The Binscombe Doctor Blog

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Cough for three weeks? Take a good dose of common sense when symptoms occur

My fondness for waking up to the sound of the radio was put severely to the test on Sunday morning when the words ‘should consult their GP’ drifted nonchalantly into my dreamy subconscious. The correct response, of course, since I am a husband and father on Sundays and not a GP, is to groan to myself: ‘What have they done now?’, hide under the pillow and hope it will all go away. Curiosity got the better of me, however, and shortly after I joined the ranks of other disbelieving GPs on Twitter, threatening to drown out the dawn chorus with our tweeted mutterings.

What ‘they’ (which is the Department of Health (DOH) in this case) have done is to launch a publicity campaign advising anyone with a cough for more than three weeks to see their GP, because it could be a sign of lung cancer. GPs are all for helping people with lung cancer, but no-one was saying that this was a good idea. There was a mixture of stress about a tidal wave of expectorating patients flooding our Tuesday surgeries (why does the Government have to launch these initiatives on a Bank Holiday weekend when we only have a 4 day week to mop up the fallout?), to concern about raising unnecessary anxiety, the harm of unwarranted chest x-rays and the overall cost to both patients and the health service of this newly trumpeted advice.

Anyone with a cough? Really? Taken at face value, the advice would mean that a baby with a cough for more than 3 weeks should see their doctor to exclude lung cancer – clearly this is ridiculous, but if the campaign makes no mention of age then how are the public meant to know who is too old and who is too young? And 3 weeks? Did they really mean 3 weeks? Don’t the DOH know that 35% of people with a simple viral respiratory infection will cough for 3 weeks? Of course they do – their own publicity poster on coughs and colds states that ‘Colds can last about 2 weeks and may end with a cough’ so don’t worry, and certainly don’t think about antibiotics – about 2 weeks must mean that some last 3 weeks, surely? Now this means that the public are meant to understand that a normal cough can certainly last 2 weeks or more and is nothing more than a harmless virus, but if your cough lasts 3 weeks then DON’T DELAY, IT COULD BE CANCER! Hmmm…can’t help feeling we need a large dose of common sense here!

So why have the DOH done this? Well, lung cancer is worth looking at because survival rates are currently very poor – with approximately 40% of patients being alive 1 year after diagnosis, and only 15% surviving 5 years.  Earlier diagnosis could make a difference in some (but not all) lung cancers, and who would not want to achieve better survival from cancer? Lung cancers associated with cough are more likely to be in a place where they can be fully removed (and so cured) by surgery, and so cough is a better symptom to focus on than, for instance, breathlessness or chest pain (by the time you have these symptoms with lung cancer you are not very likely to be cured with treatment). They have chosen 3 weeks in part because of something called ‘slippage’ – the tendency for public health messages to be watered down. If you say ‘drink no more than 14 units of alcohol’, people are likely to assume that 21 wouldn’t be too bad, if you advise people that their cholesterol should be below 5.0 then 5.5 sounds ok, and if you say 3 weeks for a cough, then people might just go to their doctor after 4 or 6 weeks. The problem is that we are all wonderfully different when we behave as patients. Some will ‘slip’ far further then 6 weeks (or even not go at all – maybe if it could be cancer they don’t want to know) while others will now present to the doctor without fail on day 22 of any cough.

Let us assume that a person has lung cancer, and is just beginning to get symptoms from it. We could put that person into one of four categories like this:

Those in the blue sections do not need this campaign, as they will see their doctor early anyway, while those in the white quadrant will not be helped by the advertising either, as sadly their cancer will already be too advanced once it has started to give symptoms so going earlier will not change the outcome. The red quadrant, therefore, is the target group – those who have cancer which could be treated, but whose natural tendency is to see their doctor late. The questions then, are these: How large is this group? Will the campaign reach them, or are they the sort of people who don’t respond to advertising campaigns? And will the earlier pick up really lead to a better survival? On the other side of this argument also lies the potential harm of the campaign – how many people who don’t have cancer will see their doctor unnecessarily, worry needlessly and be exposed to chest x-rays that do not reveal anything of concern?

