Welcome back to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode, we consider the current state of general practice in the UK and what lessons the countries can learn from each other.
We examine a new paper in the BJGP on how patients feel about general practice in Scotland since the introduction of the 2018 GP contract. Is it meeting patient and policymaker goals?
In other research, we see what lessons a new paper in JAMA on weight loss and cancer association can tell us about a seemingly obvious connection, and from the NEJM what effect testosterone replacement for hypogonadism has on men's fracture risk.
References
BJGP Patient experiences of Scottish GP paper
BJGP Family physician's moral distress when managing health inequalities
JAMA Cancer diagnoses after weight loss
NEJM Testosterone replacement for hypogonadism and fracture risk
www.nbmedical.com/podcast
Welcome back to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode, we consider the current state of general practice in the UK and what lessons the countries can learn from each other.
We examine a new paper in the BJGP on how patients feel about general practice in Scotland since the introduction of the 2018 GP contract. Is it meeting patient and policymaker goals?
In other research, we see what lessons a new paper in JAMA on weight loss and cancer association can tell us about a seemingly obvious connection, and from the NEJM what effect testosterone replacement for hypogonadism has on men's fracture risk.
References
BJGP Patient experiences of Scottish GP paper
BJGP Family physician's moral distress when managing health inequalities
JAMA Cancer diagnoses after weight loss
NEJM Testosterone replacement for hypogonadism and fracture risk
www.nbmedical.com/podcast
It's Friday, the 26th of January 2024, and this is the Hot Topics podcast. Welcome back everyone. This is the Hot Topics podcast from MB Medical. My name is Neil Tucker and happy new year. It feels like a long time since we've done one of these, but I'm afraid we've been really busy. We've just been putting together the latest spring summer 2024 Hot Topics course. We're done with the writing. Next off, we've got the presentations all in time for the start of March, when we've got the first of our new series coming up.
Speaker 1:Today, as ever, we're going to talk about a little bit of news that's been happening over the last few weeks and we've got three new pieces of research. One in the BJGP came out today examining patients experience of general practice after primary care transformation in Scotland with their new contract from 2018, with some potential lessons for those of us outside of Scotland. Then we've got a paper in the New England Journal of Medicine looking at testosterone treatment in men with hypogonadism and the risk of fragility fractures, and then we've got an interesting paper in JAMA looking at the links between weight loss particularly unintended weight loss and cancer. What's new going on with MB Medical apart from the new Hot Topics course coming out in a few weeks. Right now we've got a fantastic deal on MB Plus on the MBmedicalcom website. If you've not come across it before, check it out. It's our subscription service and at the moment you can get an annual subscription for just less than £300. That means you can come on all of our courses I think there's 12 of them now live or on demand. You get all of the course books available online and there's loads more in the website as well. It's an absolute bargain. That means you could come on our current Hot Topics course that's going on tomorrow. You could come on our Women's Health course, which is going to be next Saturday, saturday the 3rd of February. I'll be helping out with that one, for better or for worse. You could come on our Pediatric and Child Health update, which is on Thursday, the 8th, and then you could come on our new Mental Health for Primary Care course on the 10th of February and then still come on our new Hot Topics course at the start of March all under this one subscription. So do check it out Now. While I'm thinking about promotional stuff, this is non-MB, but I thought I'd slip it in here anyway, if you are interested in the environment and you're wondering how you can help in general practice and you're new to all of this idea, then on Wednesday, the 31st of January so this coming Wednesday, that's assuming you're listening to it in the next few days the RCGP is running a course called I'm a GP what does climate change have to do with me? It's going to be short and snappy. It's 6.30 till 8 o'clock. It's free to members and non-members alike. So if you want to know a little bit more, come and join me. I'll be running one of the sessions, and my friends and colleagues who will be running some of the others, and we can keep the environment high on everyone's agenda.
