Waiting for her University interview, my daughter found herself next to a young man who pronounced that he already had a place at Charles University.

“Do you think that I should mention this in the interview”, he asked.  “Oh absolutely”” was the unequivocal reply. Cruel, but in Medicine there is no prize for second best in the high stakes University Interview.

Nevertheless, the young man had a University place assured at Charles University in Prague.  Nowadays, every University is doing their utmost to attract foreign students. The incentive is clear; money! The flow of foreign investment is welcome to Universities which are falling over themselves offering tuition in English or German. For students too, there are advantages; pulling free from overbearing parents, getting an International education from a famous institution, meeting people from other cultural backgrounds.

I don’t take issue with the idea of paying for an education. It is hard to imagine a better investment. Nor can I blame bright and bushy tailed youngsters for seeking a Medical education abroad if they have been turned down by their own establishments. 

Nevertheless, I am worried.  As a young Swede, I spent 5 years training in medicine in the UK. Once I had passed my exams, I was free to practise anywhere in Europe. I don't think that I would have been much good looking after patients outside of the UK or Sweden!  After all, without communication skills, as doctors we can not hope to build rapport or explain a schedule of investigations or the rationale for medication to our patients.   

Naturally, the challenges of moving to a new country and learning a new language may be somewhat less acute for senior doctors who not only have already been fully trained in a system they understand but also have years of practical experience in communicating with patients in their own language.

I do have a second concern. Charles University is a venerable old institution, founded in 1348, but there are other establishments with less of a track record. Medical courses in English for foreigners are now offered in more than 30 institutions in a wide range of countries incluing Austria, Italy, United Kingdom, Spain, the Czech Republic, Slovakia, Hungary, Latvia, Estonia, Lithuania, Malta, Croatia, Bulgaria, Poland and the Netherlands.

How do you know that every institution produce graduates who have received a training which equips them for caring for patients in any European country, although there may be different medical problems, requiring different tests and different management to the country they trained in? 

Conversely, imagine a great medical course, providing excellent training from which a fantastic junior doctor graduates who has the misfortune of becoming embroiled in some medical mishap in a foreign country. It would then be all too easy to cast dispersions on his training, albeit of the best standard. Would it not be in the Universities own interest to have tests in place to prove the quality of their graduates if they choose to work in another European country to that in which they trained?

Of course, many students leave a University after receiving education which does not equip them well for the world they are facing. Students may graduate from Leeds University with an education in Hotel Management which may not equip them well for looking after a Hotel in Nigeria. However, the havoc a badly trained doctor can wreak is of a different order. After all it is difficult to kill someone with a “bad degree” in business management. 

Currently, it is also possible for doctors to simpy move country when struck off a medical register.  In 2008, a German doctor was struck off the UK medical register after a patient died following a diamorphine overdose. He may still be free to practise in Germany.

Finally, even if the medical knowledge is sound, doctors may not understand “the system” of when and how to investigate and when and how to treat.  A case in point was my daughter (she is now in her fourth year) who, during a recent “elective period” in Fiji, was advised to treat a patient complaining of leg cramps with potassium tablets. Unconventional therapy in the UK - but perhaps it works on a tropical island? However, when given to an old patient in Birmingham, potassium tablets may well prove fatal.

Isn't it about time that all countries of the European Union introduce comprehensive checks on the medical knowledge and communication skills of doctors trained in outside institutions?

At a recent dinner party, I found that our hosts had converted their kitchen and dining room into a modern, combined “dining kitchen”.

Knife and fork in hand, I sat at the table attentatively following the hostess preparing dinner.  Her conversation was unusually interrupted and I soon realised that she was unable to talk and cook at the same time!  A basic consideration before deciding on a dining kitchen?  At live endoscopic demonstrations, the endoscopist must be able to talk and scope at the same time.  Perhaps the showbiz equivalent is playing an instrument or juggling and simultaneously singing?  Dropping a ball or missing a note may be embarrassing but live endoscopic demonstrations come with greater hazards.  First you may find your decisions challenged by the audience. Leaning back on the soft chair in the air-conditioned auditorium, it’s easy to propose an alternative management plan to the endoscopist, who is sweating in the hot endoscopy room.  It can be all too easy to get persuaded to undertake something which is inappropriate or worse, imply that the professor in the audience is talking rubbish! Secondly, you may not be familiar with the local equipment.  Most live demonstrations are supported by one or two companies, limiting the equipment available.  The diathermy device can be particularly bewildering.  The newer diathermy machines have complex pre-set menus into which you must delve to confirm that the underlying settings are correct for what you are planning to do.  The more involved the procedure, the more important familiar equipment becomes.  After all, a live demonstration is not the right time to familiarise yourself with the ERBE combined waterjet system and hybrid knife.  Finally, as the visiting expert you may feel the pressure to “put on a good show”.  Deciding that the risks are too great and “bailing out” may be in the patients’ best interest but could imply that the visiting expert is less of an expert than expected!  For this reason, there is always the temptation to undertake procedures which you may not have carried out “at home”. Having carried out close to 100 live endoscopies, I would propose the following 3-point checklist to avoid the greatest pitfalls:

1) Once the live cases have been confirmed, inform the endoscopist of all clinical details together with radiology, images/video footage and histology.  Full details of the patients’ preferences, medical history and comorbidities, is even more important.  If possible, try to arrange for the patient and endoscopist to meet before going live.  With this preparation, the endoscopist will have all the facts at the fingertips and can better explain why the patient has been selected for a particular procedure.  2) Encourage the endoscopist to bring his own consumables and ask which diathermy machine would be preferred. 3) Arrange for staff in the endoscopy room to be able to speak the language of the endoscopist as well as the patients’ native language. In spite of the obvious pitfalls, Live Demonstrations are unique. There is no better way of illustrating a technique to a large audience.  However, it is the discussion around the case which is more important than the actual “cutting".  Yes, a Zenker’s diverticulum can be treated endoscopically but when is it better to do this surgically?  When is a Heller’s myotomy inadequate and the patient should be referred for POEM? At a good Live Demonstration, the audience is provided with a clear explanation of why a particular procedure has been selected over alternatives strategies such as “watchful waiting”, surgery or an alternative endoscopic technique.  Naturally, as the case unfolds, the management plan may change and “plan B” or even “plan C” may be invoked.  Indeed, the best and most educational Live Cases are those in which the Endoscopist changes his mind. Almost everything we do as doctors are balanced, continuous assessments with few absolute rights or wrongs.  Indeed, being comfortable with making decisions when there is no protocol to follow, is what we are trained for and what sets us apart from other healthcare professionals.

