Whilst most would make resolutions of things to do in 2014, I am more certain of things that I may not do ...

Last year my wife was called to attend for breast cancer screening.  Seeing the spectre of “small shadow” -> “inconclusive histology” -> “extended lumpectomy” -> “still not sure”,  playing out in my mind, I suggested that it may be wiser not to attend.  Of course she ignored me and of course a small “probably a calcified node” was found.  She attended for a targeted biopsy whilst I got on with another endoscopy list.  To my surprise she phoned after the biopsy to ask me to pick her up as she felt unable to drive home!?  When I collected her she described how they had spent an hour, repeadedly poking deep into her breast with an increasingly blunt biopsy needle.  She had been locked into some sort of frame to keep her still in the X-ray machine. Once freed from this fixation device, she collapsed on the floor with a vaso-vagal attack.  She apologised for fainting and vomiting on the floor of the X-ray department and asked if there was anywhere to lay down and recover.  Cheerfully the staff assured her that this happened all the time and that she may just as well stay on the floor as there were nowhere else to recover!  Seeing all my worst fears coming true, I anxiously waited for the histology (which I was sure would be inconclusive).  Luckily histology was a clear-cut calcified tiny lump and the screening programme scored another “success”.   The tenderness and bruising lasted a month. Most screening programmes were started with little evidence as they simply seemed a good idea.  Unfortunately, after a screening programme has been launched, there is no way of determining if it is doing any good.  The reason for this includes “lead-time bias”, “length-bias” and “healthy volunteer bias”.  Take screening for Barrett’s dysplasia as an example.  We have done it for decades without a shred of evidence.  The brave “UK BOSS trial”  is turning the clock back and will hopefully provide some evidence in support.  If the benefit of a screening programme is not confirmed (by a prospective randomised trial) before it is launched, sooner or later concerns about expense, lack of benefit or even harm may start to emerge.  Without solid trial evidence gathered before launch, costs may become difficult to justify and the issue of benefit vs. harm impossible to weigh up. Breast cancer screening is a good example. A Danish review (BMJ 2010;340:c124), found that the mortality of breast cancer was falling at a similar rate in both screened and unscreened women. A year later, a retrospective analysis looked at the breast cancer mortality in Europe to compare the timing of the reduction in countries starting screening at different times (BMJ 2011;343;d4411). The authors concluded that screening did not seem to play a direct part in the reduction in breast cancer mortality. Fifteen years ago, the same concerns were put forward regarding screening for early gastric cancer by Tony Axon (Lancet 1998;351:1350-2). Luckily, screening for colorectal cancer has been thoroughly studied.  We all know that a centrally organised, National comprehensive screening programme reduces an individual’s risk of dying from colorectal cancer.  Surprisingly, I did not have a reply at my fingertips when a patient asked me, “OK, I understand that my lifetime risk of dying from bowel cancer is 1:50 but what will my risk be if I now send my poo off for testing ?”  With the UK guaiac FOB kit, presumably the answer is 1:75?   You may be surprised to hear that 25 years ago, my wife got my genes checked out.  This was in a pilot screening trial open to pregnant women searching for the “delta 508 mutation” responsible for most cases of Cystic Fibrosis in the UK.  A month later, we were surprised to hear that she was a carrier.  Subsequently, I tested negative for the delta 508 mutation.  I thought that this was reassuring but the research team was less clear-cut in their assessment;   “We are not sure about the CF mutations which occur in Scandinavians…”, “there are hundreds of mutations which can all cause the disease…”, “you may have some other mutation which will interact with your wife’s mutation…”, The risk of your child being born with cystic fibrosis is probably no greater than 1:300… we hope“. Rapid DNA sequencing using powerful machines has now brought down the time and cost so that a complete map of your DNA can be delivered for less than $1000 and within just a few days.  