Talking to… Dr. Aaron Milstone

Aaron Milstone

Dr. Aaron Milstone is a pulmonologist in Franklin, Tennessee and has been in practice for more than 20 years, 15 of them as an Associate Professor in Medicine at the Vanderbilt University Medical Center. In this interview to the M3 blog, the doctor shares the novelties in the treatment of COPD and asthma, his main areas of interest, and his opinions on e-cigarettes and home-test for sleep disorders.

Data from the United Network for Organ Sharing shows a 3% increase in organ donation in the US since 2016, and a 27% increase over the last ten years. What’s your opinion on new techniques which are helping to facilitate that?

I was at Vanderbilt University Medical Center in Nashville, Tennessee, where I directed a lung transplant program for 15 years, so obviously was involved in a great deal of critical research into transplantation. In terms of lung transplants, there are many aspects contributing to the increase in organ donation, including educating the public, and expanding the donor pool to include older patients, and the preservative solution used has improved so an organ can last longer outside the donor body than ever before.

Another one of your areas of expertise is the management of COPD. What are the hottest news in this field?

Yes, my main areas of interest are COPD and asthma. I have a large clinical research program conducting phase 3 and 4 studies in both asthma and COPD. COPD is a real hot topic now as we get ready to have biologic options for patients with the condition. COPD is an enormous problem in the US, especially in the South-East of the US where smoking rates are particularly high – the highest in the US. Just in my own state of Tennessee, the incidence is very high compared to the US in general. In turn COPD rates are very high here as well. My opinion is that we are in the era of Columbus in terms of COPD treatment.

By that I mean that historically we’ve used inhalers, but now we have drugs with new mechanisms of action and new delivery systems. Now a fixed dose, triple drug therapy has come to the US market, within the last year, and there are also multiple LABA/LAMA combinations and many more therapies to come. Triple drug therapy is going to have a significant impact – patients can now use a single device rather than three inhalers, so adherence improves.

Historically we’ve relied on patients to tell us whether they’re taking their medications, but now we’re doing a lot of research looking at new ways to improve compliance, and many of those involve smart electronic devices and smart phones. In the future, your inhaler will be able to report how frequently it’s been utilized, whether the correct dose has been administered and, most importantly, give feedback to the HCP. There’s lots and lots of knowledge on the horizon that will revolutionize the use of inhalers at minimal cost to the patient and HCP.

We’re also doing a lot of work with biologic therapy. Recently one of the larger drug companies published data on biologics and exacerbations of COPD. The impressive feature of biologics is that they have the ability to improve lung function but also may have the potential to reduce flare ups. So, I think there’s going to be a change worldwide in how we treat COPD and asthma in the near future. There are currently four different biologics treatments already on the market for asthma, and many more in the pipeline, and I’d expect to see biologics treatments for COPD coming soon. It’s an exciting and unique time to be in pulmonary medicine. I believe that soon there are going to have to be niche sub-specialists who are very familiar with immunology and biologic drug classes.

Data on smoking in the US shows that the percentage of people smoking has declined from almost 21% in 2005 to 15.5% in 2015, but cigarette smoking is still the leading cause of preventable deaths in the country. In other countries there have been initiatives to reduce smoking via taxation etc, how do you think the US should approach this?

The data in the US is very similar – there is a linear correlation between smoking tobacco and higher taxation. The states that have the highest taxation on tobacco tend to be in the east. The states that have the lowest taxation tend to be in the south-east, and there is a very clear correlation between taxation and prevalence. Taxation on tobacco products can be very effective at keeping prevalence down.

Another strong approach that I’m an advocate for is improved pharmacologic coverage by insurers. Unfortunately, most insurance companies do not cover the cost of smoking cessation products such as nicotine replacement patches. I think that insurance companies should be lobbied to cover the cost of treatments for smoking cessation. At the moment if a patient can’t afford nicotine replacement patches or other treatments they have a much lower likelihood of stopping smoking. Some insurance companies now are giving discounts on premiums to patients enrolled in tobacco cessation courses or if the patient makes a ‘valiant attempt’ at cessation, and I think that’s a really good way to increase quit-rates. I think that counselling combined with pharmacologies is the best approach.

I do agree that the Australian approach to taxation is helpful, but I also think that you need to look at secondary intervention in terms of helping people to quit and giving them affordable ways to quit. This has been a real focus for me as I live in the South, and Tennessee has one of the lowest rates of taxation, and hence is a state with very high tobacco use prevalence. The reality is that I see so many complications of tobacco in terms of stroke, myocardial infarction, and lung cancer, that this area of medicine is very important to me.