Social media is one of those technological developments which set generations apart.

My grandparents never got used to talking on the telephone and my parents don’t quite understand the PC, let alone the Tablet.  My own generation don’t get Social Media.  I never did see the point in having photographs from our Team Christmas Party uploaded onto Facebook. On the contrary, there are many reasons why it would be preferable not to have those images of Dr. Rembacken on the dance floor uploaded.  A point in case is our non-winning Swedish contribution to the singing competition at the recent UEG Summer School Party which are displayed on the UEG site.  My brother who runs a successful veterinary surgery has a different opinion. He would never appoint anyone who can’t be found on Facebook or some other Social Media.  He points out that, as a generalisation, eccentrics and oddballs don’t do Social Media.  Indeed there is a wealth of evidence that there is a link between the size of your Social Media friendship group and your number of “real” friends. Nevertheless, until recently I was happy not to use any Social Media.  This all changed during a recent and particularly difficult gastric ESD.  I glanced over my shoulder to pass on yet another nugget of pure wisdom when I realised that my Endoscopy Trainee was paying no attention to my heroics.  Instead he was scrutinising something far more important on his smartphone.  Afterwards, I realised that I was missing a trick.  They modern way to share hints and tips is not to point them out on the endoscopy screen but display them on the smartphone’s Twitter app.  In this way, not only can more trainees be reached but the information can be tailored to the attention span (Twitter has a maximum of 140 characters) of our modern trainee. Now, I am a convert!  Every day, I “Tweet” images of interesting and rare pathology seen in my daily tertiary referral practise.  In fact, I am evangelical!  Without effort, I can reach more people, teach more “Pattern Recognition” and help more, including myself, to become a better endoscopist.  Furthermore, with my small number of “Twitter followers”, I can proudly announce that I am now of the new generation which “Gets Social Media”.  In the “Social Media Friendship Stakes”, my paltry number of followers puts me somewhere between Geek and Bore but at least it’s a start! 
Join our Growing Band of Endoscopy Brothers on Twitter (click the photo below)! 

A couple of weeks ago, BMJ launched “Let the Patient Revolution Begin” on its front page(BMJ 2013;34).

A couple of weeks ago, BMJ launched “Let the Patient Revolution Begin” on its front page(BMJ 2013;34). The idea is that patients should be more involved in decision making and strategic planning. Running the risk of coming across as grumpy and backwards, I must admit that I am sceptical.  The proponents believe that increased patient engagement will “reduce healthcare costs by avoidance of unnecessary investigation and treatment”.  I would like to see the evidence for this!  As a clinician, I am concerned that the result will be INCREASED cost of investigations and treatment.  I have three reasons to believe that this will be the case; 1) As far as I know, no study has demonstrated a cost saving. Not sure if there has even been any convincing findings of improvement in Quality of Care arising from the involvement of patients in the planning of health care services.  Supporters of the “Patient Revolution” bandwagon often contend that medical practice is informed by incomplete research, bedeviled by bias and sometimes by fraud (BMJ 2013;346:7). In reply, I would like to point out that no research into patient involvement has reported improvements in key quality parameters such as;  a) improved accessibility or acceptability of medical services or b) improved health, or quality of life of patients or c) a convincing reduction in costs. Indeed, JAMA has recently  published a study which found a 6% increase in healthcare cost when inpatients were more closely involved in decision making.  2) my second reservation is the effect of “volunteer bias”.  It will be the better educated, younger, vocal (and militant if the patient blogs are anything to go by) minority who will step forward to “shape services”.  Patient advocacy groups, sponsored by Industry, are likely to position representatives onto key “Patient Partnership Panels” in order to drive an agenda favoring their own interests above that of others. Paradoxically, citizens with the greatest needs are the least likely to be able to afford the time and expense to get involved.  Indeed, this was the conclusion from one of the first reviews of one of Americas most ambitious “Citizen Participation Program more than 30 years ago! 3) The third reason for my scepticism is grounded in the fact that I actually see and care for patients. Professors of Social and Epidemiological sciences, devoid of patient contact, have long forgotten that people may not be rational.  People with real or perceived disease (i.e. patients), may even be irrational!  My own mother decided to seek the help of an acupuncturist rather than having a colonoscopy to investigate her loose motions.  Recently, a patient with symptoms of early motor neurone disease decided to have all amalgam fillings removed rather than seeking the advice of a neurologist.  One of our patients with intractable ulcerative colitis has now failed to respond to every possible treatment (yes, I mean every treatment including ADA column, infliximab and adalinumab) to bring the disease under control. Rather than accepting surgery, she is now asking for stool transplantation to be paid for by the NHS!  Rather than pandering to every desperate, irrational demand of my patients, it is my responsibility to advice, investigate and manage patients in a cost-effective manner so that the NHS get the most “Bang for our Tax Buck”.  People seem happy with this approach until they become patients.  There are plenty of patients blogs out there, sometimes with a missionary or militant tone, describing how patients have to wrestle control of the disease away from the doctor or how doctors need to be re-educated (BMJ 2013;346:27).  Indeed, the theme that “doctors simply do not understand” has been recurrent in the BMJ Series “Patient Journey” where every patient seem to believe that he/she is a special case, deserving special attention and a larger than average share of resources.  I maintain that saying NO to outrageous patient demands does not signify a “lack of respect”, “patient disempowerment”, “denial of patients needs” or a “lack of support”!  Now a cadre of  Specialists in "Health Service Delivery”, “Epidemiological Psychiatry”, "Research Evaluation" or similar, is setting us on a journey which may result in confusion of responsibilities or bankruptcy of our NHS. 