Speaker 1:Now, what's going on in the world of general practice in the UK at the moment? Loads of measles Now for a condition that we were meant to have eradicated a few years ago. This may come as a bit of a surprise to some, but given the fact that vaccine rates have been steadily falling since the pandemic, maybe it shouldn't come as such a surprise. One big problem, of course, is going to be identifying cases of measles when most of us will have never seen a case in our working lifetimes. If you want a bit of a reminder about that, my fantastic colleague, rob Walker, has written a fantastic blog about it on the MBmedicalcom website this week. Do take a look. The other big problem is that many of us are having to go scrabbling around in dusty cupboards trying to find our immunization certificates from 40 years ago. All of a sudden, hr is very interested in our MMR status. Have you had your MMR vaccine? No, why not? Because I'm too old. It didn't exist when I was a kid, but I know that I've had two doses of a measles vaccine. What I'm less sure about is where I keep a little tiny book where, 43 years ago, a practice nurse scribbled something down about measles vaccination in pencil in it. While I jest, if you are uncertain about your measles status, then just get another vaccine. I didn't want Covid, I really don't want measles.
Speaker 1:What else was in the news? Oh, you probably heard the story about the GP practice that was sacking salaried GPs. This was a very unfortunate story, not least because it fell foul to really populist reporting. The partners were being demonized for having recruited people through the additional roles reimbursement scheme and then getting rid of these salaried GPs good GPs being replaced by other clinicians when in fact it was much more complicated than that. So, yes, they've recruited through the ARRS, as most practices in their PCNs have done over the last few years. That's where NHS England has pushed all the funding You've got to recruit. Through that, the GPs weren't sacked, they took voluntary redundancy.
Speaker 1:And then the real twist to the story it turns out the partners hadn't even been able to pay themselves for an entire year. What level of madness do we need to be in that we do a job where you don't get paid for an entire year and potentially no prospect of being paid in the next year either? Rather than demonizing these partners, we should be standing up and saluting them for their altruism. This situation and I know that this has been replicated in many places around the country can't and shouldn't continue. So I know what you're thinking. Thank goodness, this year is the year that we get a completely new GP contract. Time to turn the page, ramp up investment in primary care. We've had the current contract for five years. There's been plenty of time to think what we're going to do next, and yet, even early on in 2024, it has become patently obvious that there is no plan, there is no contract, and this is something else I just can't get my head around.
Speaker 1:General practice is such an important part of the NHS, it's such an important part of so many people's lives, and yet policy makers in England appear to have done absolutely nothing to thinking about how we're going to maintain this sustainer and pay for it, perhaps with the exception that everyone seems to believe that working its scale is going to continue, and so is ARRS. There was an interesting article in the new edition so February's BJGP by Nada Khan, who's the Associate Editor, and she was talking about the ARRS scheme and where it fits into things and the unintended consequences perhaps hadn't been anticipated when you're introducing a scheme which is quite so large. National pharmacy groups are warning about the stripping of pharmacists from both community pharmacies and acute hospitals. And then we've got these issues around the GP workforce, and one of the consequences that I came across a couple of weeks ago was with one of my friends and colleagues who is a GP trainee and she's found the whole thing really demoralizing.
Speaker 1:Relentless news headlines that as a GP you're going to struggle to find work. That's not what you want to hear when you're in an ST3. And one of the consequences of that is going to be down to retention Retention before they've even become GPs. If I was that person and I thought maybe I don't, I'm not going to have a job coming up soon, I'm going to start looking at my other options. It's not a leap to think that many of those other options might actually be more attractive than the job that you've been training for and all of a sudden, we could lose huge swathes of young, talented, well-trained doctors to other industries.
Speaker 1:I try to reassure her that everything is going to be fine, that they're always going to need GPs and she will definitely have a job, and I do believe that's true, although I'm not entirely sure what I base that belief on, and I would have loved to give some advice about how to influence that whole area in the future. But the best advice I could give was stop looking at those negative news headlines. Is that basically saying don't doom scroll on Twitter Because that is good advice, or is it essentially bearing your head in the sand? I'm not entirely sure. On a positive note, the delay to the genuinely new England GP contract affords us an opportunity to see what may be working or not working so well in other areas, and Scotland is now our little microcosm experiment, because in 2018, they had an entirely new GP contract focusing on reducing inequality for patients and focusing on the GP workforce by introducing a new funding formula. Some minimum earnings expectations had a look at those. I still don't think they're that great, to be honest. But at least you could guarantee that you're going to be paid something if you're in a partnership in a business that's maybe struggling a little bit, and some help with managing workload, reducing risks for practices and improving retention and well-being of GPs.