Well there has been a pilot study that answers some of these questions. In response to a similar, local advertising campaign people were nearly twice as likely to see their GP if they had a cough for more than three weeks, and the referral rate for chest x-rays went up by 20%. While this was hailed in the study as evidence that the intervention was successful, we must remember that these are not, in themselves, good things. In fact appointments with a GP and chest x-rays must be seen as costs in this programme, not benefits, and the question is – is it worth it? More positively there was an increase in the lung cancer diagnosis rate of 27% in the study period. Even this, however, is not the ultimate goal, which is better survival from lung cancer. The extra cases of lung cancer were spread across all stages of the disease from early to advanced, and so many of them would not fall into the crucial red quadrant in the above diagram. The study authors concluded that a larger study was required, but, as so often happens with pilot studies, it has been hailed as a success and a national programme rolled out.

So where does that leave us? In need of a good dose of common sense! The DOH know that a public health message has to be simple in order to hit home – and so they have reduced this to a one-liner: Cough for 3 weeks = see your GP. The GP is left to fill in the details. Well here’s my take on it:

Certainly we should be mindful of lung cancer in people who are at risk. A smoker over the age of, say, 40 with an unexplained cough for 3 weeks would do well to take the advice at face value – I would want to do a chest x-ray. If the same person coughed up blood, I’d be concerned enough to do an x-ray even if it only happened once. On the other hand, if you are young or have never smoked, but your cough is dragging on, we might decide to do an x-ray at some stage, but are far more likely to sort your cough out if we look for other causes – like asthma, allergic rhinitis or heartburn. Certainly a cough that goes on much beyond 4 weeks is worth seeing your doctor about – but in most cases this won’t be because we are worried about lung cancer, it will be because the cough is driving you and your family mad, and there might be something we can actually do about it!

Fear According to Pi

From time to time, you come across a piece of writing that is so compelling, so beautifully written, so resonant with what matters to you that you want to shout it from the rooftops – to call to anyone who will listen and declare to the heavens: “Look at this everyone! Stop whatever you are doing! Just stop for a moment and read this!”

So with Yann Martel’s marvellous novel Life of Pi, and more specifically chapter 56 – a single page offering that is the most powerful, emotive and yet eerily accurate description of fear that I have ever come across. It is worth quoting here in its entirety. If you have ever experienced the overwhelming power of panic, you will relate to every word and find relief that someone can so reliably describe how you felt. If you have never been to the depths of fear, it is worth reading all the more so that you can  understand better those that have.

I must say a word about  fear. It is life’s only true opponent. Only fear can defeat life. It is a clever, treacherous adversary, how well I know. It has no decency, respects no law or convention, shows no mercy. It goes for your weakest spot, which it finds with unerring ease. It begins in your mind, always. One moment you are feeling calm, self-possessed, happy. Then fear, disguised in the garb of mild-mannered doubt, slips into your mind like a spy. Doubt meets disbelief and disbelief tries to push it out. But disbelief is a poorly armed foot soldier. Doubt does away with it with little trouble. You become anxious. Reason comes to do battle for you. You are reassured. Reason is fully equipped with the latest weapons technology. But, to your amazement, despite superior tactics and a number of undeniable victories, reason is laid low. You feel yourself weakening, wavering. Your anxiety becomes dread.

Fear next turns fully to your body, which is already aware that something terribly wrong is going on. Already your lungs have flown away like a bird and your guts have slithered away like a snake. Now your tongue drops dead like an opossum, while your jaw begins to gallop on the spot. Your ears go deaf. Your muscles begin to shiver as if they had malaria and your knees to shake as though they were dancing. Your heart strains too hard, while your sphincter relaxes too much. And so with the rest of your body. Every part of you, in the manner most suited, falls apart. Only your eyes work well. They always pay proper attention to fear.

Quickly you make rash decisions. You dismiss your last allies: hope and trust. There, you’ve defeated yourself. Fear, which is but an impression, has triumphed over you.

The matter is difficult to put into words. For fear, real fear, such as shakes you to your foundation, such as you feel when you are brought face to face with your mortal end, nestles in your memory like a gangrene: it seeks to rot everything, even the words with which to speak of it. So you must fight hard to express it. You must fight hard to shine the light of words upon it. Because if you don’t, if your fear becomes a wordless darkness that you avoid, perhaps even manage to forget, you open yourself to further attacks of fear because you never fought the opponent who defeated you.