Without a word, the “Medical Rep”, slid the device across the table

“It would never fit” I exclaimed.  “It attaches onto your endoscope”, he replied in a tired voice.   He had heard the joke before.  “Well what is the evidence that it works?”  Since my days in medical school, my requirement for evidence, randomised and prospective, runs deep.  I pity doctors who stagger through a medical career without the guiding light of the meta-analysis. This is why I was appalled to hear that there was little evidence supporting the use of the device.  My smile faded – “What! No evidence? And it looks crazy too!  I’m sorry but I think that I got a patient to see!"  As he packed up, he tried a final thrust – “I’ll give you a couple, just try them!”  “I’ll send you the result of a small study!”
As I started to feel sorry for the poor guy afterwards, I remember the first time I saw a “Roth net”.  It too looks bonkers but works much better than retrieval graspers.  I was converted the first time I used one.  Parachuting is another evidence free zone.  There will never by a randomised, prospective study to prove that jumping out of an aircraft with a parachute is better than without one.  
Is it possible that “equipment” is fundamentally different to pharmaceuticals?  Whilst drugs need the support of randomised, prospective, double-blind trials, perhaps new medical devices, simply need to be tried?  Perhaps we form a unique partnership with the equipment which suits our particular techniques?  Like buying a new coat – it can look great on the hanger but can still look terrible on your shoulders – you simply have to try it to see if it works for you!  With endoscopic accessories, perhaps we simply need to try new things with an open mind?  
I decided to try the thing out...  Quickly decided that I didn’t like it...  Knew that it looked too bloody crazy to work in the first place…  Decided not to read the research which the rep sent in the post... The thing looked too crazy to work all along…

Old age is a country which few plan to visit

British doctors, due to retire within the next 20 years, received a government questionnaire last year to enquire into retirement plans.  Until that moment, I had never thought about retirement.  My wife advised that, since I have no hobbies and even fewer friends, I should elect never to retire.  With no sick-days in 10 years, I was inclined to agree.  The only question was; how to do I stay healthy so that I can continue to contribute to Society and the NHS until the very end? “Have you ever seen an overweight 80 year old man”, asked a GP friend?  OK, he continued; “forget Atkins, it’s all about the 5:2 diet. Basically, you eat normally for 2-3 days and then restrict your calorie intake to 500-600 calories for a day”. Apparently, it encourages fat burning, protects against Alzheimer's and makes you live longer.  Hmm, 24 hours of near starvation is close to my limit of fortitude but may be achievable… “Sarcopenia” is the second enemy. This is the process which turns us into old looking folks.  The process starts to kick in after the age of 50 when muscle mass begins to shrink by 0.5-2% per year.  How to fight back?  Forget running and start lifting weights!   No need for any endurance training!?   Well there is irrefutable, good news from the University of Aberdeen. Only 150 seconds of high-intensity exercise reduces post prandial serum fats by 33% compared with 11% after less intensive but more prolonged exercise.  Again 150 seconds is close to my limit of endurance but it is achievable… How about “supplements”?   Fish oil is not only good in heart disease.  A recent study found that muscle strength improved (with exercise) by 20% in those taking fish oil supplements compared with 11% taking placebo.  But why be content with fish oils?  Olive oil contains oleocanthal, a potent COX inhibitor which may be the pivotal component in the “Mediterranean diet”.  For many years I have been taking a couple of gulps straight from the olive oil bottle every morning.  It’s probably the only habit which I share with Jackie Collins. Some go further!   “Dr Life”, injects himself with testosterone and Sylvester Stallone uses growth hormone.  Both anabolic steroids may have rejuvenating effects but are also associated with a shortened lifespan. Personally, I always leave the oxygen tap fully open in the endoscopy unit.  Essentially, I work in an oxygen tent. No open flames, please. As usual, it was my wife who brought me down to earth; “You know, all this stuff you are doing – it will only get you an extra 15 years in the “Heaven can Wait” Nursing Home in Grimsby”…  Perhaps those hormone injections are not such a bad idea after all ...

Professor Carol Dweck and my mea culpa

Somewhat late, I have come to agree with Professor Carol Dweck.   For many years I was praising my children in terms of;  “you are very smart and you can do it”.   However, when my children became teenagers this no longer worked.  They would say things like “the teacher hates me and I can’t do it” and were no longer willing to put any effort into an endeavour which they regarded as beyond them. Now I realise that I had inadvertently given them a “fixed resource mindset” in which it made no sense to “work hard” at, for example, mathematics.  In their minds, they had been given a certain amount of brain capacity for mathematics and no amount of hard work could change this fact.  Trying harder would just make their inevitable failure even more pitiful.   Instead, throughout childhood, I should have praised my children for their hard work by saying things like “well done, all your hard work has paid off”.  The deep realisation that the amount of effort spent is directly related to the results achieved would have empowered my children.  Professor Dweck’s “growth mindset” allow people to cope better with failure (which they see as a consequence of not having prepared sufficiently rather than being inept and stupid) and live less stressful and more successful lives. Of course many sportsmen and musicians intuitively understand that there is a relationship between amount of practise and results.  After all, nobody sits down and plays the piano like a virtuoso without thousands of hours of practise.  Indeed Mozart was a child protégé who had spent more than 10.000 hours playing the piano by the age of 12.  In his book “Outliers”,  Malcolm Gladwell describes the many circumstances which must be in place to allow a person to reach thousands of hours of experience.  It does not happen without support! The fact that Mozarts father was a well known piano teacher does illustrate the point.  My Swedish compatriot, Anders Ericsson, a World leading expert on “expertise” has proposed the 10,000 hour rule.  According to this theory, there is a linear relationship between expertise and the number of hours spent.  To become “Brilliant”, you will need to spend more than 10,000 hours “practising”.  Accordingly, a good amateur would have spent about 2000 hours practising, a good professional about 4000 hours etc.  I have looked at the annual “colonoscopy flight hours” amongst our endoscopists in Leeds.  On average, a colorectal surgeon would spend about 100 hours every year colonoscoping at Leeds Teaching Hospitals.   The corresponding figure for a gastroenterologist is about 200 hours, a specialist endoscopist about 500 hours and a nurse endoscopist about 750 hours.  The low number of hours is not because our Leeds colorectal surgeons are lazy.  On the contrary, they don’t have enough hours available to accumulate endoscopy expertise after 3 weekly ward rounds, 3 operating lists and 2 outpatient clinics etc.  According to Anders Ericsson’s theory, this means that after 10 years, a colorectal surgeon in Leeds would not even reach the level of a “good amateur” as far as colonoscopy was concerned.  After 10 years practise they could at best be described as “mediocre” at colonoscopy.   Paradoxically, surgeons have in general accepted the notion that to achieve good results you have to focus on a small area of practise.  It is for this reason that we now have surgical specialities.  Few surgeons would in the West “have a go” without the necessary expertise.  Just as a pianist could not be expected to play the trumpet without practise, a colorectal surgeon could not be expected to carry out a competent aortic aneurysm repair.  Why then do surgeons think that they can “have a go” at colonoscopy?  Probably for several reasons; 1) it’s seen as a “trivial” procedure, 2) income from private practise colonoscopies are welcome and 3) Quality Assurance and insistence on the appropriate annual “Flight hours” is still a  toothless tiger. The irrational surgical insistence on training in endoscopy is also robbing our surgical trainees of the surgical training which they deserve.  The 2009 Position Statement of the “Association of Surgeons in Training” concludes that the current UK surgical training is inadequate and produces Consultant Surgeons who may appear competent on paper but are not necessarily competent OR confident!   (click this link for an outline of British Surgical training).