Speaker 1:And this brings us on to our first piece of research. So in today's BJA GP, it is patients experiences of GP consultations following the introduction of the new GP contract in Scotland, a cross-sectional survey. This was a postal questionnaire of patients who'd had a recent GP consultation. They were looking at patients from 12 different practices in three different health boards and they categorized patients into one of three groups depending on the area that they lived in. So either deprived, urban, affluent urban, or remote and rural. The aim was to determine the health characteristics and experiences of these patients in their different areas, having consulted with their GP, and then use that information to try and work out if the strategy had been successful, that they'd managed to reduce health inequalities within Scotland. Just over 6,000 questionnaires were sent out, they got just over a thousand back. It's a response rate of 17%, which doesn't sound great, but as in keeping with this type of study let's be honest none of us would expect loads of patients to send back these random questionnaires that had been sent out to them, and it still provided a large enough data set to be able to draw some conclusions. So the results showed that basically, people in deprived urban areas did worse, or reported things were worse, for basically every outcome. I know what you're thinking. This is not new news.
Speaker 1:The authors did go back and compare this study to previous studies that they conducted in a similar vein in 2017 and 2016. And although they commented that direct comparison is tricky because of some of the methodology, with this latest study they essentially concluded that health inequalities had not improved. There are some notable points that were raised in the results. So if you were in the deprived urban area, you were 20% more likely to have multi-morbidity than an affluent urban area. You're more likely to have complex presentations and telephone consultations as well. Your overall satisfaction about the consultation is likely to be lower 82% to people were completely, very or fairly satisfied with their consultation, compared with 90% in the affluent urban area. I can't help but feel well clearly the discrepancy between the two is troubling.
Speaker 1:Overall, those figures come out pretty good in the context of current general practice. They also reported reduced perceived empathy and reduced symptom improvement. The authors conclude that four years after the start of the new GP contract in Scotland, patients' experiences of GP consultation suggest that the inverse care law persists. I think there are other learning points to come out of this. So perhaps no surprise, face-to-face consultations are associated with significantly better satisfaction than telephone consultation and that might explain some of the difference between the outcomes for the deprived versus the affluent urban area. It can explain the difference in perceived empathy and this is an interesting point because the authors then in their discussion point out that GP empathy predicts consultation outcomes and may be associated with improved longer-term outcomes as well. So empathy alone can make people feel better and might even make people be better. But you're more likely to perceive empathy when you're face-to-face with the clinician and I think probably we would agree that it's more easy to give empathy when you're seeing someone face-to-face as well. The second learning point is that despite one of the drives in the new contract to be longer consultations, which was meant to help those patients who do have more complex medical problems. This doesn't seem to have resulted in a narrowing of the health inequalities and the inverse care laws still persists. And this goes back to this idea that we in general practice are the ultimate solution for health inequalities. I know we deal with health, but we're not the drivers of health inequality. I think it's absolutely delusional, whether it's from policymakers, researchers or even ourselves, if we think that we can be the solution for this.