This ‘wordless darkness that you avoid’ is the hallmark of fear. The key question to ask if you suffer from anxiety is this: Do you avoid anything that most people see as routine? Avoiding activities such as bungee-jumping is most people’s idea of common sense, but what about using a lift, getting on a train, going into a room with a spider in it, or having an MRI scan? The military analogy works well here; fear is like an invading army that can annex part of your life if it is left undefeated. The greater the fear, the more restrictive the occupation can become, and negative phrases like ‘I can’t’ and ‘I don’t’ become commonplace. Avoidance behaviour seems so natural and logical that it often creeps in unnoticed and unchallenged over years.

It is possible to reverse this trend, to reclaim the occupied land and plan a strategic advance into enemy territory. It is not easy, as it involves facing up to fear and staring it down until eventually, like any bully, it reveals itself to have less substance than first seemed (it is, after all, ‘but an impression’). Each victory over fear, no matter how small, diminishes its power – making the next step in the campaign seem possible, and ultimate victory a realistic goal.

An Englishman Stirred – the False Dichotomy of “Children’s” and “Adult’s” Cereals

I doubt I will be accused of being overly hasty in my campaign against the labelling of cereal products by supermarkets, but that does not mean that my quest has faltered, nor has my zeal lost its edge. I first blogged on this subject at the end of December, and that it has taken me 4 months to plot my second move is something I like to put down to an English predilection for a measured, well-considered response, respect for the other side to give them ample time to deliver their riposte – oh and being a full-time GP with a busy life might have something to do with it.

Nevertheless, I promised to report back the response of the giants in the supermarket world to my humble request to remove the label “Children’s” from its close attachment to certain types of sugary, chocolatey cereals. This on the seemingly reasonable grounds that separating cereals into those suitable for children, and those suitable for adults, is a false dichotomy that sends completely the wrong health message in these times of increasing obesity.

I sent letters to the local managers of both Tesco’s and Sainsbury’s and am disappointed to say that they scored 0-0 in their response – not a word or a peep or even an automated acknowledgement from either of them. Customer service is not what it used to be! The regional Customer Services offices at least wrote back, and I attach a scanned copy of their letters. Sainsbury’s were non-committal and advised me that they will be considering my comments at their next marketing team meeting – but they have not committed to responding again after this meeting and I am not holding my breath. Tesco’s gave a fuller report – full of PR babble that had little bearing to my concern. They commented on problems with space on the shelves and not wanting to take anything away from children, when all I am concerned about is the sign coming down from the ceiling. Maybe my letter was confusing and I need to restate my case – or perhaps they prefer not to understand and would rather waffle away my objection than seriously consider it.

Let me be clear. I have no problem with the fact that cereal companies manufacture sugar-coated products – some regulation here to try to keep them healthier is important, but freedom to buy unhealthy food if you so choose is necessary in a liberal democracy. I have no issue with supermarkets stocking them and giving them ample self space. Unlike cigarettes, I have no wish to see them in plain packaging or behind protective screens – they are not that bad for you after all. However, why, oh why, oh why do the supermarkets feel the need to separate them into “Adult” and “Children” categories? Granted, you won’t want to give hard-to-chew lumps to a 7 month old baby, and may prefer to avoid nuts altogether in the under 3′s, but with these minor exceptions there is no reason why an adult should not choose Frosties for breakfast, or a child prefer Shredded Wheat - or am I missing some vital nutritional understanding here?

So I shall write again, and enclose photographic evidence this time to make my point clearer. And my MP happens to be Anne Milton, Health Minister – I think a letter to her might not go amiss either. Once more into the breach…

Sainsbury’s Letter of Reply

Tesco’s Letter of Reply Page 1

Tesco’s Letter of Reply Page 2

Letter to Anne Milton MP

Letter to Tesco’s

Letter to Sainsbury’s

Quick Post – Mixed fortunes for new Prostate Cancer Treatments

Doctors have always had a particular weakness for new gadgets and flashy technology, and surgeons more than most. The prospect of being able to send Proton Beams deep into a tumour, or smash a cancer into submission with High-Intensity Ultrasound is truly heady stuff to a urologist. All the better, therefore, that we have clinical trials to help work out if these new techniques actually work before getting too carried away with these exciting toys.