Sometime I surprise myself by remembering key moments in the path to the present English NHS.

Sometime I surprise myself by remembering key moments in the path to the present English NHS. In the 1980’s, I remember clinicians being invited to step forward and play an active role in the management of their hospitals. I recall people saying that they were too busy or had no interest. As a consequence, English hospitals are nowadays managed by non-clinicians.   Could anyone have foreseen the consequences?  Was nobody worried about this?  There were ominous signs; managers are not bound by any ethical code.  They have no regulatory body.  Their promotion and performance related pay depends on driving through centrally directed objectives and preparing favourable reports to hospital boards. Managers and Clinicians who speak out about poor care or medical failure, risk losing their jobs or are silenced by confidentiality agreements. As the power of hospital managers grew, the focus of our British hospitals moved away from providing safe, compassionate, high quality care to achieving “foundation trust” status, realising cost savings and fulfilling waiting list targets. Both worthy goals? The scandals at Stafford Hospital, Stoke Mandeville and Maidstone & Tunbridge Wells suggest that both objectives can not be achieved. Reading the recent Francis enquiry into a failing English hospital, it seems that the combination of turning an already struggling hospital into a foundation trust and making excessive savings to achieve this had disastrous consequences for patients (BMJ 2013;346:25).  Soon their “Hospital standardised mortality ratio” started to look decidedly poor.  It was at this point that the hospital decided to increase the number of patients who died whilst coded as “undergoing palliative care” from 0% to 34% (BMJ 2013;346:16-18).  Gaming or a queer coincidence? Nothing has been proven and your guess is as good as mine but it had the effect of artificially bringing the hospital’s mortality ratio back into line with other hospitals.  I say artificially as it is now accepted that patients did die unnecessarily at that hospital. NHS management has gone wrong and it’s about time that we clinicians stand up for our patients and for quality of care. Even the most timid, “yellow-belly” doctor or nurse in England may not have any choice as the Francis inquiry recommends court proceedings and jail terms when we turn a blind eye when our patients are in peril.  Our barricades are the only thing that stands between our patients and our managers - lets man them!

My daughters primary school teacher recently asked me to come to school and do a short presentation on healthy living.

I finished my presentation with a short quiz and my final question was; "What do you think is the animal most dangerous to our health - the mosquito or the lion?"  Half the group put their hands up and confidently stated that it was the mosquito.  Impressive! 
Before going to school I had to promise my daughter that at no point could I tell anyone what I do for a living.  I did have a suspicion that my job as an endoscopist was unacceptable. My 10 year old daughter has a habit of quickly intercepting any general medical questions with “he is not that sort of doctor”.  
The science of disgust is interesting.  Of course, it is an important feeling which serves to protect against contamination and infection.  It is for this reason that if you touch clean food with a dirty finger, the food seems contaminated and not the other way around. 
As I spend my days inside peoples guts, I do come across some disgusting sights and smells, but I must admit that it has never repulsed me particularly.  It is clear that some people are more easily disgusted than others and this “disgustability” can be measured on a reproducible scale.  Naturally, in my line of work as an endoscopist, it helps to have a very high “disgust threshold”.  
Interestingly, having a high “disgust threshold” is linked to other personality traits (Inbar Y. Emotion 2011;12:23-27).  For example, people with high disgust thresholds are more likely to vote liberal and are less likely to find socio-moral issues in the sexual domain offensive (such as masturbation), are less harsh in morally judging other people and even in their attitude towards entire social groups (such as homosexuals).  
The science of emotion is not only of interest to psychologists.  Neuroscientists have mapped this to the “anterior insular cortex” which is involved with emotions such as empathy, disgust and maternal love (Phillips ML. Nature 1997;389:495-8)! 
Like me, you may have wondered why some professional groups such as endocrinologists or neurologists often seem very prickly and difficult. Conversely, Gastroenterologists, GI Surgeons and, perhaps most of all – Endoscopists are usually very likeable!  Is it possible that becoming an endoscopist changes us to become more empathic and liberal?  I think that it is more likely to be the other way around; liberal, loving and empathic people are less likely to be “put off” by occupations which initially seem to expose practitioners to disgusting sights and smells. 

Last week I was referred a patient with Peutz-Jeghers syndrome. An earlier enteroscopy had found some polyps in the duodenum which they wanted me to remove.