The problem is that we don’t have the faintest idea of what the data means.  Furthermore, the “epigenetics” of how genes are silenced and switched on, in response to environmental triggers, is also unknown.  Interestingly, the setting of these switches can be transmitted to our children and grandchildren! Perhaps the reason why your wife is afraid of dogs is that her great grandmother was bitten by one? Naturally, enthusiasts are lining themselves up to praise the rapid march of the technology from research bench, to clinical practise and soon the supermarket checkout.  Nobody has paused to consider than having someone’s complete genome sequenced opens a can of worms;   “Did you know that you carry these 20 lethal recessive genes?”  “Another 350 of your genes have been linked to Alzheimer’s, early heart disease or rapidly progressive cancer or psychiatric disease”  “but we think that some of these risk may only be of relevance if you have red hair or eat a lot of bacon or marry the wrong person”, “Sorry but we can’t advice you any further”.  “We should now really screen your partner and your children and your children’s children“. The screenee will suddenly have many legitimate questions;  “Will this data be cross matched with other databases such as the insurance industry, the police or International Research databases – “for the benefit of others?”  Will I have any say in this?  One thing is certain, once your genome has been entered into the “DECIPHER Consortium database” or the “Leiden Open Variation Database” or the “Locus Reference Genomic Collaboration database” (to mention just a few) you will spend your remaining life completing lifestyle forms and replying to upsetting letters asking if you have noticed any chest pains, deterioration in memory, suicidal thoughts or any funny lumps in the last 6 months. Finally, I am resolved not to accept a blood transfusion unless my life depends on it.  This is not because of any religious convictions. My concerns are twofold; first there is evidence from our armed forces that liberal transfusion of wounded on the battlefield leads to worse outcomes. In fact, soldiers who get shot “in theatre” (this is what the military calls the dusty backstreets where wars are nowadays fought) receive just enough fluids to have a detectable radial pulse.  During the helicopter transfer to the nearby field hospital they get their blood analysed by “thromboelastography”, to guide red cell+/-plasma+/-platelet replacement to replenish oxygen carriage and pre-empt coagulopathy.  Within an hour they undergo “Damage Limitation Surgery”. The outcomes are impressive as fewer than 10% of soldiers die from their injuries.  In contrast, patients with a bleeding upper GI lesion are managed with liberal transfusions, not guided by anything (at least not thromboelastography) and the “emergency endoscopy” is carried out sometime in the next 24 hours!  The outcomes are less than impressive in that you are more likely to die from a bleeding ulcer in the suburbs than of a high velocity bullet in Helmand.   Apart from worsening outcomes associated with liberal transfusion, there is also ”Transfusion-related immunomodulation” (TRIM) to consider.  Forty years ago, it was discovered that patients who had previously received a transfusion where far less likely to reject their renal transplant (NEJM 1973;5:253-9).  The reason for this is that donor white cells somehow damage immune systems causing impaired natural killer cell function, decreased phagocytosis and suppression of lymphocyte production and antigen presentation.   This is one of the reasons why transfusion services are trying to remove as many white cells as possible.    Another reason is the outbreak of “new variant Creutzfeld-Jacob disease” (nvCJD) in the UK. To prevent the spread of “prions”, virtually all our endoscopy accessories are now disposable and certain operations such as tonsillectomies are no longer carried out.  In 2004, a study  (Lancet 2004;364:527-9) confirmed that the condition could also be transmitted by blood transfusions.  The UK government has now banned anyone who have received a blood transfusion since January 1980 from donating blood.  Most other countries have gone further and have banned blood donations from anyone who set foot in the UK between 1980 - 1996.  Even sperm donations are banned!   How the mysterious “prion protein” causes our brains to rot is unknown. But it makes me wonder, what other mysterious proteins, currently floating around in seemingly healthy blood donors, remain to be discovered?

