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Post by dtt on Jul 17, 2009 9:04:19 GMT
Hi Pete ( can we drop the suffix now please) If a patient comes into me with sensory loss that I find on a routine examination surly it is my duty to refer that patient on to the GP to make the diagnosis though blood testing or whatever to find out the cause ?? I cant just ignore it ?? Every patient I send off to the GP is always told "it is a precaution" and the GP will follow it up if the blood tests prove positive. I also tell them what to look out for as a routine in diabetic foot care. I am a DM2 so I have a vested interest in the early diagnosis of diabetes so that perhaps is one reason I build the test into my primary assessment also John McCall designed my practice management system which has the screening forms built in which makes it a lot easier time wise. Cheers Derek
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jbb
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Post by jbb on Jul 17, 2009 11:03:38 GMT
Hi Pete,
the ethics committee turned this down for a number of reasons :
1. the use of a glucometer in this situation would be a completely random measure of blood glucose levels, and therefore have a massive false positive outcome.
2. leading on from this, the potential for psychological stress on a vulnerable patient is huge - imagine you have a high BM reading on the glucometer, and you are told that this means you could potentially be diabetic - the impact this has not only on the patient, but their family, and possibly their means of earning a living, is extremely high. add to this that their result could be a false positive, and you may be leaving yourself wide open to litigation. I know it sounds far fetched, but think of it this way - patient comes in, has a random BM that's fairly high, makes an appointment to see the GP, who arranges for a fasting GTT. This may take a few weeks, during which time the patient is highly stressed and worried. After the GTT comes out perfectly normal, the patient is angry that you, the original practitioner, knowing the high false positive rate of random blood glucose measurement, and the unnecessary trauma they have gone through, may well be justified in seeking legal action. Remember, you as the practioner, no matter what your discipline (so opthalmologist, pod, physio, etc), should understand the process of any tests you perform, and the implications of the outcome, as well as the reliability of the tests. If you know that the test in question is known to be highly unreliable, then you should not be doing it, and as such are not fulfilling your duty of care, and may even be negligent. Bear in mind that the Ethics Com doesn't just have Uni staff, but also GPs, members of the SHA, PCT managers, and where there is a clinical aspect, usually a consultant in that clinical specialism, so in this case it involved and Consultant in endocrinology.
3. A further, and extremely important reason for non-approval was that if a patient is sent along to their GP after the random BM, who bears the cost of further investigation, who then takes responsibility for that patient - this may seem a daft point, but the general consensus from the GPs on the committee was that they have neither the time, nor resources, to deal with an influx of people who, to all intents and purposes, are the worried well.
These were the three main reasons why that project was turned down, there were lots of other smaller things, mainly procedural, but when added together were insurmountable.
The comment about this being out of the remit of an opthalmologist has no place - if that was the case then you would have to prevent the sale of glucometers to the ordinary man on the street - anyone can carry out this kind of testing, it's nothing to do with professional remit. So you could do it, but it is completely pointless, and a waste of time. I've also seen projects for the same kind of thing presented by Pods to ethics committees, and they been turned down for the same reasons.
JBB
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10feet
Junior Member
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Post by 10feet on Jul 17, 2009 18:28:46 GMT
Jbb
Thank you for your thought provoking answer. OK most of my response was wide of the mark, all but the vulnerability of the pre and post diagnosed diabetic patient as they go through the dawning realisation of the implications of the condition.
The number of times I am the first port of call for the post diagnosed diabetic thanks to the rumour of no longer being allowed to cut toenails. I don't whip out the testing implements and declare them sensory deficient, we sit and we talk. Many times I am the first to explain what diabetes is, in terms average Joe can understand and what the short term and long term implications are. So often that talk settles many concerns and the patient can move on to rationalise the future, listening to and "hearing" the advice offered by each healthcare provider who is involved in the post diagnosis process. Oh and if fit and able the patient is encouraged to continue to cut their own toenails in the confidence that really nothing has changed since pre diagnosis on that score!
DDT
Sorry no, I love my new moniker and I wear it with pride. I will continue to use it as I see fit just as you do with Silverback.