On talking to the patient before the procedure, I realised that we had completely different expectations of the procedure.  I explained that we normally remove polyps from the duodenum to reduce the risk of intussusception and bleeding.  Admittedly, the risk of intussusception is not great and only some 50 cases of duodenal intussusception have been reported in the last 150 years. However, the patient wanted to have the polyps removed to reduce the risk of subsequently developing cancer!?  As you know, patients with Peutz-Jeghers syndrome have a mutation of the tumour suppressor gene “Liver Kinase B1” (LKB1) resulting in an appallingly high risk (80 - 95% of developing cancer with age.  The most common are; breast cancer (54%), pancreatic cancer (36%) colorectal cancer (29%), gastric cancer (29%), ovarian cancer (21%) and cancer of the small intestine (13%).  For this reason, there is an ill considered recommendation to offer life-long “surveillance” from the age of 10 in these cases.  Sadly, this recommendation does not fulfil even the first of “Wilson criteria” (World Health Organization. 22(11):473) for a screening test; "The natural history of the disease should be well understood, with a recognisable precursor stage which can be effectively treated"  Sadly this is not the case in PJS!  We simply don’t know the natural history of this disease.  What is the precursor lesion which develop into cancer?  The polyps?  Unfortunately, the polyps may just be a distraction!   After all, LKB1 orchestrate a number of intracellular phosphorylation cascades involved in the regulation of fundamental processes such as cell metabolism, cell polarity, cytoskeleton organization, cellular proliferation and differentiation.  It is not surprising that when the LKB1 gene is silenced, the results are profound, unpredictable and diverse in different tissues.  Furthermore, a fundamental role of LKB1 is also suggested by the fact that it’s one of the most commonly mutated genes in several cancers like lung and cervical carcinomas. There is no evidence that removing the hamartomatous polyps which develop throughout the body in patients with PJS reduces the risk of epithelial cancer.  Thousands of polyps are removed every year in these patients but there have only been a handful of  reports of polyps harbouring any dysplasia or neoplasia.  We simply don’t know what precursor lesion we should search for in PJS and for this reason it is unlikely that endoscopic surveillance will be of any benefit.  Two reviews on the topic, including 63 youngish patients with PJS at St Marks and 29 patients with GI cancers (Hearle N. Clin Cancer Res. 2006;12:3209 –3215) concluded that there was no evidence that endoscopic screening reduced the risk of GI cancer.  Interestingly, in the study from St Marks 2456 hamartomatous colonic polyps were removed. Only 4 harboured mild dysplasia and there was no link with the size of the polyp and the risk of containing unstable looking cells (Latchford AR. Dis Colon Rectum 2011;54:1547-51). In spite of this, 2-yearly screening has been recommended (Giardiello FM. Gastroenterology. Dec 2000;119(6):1447-53).  Unfortunately, PJS-related cancers are known to be aggressive and it is quite possible that “early cancers” become advanced within the 2-yearly screening intervals.  We simply don’t understand the natural history of cancer in these patients. Is it possible to detect early ovarian cancer by ultrasound (we don’t know), can regular mammography pick up early breast cancer (we don’t know), how about regular pancreatic ultrasound to pick up early pancreatic cancer (we don’t know).  Surely, regular physical examination will be of benefit?  Perhaps not!, many years ago, it was demonstrated that regular self-breast examination in women had no benefit but did generate lots of anxiety. In fact, it is quite possible that endoscopic screening can directly or indirectly harm the patient.  The removal of hamartomatous polyps is not without risk.  In the small bowel these polyps frequently pull the full thickness of the intestinal wall into the stalk.  Therefore, polypectomy is associated with an unusually high risk of perforation.  Probably much greater than the 1:50 risk which I quote patient referred for duodenal EMR.  Similarly, I quote a 1:10-20 risk of late bleeding after duodenal EMR’s.  Luckily duodenal bleeding can (usually) be managed relatively easily by endoscopic means.  However, bleeding from somewhere a few metres down the small intestine is a different matter.  "Indirect harm" may ensue as these patients undergo repeated endoscopy, ultrasound and “physical examinations”, they are less likely to present early when they develop a new and unexplained symptom.  Finally, I have a rather selfish reason for worrying about surveillance in these patients.  Given that cancer is almost inevitable and that there is no evidence that surveillance "works", when these patients do present with a cancer, I will be to blame!   Imagine the scenario; the patient has undergone 40 years of 2-yearly regular examinations, including gastroscopies, colonoscopies and ultrasounds.  This has evidently "worked" as no cancer has developed until now.  Suddenly, at the age of 60, the patient is found to have cancer!  It’s too late to start talking about “no evidence for screening”.  The patient will conclude that there must have been some benefit as otherwise they would have developed cancer many years earlier!   Furthermore, if screening was of no benefit, why have we persevered with it for so long !  In the patients mind, the reason why he now has cancer is obvious;   it was my slapdash screening which missed the early buds of disease! 

There would have been strong arguments against the UEG developing an eLearning site in 2010.

“Developing eLearning may cost over a million Euros over the next 5 years!?”.   “Why spend money ensuring educational standards and a comprehensive index?”  “For Free !!?”  “Don’t you know that the Americans are charging for access to DDW presentations?”  “They don’t spend resources on recording the presenter!”  They don’t give access to previous material!”.  However, the decision to go down the road of eLearning was made, not because it was easy or profitable, but because it was the right thing to do.   It fulfilled the UEG mission; “to advance the standards of care for patients with gastrointestinal disease”.   As the opportunity came up to join the project, I asked myself;  “In a lifetime, how often can one hope to join an exciting new project, launched for the benefit of patients without apparatchics asking for your business case at every turn?”  Of course I jumped at the chance!  Our small group was chaired by Prof. Niek de Wit from the University of Utrecht, Dr. Gavin Johnson from the University College London provided us with input into educational theory and Prof.  Marco Bruno was the chairman and representative of the UEG Education Committee  Keeping us focused and coaxing us along were Verena and Doris of the UEG Secretariat.  Indeed most medical societies are run by capable women with multitasking brains and the persuasive skills to make you work late into the night.   At the beginning of 2010, the eLearning website was a blank canvass.  We decided that it should host a Library of educational material developed by the UEG since 2008.  UEG member societies were invited to upload their educational material.  The advantages were obvious;  “why reinvent the wheel, at huge cost and effort, when the material could be hosted for free?”.   Of course some member societies were cautious.  How could their interests be protected?   By always identifying the origin of the material and providing links to their Society’s home page.  We also came up with an acronym: Online Learning in Gastroenterology (OLGa).  Unfortunately, putting OLGa into Google would invariably take you to a site dedicated to Olga Kurylenko.  I am now quite familiar with her range of lingerie.   In 2011, the first full CME accredited eCourse, dedicated to Colorectal Cancer was launched by Prof. Reinhold Stockbrugger.  It was an ambitious review of a huge topic, ticking all the educational boxes;  user interactivity, stated objectives, self-testing and encouraging feedback.  Further Courses are in development such as; Irritable Bowel Syndrome, Dyspepsia, Coeliac disease and Acute Pancreatitis.  The latter two will be “mini-Courses”, bite-sized educational packages which will earn you 1 CME point. Developing eLearning material which fulfil the strict European CME Council (EACCME) criteria is difficult and expensive. Only educational material of the highest standard is approved.  In return you earn undisputed CME points which are recognised Internationally.  Of course our Group agreed that all our Courses must be recognised by the highest  authority and be fully compliant with the 2001 Basel Declaration on CPD.    By 2011, I would still get lost and spend a few minutes ogling at Olga Kurylenko before uploading my Case of the Month and Blog.  Then came the UEGF rebranding exercise.  A top London firm spent several months learning about the different aspects of the UEGF and then came up with their verdict; The “UEGF” should become the “UEG”.  I am sure that there must have been a cheaper way to loose an F!   As part of the rebranding exercise, OLGa became UEG eLearning (part of UEG education) and was given a blue logo whilst the UEG stuff became green.  Oh, but I still miss that catchy “OLGa” acronym!   I can’t come up with anything similar for “UEG eLearning”.  I have even tried creating anagrams;   “UnLearn”,  “EnLarging” or perhaps “GanGrene”?   No, it’s hopeless.   Currently there are some 4000 regular users. These clinicians log onto the site, either to brush up on a topic, or to have a look at previous talks when working on their own presentations.  And there are rich pickings!  More than 750 presentations and over 8000 documents to search.  After the UEG Week 2012 there will be a further 170 presentations uploaded together with another few thousand abstracts.  The plenary sessions from the Postgraduate Course and Open Plenary Session on Monday will also be available online from Tuesday afternoon.  Make sure that you save your electronic voucher which will be sent to you after the UEGW.  This is your Passport to the Worlds most comprehensive eLearning site!   So what’s new?  Well, there is an interactive Notepad which makes written notes unnecessary. You can create your own bespoke “Collections”.  Great if you need to store links to material for a later date.  There is a “Tell a Friend - tool” and you can now rate any presentation according to a 5 Star ranking system.   Hopefully, we will one day be able to offer “real-time virtual access” to the UEG Week for those who would rather learn from the comfort of their own chair or can not afford the expense or want to limit their own carbon footprint.  You already have the ability to submit questions to the presenter electronically.  Streaming video and sound directly into cyberspace can not be that difficult.  Every TV channel does it!  

