Talking to… Dr. Devika Umashanker

Dr. Devika Umashanker is an Obesity Medicine specialist practising in the US. In this interview with the M3 Blog, she speaks about fat-shaming, personalisation of treatment, the use of MDTs in the management of obesity issues, and taxing sugary products. Read the full interview below.

What inspired you to specialise in obesity medicine?

After completion of residency I worked as a hospitalist for a couple of years during which I noticed that the underlying cause of many of my admissions was obesity. During medical school or residency, there was not a significant amount of time allocated to teaching obesity medicine or nutrition. After studying the subject on my own and going to various conferences on obesity medicine, I was fascinated and intrigued with the sub specialty, which then led me to pursue a fellowship in obesity medicine at Weill Cornell Medical College.

If you look at data shared by The World Obesity Federation, it is clear there are differences between the percentage of obese adults in each country around the world. What could influence the level of obesity from country to country?

In my opinion, possible factors influencing the level of obesity from country to country are access to food, access to care and being able to treat obese patients effectively.

Further data shows the differences between the percentage of obese men and women in every country. Biologically, are there main differences between male and female metabolisms?

Women tend to have greater adipose tissue compared to men. Increased adipose tissue leads to increased insulin resistance, increased inflammatory markers, and decreased adiponectin levels, which all play a role in the pathogenesis of obesity and affect metabolism.

Would you say that the treatment for obesity must be personalised? In what way?

The treatment of obesity must be personalised because each patient is different. For example, each patient with obesity has a different set of comorbidities and a different combination of medications treating their comorbidities, which then leads to a different treatment plan.

Data shows that on current trends 2.7 billion adults worldwide will suffer from overweight and obesity by 2025. In your opinion, what would be the main points to work on in order to treat and prevent obesity?

The main points to treat and prevent obesity are early intervention, nutrition and exercise counselling, availability of anti-obesity medications, and universal insurance coverage for bariatric surgery, when appropriate.

What is your opinion on taxing sugary drinks, a measure that has recently been approved in the UK? Do you believe the impact will be significant? Are there other similar measures that you think would have a bigger impact?

In my opinion, obesity is similar to cancer. Obesity decreases quality of life, increases mortality, and individuals die from the complications associated with obesity. If cigarettes are taxed to prevent consumers from purchasing the product to reduce lung associated disease such as lung cancer and COPD, we should strongly think about the impact that taxing sugary drinks will have on our consumers in regards to obesity. In my opinion, I think the impact will be significant as it will make the consumer think twice before purchasing a sugary drink. Would taxing sugary drinks eliminate obesity? The answer is no. However, it may be a good starting point to consider.

How can physicians treating obesity benefit from working with different healthcare professionals, such as psychologists and psychiatrists, nutritionists, physical education professionals etc?  

Working with a multi-disciplinary team including psychologists, exercise physiologists, bariatric surgeons and nutritionists is the most effective way to treat individuals with obesity.

What do you think about so-called ‘fat-shaming’ by healthcare professionals towards patients dealing with obesity? How can this be tackled?

I think ‘medical fat-shaming’ is prevalent in the medical community, but this can be tackled through education on the pathophysiology of obesity. Obesity is not volitional but rather a disease. Neuro hormonal dysregulation and hormonal imbalances play a significant role in obesity and as a medical community we need to come together and understand this universal concept.

 Is there anything you would like to add?

Obesity medicine has come a long way but we still have a long way to go.

Talking to… Dr. Lawrence Feldman

Dr. Feldman, a dermatologist specialising in the treatment of melanoma, practising for 30 years in the US, spoke to the M3 blog about prevention, new treatment developments and the changes in patients’ approaches to the condition.

M3 Global Research is about to launch a large patient outcome study about melanoma. If you are a dermatologist or an oncologist and are interested in participating, please contact blog@eu.m3.com. If you are not a member of our panel and are interested in participating, you can register for this study here.

What do you think about new developments such as optical biopsy, or tests that look at gene expression patterns and allow physicians to see if stages 1 and 2 are likely to spread, new types of immunotherapy and targeted therapies etc?