Some musings over traditional family values, happiness, consumption and the perils of having children late in life.

In the lead-up to Christmas, I came across a survey which asked people how much their happiness depended on material belongings rather than other things.  The Brits found themselves quite high up in the survey.  Unicef believes that this is the reason why British kids are unhappy .  Their analysis found child well-being in the UK at the bottom of a league of developed nations whilst the Swedes were second to the top.  The Unicef researchers concluded that British parents work all hours to increase family income but are too exhausted and busy to give their children attention.  Naturally, the children themselves would prefer time with their parents to consumer goods.  What can you expect in a country where the average age of having children is 30 (the highest on record until we see next years figures).  The Unicef finding are little wonder as British parents in their late 30’s and 40’s find themselves cash-rich and time-poor. The researchers commented that;  “We were struck by the volume of toys in the UK…”. “Our ethnographers observed boxes and boxes of toys, many of which were broken, and children appearing to 'rediscover' toys which they had even forgotten that they owned. Parents spoke of having to have 'clear-outs' of children's toys in order to make room for new things…”.  “One mother in the UK felt that she had bucked the trend because as she told us, “I don’t buy something for the girls every time I go out”.  It's all about values and the "World Values Survey", has monitored these values for a long time.  Of particular interest is the “Inglehart-Welzel” graph.  In this graph “survival values” are plotted close to the intersection of the X-axis (which places a priority of security over liberty, disapproval of homosexuality, acceptance of repressive, authoritarian regimes, distrust in outsiders etc) and “self-expression values” (acceptance of homosexuality, democracy, trust in outsiders) at the right hand end of the X-axis.  At the Y-axis there are “traditional values” (religiosity, national pride, respect for authority, obedience and marriage) close to the intersect and “secular-rational values" (secularism, cosmopolitan orientation, non-violent protest and individualism) at the top end of the Y-axis.  They concluded that values of a society moves from the bottom left part of the plot towards the top right as peoples sense of security increases and societies move from agricultural to industrial and then to “knowledge societies”.  Interestingly, the advance from bottom left to top right is also mirrored by the empowerment of women and increasing happiness. However, in the above survey it was the Chinese who were the most likely to link material belongings with happiness.  I must admit that this did not surprise me. I recall a conversation I had with a Chinese girl from Singapore.  On asking what she looks for in a man, she answered “the 5 C’s of course – every Singapore girl knows these”.  Innocently, I proposed that these would be;  “Cheerful”, “Colourful”, “Cerebral”, “Charming” and “Clean” (an inspired guess as Singapore is a very clean place).  No, she replied, the Five C’s are: “Credit Card”, “Club Membership”, “Condominium”, “Cash” and “Car !”. These C’s are largely wasted on a Swede as the above survey found that Swedes were the least likely to link material goods with happiness.  This must be why I have little enthusiasm for buying Christmas presents.  Luckily my wife has stepped into the breech and now does all the Christmas Shopping. Unfortunately, she steadfastly refuses to buy her own! Merry Christmas and a Happy New Year to all of you !

Discovering a forgotten letter triggered some ambivalent recollections of different times.