Well the celebratory 20th anniversary the UEG Week is finally here!

On Sunday evening, it kicks off with the Party Boat “Oceandiva”.  If you like me, can’t dance for toffee, there are free drinks and who cares anyway! If I decide to go for a midnight swim, please stop me someone - or join me!  If you are up for a laugh, click this link for further information and get yourself a ticket quickly (you can only do it on site)! As I rule, I always stay firmly in bed during the Opening Plenary Session.  However, on this occasion I may be making an exception. There is a “Grand Surprise” planned and I have been told that it is much better than John and Colm singing a duet. My imagination is working overdrive, could it be Cirque du Soleil, perhaps The Blue Man Group?  Then we have the usual smorgasbord of ESGE hands-on learning area, ultrasound hands-on, clinical cases, lunch sessions, Q&As sessions, the e-learning lounge etc etc.  Click this link for further details. By the way, there is a great UEG Week Planning tool (just click the link) which helps you to plan what you want to attend.   If you find that you only have a vague recollection of presentations, and your colleagues, who had to stay behind, start to ask awkward questions, there is help at hand. From Monday the Postgraduate Course is available online. From Tuesday afternoon, the Postgraduate Course Plenary and Open Plenary session is available for free on UEG e-learning.   I you have to bring your family along to the the UEG Week, there is a kindergarten. Please drop them off on Monday morning and pick them up on Wednesday afternoon.  Click this link for further details. I hope that you will enjoy the UEG Week 2012 - You are amongst friends!  

It's about time that we take the lead on this contentious topic.

As a young medical student, I recall watching my first gastroscopy.  I was surprised to see that the consultant gastroenterologist did not wear any latex gloves.  He explained that most gastroenterologists and surgeons would only wear gloves for colonoscopy.  He defended his bare hands with the words;  “I can feel the scope better without gloves and will wash my hands carefully between cases ”.   In those days, the endoscopists would also don a heavy-duty plastic apron, occasionally wiped down, and tuck his tie into the shirt.  To “tuck in the tie” was important as it otherwise ran the risk of inadvertently becoming inserted.  
The endoscopy nurse recalled such a mishap when the endoscopist found that he was unable to stand up straight after negotiating a difficult sigmoid bend.   The reason was that he had managed to insert both endoscope and silk tie into the descending colon!  
Rather than pulling the two items out and start afresh, he just asked for a pair of scissors and without a word cut the tie.  This act earned him ridicule from colleagues, most of whom would have withdrawn and rinsed off the perfectly good tie.  However, In the eyes of us medical students, he was a hero.  On par with that Australian guy who drank Helicobacter to prove his theory to scornful and sceptical peers.   A few years later, it became compulsory to wear “scrubs” and gloves during endoscopy in the UK.   It did seem unnecessary and ridiculous!  Bodily fluids and excrement which found the way onto our trouser legs could easily be wash off at the end of the working week. 
The latest dictate from microbiologists is that we now have to insert intravenous cannulae with “Full Sterile Precautions”.  This includes careful wipe of all surfaces, opening a sterile IV cannula pack and whilst wearing sterile gloves, finding the vein and inserting the cannula.  It can just be achieved within 5 minutes.  As most of our endoscopy assistants do not have the required credentials to site the cannulae, it does slow down our endoscopy lists, it is also expensive and without any evidence base.  However, this is missing the point!  Sometime you have to do “the right thing” without whingeing about evidence and cost!   I do worry that future doctors will tell stories of their first trip to an endoscopy unit to see endoscopists with bile, spit or excrement dripping from bare elbows and unprotected faces.  When they ask why we don’t use the protective equipment, the reply that “there is no need as I wash between cases”, will probably seem as lame now as it did 20 years ago. 
It is now time that we agree a uniform standard of protective equipment which should be worn by all during endoscopic procedures!    It’s shameful to defer these decisions for microbiologists, managers and nurse consultants!   Please click on this link; (Audit of Minimum Protective Endoscopy Gear), to enter your own views on what protective equipment should be worn.  It will take minutes and hopefully we can force those in the corridors of power to accept our verdict. 

The English Equality Act 2010 has now made “Ageism within the NHS” illegal.

