How to Choose a Basal Insulin

Bismillah, alhamdulillah: 

Some very simple, short and to the point tips on the choice of basal insulins in this podcast. My take home message:

NPH has a peak at 6 hours, hence good for people who have high sugars at dawn but are relatively okay for the rest of the day. If you use a longer acting insulin they are likely to get hypos at the end of the day.

NPH works best for steroid induced hyperglycemia because the peak onset – at least for prednisone – matches the peak onset of NPH. 

More than 50 units of insulins like Glargine & Determir can have problems in absorption due to the large volume needed for injection. Hence splitting the dose is an option.

We now have 40 hour basal insulins!

Have a listen…

How to Choose a Basal Insulin
Medscape Diabetes & Endocrinology Podcast
Duration: 09:11
Published: Mon, 12 Dec 2016 16:35:48 EST

So many choices! A diabetes expert provides tips on selecting a basal insulin for a patient with diabetes.

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Test yourself: How good is chemotherapy for 90% of adults with metastatic cancer?

Bismillah,  alhamdulillah:

What answer would you give to someone who asked you the following question:

Someone sent me a video of an interview of a doctor in the USA who was criticising the extent of use of chemotherapy despite its poor outcome, especially in adults with cancer. Having heard the clip and the doctor talking about the ability of Selenium supplementation to prevent cancer, I filed it under the ‘not too sure this sounds right’ folder in my brain. Later I found out that he was a ND (Naturopathic Doctor and not a Medical Doctor). I dismissed the issue from my mind because my MD gut answer to the above question was at the higher end and surely the ND had to be wrong! But then I heard a BMJ podcast on the very same issue and it was quite an eye opener.

The interview was with Dr Peter White a former consultant and senior lecturer at the Imperial School of Medicine. He recently authored an article for the BMJ called Cancer drugs, survival and ethics.

He points to a meta-analysis done in 2004  looking at the 5 year survival of patients with metastatic cancer in randomised trials published in Australia and the US. How much do you think chemotherapy increased survival by in 90% of cancers including lung, prostate, colorectal and breast cancer? The answer was 2.5% or in terms of months 3 months. But what about newer drugs? Surely biotech and pharma industry have improved leaps and bounds since 2004? He says (the emphasis is mine):

Similarly, 14 consecutive new drug regimens for adult solid cancers approved by the European Medicines Agency provided a median 1.2 months overall survival benefit against comparator regimens.4 Newer drugs did no better: 48 new regimens approved by the US Food and Drug Administration between 2002 and 2014 conferred a median 2.1 month overall survival benefit.5


There have been exceptions to this poor outcome of the fight against cancer and these include cancers such as:  testicular cancer (40%), Hodgkin’s disease (37%), cancer of the cervix (12%), lymphoma (10.5%), and ovarian cancer (8.8%). The improved 5 year survival is given in brackets. Sadly these cancers account for less than 10% of cancers.

He goes on to argue that the financial motivation for such drugs is very high and the regulatory process for their approval needs tightening.

Have a read or a listen:

Article:  Cancer drugs, survival and ethics



Advertising junk food to children

Bismillah,  alhamdulillah:

Have you heard of YouTube Kids? It was news for me. What was more surprising is that some of the channels, according to the panelists on this BMJ podcast,   are sponsored by fast food companies. 

The panelists discussed how subtle advertising and product placement are being used in these channels to advertise junk food to children. In some cases circumventing advertising restrictions that apply to traditional media such as TV. The WHO are currently thinking of coming up with ways to tackle the problem. First step: awareness. Please have a listen, the link and excerpt are below:

Advertising junk food to children
The BMJ Podcast
Duration: 18:30
Published: Fri, 04 Nov 2016 17:18:13

In the UK, junk food advertising is banned on children’s TV – but manufactures are still able to target children in other ways.  A recent report from the WHO  “Tackling food marketing to children in a…

Subscribe to this podcast:

Sent from Podcast Republic 2.9.1

Are doctors ready to share their notes with patients?

