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 firstname.lastname@example.org. 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.
Patient outcome studies are becoming increasingly important as they provide a truly in-depth analysis of the chosen subject matter as well as benefits to the participants.
We are pleased to announce that we will have a patient outcome study regarding melanoma very soon in the United States and the incentive will be up to $600. We are looking for oncologists and dermatologists practicing in the United States that specialize in melanoma treatments to participate in this exciting study.
This multi-stage study involves both treaters and those receiving the treatment providing an in-depth understanding of clinical, behavioral, and payer practice in distinct areas. All data is strictly confidential.
If you are not a member and you wish to participate in this study, register below by clicking here.
If you are already a member of our panel and you wish to reserve your place, please let us know: M3_US_support@eu.m3.com
Read the interview with a melanoma specialist from the United States in the section “Our Doctors talk”.
Dr 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.
Welcome to the October edition of ‘Inside M3 Insights’!
This month, we are sharing the results of one insider survey carried out by MDLinx, with nearly 900 physicians and advanced practice clinicians in the United States.
The purpose of this survey was to find out what healthcare professionals think about the latest healthcare reform, which was carried out by the Republicans to replace the Affordable Care Act.
The survey asked for a comparison between the multiple-payer system and a single-payer system sych as Medicare for All model proposed by Sen. B. Sanders.
If you’re not part of M3 Global Research’s medical panel yet, we invite you to register and share your thoughts and opinions with the wider medical community
You can access the results of the study below.