Dr. Soon Song spoke to M3 about the growing health threat that is diabetes, medical students and new agents like GLP-1 agonists and SGLT2 inhibitors and new technologies like CGMS
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.
Dr. Soon Song and the relationship with patients
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.
Dr. Soon Song and the learning process
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.
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IL-6, hs-CRP, hs-cTnT, and NT-proBNP were independent predictors of the incidence of heart failure in patients with type 2 diabetes. However, only the addition of NT-proBNP materially improved the predictive performance for heart failure beyond that from conventional clinical risk factors. Further studies are needed to validate our findings.
Dear Dr. Massimiliano,
Thank you very much for your valuable comment and constant participation in our blog. We really appreciate your engagement.
M3 Blog Team.
Dr. Song has an interpretation of care that may be unique to the British experience. Although I agree with his comments on the care and Rx of diabetes and how the new drug classes are beneficial, the NHS in England is probably most similar to Medicare in the US. I see a problem in maintaining the doctor-patient relationship, so necessary in type-2 diabetes, being impeded by the growth of groups and the lessening of the private office where there is sufficient one on one care.
Dear Dr. Karns,
Thank you very much for your interesting insight on the differences in healthcare in the UK and US. Comments like this are always welcome in the blog.
M3 Blog Team.
Dr Soon Song stated “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.” Please address the epidemic we have both in the U.K. And here in the US with foods with low nutritional value but high caloric value.
There is now good evidence that, among people with diabetes, psychosocial factors such as depression are stronger predictors of medical outcomes such as hospitalization and death than are physical and metabolic factors such as presence of complications, body mass index, or HbA1c level
Dear Dr. Guzik,
Thank you very much for your comment. The epidemic of diets with low nutritional value and high calorie value is indeed a serious issue all over the world today. Thank you for pointing that out. Feel free to comment any other posts in the blog.
M3 Blog Team.
This is the first blog that I’ve read so my comments are by no means that of someone who reads blogs regularly.
I was expecting a bite sized educatio piece from an expert. I was hoping to gain something not necessarily present in textbooks – a real ‘education in action’ piece.
Dear Dr. Chirnside,
Thank you very much for your comment. We are pleased to hear this is the first blog you’ve read and we will definitely take your suggestions of having “education in action” pieces posted here.
M3 Blog Team.
Il dr Song ha evidenziato il grande problema del medico di oggi, ovunque operi :da una parte il progresso tecnologico che porta a nuovi farmaci, device per il monitoraggio della glicemia, modalità di comunicazione più rapide tra colleghi e pazienti ma contemporaneamente un afflusso smisurato di pazienti con anche comorbilità e con scarsa educazione nello stile di vita. Ciò che si dovrebbe semplificare da una parte si complica dall’altra ; sta al medico sapersi organizzare e reggere lo stress quotidiano. Certamente il sistema sanitario non lo aiuta ma continuerà a chiedere sempre di più.
ho scritto forte afflusso non influenza
afflusso afflusso non influenza cambia il senso
L’incidenza del diabete soprattutto di quello di tipo 2 sta aumentando sempre più in tutto il mondo tanto che alcuni parlano di un’epidemia. È molto importante in questa patologia per un’efficace prevenzione assumere un corretto stile di vita ed in particolare avere una corretta alimentazione con basso contenuto calorico e svolgere una regolare attività fisica. Il Dott. Soon Song in questa intervista sottolinea molto bene questo concetto e si sofferma anche sulle abbastanza recenti terapie che hanno modificato il decorso di questa patologia. Complessivamente l’intervista è molto interessante
En conjunto estoy de acuerdo en el enfoque de la diabetes que plantea el dr. Soon . Por una parte el factor longevidad de la población ,la mejora de recursos,el tipo de alimentación , y en conjunto factores ambientales que hace que la prevalencia haya aumentado estos últimos años .Por otra parte el cambio de la medicina ,con las nuevos medicamentos ,el trabajo en equipo de los profesionales y el autocuidado de los pacientes -el concepto de paciente activo que se va introduciendo cada vez mas en patologías crónicas -diabetes ,hipertensión ,en que el papel para educación de la enfermera tanto de atencion primaria como de especialialidad es tan importante .Todo ello supone un cambio en el enfoque de la enfermedad.
Habría que pensar en un futuro en el que la prevalencia de patologías crónicas aumente, los recursos de los que dispondremos para hacer frente a este reto .
en este sentido la privatización de empresas y servicios tendría que ser tenida en cuenta.
Completamente de acuerdo, odesidad, sedentarismo y longevidad cada vez mayor convierten a la diabetes y sus comorbilidades probablemente en la enfermedad crónica con más repercusión económico- sanitaria, sin duda un reto para todos los sistemas sanitarios.
I agree with your comments, and I would like to add my opinion to yours , I want to add the importance of mental health in the treatment of chronic deseases.I want to mention the psychology of renunciation as an interesting point. In a world of opulence and desire for material goods, renuntiacion is a challenge. The change of lyfestyle is linked to a renuntiacion for wich we are not educated.
use of glucose-lowering therapies with complementary activities that address multiple facets of the disease may improve long-term outcomes for patients with t2d. two recent drug classes developed for use in t2d, glucagon-like peptide-1 receptor agonists (glp-1ras) and sodium glucose cotransporter 2 (sglt2) inhibitors, have been shown in clinical trials to have beneficial effects on glycemic control, body weight, cardiovascular risk factors, and (for liraglutide, semaglutide, and empagliflozin) cardiovascular outcomes, while having an acceptable safety profile. between them, these drug classes directly or indirectly affect many of the organs and tissues involved in the pathogenesis of t2d, and their beneficial effects on glycemic- and cardiovascular-related parameters are likely to be complementary and potentially additive.
I agree that poor mental health such as depression and lack of motivation is strongly associated with adverse outcomes in diabetes. Poor self care is common. Since diabetes requires patient to be empowered with their condition, this factor often hinders this management goal. Thanks for raising this point.
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Agree with Dr. Song’s observations. The privatization also seen here in the US is taking a more extreme turn with the advent of direct or concierge care (mainly for primary care delivery). It seems to have created a 2 class/tier system based on financial access.
This goes against the very grain of most physicians’ training and make the Hippocratic oath seem obsolete if the trend continues. It may also lead to paucity of access for those that may need it the most.