Bismillah, alhamdulillah: Are you ready to share your notes with your patients? Your paternalistic side will probably shrink from the idea. You may start to imagine horrific consequences but the world seems to be in the let’s move forward gear. This article in Medscape presents the idea and gives helpful tips to all those who wish to engage in this approach. The idea to me sounds like one of those really good ideas but I do worry about the way this increasing oversight is going to affect the way doctors will start to behave and how it will affect the privacy of the consultation. 

Medicine was an altruistic profession where helping others was an important motivational factor in choice of career. The trend of patients becoming clients, health institutions becoming health industries mark the increasing influence of a profit metric on every aspect of care. 

While there is nothing wrong with business and profit motivation,  like all good things balance is the key. Sharing notes can be great but is it motivated more by better patient outcomes or by the Health Information Industry and the great potential – and cost – of designing systems that allow patients to read their notes and gain access to many “add ons”.

Possibilities include:

  • Automated note review by Oogle analytics or 
  • A medical record check by Real Doctors from St Elsewhere who will offer many helpful suggestions for the next consultation.
  • Will patients be required to co-sign their own notes, to confirm they actually said what they said?
  • League table of misspelled words.

While the speculative list can be endless and some may seem a bit far fethced the advantages and pitfalls clearly exist. What is needed is  a common sense rather than a ‘can do’ approach.We also need to learn from our colleagues who are used to patient held records such as obstetricians, radiologists and pathologists.

The above three fields have a limited scope or well structured layout to their notes and these help the physicians ‘stay on track’ and not get derailed into areas that are likely to prove to be problematic or embarrassing in the future. Writing for the select few is a different art than writing for the many. Medical schools would do well to start training their students on what to and what not to write. 

The article link on Medscape is given below:

Desert Doctors – invitation

​Bismillah,  alhamdulillah:

I am setting up a group for doctors interested  in, or currently  working in the Middle East. Old ME’rs are invited too. It’s called Desert Doctors on Telegram. It will inshaAllah be a good place to network and search / advertise for job opportunities.  Please click on the following link to join and forward this message to those who may be interested.

Driverless cars and the human resistance –  a lesson from the doctor patient relationship

Bismillah,  alhamdulillah: The driverless car is a clearly disruptive technology. With the rapid and breathtaking advances in technology it seems the limit to this technology being introduced is no longer technological but human. 
Once the technology companies consistently demonstrate that a driverless car is 100 or 1000 times safer than  one driven by a human they will have proven their technological prowess. But one significant obstacle will stand in their way: the human.  What I mean by the human is the emotional reluctance of us as humans to be driven by computers. The thought of putting our lives in the hands of algorithmic robot drivers makes us balk. But why? Two things come to my mind: autonomy and irrationality.
Autonomy appeals to a base human instinct: freedom. As humans we got used to driving our cars and having the autonomy to drive them, wherever,  whenever and sadly sometimes into whoever and whatever. The driverless car will virtually eliminate this negative effect of driving, the roads will be safer, little children  who run out in front of a car will have an amazingly improved survival rate. But this safety will come at the price of the loss of freedom. The freedom to off road, to park in tight spaces, to climb the pavement when no one is looking, to break the speed limit when the road is clear and empty. To let the wind rush through your hair and feel the exhilaration of adrenaline pumping through your body and awakening your senses. 

Technology companies can try and talk logically about the issue,  state the number of lives saved, the increased time we can spend answering emails and social media messages while being driven to work and all the other wonderful economic reasons. But I am afraid we have become rather accustomed to driving ourselves around. The tech companies will have to learn how to pander to our hurt sense of freedom.

An idea would be to have ‘cheat’ modes that assuage this emotional resistance. The degree of ‘cheating’ should be enough to appeal to our emotional side but constrained enough to not cause harm. You can imagine a program that calculates the distance to the next car and tells the driver that s/he is a zone where certain rules can be relaxed and the controls can be handed to the driver or ideas that appeal to younger drivers may include the option to drive on two wheels or do perfect handbrake turns. You get the idea.