The UK has reached a record low in terms of smoking rate, with over a million people reporting using e-cigarettes, which can be somewhat controversial. What are you take on them?

I think the main problem with e-cigarettes is that the long-term health effects of these cigarettes remain unknown. There’s a multi-center study looking at the long-term impact of their consumption, and until the effects are known I strongly advocate against using them to quit smoking. Yes, there are less carcinogens, but many still include high levels of nicotine. The way I see it, is that you’re just switching out one addiction (ie. cigarettes), for another (ie. e-cigarette). I believe that when we see long term data we may find that e-cigarettes are no safer than regular cigarettes, but we don’t know that at this time.

Regarding sleep disorders, another area of concern in Pulmonology, what’s your evaluation on the recent practice of home tests for the diagnosis of sleep disorders?

Definitely a hot topic. Any physician, such as a primary care physician, for example, can now order a home sleep test for a patient. However, I think the patient really loses out on some of the analysis and expertise when they’re not seeing someone who is board-certified in sleep medicine. The reason I say that is that many of the home sleep tests lack data on aspects like leg movement, so you may not be able to make a diagnosis of periodic limb movement disorder with a home sleep test.

In addition, there’s a very crude analysis of REM and non-REM.  So, many times the home sleep study may not be adequate for a diagnosis of, for instance, narcolepsy or idiopathic hypersomnia. At the end of the day, home sleep tests are best when the health care provider is looking specifically for sleep apnoea. However, a home study can lack sensitivity for patients with mild sleep apnoea. Unfortunately, if you haven’t seen a board-certified physician for the analysis you may not have been fully assessed for other diagnoses like idiopathic hypersomnia, and most importantly, may not get the degree of follow-up after starting CPAP if you have been diagnosed using a home sleep study.

That being said, home studies are a trend that’s not going away. Physicians have to be very selective about who gets a home sleep study. The health care provider has to be purely thinking about sleep apnoea and ensure that the patient is safe to be assessed in the home environment. If someone has significant heart or lung disease or underlying seizure disorder, those patients should all be assessed in a monitored sleep lab setting. Also, if you do a home study you want to make sure adequate follow-up is in place when the patient initiates therapy with positive pressure (ie CPAP or BPAP).

Talking to… Dr. An Pham

Dr. An Pham, a pulmonologist from Pennsylvania, USA, shares his opinion on stress and quality of sleep, tobacco taxation, and advancements in procedures and drugs in the treatment of pulmonary conditions.

M3 Global Research is currently conducting studies on various pulmonology-related topics. If you are a pulmonologist or internal medicine physician specialising in pulmonology and practising in the US, please contact M3_US_support@eu.m3.com. If you are not a member of our panel already and are interested in participating in healthcare market research, you can register here.

What inspired you to specialise in pulmonology and what is the most interesting aspect of working in this area?

I did a rotation with a wonderful pulmonologist who became my mentor and made me want to follow in his footsteps.

You are certified in sleep medicine. What are your thoughts on new trends like home sleep tests, for example? Currently, the American Academy of Sleep Medicine recommends home sleep tests should be used in conjunction with a comprehensive sleep evaluation to diagnose obstructive sleep apnoea (OSA).

Mixed feelings. Most of the time this works out, but a lot of times the results come back inconclusive and have to be repeated. Additionally, the Apnoea Hypopnea Index (AHI) is frequently underestimated, which impacts treatment decisions, especially for borderline cases.

Short sleep duration has been associated with a variety of adverse cardiovascular outcomes in cross-sectional and small prospective studies. As someone with more than 20 years of medical practice, during your career have you noticed much indication of lifestyle directly influencing quality of sleep and resulting in other health issues? 

That varies from individual to individual. In general, yes, to some degree, but many patients don’t even realise that.

The percentage of the population in the United States that smoke has declined from 20.9% in 2005 to 15.5% in 2016. However, cigarette smoking remains the leading cause of preventable disease and death in the country. Do you agree with measures trying to address this? The Australian government, for example, has announced it will raise tax on tobacco by 12.5% every year from 2017-2020. Would you agree with something similar being put in place in the US?

Mixed feelings. The effect of cigarettes on health is no longer a secret, so if someone chooses to smoke he or she is willing to take that risk. It’s the same with alcohol. I’m not sure where to draw the line as far as controlling what people do with their lives.

In your opinion, how has technology improved the treatment of pulmonary diseases in the last decade?

 Lung transplants and interventional pulmonology have advanced significantly. Older patients can now be candidates for lung transplants. Many patients can now avoid surgery given new intervention bronchoscopy procedures. Also, new drugs, especially the biologic agents, have improved patient outcomes significantly.

 

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.