do you learn from your patients?
It can be a complicated relationship that is different for every patient. You want to empower patients and share with them decisions about their management, as the more engaged they are with their clinical care, the better the outcomes. Unfortunately, this may not be possible with everyone.
Your research interests lie in cardiovascular risk and complications in type 2 diabetes in the young. According to Diabetes UK, ‘diabetes is the fastest growing health threat of our times and an urgent public health issue. Since 1996, the number of people living with diabetes has more than doubled. If nothing changes, it is estimated that over five million people in the UK will have diabetes.’ From your experience, what are the main reasons for this catastrophic scenario? Also, what is the future for diabetes treatment? Do you see the situation changing for better?
The reason is basically lifestyle changes: less physical activity and more access to high calorie diets, which are all increasing the incidence of type 2 diabetes. A combination of environmental and social factors is having the biggest effect, as well as some genetic influences, but mostly it’s the environmental factor that is driving the rise.
The new treatments coming through in the last 4-5 years are much better – new agents like GLP-1 agonists and SGLT2 inhibitors which not only improve diabetes control but also tackle the obesity problem and induce weight loss with minimal hypoglycaemia risk, whereas older agents don’t help with weight loss and may cause hypoglycaemia and weight gain such as sulphonylurea. Obesity is an important issue in the management of type 2 diabetes, together with the complications of treatment-induced hypoglycaemia. The future looks more promising as the standard of care has improved driven by high quality research work.
What are your main sources for learning about new drugs and treatments in your area?
Publications in major journals, conference news and medical news are sent to me, and I go to conferences. Those are the main sources I’d say. Conferences are mainly in the UK but sometimes I go to European meetings. Due to the vastly improved communication technologies, you no longer have to physically attend to get the latest information from major conferences such as the ADA (American Diabetes Association) and EASD (European Association for the Study of Diabetes). You can log in and follow proceedings via webcasts. I get the latest updates on medical research and news almost daily via email. I don’t have much time to get away, so I rely more and more on electronic communication channels.
Do you feel you have a good support circle when talking about your professional life? Do you often exchange knowledge and discuss cases with your colleagues?
We have big teams here, working with consultants and nursing colleagues, and it’s great to be able to discuss cases. If you go to any hospital in the UK now you don’t work in isolation, you work in a team because you can’t work on your own – that’s the bottom line. It’s good to have a circle of colleagues you can discuss cases with, and bounce ideas off.
How do you see the use of technology by physicians and patients today, in particular patients who live with diabetes?
We use it because we now have CGMS (Continuous Glucose Monitoring for Diabetes device) where we can check blood sugar multiple times a day without needing to do finger pricks. This technology is becoming more widely used, especially for patients on insulin therapy, although we do limit the use to certain cohorts of patients as it’s quite expensive, for example those with poorly controlled diabetes despite insulin adjustments, or patients with severe hypoglycaemia, especially those with hypo-unawareness. I think technology will play an increasing role as time goes on. For patients on blood glucose meters, we’re able to download those results and information on to the computer system, and look at the blood sugar profile and see if there are any trends or problems occurring – this is now the norm.
For the more sophisticated technologies like CGMS the limiting factor at the moment is cost. Until it becomes more affordable or reimbursed by the NHS, it won’t be widely adopted.
What do you think will be the main challenges for healthcare in the near future?
There’s increasing privatisation in medicine, with private companies coming in to deliver services, although not for acute services. If you are a healthcare provider in the private sector your goal is to make profit, so things are changing. I think in the future the NHS may turn more towards the private sector to deliver more services through negotiations with the trust and CCGs. This may mean the consultants’ role and who they’re employed by may change. This will be a new territory that consultants have not been exposed to, or trained in dealing with this kind of scenario, which is already starting to happen and may become more widespread.
My concern is how this privatisation movement will turn out in the future: what changes there will be to the services and how the services are delivered, how much the consultant role will change, and whether there is job security.
Is there anything else you’d like to share with us that we haven’t covered already?
The people working in the NHS are still keen and they work hard, despite the cutbacks and financial restraint. Innovative work is still being produced, and the NHS is lucky to have this workforce. The challenge is to maintain this endeavour long-term in the face of low morale and I hope more positive changes will come. Patients are very lucky – everyone is doing the best they can.