The field has definitely changed dramatically, more so than any other field as we have gone from a situation where there was really no therapy that was effective, to now seeing therapies that can induce prolonged remission and even overall survival rates. As far as the gene expression profile, it is a huge advance, perhaps even replacing biopsy in the future. And with optical biopsy and dermatoscope use, the clinical diagnosis of melanoma has gotten much better.

How long ago would you say was the breakthrough?

I would say it began about five years ago. It’s really when things started to change, I guess with the introduction of Zelboraf (vemurafenib) – that was the big turning point.

How do you personally keep updated with news in melanoma treatment?

I would say conferences, congresses, symposiums, journal articles, Tumor Board. We have a Tumor Board at the hospital on a pretty regular basis, so all these things help us to keep up to date.

From your experience, how is the level of treatment in the US compared to other countries?

I think the level in the United States is high, I’d say it’s quite advanced. We definitively have access to many of the newer therapies.

And how is access to treatment for patients? Do most insurances cover melanoma treatment now?

If you are following NCCN (National Comprehensive Cancer Network) guidelines, access is very good. It is harder to get access off-label.

What’s the part played by prevention in skin cancer?

I would say it’s the key. Prevention is better than treatment. So, especially if it’s about avoiding sunburn early on, that would be probably the most critical thing.

During the past 30 years have you noticed changes in patients’ attitudes and empowerment? Are patients more aware of conditions such as melanoma and therefore pay more attention to their own bodies, coming to you with questions?

I think people are more aware of it. Even younger people are more aware of the sun causing it, and even tanning salons, that are ‘a big thing’ in the United States and also a big campaign that has got more publicity recently.

How important is early detection for the treatment of melanoma?

It’s key. We talk about 3 things: prevention, early detection, and treatment. Prevention is the most important, so you don’t have the problem at all; early detection is vital because if you catch the melanoma before it’s reached a certain depth, then you don’t really need any other therapy; and then early treatment, for patients that are less fortunate.

Talking to… Dr Suhail Hussain

Our Doctors talkDr Suhail Hussain is a keen advocate of holistic and patient centred care, coupled with physicians’ continuing education. He balances work as a portfolio GP for the NHS and private sectors and is a senior tutor at three major London medical schools.

 

Can you tell us a little bit about your routine during a regular week and how you cope with the workloads faced by physicians in the UK?

My work is very varied, as I am what’s known in the UK as a portfolio GP, which is becoming an increasingly common phenomenon. This involves the practitioner undertaking several diverse (sometimes unrelated) roles. Some years ago, I worked as a partner in a community based primary care clinic, where I had my own list of patients to whom I provided care. I would see patients every day in scheduled clinics and occasionally visit some at home.

Following this, I undertook a period of out of hours work (evenings and weekends) for a couple of years. However, for the last three years I’ve been working as a portfolio GP. As mentioned, this involves several diverse roles. For me, this encompasses work as a locum, medico-legal work, one day working in a service called “rapid response”, online consulting and a weekly private clinic.

When working as a locum I might provide holiday or sickness cover in a surgery  where, on any given day a regular doctor is away. The medico-legal work entails seeing and examining patients who have been involved in road traffic accidents for example, and preparing written reports on my findings. The work in rapid response, which I find personally very rewarding, involves working with nurses to provide a home-visiting service that is designed to reduce hospital admissions, visiting patients who perhaps can’t be seen by their own GP, due to their time constraints. These days can be quite quiet, and it means that I can spend time teaching nurses and helping them with their professional development.

I also do online consulting, which is becoming more common in the UK. I work from home and patients log in to an app for a consultation. This has its advantages for the patients in terms of ease of access and diagnosis for simple problems where we can talk about managing such issues or I can refer them on.

Once a week I carry out a private clinic (www.cpmedicalclinic.com/team-members/dr-suhail-hussain). Working as a portfolio GP means sometimes my schedule changes every week, which means I must be very organised to make sure I don’t overbook or under book myself!