Speaker 1:There was an interesting research paper in January's BJA GP with the title Family Physicians Moral Distress when Caring for Patients Experiencing Social Inequalities. I hadn't really considered it as a paper to present on the podcast before, partly because this was about family physicians in Ontario, canada, and partly because this phrase moral distress kind of irks me somehow. I appreciate the sentiment around it and actually I agree with what it's trying to impart as a phrase, but I think it must be something about Britishness and maybe growing up in the NHS. Thinking about, or being allowed to have moral distress just seems to go against the grain, against this idea that we should have a stiff upper lip. Don't worry, keep working, don't cry, get on with it. That's obviously working out really well for the NHS at the moment, but the reality is that sure, there's some things that we could maybe improve in practices, but what we can't improve, I can't improve your employment opportunities, your housing, your benefits, your education, your access to safe shelter, good food, all the really big health determinants. And, as the lead author quite rightly points out in her interview on the BJA GP you can watch it if you go on the website physicians will be the downstream solution if nothing else is done. The bad news is nothing else is being done. Well, I mean, I've just realised. If I listen to this back, it may sound like I've gone a bit dark, so let's finish on that paper and move on to JAMA and talk about cancer, something much more upbeat.
Speaker 1:This paper has the title cancer diagnosis after recent weight loss. Now, when I first saw this, I thought to myself hang on a second. Are you trying to prove whether weight loss may be linked to cancer? Because I'm pretty sure most of us already know this. Then I thought well, it's an American study in an American journal. Maybe they're trying to teach American family physicians that weight loss could be a marker for cancer, but I suspect that they already know that as well. It's not just us here in the UK. Then I wondered is this just the authors of this study, which has been running a really long time, and they really want to get some publications out of it? So they're just going to publish any old kind of information. But then I thought but this is a publication in one of the biggest journals in the world, there's got to be something more to it, right?
Speaker 1:So the objective of this paper was to determine the rates of subsequent cancer diagnoses over 12 months amongst health professionals with weight loss during the prior two years compared to those without recent weight loss. And they did this using data from two long running cohort studies in the US. So one was the nurses health study recruiting women age 40 or older, and the health professional follow up study recruiting males age 40. Boy, there's some gender assumptions going on there. Welcome to the 70s and 80s in the States. And they sent these groups out a questionnaire every two years, and part of that questionnaire was asking about weight loss, also inquiring about physical activity and diet quality, the latter two being used as a potential indicator for intentional rather than unintentional weight loss. The questionnaire wasn't specifically asking did you mean to lose this weight or not. So they needed some kind of alternative way to try and work that out. 157,000 participants, slightly more than on our previous study. 71% of those were female, 95% were white and during a total of 1.64 million person years of follow up, almost 16,000 cancers were identified.
Speaker 1:So the key result here is that, unsurprisingly, weight loss is associated with cancer risk. But beyond this there are some interesting learning points. So this as well may not be a surprise to most of us, but the first year of weight loss is the most important and is associated with the most excess risk. So if it's going to kill you, it's probably going to do it fairly quickly, and if you survive longer than a year, then there's less chance that it's cancer, more chance that it's something else. That's not to say that you are in the clear. In that second year your risk is still increased for cancer, but it's just not as high as in that first year.
Speaker 1:The degree of weight loss wasn't a good indication for the staging of cancer, so whether you lost five or 10% of your total body weight didn't help determine whether this was more likely to be localized or advanced cancer. Another learning point, or maybe perhaps a useful reminder weight loss and a smoking history or current smoking is a risky combination, much higher than just weight loss by itself. Certain cancers had a greater association with weight loss, particularly upper and lower GI, hematological and lung cancers, while breast, genital, urinary, brain and melanoma cancers did not see as an association with weight loss. Perhaps that gives us an idea about where best to target our investigations if we're looking to someone's weight loss. And the last learning point is to have something just a little bit upbeat in an otherwise downbeat study, and that's that if you're over 60 with unintentional weight loss, your one year risk of having cancer is 3.2%. That feels pretty low to me. I was expecting it to be much higher than that. You could argue that that is over the nice suspected cancer referral threshold of 3%, but it also means that 97% of this group don't have cancer. I'm not saying we should ignore this as a symptom, quite the opposite. But when we're talking to patients about why we're doing what we're suggesting, maybe it just can help tailor, or indeed temper, that discussion.