Discovering a forgotten letter triggered some ambivalent recollections of different times, when doctors where seen as omnipotent and patients suffered for it. It is a rare occurrence that I tidy my desk.  There are usually more pressing tasks.  But I couldn’t put it off any longer and after filing away paperwork, one foot deep, I came across a hand written letter from my previous boss, Tony Axon.  Tony gave each of his juniors a nice handwritten letter of support and Best Wishes when he retired after 40 years service.  Tony developed Gastroenterology in Leeds from humble beginnings some 40 years ago.  In those days, gastroenterology, and endoscopy in particular, were not seen as “worthy” medicine.  It didn’t help that medics and surgeons in Leeds were at a war footing, with fisticuffs in the corridors.  In this infertile soil, Tony Axon built a comprehensive gastroenterology firm which included cutting edge technologies such as ERCP.  I wonder if Tony felt any unease over handing over “the keys to the Firm” to his young apprentices. Sadly any feeling of responsibility to “the firm” has now long disappeared from the National Health Service.  Most of our young trainees work a full shift pattern with little sense of being united in the workings of a “firm”.  They understand that they are nothing but small wheels within a larger machine.  In contrast, in my generation, we thought that we were the machine.  Of course, the old system had to change.  I do remember the 110 hours of continuous on call, covering all medical admissions from Friday morning to Monday afternoon.  If you did grab some sleep, the nurses would phone you with the latest urinary outputs or ask if it would be OK to give a couple of paracetamols.   Each ward you covered had “IV’s”, which you had to make up and administer.  The nurses wouldn’t lift a finger as “it was not part of the nursing model of health care provision”. The result was not no IV’s were given on time and “slow intravenous infusions” were 10 second injections. I was surprised to learn that ringing in the ears was not an inevitable side effect of IV Frusemide.  Perhaps it was wrong to tell patients that “you have to choose between hearing and breathing  - you can’t have both!” “See one, Do one and Teach one”, was the way you learnt day-to-day procedures.  And we did EVERYTHING! Urinary catheters, suprapubic catheters, arterial lines, central lines, lumbar punctures, chest drains, liver biopsies, pleural biopsies, temporary pacing, shocking people out of AF, Swan-Ganz measurements, blood gases and chemotherapy.  The ECG machines were particularly challenging.  The leads ended with small suckers and these little buggers would always fall off at the crucial moment.  With skill you could press the start button and then quickly but gently drape both hands over as many of the suckers as possible to keep them in place.
I now realise, that my generation is unique.  The generation before me, had very few practical procedures and doctoring largely involved furrowed brows, a limited number of blood tests and lots of bed rest.  Conversely, the generation after me has delegated the responsibility for procedures to other departments.  Now the liver biopsies are ultrasound guided.  Chest drains are only placed by respiratory physicians.  Pacing is done by cardiologists. But it wasn’t all bad.  I fondly remember the after-wardround coffees when we would laugh and exchange anecdotes.  I remember the story of the vagrant having a VF arrest in A&E.  When the defibrillator shock was administered, all his flies jumped out of his hair, in beautiful synchrony!  I recall the patient who had a VF arrest in the middle of a sentence. He fell back unconscious onto the pillow. Glancing at the cardiac monitor, I gave him a thump in the chest. To my surprise he immediately sat up again and shouted “OUCH - WHAT DID YOU DO THAT FOR!?!”.  Our camaraderie translated into a deep sense of loyalty.  Nobody took any sick leave.  Absence would land colleagues in impossible situations.  If you didn’t come to work, your colleagues would have to pick up twice their normal workload, see twice as many patients in clinics  or the ward round would last 6 hours instead of 3 hours.  Acute medical takes were busy, usually with 20-30 medical admissions.  This was an era when patients were stockpiled on trolleys in A&E and women gave birth in corridors next to heart attacks and acute abdomens. I recall feeling particularly rough in the middle of a Medical Take, I checked my temperature to find it to be 38.7 ⁰C.  I phoned my wife for a moan and ask for her opinion about taking some ampicillin.  “Don’t be an idiot, take a paracetamol and GET ON WITH IT!!!”, was the reply.  What did I expect from a doctor?

