Tuesday, September 9, 2014

Picking cherries

It was always the thin end of the wedge. The day one specialty was allowed to have the option of opting out of general medicine because they were "special". Anyone worth their salt knew what was coming..and lo and behold...the leak on the dam gradually just kept getting bigger..and bigger..and inexorably we keep sliding, or even hurtling towards an inevitable conclusion.

History would suggest the cardiologists took the first plunge in spite of objections from others and that very day, whatever the reason, the camaraderie amongst physicians ended. One group was deigned to be more special than the others..they would have their own rota,their own service, their own cherry picked patients. Flip the coin and you actually see that also made sense for patients with cardiac problems, Up and down the country,many hospitals have swashbuckling cardiology units,swanky, efficient, slick..let me even use a management speak for a second..Lean. Financially it made even more sense...in a world of PbR where every single catheter gets costed and put on  a spreadsheet, the more stents you put in, the more profitable the unit became..the more the swagger of the cardiologists..they were the top dogs in town...and Frankenstein was born, the camaraderie was gone.the cherry pickers were in town.

Then one by one, they all left or are in the process of.....Rheumatologists, Dermatologists, Gastroenterologists...procedure was king, procedure meant money, procedure was sexy..a bit more IV zoledronic acid, a bit more bowel screening...Flip that coin again and you see patients have indeed benefitted from that..some absolutely remarkable departments. I personally have had amazing service from Rheumatology and can in fact see the benefits too...why spread yourself thin when you can do so much better in your specialised area? Why indeed do something else when your own specialised area lacks, you see patients suffer..because YOU are doing "something else"?

It's a tough one, isn't it? On one hand, you have the patients who don't fit into a niche, on the other hand, you want specialists doing 7 day service, helping out in the community, running their services slickly..something had to give, didn't it?And once you have precedence and indeed success, the thin end of the wedge was only just that. The success of Cardiology spawned the way for other specialists to adapt the same approach. Problem? Now we have an elderly population with multiple problems..single disease pathology doesn't exist anymore...how's that game of chess looking now?

It's also a vicious cycle..the ones who pulled out, left the others to carry the system of general medicine ..the smaller their pool became, the more disgruntled they got,torn between a desire to do the "right thing" of helping the patient without any label or triage...while mulling how to improve their specialists services.And no one is exempt from the habit of cherry picking.Acute physicians don't tend to look after patients more than 24-48 hours, rarely follow patients through on other wards...don't blame them..they have multiple fronts to fight. Some clever clog recently said at a meeting they weren't trained to look after general medicine, their training was special...the physician in me, the trainee in me who had worked through hospitals which didn't have acute units..cringed. Elderly medicine know they are getting or about to get swamped..as the age of the population increases, so everyone sets their own tramlines..age cut offs, greater than 1 morbidity,etc etc..again, no ones to blame..you are just trying to fight the tide with existing resources...make sure as the cherry pickers leave, they don't get swamped.

I have always maintained that we should have a simple rule..either all in..or all out. All in makes it equitable, all out makes it clear that we have to redefine how unscheduled care works. I have long held on to the romantic belief that the cherry pickers would be stopped and it has been lovely to see the College harbour that view...but one thing I have learnt in life...there are some battles which you need to learn to walk away from.In the battle between lets help all and lets make care for people with diabetes better, finally, specialism won.
For a system to say that a patient with a heart attack or a patient with an alcoholic liver disease is more precious or special than a patient with diabetes in ketosis is simply..wrong.  For a long time, it has been the issue of "he who shouts loudest"...but finally it is time for the white noise to stop. 20% of patients in hospital beds have diabetes..they deserve better, much better than what they are getting now..they suffer poor care partly because the specialists within the hospital have held onto an altruistic romantic notion while others have left and mock them for their naïveté. Swaths of areas in the community need better diabetes care...something which the specialists could and should support. Something had to give, didn't it?

Medicine is going one of two ways..either all will come back in and share their burden of general medicine..or hospitals will be run by acute medicine and elderly medicine, admittedly with resource- either transferred from other teams or perhaps even new investment..with specialist input along the pathway from all specialists. I suspect it's the latter...but would, be delighted to be proven wrong. Till then, we have a responsibility to improve care for people with diabetes..and I am more than happy to fight their corner every step of the way at any meeting or forum.

There will of course be some who don't agree...but it is indeed the direction of travel we all are heading towards...and much kudos to management for supporting the vision and looking ahead. As a team, we are immensely proud of the community set up we have and how that is seen by many as one for others to emulate. I have a feeling we may just done the same for working within hospitals....and could be a fundamental step to improving care for patients with diabetes admitted to hospital...for any reason..anytime of the day.  


  1. In my 39 years as a type 1 diabetic I have always treated the specialist of my condition to be *me*. I live with the condition 24/7 and it's impossible for a healthcare professional to be there all the time. If I get my self-management wrong it is unfair to blame the diabetes team, they are not carrying out the day-to-day (hour-to-hour) management, it is me. So the diabetes team are there to advise me and they provide the reassurance that what I am doing is right. It's a moot point about how often this monitoring and reassurance should occur, but it is clear that if it is given by a more specialist healthcare professional the reassurance and advice carries more weight.

    The problem I find with moving "care into the community" is that by necessity that means de-specialising diabetes care. Indeed, I am no longer a type 1 diabetic, I am a "diabetic", yet my condition, and treatment, is different to a type 2 diabetic. My CCG gives me blank looks when I point this out. (To be clear: I do not think there is any hierarchy, neither type 1 not type 2 is more "important" than the other, but it worries me when they are treated as if they are the same.) The de-specialising is not just a GP seeing "diabetics" instead of a consultant, it goes further. Our CCG when they first announced they would "move care in the community" claimed that there would be GPs with a Special Interest in Diabetes (I am told, this involves recognised training), that has now been watered down to the GPs will "have an interest" (ie no formal training) and further we are told that 2/3 of the GP practices will care for diabetics with a practice nurse-led (not even a Diabetic Specialist Nurse-led) clinic.

    But that is not my complaint. My complaint is that I am the specialist, but I am told that under the GP service I will be seen more frequently by a practice nurse. It will no longer be my diabetes, and it will be largely pointless since most of the monitoring reinforces what I know already. The new service will create a "pass the parcel": I raise an issue with the practice nurse and she tells me to see a GP, I raise the issue with the GP and she tells me to see a consultant. The effect of this is that I will only raise an issue when it has become serious, and potentially it will be too late.

    Moving care into the community should be about engaging with the patients, providing education, creating a culture that the patient knows they can seek advice when *they* want it. (Education for type 1 diabetics have never been available in my area.) This is not what is happening.

    What is happening is that the diabetic clinics are being de-specialised, the doctors and nurses caring for the patients are being de-specialised, and more concerning, the patients are being de-specialised.

  2. Hi there! My name is Cameron Von St. James and I had a quick question for you! I was wondering if you could email me at your earliest convenience at cvonstjames AT gmail DOT com :-) I greatly appreciate your time!!