Regarding online consultations, what would be the advantages and disadvantages of it?

The advantages for the patient are that they can contact the doctor at their convenience from their phone, during their lunch break, for example. There are limitations though – while we can see them on a screen, we can’t carry out a physical examination such as listening to their chest or palpating their abdomen. Consequently, this might mean more time spent by the patient in total, trying to resolve their problem, as they have spent time on the video conference and then have to make an appointment with their GP for a chest/abdo examination etc.

For other things it can be a great time saver e.g. if someone wanted an orthopaedic referral for their knee, then although ideally, I would always prefer to see them in person, that kind of thing can be done by video, as they’ll get examined by whoever they’re referred to as well.

What about the home visits?

Home visits are a distinctive element of primary care in the UK. I always tell my students that home visits often give you a lot of information and an irreplaceable insight into the patient and their condition. Often revealing facets of their disease that are not immediately apparent when they come to see you in clinic. I’m not sure how home visits work in other countries, but in the UK, they are unique to general practice.

For example, I saw a lady who was admitted several times for falls. When I went to visit her at home I could see that in addition to her severe osteoarthritis, the house was very cluttered, which meant she was tripping and then falling. I would never have known that having just seen her in the surgery. As a result of this I was able to request occupational therapists to come and make adaptations to her home which reduced her falling frequency.

You are a sort of advocate for GPs continuing to improve their knowledge and not getting “lost” in their routine. What would be your suggestions for doing so?

If you’re in a regular practice it’s easier to keep up to date with your education, however as a locum or portfolio GP it can be more difficult to keep up to date with CME. I run a group with a friend of mine where we meet every 6 weeks or so, with an invited speaker, and have a discussion with 10-15 attendees each time. You can also attend education days at hospitals or learn around patient cases you see.

I am currently in the process of setting up an online portal of educational resources for primary care physicians (www.gpeducationacademy.co.uk).

 You work as a medical tutor at three London medical schools (UCL, Imperial College and Bart’s). How do you expect Brexit will affect these and other medical schools in the UK regarding both staff and students?

Brexit will be a very bad thing for the medical profession – overseas nursing applications have dropped drastically recently, and that will be common across the profession, with overseas doctors (and other healthcare professionals) not wanting to come and work in the UK.

If universities applications are restricted access to overseas students then they will also lose a lot of income and, I think, a great deal of diversity. Diversity enriches your learning experience and helps with patient care as you get used to dealing with a wider group of people from different cultures and backgrounds.

 How long have you been a medical tutor? During these years, have you noticed many changes in medical education?

I have worked as a medical tutor over the past 9 years and I’ve seen quite a few changes. When I was at medical school we learned lots of facts, were examined on them rote fashion, and were then expected to apply those facts to clinical work. Now, medical students learn fewer facts, but learn via problem-based approach, around a case in small groups. This means they should have a more holistic approach to the patient. However, it can also mean the knowledge is lesser, and unless a student is very self-motivated then they may struggle with the less structured learning.

When I’m teaching we’ll look at the case, and I’ll ask them what their diagnosis/management is. Then I will challenge their responses and encourage them to go back to basics and apply the pathophysiology to the clinical context. I think it’s important that they understand the aetiology of the symptom; working on first principles to try to derive the answer.

You work for the NHS and in the private sector. What are the main differences regarding the way you are able to relate to the patients in each environment? 

I do want to say how great I think the NHS is, and that there are very few healthcare systems in the world where everyone has access to everything at the point of need. From a general practice point of view though, the amount of work we have to do and the volume of patients we have to see is increasing almost exponentially, whilst the amount of time we have to do it in is becoming less and less. This makes it very hard to meet unrealistic patient demands. Patient expectations are becoming greater and greater, and they often present with minor ailments which increases the strain on the service.

By contrast my private appointments are thirty minutes as opposed to ten. I have time to sit and talk with patients, take a very detailed history, do an examination, and discuss, in depth, their management and treatment, so they understand why I’m suggesting what I have, which means their adherence will be better.