Well another successful UEG Week draws to its conclusion

The feedback has been excellent and another milestone has been passed - for the first time in the history of the World, the European Gastroenterology Society meeting has overtaken the DDW meeting in size and scope.  The Postgraduate Course on Saturday and Sunday was very well attended.  I have been told that the format will change a little next year with the afternoons having more, smaller “breakout sessions”. The tandem talks have also been well received.  Preparation is particularly important with these as ideally, the two presenters should liaise closely and try to merge their respective talks into a single coordinated delivery. The new stuff has also been great.  The live feed on the UEG Week is fantastic (first proposed by me in 2010).  There were some teething problems but after “boosters” were put in to allow more internet traffic, the signal has been stable and more people have been able to patch in with their smartphones and tablets.  The ClipCube video clips have been hilarious and a welcome contrast to serious academia.  The Conference App has been good although I am missing a “Right Now” button to show me what is currently going on in the different lecture halls. All the talk of change and improvements in the UEG Week, is in stark contrast to our personal lives were we value stability and status-quo over change.  I recently returned from a meeting abroad to join my wife, (I was a little late), at a party.  Gazing across a large group, she had to be pointed out to me.  Unknown to me, she had changed her hair, got a deep brown (spray) tan and a sharp new light green dress.  She looked great, but the transformation left me a vague feeling of unease.   The simple fact remains that when a woman decides that it’s time for something new, her partner/husband remains part of the old.  She addressed my concerns in her usual direct manner; “Bjorn, imagine that I have three options, boxes if you wish.  Imagine that I really want what is inside one of the boxes but I don’t know which box it is hidden in.  I choose box 1 but then someone shows me that box 2 is empty.   Should I now change my mind and select box 3?  Not sure if there were husbands inside these imaginary boxes, I proposed that she should stick with her first choice.  “Wrong”, she cried, you should change your mind and choose box 3!  The odds that box 3 is correct, is now 2/3 !

I still don’t get it but hopefully this is only true in our Professional Lives !

Voter apathy is well recognised phenomenon. No doubt caused by our pulverisingly boring politicians.

Paradoxically politics should not be boring. It should be about passion!  A passion to change things for the better, for the majority, for the country, or for humankind. 

The reason why you have not heard of “medical meeting apathy” is because I just made the term up. I have seen it creeping in over the last 20 years.  Many past colleagues and research compatriots are nowadays never seen at medical meetings. Perhaps they feel that they can keep up to date by reading journals and looking up the occasional guideline on the BSG website? No doubt, the institutions they work for are happy to keep their noses firmly pressed against the rockface. Furthermore, partners and young children are rarely pleased to see you go away.  How is little John going to get back from Rugby camp on Sunday? Who is going to take young Phillippa back from her dance classes on Tuesday? 

Taking a little “me time”, away from the coalface not only make us better doctors, but also more fulfilled human beings.  Furthermore, a larger membership base makes it more difficult to ignore Gastroenterological issues in Brussels, Whitehall or wherever the corridors of power lie.

So how can we claw back some territory lost to “medical meeting apathy”?  The UEG Week 2013 has several new features attempting to do just this. Naturally, you can still ask questions using your mobile telephone, but you can now also linger after presentations for a more in-depth discussion with speakers.  Daily, round table discussions have also been introduced.  To encourage participation, there is even a free lunch!  Will more tedious topics such as viral hepatitis, be provided with a better lunch?  In addition, there are more “tandem talks”, whereby two presenters thrash out the ins and outs of some topic.  For the Postgraduate Course, I have been paired up with Dieter Hahnloser to debate the “Management of Dysplasia in Colitis”.  We have put something special together. 

Some other controversial topics have been juxtaposed such as Guy Boeckxstaens who argue that refractory GORD is all about the acid pocket, versus Ronnie Fass who believes that it’s all in the brain (does he mean in the mind?).  Fernando Azpiroz talks about functional disorders being part of the lifestyle versus Robin Spiller who believes that it is post-infective. Naively, I am surprised that there is nobody arguing that its usually in the patients head. I guess that its no accident that I am an endoscopist. There is also a session looking into non-invasive monitoring of liver disease (biomarkers vs elastography).  Can’t help to think that we can get all the prognostic information in reply to 3 simple questions: a) Do you have a Job?  b) Do you have a Drivers License? c) Do you have a Wife?  If the patient replies "No" to all 3 questions, the prognosis is grim!

For those poor people left behind, manning the coalface, there is “live streaming” from 2-3 sessions every day. Furthermore, 3 sessions will be recorded and published online by Tuesday 15 October; “Multidisciplinary management of IBD”, “Non-invasive testing and staging in GI and Liver Disease” and the Monday morning Opening Plenary Session. Finally, your friends and colleagues can monitor your social activities on the new Live UEG Social Wall.

By the way, don’t miss an opportunity to see my latest, hot dance moves in the "Wasserwerk" on Sunday evening! 

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.
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