Our previous “equality minister”, Harriet Harman, has stated: "People are not over the hill at 60 – they shouldn't be discriminated against in healthcare”.   The previous “Care Services Minister” Paul Burstow went further: "There can be no place for arbitrary age discrimination in the NHS”. These lofty words are in stark contrast to clinical reality.  Not a day goes by, when I don’t take a patients age and comorbidity into consideration when making a treatment decision.  The reason is that the risk of complications increases with the age and comorbidities of your patient. In the arena of endoscopic therapy, the outcomes are particularly stark.  A 73 year old patient undergoing polypectomy has three times the normal baseline risk of suffering harm (Rex DK DDW 2102).  The risk increases doubles with an ASA status of 2 and increases further to 11 times the normal background risk when the patient reaches the age of 86.  Not only are elderly patients more likely to bleed or suffer a perforation, because of a polypectomy, they more likely to die when it happens.  Paradoxically, elderly patients will not benefit from the removal of a neoplastic lesion to the same extend as younger people.  This is because most elderly patients will die with their polyps and early cancers rather than from them. Of course, this is true for most health care interventions.  Elderly patients, with a shorter life expectancy are less likely to benefit from “treatment” (medication, screening or surveillance) which seek to reduce harm in the intermediate or longer term.  Age and frailty also mean that they are less likely to benefit from high-tech acute or emergency care.  At best, I am completely out of touch, at worst, I am breaking the law.  However, I will maintain that it is every old person’s right to die OFF a ventilator.

Radiofrequency ablation (RFA) has now been given the go-ahead

RFA has been given the go-ahead by our “National Institute for Clinical Excellence” (http://guidance.nice.org.uk/IPG344) for use in patients with Barrett’s harbouring high-grade dysplasia.  As a result some 31 units around the UK have now begun to offer this treatment to their patients.  It may sound like good news but I am predicting a disaster.
The problem is that NICE never stated that the therapy should only be offered by units with particular experience in managing early oesophageal cancer.  
The NICE guidelines states that only “flat dysplasia” should be treated by RFA.  The problem is that some invasive cancer appear as  “flat dysplasia” at endoscopy.   Please click on the photo to seen an example of a small ulcerated lesion (i.e. a IIc lesion) within a long stretch of Barrett's. Repeated biopsies could only confirm high-grade dysplasia and neither EUS nor CT could refute this.  However, to an experienced endoscopist, a IIc lesion within the Barrett's is suspicious and if histology confirms dysplasia it's probably an invasive cancer.  The patient was not offered RFA and was instead referred for an oesophagectomy and a T2, N1 adenocarcinoma was confirmed. Personally, I don't think that it is  possible to make a reliable distinction between early invasive cancer, intramucosal cancer or high grade dysplasia by EUS, CT or surface biopsies.   The diagnosis is best made by an endoscopist with experience in staging early oesophageal cancer and with experience of oesophageal EMR (which at worst provides great staging and at best a cure). 
Am I over-reacting?  Perhaps creating a mountain out of a mole-hill?  I don’t think so!  An abstract from the recent Digestive Disorders Federation meeting in Liverpool (17-20 June 2012) provided alarming reading (BSG endoscopy section symposium and free papers: Dealing with endoscopic disasters – “How do I do it” Gut 2012;61(2): Abstract OC-011).  
The abstract is somewhat difficult to understand and I urge you to read it for yourself (just click the link). Essentially a  large centre treated 59 patients with Barrett's harbouring HGD or IMca with RFA.  Only half of the patients were thought to have a visible nodule requiring EMR before RFA.   The results were not encouraging.  Nine of the patients PROGRESSED TO INVASIVE CANCER within 12 months!   We can only hope that the 12 month delay did not result in some patients becoming incurable.
In the Euro-II study some 130 patients with dysplastic Barrett's have now been treated in selected centres.  There have been no cases of progression from HGD/IMca to invasive cancer.  However, the high success rate in the Euro-II study can not be entirely attributed to RFA as quite a few patients required an EMR to remove a stubborn patch of Barrett’s which RFA could not shift. My own experience is limited to some 20 patients.  The only complication I have had is a single very troublesome stricture.  I have carried out lots of dilatations and it still keeps narrowing down a week or so later.  I am beginning to think that we will have to place 2-3 biodegradable stents to allow this patient to eat anything more solid than yoghurt.  

After analysing the results of our online survey, I have an update to our earlier issue on sampling bleeding gastric ulcers

Please have a look at my earlier Blog on “Finding myself on the wrong side of common opinion”) which sets out the problem.  The Survey confirms that our unit is representative of “European practise” (assuming that the surveys 112 responders are representative).  
To summarise the results (so far –it’s still open!), about one third of responders work in units with No particular policy on when to sample gastric ulcers.  Another third work in units with a policy to Never Sample a gastric ulcer (at the time of emergency endoscopy).  The final third, would only permit samples to be taken Only IF there are no stigmata of recent bleeding from the ulcer.  
Half of the responders had no recollection of a case of bleeding being precipitated by sampling the ulcer edge.  However, another half could recall such a case of re-bleeding being linked to sampling.  
When should samples be taken (if not at the emergency examination)?  In roughly half the cases, the policy was to obtain samples before discharge and in the other half, to organise these samples soon after discharge.  
However, the potential drawbacks of a “sample later” policy was recognised by about half of the responders who could recall the odd case when the diagnosis of cancer had been delayed because the follow-up endoscopy was not carried out in a timely fashion. 
Where does this leave us?  I do find it reassuring when my prejudices are found to be backed up by some scant evidence.  My concern that the diagnosis of gastric cancer may be delayed, is shared by half of my peers.  
Unfortunately, a similar proportion could recall a case of re-bleeding being linked with taking samples.  Of course, these ulcers would have re-bled anyway!   However, the mere association clinches my decision.  I will now stop taking biopsies from gastric ulcers at the time of the emergency endoscopy.  Why leave yourself open to criticism when that ulcer re-bleeds after your samples?  Particularly, when you so easily could find yourself “On the side of the Righteous”, condemning poor management when circumstances conspire to delay a timely follow-up endoscopy?  

I am the most spiritual of atheist and rigidly observe Lent (fasting) in the 40 days leading up to Easter.  My fervour has nothing to do with a belief in the divine.  As many religions include a period of fasting, I reason that there must be some merit in the practise?  It’s a leap of faith!