Even with your rationale I cannot agree with the reasons you give for sending all patients with sensory changes to the GP. Jbb states very succinctly why in points 2 and 3 of her response. Surely you need further evidence of diabetic symptoms before you refer onwards for blood test - tiredness, irritability, weightloss without trying, increased frequency of urination, increased thirst.
I would certainly be using my diagnostic skills and looking at other reasons for sensory loss before referring to a GP.
I cannot detect a 10g monofilament, hopeless at detecting temp differential and vibration perception, forget it. Wonder why? What questions would you ask me or would you refer me to the GP with suspected Type 2 Diabetes?
Pete the Prat (PTP)
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Post by dtt on Jul 18, 2009 16:22:05 GMT
Hi Pete It's DTT actually although perhaps there are some that wish I would DDT ?? I was awarded the mantle of " silver backed gorilla" by those kind thoughtful folk on TFS so I feel it would be terse not to use it . You awarded yours to yourself after making an error of judgement. We have forgiven you now forgive yourself and drop the suffix please ,bashing yourself up helps no one Of course I ask relevant questions before sending the patient !! I make a considered judgment on each patient if I consider there is a possibility they are diabetic because of my primary assessment ( which includes loadsaquestions about their health) then I refer them on for further testing. Sorry Pete I'm not into the "must not frighten the patients bit" in the Nanny state we live in today. If as a health care professional I believe a patient has a condition and refer them on it is done with compassion and in a sensible way not as some of the drama queens of today's mindset do and the patients are happy to comply and in some cases take the trouble to contact me to thank me for my care in picking up the condition. Now what would they be Pete ? Cerebral Cva ? spinal nerve entrapment or Vascular PAD /PVD ( which would need a similar referral anyway) ?? Sorry Pete dont understand that bit ?? Cheers Derek
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10feet
Junior Member
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Post by 10feet on Jul 18, 2009 17:34:27 GMT
Derek
My profuse apologies for the slip of the finger. Derek it is from now on.
It can be insulting when forum posters name call unless one has a good sense of humour.
But don't you think Jbb gave us a thought provoking response? Worth debating?
PTP
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Post by Admin on Jul 18, 2009 20:04:43 GMT
I certainly do! I'm loving this thread.
Intelligent but passionate debate. What I'd hoped for!
Thanks for the information there JBB. That is a HUGE ethic question. Is it better to worry 99 patients needlessly than miss 1 potentially life saving diagnosis.
I suspect we will all have individual views here but the thought which springs to my mind is this. We routinely terrify patients who ARE DM with the advice we give and the potential consequences of not following same. Is that different?
Regards Robert
PS JBB, I'm assuming you're judith. If so drop me a pm or confirm here and I'll enter you as a moderator.
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jbb
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Post by jbb on Jul 18, 2009 21:24:29 GMT
yes, its Judith - I cannot tell a lie!
Interesting point about routinely terrifying patients who do have DM - does it work?
To add my twopenneth about when to refer, yes I'd check the clinical tests, but would only use these once I'd asked more pertinent questions. I've always felt very strongly that clinical tests are the last thing you do, and their place is to support (or not) the diagnosis you suspect. In the case of someone with loss of sensation, evidence suggests that over the age of around 70ish vibration perception is lost anyway, lower in smokers and those on certain medications, plus sensory perception generally is known to decline with advancing age, so a loss of sensation wouldn't really be a major flag for DM in a typical elderly patient.
Looking at your symptoms Pete, one of the earlier questions I would ask would be had you had any injuries to your back, or disc problems, I'd also want to know if you'd had and kind of central nervous system problems. Yes, DM would be something I'd consider, but along with many other things. I'd also try and found out your alcohol intake habits - a very common cause of neuropathy in those who enjoy a wee drink on a very regular basis !!
Going back to the ethics debate about worrying 99 and finding 1 postive diagnosis- this is the approach used when looking at potential maliganant melanoma - if in doubt, refer on immediately. So what do you think the difference there is?