Speaker 1:Okay, on to our last study. This was in the New England Journal of Medicine titled Testosterone Treatment and Fractures in Men with Hypogonadism. Do you remember? Going back a few years not that long ago, less than a decade ago there was a bit of a drive about the male menopause, hypogonadism, checking testosterone levels, maybe thinking about testosterone replacement therapy for some of these men. I'm not sure how much of this ever got embedded in today-to-day practice for many of us, and no doubt maybe restrictions on our access to testosterone therapies for our patients has been something that's holding us back. But now, looking back on the whole scenario, you do wonder whether some of these recommendations were being driven by excited and interesting researchers or if there was a darker hand of pharmaceutical companies pushing the agenda.
Speaker 1:The thing that I found most interesting about this study is that it is a drug company-sponsored study. In fact, it's sponsored by four drug manufacturers, and I'm making an assumption that they are all manufacturers of hormone therapy and testosterone replacement. Fair play, then, that they didn't just bury this study because it is a negative finding for testosterone. So they had 5,200 men that were recruited from primary care, age 45 to 80, with clinical hypogonadism. They'd had that confirmed by two morning testosterone tests with a level of less than 10.4. They also had to have pre-existing cardiovascular disease or high cardiovascular risk, because actually this is a secondary study.
Speaker 1:The initial study was a non-inferiority study, trying to show that testosterone doesn't increase cardiovascular risk. We had those concerns around older men being given testosterone replacement to bump up their levels so that they could feel a bit happier, improve their muscle mass and get an erection, and then they all got heart failure. Well, not all that's an exaggeration. But after that no one really wanted to prescribe testosterone replacement anymore and in that trial, which published in the summer in the New England Journal of Medicine, it showed that testosterone appeared to be a non-inferior option as in it didn't cause more cardiovascular events in this group Reassuring to know. But in this sub-trial it did cause more fractures.
Speaker 1:I've digressed, so back to the methodology. They excluded patients with prostate cancer, severe lutz, a hematocrit of over 50% or severe untreated obstructive sleep apnea. They were prescribed either transdermal testosterone gel or placebo and treated for as long as they continued in the study, with the average follow-up being three years. Over that time, 3.5% in the testosterone group, that's 91 out of 2,600 participants versus 2.5%, so that's 64 out of 2,000. 600 participants ish in the placebo group had a fracture, so 1% more fractures in the testosterone treated group.
Speaker 1:The authors, who are quite clearly in a state of shock and I've never really seen it in a research paper before, but that is very much carried through into the writing up of this paper. They said they didn't expect this finding, so the study wasn't designed to assess the possible mechanisms. The linked editorial points out that the fracture risk actually seems to increase immediately when they start the drug. So it's unlikely to be purely down to the structural changes that they see over time with testosterone therapy. Perhaps then they suggest it's behavioral change People do more physical activity and so at greater risk of having a fall in a fracture. They suggest maybe the time frame of follow-up is too short to recognize the potential benefits of testosterone, although that is purely speculation. And also they note that some of these men may have had pseudo-hypogonadism. So if you've got a raised BMI and diabetes, which many of them did, that lowers your sex hormone binding globulin and that alters the amount of free testosterone you've got circulating around, I guess that could mean that people in the treatment group don't actually need that much treatment. So when they're given treatment they're having too much treatment and then perhaps that predisposes them to deleterious events like fracture. The editorial also points out that these findings shouldn't apply to men with hypogonadism due to an identifiable disease of the hypophilamic pituitary testicular axis, who do need testosterone for normal functioning. But this does call into question the role of testosterone replacement in normal aging.
Speaker 1:What can we learn from all of this? Well, if you're Hugh Hefner and you're struggling with a hard on, probably start with Viagra. Okay, that'll do for the research today. Thank you for joining us on the Hot Topics podcast. Don't forget that MB Plus offer. Don't forget. If you want to know more about general practice and the environment, you can join me and some friends on Wednesday, the 31st of January for that RCGP chat. Check out MBMedicalcom for all of the courses that we've got coming up and, as ever, you can always get in touch Hot Topics at MBMedicalcom for the email or at GP Hot Topics on X Facebook too, if you still do that, and I'll be back in a few weeks. See you next time. Look after yourselves, everyone. Bye, bye.