There have been two new studies published recently, with mixed fortunes emerging for the latest technological assault on prostate cancer. Proton beam therapy, disappointingly, has not fared well. This treatment is not much used in the UK, but a large study in America has shown that it is no better than conventional treatment, and may even have a higher incidence of complications. Side effects – in particular impotency and incontinence – are frequent, and a major problem with both radical surgery and brachytherapy, the standard treatment for early prostate cancer. Ultrasound treatment does seem to offer early promise in this regard, and the widely reported results of treatment in 42 men has shown an encouragingly low incidence of serious side effects. Far more work is needed, however, as this was a small study with only 12 months follow-up.

We also have to note that these men had early cancer – which means they were picked up through screening – and the major question remains – should these men be treated at all? I have blogged on this before, and we must remember that it is hard for a new treatment to have fewer side effects than no treatment at all.

To Tweet or not to Tweet?

It has taken me a while, but I think I finally get Twitter. I like to think of myself as an early adopter of new ideas and novel technology, but like most of my non-tweeting friends, I assumed that this strange world of 140 characters would be full of the banal comments of the very dull, or the vain utterances of the very famous. Surely even the wit of the excellent Stephen Fry could not compensate for this tedium, and don’t I already get enough of this on Facebook anyway? (except, of course, that I don’t have a single celebrity friend to boast of there).

My brief flirtations with the little blue bird were not helped by the dominance of @ signs and # tags, coupled with confusing, abbreviated hyperlinks, which hampered my attempts to decipher anything at all. I thought it best left for those with more time than sense, and left it sitting comfortably next to day time television as something to avoid.

Recently, however, I have become a convert, and like all new converts I feel a need to evangelise. If you have no desire to succumb to my attempt to persuade you to join up, you would do well to stop reading now – but if you enjoy reading new things on the internet, like this blog, then the chances are that Twitter is for you. The first thing to say about it, is that it is not at all like Facebook. The latter has the potential to both connect you to your family and friends and bore you silly in equal measure, while the former has almost nothing to do with people you actually know, and everything to do with people you would like to be influenced by. If you like where someone is coming from then you can follow their tweets, read what they are reading and be challenged by their point of view, all with the assurance that if you become irritated or offended by their utterances then the unfollow button is just two clicks away.

The beauty of Twitter is not the occasional amusing comment, but the links to interesting newspaper articles, web-based resources and the general intellectual stimulation that is out there. In all my attempts to find other blogging doctors, a Google search has only every resulted in a handful of contenders. Within a week of tweeting among the health community I now have GP blogs coming out of my ears, each one unique and interesting, tackling the same issues I face, but with its own perspective. I have discovered health resources that I never knew existed, and been prompted by the latest research as soon as it is published.

Twitter works much like a newspaper, and the great thing about it is that it is customisable and personal. My own Twitter Gazette, as you might expect, has a weighty health section with several GPs, Health Correspondents from major newspapers, British Medical Journal columnists and the like. A much lighter general science supplement comes next – with the New Scientist taking a lead here – and political interest is kept going mostly by following programmes on Radio 4. I love the fact that my newspaper can combine both print and audio media, or link to the videos of You-Tube or TED talks. What is more, the Sunday supplements that usually go straight into the recycling in my house – namely Fashion, Travel and Money Matters, can be completely absent with no wasted resources. Most of the content I have chosen is of a fairly serious nature, as I hope to learn something and not just be entertained, but since every decent newspaper has a good cartoonist, I follow Larry the Cat for some light relief. This spoof cat from No10 gives an amusing, irreverent insight into life with the PM!

Like any newspaper, I can read it carefully from cover to cover, or I can skim through it if time is short. Unlike my e mails, or even Facebook messages for that matter, if I miss a day or even a week it really doesn’t matter. I may be a little out of touch with the news, but no-one is going to ask why I haven’t replied to their urgent message, and nor will I have an overflowing in-box when I return. Unlike my newspaper, however, I can choose to interact with my virtual newsfeed if I choose to. I can put my own tweets out there, retweet what I find interesting, reply to tweets and join in conversations.

However, what I like most of all about this new medium is that it has something delightfully subversive about it. I think this stems from the fact that most of the content I read has nothing to do with Rupert Murdoch, or anyone like him. For once, I can choose to follow the thoughts of those without an editor hovering over them to make sure that they follow the political agenda of whichever media mogul owns their pen.

So, I shall be tweeting from now on. Love it or hate it, I’d be fascinated to know what you think about the site, and delighted if you would be interested in following me.