Judith ps, it is a Saturday night, so please forgive my not putting in the evidence that backs up my comments about sensory loss - I'll find time to do it sometime tomorrow as it's way past my bedtime, and my cocoa and Terry Pratchett await.
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Post by dtt on Jul 19, 2009 11:56:25 GMT
Hi Judith et al My question is , if like me you screen for sensory loss in all new patients ( I should add to that in my case my average age in the practice is around 40 years old and have very few elderly patients) and as I instanced the patients in question are in the 50/60 age group, is it reasonable to assume that finding sensory loss, your questions would then be guided toward arriving at the possible cause DM being one ?? That puts the testing first and the questions second ( in reality they come at the same time during the testing) and once arrived at the suspected diagnosis is it correct to refer on to the GP for further testing ?? I find it amazing that virtually anyone you speak to in the 50/60 age group is on Statins, Sartans and other hypertensive medication Rxd by the GP on NICE guidelines and to ? expand the income for the GP practice in the process and now the GP's are moaning about it I do not believe it is ethical to ignore a symptom that is apparent and once you arrive at a conclusion on that patients diagnosis to do nothing about it. That is the remit of the GP IMHO, if they feel it is not appropriate for whatever reason to carry out further testing,then that is their choice, not yours, then there can be no legal criticism leveled at you. The referral must of course not be guesswork and must be arrived at by thorough means but nevertheless , refer we must, again IMHO Cheers Derek
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jbb
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Post by jbb on Jul 19, 2009 18:11:15 GMT
Sorry DTT, but I have to disagree with you unequivocally - questions first and then testing. If you do it the other way around then you run the risk of limiting the scope of questions that you ask. Tests are only ever used when you have a diagnosis in mind - if you carry out tests without having an idea of what's going on, then you're on a hiding to nothing - this is exactly what the med students are taught to avoid - you can order all the tests in the world, as many times as you like, but if you don't know what direction to look in, you're wasting both time and money. Taking your point about screening for sensory loss, if I took the line you suggest then it infers that I am already making the decision that any patient with sensory loss is likely to have DM - there are so many other reasons for sensory loss it's too risky to give everything a blanket 'diagnosis'. Yes, I agree it's not ethical to ignore what may appear to be a symptom, but I'm not sure where this comes in this debate - I don't think that's what was said. The point made was that as a GP, to be inundated with 100 people (for example), 99 of whom don't have a problem, is a huge burden on their resources. If you spend as much time in the company of medics as I do, then you soon come to realise that the practice of medicine is not the purely altruistic process that you think. Yes, they do hand out some medication like sweeties, but you might find that there are funding incentives linked with things like that - hitting targets for getting X percentage of patients doing certain things ticks certain boxes, which raises the income for the practice - have you not heard of QOF ? For a bit more info, have a look at the following link (you might need to cut and paste into your browser): www.telegraph.co.uk/health/healthnews/3478550/Government-GP-targets-turn-the-NHS-into-a-game-to-make-money.html You'll find this explains the blanket approach for statins etc I think. When it comes to referring to the GP, I prefer to do so when I think there's something genuinely amiss, rather than send anything that 'might' be a problem, and naff off the GP with pointless referrals. That way, when I do send them something, they know it's because I have a genuine concern, and they take me seriously. Judith ps, assume you mean anti-hypertensive medication ? Hypertensive medication might be a good idea though - think of all the further targets they could reach be giving patients hypertension, and then reducing it back to normal levels again!