Doctors sometimes do this with their patients. As a medical profession we emphasise the importance of taking medication on a daily basis, but we know that as many as 50 or 60% don’t follow the rules, even though it’s for their benefit. A good doctor who perceives this problem in a particular patient may negotiate a ‘cheat’ day or two and achieve a  much better compliance then the stern faced doctor who insists medication has to be taken everyday. Patients can take a pill break or be simply told it’s okay to miss a day or two of medication  every now and then – as long as it’s not a habit. Patients respond to this flexible approach.

The second problem is our tendency to use irrational comprehension when we think about safety. The safety of a driverless care is demonstrably safer and is likely to become safer still. Yet, as with all machines there are things that will go wrong,  as seen in the Tesla car test fatality recently. 

When a human drives a car, it is under their direct control. This gives the human a heightened but false sense of control and hence security. This sense of security is lacking with driverless cars. Here an accident is less likely to happen but the reason why it happened is now not connected to the human. This lack of connection and control heightens the perception of risk. 

As humans we tend to analyse risk in an emotional and irrational way. This is a potential barrier to the adoption of this technology. In medicine doctors tend to face this problem frequently with patients who under or over estimate risk based on many irrational thoughts. It is not infrequent to find a patient consulting a doctor because their friend died or had had a disease. The proximity of the person and their close emotional response to their friend induces empathy. As part of the empathy they too feel they are at risk of suffering from the same disease. Irrational but real. Dealing with this ‘gut’ approach is what doctors, especially family doctors, do on a daily basis. So how do they overcome an irrational and wrong conclusion?

Trust is a key factor.  ‘Doctor I trust in you’ is not an infrequent statement that is heard in the consulting room. From a logical perspective this approach is equally irrational. What should decrease a patient’s anxiety is facts and figures.  Trust in someone, on in its own should not decrease anxiety or worry, but it does. The irrational human problem finds is best treated with an irrational solution.

Turning back to the driverless car, what equivalent approach will help?  One idea is to draw an analogy between the driverless car and another potentially driverless form of transport: the horse or camel.

These animals, once trained, can continue to take their riders on their journey even if they don’t pay attention to where they are going. Animals have been part and parcel of human history for  thousands of years and they are a symbol of trust and reliability. 

Harnessing this connection is likely to provide an avenue to bridge this gap.The technology giants have to turn back to the humble horse and camel because the rider is the same. 

I wanted to explore the idea as I can sense we are close to achieving technological breakthroughs which will introduce the idea of the doctorless or doctorlight consultation in the future. But I will leave that thought hanging in the air, for the moment.

MERS – Dr Shalhoub, a King Abdulaziz alumni on the BMJ podcast

Bismillah, alhamdulillah: Great to hear a home grown graduate from King Abdulaziz University in Saudi Arabia discuss MERS on a BMJ podcast. Dr Sarah Shalhoub, a consultant at King Fahad Armed Forces Hospital,  gives an update on the current state of affairs regarding the disease.king_abdulaziz_university_emblem

Middle East respiratory syndrome
The BMJ Podcast
Duration: 20:09
Published: Fri, 21 Oct 2016 15:25:24 +0000


What can a woodpecker teach health system managers?

Bismillah,  alhamdulillah: Yesterday I had the opportunity to see a program on how motorcycle helmets are being redesigned from studying woodpeckers. A good motorcycle helmet is able to reduce the impact force on the head during an accident. It does so by combining a rigid outer surface with a soft flexible inner foam. This slows the impact slightly and makes a potentially fatal collision into a survivable one. Is it possible to make even better helmets for the future?
That’s where the humble woodpecker has something to teach us. It hits the side of a solid tree 22 times a second and exposes itself to a force greater than 1200 g and yet remains unharmed. 

Scientists have thus turned to the woodpecker to try and understand how it manages to survive such brutal force. What they have noted is that the woodpecker has four layers of alternating but complimentary structures. A rigid yet flexible beak, an elastic layer which wraps around the brain, a thin fluid filled space which absorbs vibration and a spongy bone between the brain and the bone. Each layer helps dissipate the forces and results in a miraculous design.

So what has this got to do with doctors and health system management? The elaborate structure that the woodpecker is blessed with has one aim. To protect its most valuable asset – its brain. The brain being a neural structure does all the thinking but suffers from vulnerability to shock and sudden changes in speed.