What is your opinion on charging patients for NHS services as a way to avoid overloading the system?

 I think that the NHS is a fantastic service and that it should remain free at the point of need, and don’t think charging is a good idea. We could look at patients being removed from lists if they regularly miss appointments, and obviously if people can afford private treatment then there’s that option.

Is there any particular issue related to healthcare or general practice in the UK you would like to address?

I think the message I’d like to convey is that the NHS is a fantastic institution, and that primary care physicians provide the vast majority face to face health care. Ninety per cent of all patient care, is provided in the primary care setting. The government need to acknowledge this fact and improve the funding of general practice, as well as methods of recruitment and retention. Many GPs are retiring in their mid-fifties and graduating students are not going into general practice, which means under-staffing will become chronic. I hope that real measures are taken to maintain and promote what we have, rather than carve it up and dismantle it.

Talking to… Dr. Soon Song

Diabetologist based in Sheffield, Dr. Soon Song spoke to M3 about the growing health threat that is diabetes, medical students, doctor-patient relationship and the future of the NHS

Our Doctors talk

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.

Talking to… Dr. Masoud Rezvani

Dr. Masoud Rezvani is a passionate surgeon practising in Virginia, USA. He spoke to the M3 blog about organ donation, access to healthcare in the US and what the surgeon of the future will look like.

What inspired you to become a doctor and more specifically a surgeon? 

I grew up in a very medical oriented family. As the youngest child, watching all my siblings and cousins be involved in different aspects of medicine was fabulous. At times I even had the opportunity to shadow them in medical offices, clinics, hospitals and even operating rooms and watch them at work. Wanting to save people’s lives and have this degree of skill and knowledge was what drove me into medicine. It was a quick transition in to surgery from there. Being in medical school for 8 years, which is a normal pathway for any medical student in my home country (Iran), made me 100% confident that this was what I wanted to pursue. Since starting my surgical training and more specifically since becoming an attending surgeon, there hasn’t been a single case or operation I haven’t enjoyed.

From your experience, what would you say are the main positive aspects and the most negative aspects of practising in the US?

The most positive aspect of practising medicine in the United States is having access to the most updated technology, knowledge, large resources and unlimited supply and equipment in your medical field. That really gives physicians peace of mind, you don’t have to worry about anything and can focus solely on patient care – in my field I can walk out of the operating room feeling entirely satisfied with the procedure.

The most negative aspect of working in the US is spending/wasting a lot of time with unnecessary paper work, and watching legal aspects and lawyers and legal communities which are waiting to make money from physicians. The other negative is significant overhead expenses which make physicians’ work much harder in order to be able to cover those. Finally, people’s appreciation for the work we do is generally not high at all.

What is your opinion on access to healthcare services in the US, in comparison to what some countries (for example the UK with the National Health Service – NHS) offer to their population?

I think US access to medical services, like everything else which is capitalism driven in the US, is based on market and capital availability. However, some other countries such as the UK, with more socialised medicine, have equal access to healthcare for different levels of the population but perhaps with delays and government control.

Some countries (for example Spain and France) have automatic organ donor registration, where everyone is considered to want to donate their organs in the event of brain or cardiac death unless they opt out. As a surgeon, what’s your opinion on this matter? Should automatic organ donor registration be a global standard?

I really don’t like the idea. I think it should be the opposite, meaning everyone is not a donor by default, unless proven otherwise. I believe our population is not sufficiently educated to be able to understand the consequences and consider whether they should opt out.

In your opinion, what is the future of surgery? Do you see technology as a big part of it?

Like other aspects of science and industry, I think technology will be the first language of surgery in the future. Just think about the car industry – it really does not matter who makes a better car these days, what matters is who has the best software and puts more technology in a car. With minimally invasive surgery, robotic and endoscopic surgery is not possible nowadays without having a super high degree of access and joining the surgeon’s own knowledge with technology. The surgical world has gone beyond the time that a surgeon needed just a knife, haemostat and stitch.