In fact, my medical training is providing a powerful defence against any religious stirrings.  Epidemiology is perhaps the most powerful antidote.  Leeds is taking part in a new pilot study to screen for “Maple Syrup Disease”, “Homocysteinuria”, Glutaric acidaemia type 1”, Isovaleric acidaemia” and “Long chain fatty acidaemia”.  Our Chief Medical Officer, Prof Dame Sally Davies has announced that this pilot will give the 1:100.000 children, born with one of these diseases, a chance to live a long and healthy life.  This is a chance which, “Nature” can not provide and “Darwinian evolution” has not yet fixed. 

At work, I fight against “Nature” on a daily basis.  After all, if we left things to work out the “natural way”, few of us would live beyond 50.  Believing in the theory of evolution, I do understand that in hard times, it may have been detrimental to have old folks hanging around requiring feeding and warmth.  For this reason, “nature” introduced a natural and progressive cull, to start take effect at the age of 50 in men and a little later in women. 

Armed with education, sanitation, vaccination and medication, we now battle against "Cruel Mother Nature” on a daily basis!   Indeed, if I hear the word “Natural”, I instinctively reach for my stethoscope.

Recently, one of my more grateful patients commented that Doctors were only second to God in looking after people.  I didn’t have the heart to tell her that she got it the wrong way around. 

I am the most spiritual of atheist and rigidly observe Lent (fasting) in the 40 days leading up to Easter.  My fervour has nothing to do with a belief in the divine.  As many religions include a period of fasting, I reason that there must be some merit in the practise?  It’s a leap of faith!

In fact, my medical training is providing a powerful defence against any religious stirrings.  Epidemiology is perhaps the most powerful antidote.  Leeds is taking part in a new pilot study to screen for “Maple Syrup Disease”, “Homocysteinuria”, Glutaric acidaemia type 1”, Isovaleric acidaemia” and “Long chain fatty acidaemia”.  Our Chief Medical Officer, Prof Dame Sally Davies has announced that this pilot will give the 1:100.000 children, born with one of these diseases, a chance to live a long and healthy life.  This is a chance which, “Nature” can not provide and “Darwinian evolution” has not yet fixed. 

At work, I fight against “Nature” on a daily basis.  After all, if we left things to work out the “natural way”, few of us would live beyond 50.  Believing in the theory of evolution, I do understand that in hard times, it may have been detrimental to have old folks hanging around requiring feeding and warmth.  For this reason, “nature” introduced a natural and progressive cull, to start take effect at the age of 50 in men and a little later in women. 

Armed with education, sanitation, vaccination and medication, we now battle against "Cruel Mother Nature” on a daily basis!   Indeed, if I hear the word “Natural”, I instinctively reach for my stethoscope.

Recently, one of my more grateful patients commented that Doctors were only second to God in looking after people.  I didn’t have the heart to tell her that she got it the wrong way around. 

To my surprise I recently found myself at odds with my colleagues on a common clinical problem.

An elderly patient had been admitted with a bleeding gastric ulcer.  At her emergency endoscopy the ulcer was treated with “dual modality therapy” (injection of adrenaline followed by the application of heat).  Eight samples were then taken from the edge of the gastric ulcer.  Twenty four hours later we had confirmation that the ulcer was malignant.  Unfortunately, the ulcer re-bled and the patient subsequently died.  
Our disagreement is over the samples taken at the time of her emergency endoscopy.  My colleagues unanimously believe that these samples should NOT have been taken.  I believe that all gastric ulcers should be sampled at the earliest opportunity to avoid potential delays.

According to our limited “Bolam’s test” I am wrong and my colleagues are correct.  However, I still believe that there is no risk of precipitating a re-bleed and that there is a real possibility of delayed diagnosis when no samples are taken at the first opportunity.  Although we are in the era of “Evidence Based Medicine”, there is no published literature to help us.  There are no studies but I am aware of several in-house cases in which there has been a delay in the diagnosis when biopsies were postponed.  I also do know that the re-bleeding rate of a high-risk ulcer (Forrest I or IIa) is about 20% after dual modality therapy. 
Of course, we have local guidelines to state that no patient should be discharged without samples having been obtained from a gastric ulcer.  However, I believe that guidelines are not enough.  Instead “doing the right thing” must be built into our working practises.  In the case of gastric ulcers, I believe that the correct advice would be “If you see a gastric ulcer – you should always take 8 biopsies from its edge”.   The aviation industry understood that   some 50 years ago and now build “doing the right things right” into the working practises.   The truth is that “Guidelines from above” and “Evidence Based Medicine” only help in a small part of our clinical decision making.  For this reason, most doctors are intuitive and aim to make a “good enough decision” based on plausibility.  Unfortunately, plausibility is not infallible.  I am old enough to remember getting into trouble by forgetting to stop beta-blockers after a myocardial infarction.  The younger reader may be surprised to hear that for many years, stopping beta blockers after a cardiac event seemed the right thing to do!  In the hope of shedding some light onto our dilemma of what to do with bleeding gastric ulcers, I would be grateful for your views!    Please, click this link to take part in a 20 second, anonymous survey which would inform all of us!  Thanks  Björn Rembacken

I wonder if our Academics are congratulating themselves on what they have achieved?

In England, it now takes an average of 621 days to get a trial up and running because of our cumbersome Ethics and R&D application process.  Make no mistake, it takes this long when someone who knows what they are doing is submitting an application.  If you have not done it before, it is likely to take MUCH  longer as the process is frustrating and cumbersome!  
Paradoxically, it does not matter if you are planning on a trial comparing two types of standard bowel preparations OR are planning on putting probes into the brains of newborn children.  The turgid application process remains rigidly the same!  
What does this means for our patients?  There are several, predictable consequences;  1) patients are unlikely to be offered any new, potentially life saving trial medication, 2) patients are likely to be offered drugs which have only be shown to be efficacious in Chinese or Indian patients and 3) the NHS does not benefit from an infusion of research money. The reason for the last point is that “UK Pharma” is now taking business to the third world where trials are cheaper and can be launched within a more reasonable time frame.  Who could blame them? 
At the same time, being an “Academic” is becoming an unpopular prospect in the UK.  There is little job security and Universities are notoriously stingy and may not provide any secretarial support and may even choose not to renew your contract after 5 years.  
England was once the LEADER in Phase 1 to 4 Clinical Trials.  Now we are down to less than 2% of the World research output.   I guess that our Legacy will be;  "The Generation which killed off Clinical Trials"
<1 2 3 4 5>