In a health system the most vital asset are the health professionals who work in it and have the task of seeing patients on a day to day basis. Doctors and nurses are like the central nervous system in this regard. This soft and vulnerable structure exists in a body called the health system. If the health system is flexible and well designed, looks after the needs of its ‘brain’ and does everything to dissipate stress  then it can become like the remarkable woodpecker in its efficiency. If on the other hand the health system is rigid and succeeds in transmitting outside pressure to its brain the consequences are unpalatable.

Health system managers need to be empowered and reminded to introduce flexibility in the system at every level. An endless stream of patient initiatives and jumping hurdles within inelastic short time periods will not result in the organic growth of quality but with an increasingly frustrated and punch drunk work force. 

Accrediting agencies,  such as the Joint Commission International and Accreditation Canada International, have the ability to promote this aspect of health system improvement and promote change by setting standards for flexibility of management and standards for protected accreditation awareness time for front line staff. 

The importance of a smile

Bismillah,  alhamdulillah: a documentary from the BBC on the effect of illicit drugs on dentition. One of the dentists in the program, who runs a clinic for illicit drug users in the USA,  gives the basic pathophysiology of the severe dental decay. Most users of illicit drugs get a very dry mouth,  the lack of saliva leads to overgrowth of plaque and further damage to teeth. The thirst pushes the users to consuming more sugary drinks and this is turn makes the whole situation worse.

Part of trying to rehabilitate drug users is to try and help them get back to work. One of the key things to getting a job – that many of us may take for granted – is a smile at a job interview. For this group of patients the severe loss of dentition puts them at a huge disadvantage.
Have a listen …

Drugs and the Dentist
Duration: 26:51
Published: Tue, 11 Oct 2016 03:00:00 +0000

Drugs like crystal meth and opiates wreck the teeth as well as the mind. In America, more than just about any country, good teeth are a sign of success and so dentists like Dr Bob Carter are helping f…

Head to head – Should all GPs be NHS employees?

Bismillah, alhamdulillah: With the changes in the economic prospects of the UK following the results of the Brexit and other unpredictable global financial winds, what is the future of General Practice or Family Medicine in the UK? This is a three way discussion on the pros and cons and future direction of family medicine in the UK.  The sad conclusion was that most GPs will eventually become NHS employees and the idyllic picture of small to medium size practices run as businesses will be a thing of the nostalgic past.

There are many factors for this change.  One that was identified was the way patient demand and expectation has changed over time. The following question illustrates this: when patients are asked the question: ‘Do you wish to see the doctor of your choice in a few days or any doctor within a day’? The response of the majority is the latter. 

This is an example of the age old rule of economists, time discounting. The value of something further in the future diminishes the further away it is. If people are offered 10 dollars now or 20 dollars in a week the vast majority choose the 10 now, over the 20 next week. 

In the long run those who wait are richer and better off but our desire for quick gratification has resulted in prioritising our long term health over our short term desire to be seen. Most doctors will agree that waiting a few more days to see the doctor who is most familiar with a patient’s case – in the long run – is the best option. This naturally excludes problems of a critical nature and that need to be solved in a very short time period. 

It is a pity that though the long term costs and outcomes of good health care have been well studied and reported on by the late Professor Barbrara Starfield and others in the field. One of the key findings has always been continuity of care. Yet, we still ignore the findings and are pandering to quick wins and slowly undermining the long term quality of the once excellent health system in the UK.

All of this is potentially good news for the private sector and community medicine. If they can succeed and target the patients who value continuity of care there is a market in the community sector awaiting them. They will have to convince their customers of the value of continuity of care and sell it – not as a unified medical record – but as something far greater. 

It is a pity that the UK model of family medicine which combined business entrepreneurship and continuity of care and managed to bring this to the masses is playing out its final scenes.

Have a listen…
Head to head – Should all GPs be NHS employees?
The BMJ Podcast
Duration: 16:48
Published: Fri, 07 Oct 2016 15:44:30 +0000

Independent contractor status creates unnecessary stress, argues Azeem Majeed, GP partner and professor of primary care at Imperial College London.

Laurence Buckman, GP partner and former head of the…