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Post by dtt on Jul 20, 2009 14:23:21 GMT
Hi Judith I cant help feeling we are at crossed purposes here ? but anyway if not then I cannot agree with you sorry. I have always believed in the art of good diagnosis is to ask the right questions and know how to interpret the answers alongside a thorough examination of the patient to find any SIGNS that may help you to arrive at a diagnosis. so Are you saying that whilst your asking questions you never find and examine the pedal pulses for example?? What can you learn to help toward your diagnosis from them ?? Your are "testing" the ability of the heart to get blood to the feet are you not ?? Would you start a "sharp treatment " without doing so ?? As you are with questions alone . But Judith we are not "Med Students" we are Podiatrists and have nothing like the requirement or range of testing Doctors need or have, thats why we refer. Perhaps I'm missing something here ? I dont see how you arrive at that conclusion ?? If I cant find a DP pulse it dosent mean the patient automatically gets referred as PAD ,they may be one of the % of the population that has not got a detectable DP pulse even with a doppler. Unless he has got other signs and symptoms then I rule that out BUT I still doppler for a PT pulse if I cant palpate one. By the same token whilst I examine a patient which includes talking to them I do some sensory testing which makes up PART of the examination when all is complete I will arrive at a diagnostic conclusion and act from there. . Judith I have had 42 years in healthcare many of my friends that I worked with in my previous life as casualty officers are now GP's, Consultants ( a Consultant Doctor is my associate in my practice) and very good friends so yes I think I know a little bit of what goes on Exactly the point I was making to you in:- Agreed As they do when when I refer Sorry Judith that should have read Sartans or Other Hypertensive medication ( meaning to treat Hypertension I have amended it) Sartans as I'm sure you are aware are an Anti Hypertension medication. I wouldn't let a GP see your suggestion they will all be trying it , and pouring ice water on the tills to cool them down!! ;D Cheers Derek
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jbb
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Post by jbb on Jul 20, 2009 15:44:27 GMT
DTT - I think there must be some crossed purposes - I didn't propose 'no testing', but questions before testing - both there, but in a different order to your strategy.
If I didn't mention examination explicitly, then apologies, I tend to use 'questioning' in a more global sense, to include questioning, observation, and examination / palpation, but on reflection I can see why you picked it up to mean something different.
Yes, we are not med students, but I was using the argument as a general principle, which is applied to all health professionals - nursing, AHP, and medic. Its an approach which is widely accepted as being the best use of resources, and underpins the diagnostic process for everyone, no matter what their speciality.
It's OK to have differing opinions on these things - sometimes there will never be a consensus, and I'm happy to agree to disagree, but sometimes the whole point of the debate gets lost in the minute details, which is probably what's happening here. It's a pity that we've moved away from the original area, which was the ethicality of random screening, rather than the specifics of an individual's clinical assessment (valuable though that is).
PTP - you've disappeared from the debate, would you like to come back in ?
Does anyone else have an opinion on the original issues?
Judith
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Post by dtt on Jul 20, 2009 16:18:04 GMT
hi judith Then we agree, as you said a misunderstanding on both our parts sorry . I don't believe we have ?? I routinely screen for sensory loss as a part of my initial examination which may lead me in the end diagnosis to suspect DM and refer on. I don't believe that to be unethical. That was the original subject which pete thought was wrong. Please carry on from there I will give John McCall a shove ,he is a diabetic specialist pod and I have discussed this with him on several occasions. Perhaps he will come into the debate and explain more fully his views on diabetic screening. Cheers Derek
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Post by johnmccall on Jul 20, 2009 16:29:32 GMT
Hi Folks,
Del has given me a shove - I've loads to read in this thread so will have to get back to you when and if I get time soon. Too busy doing it while you're all talking about it! (Only kidding!!) Good discussion though.
Cheers John
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Post by dtt on Jul 20, 2009 18:00:12 GMT
John Thanks mate When preferably than if please ;D Your input I believe will be invaluable ( wot a build up I give you ;D ) Cheers D
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10feet
Junior Member
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Post by 10feet on Jul 20, 2009 21:09:07 GMT
Hi Jbb
Have had a couple of days away from feet. Back to the grind tomorrow!
Interestingly I would follow your system of assessment rather than Dereks. I would honestly find the rigidity of testing all patients as per Derek's method too inflexible. A 7 year old's (with VP) assessment would be so different to a pregnant 36 year old with O/C as again would be the 86 year old attending for palliative care. My assessments are as varied as the patients and as I am not treating any medium to high risk diabetics, I seldom test for sensory loss, certainly not as routine especially if it is not paticularly valid to my treatment plan. All credit to Derek if this is his method and congratulations to him for being involved in 1st line diagnosis of diabetes. I shall not be following his example.
I find my assessment follows a simple routine (apologies for non technical language) - get patient to tell me what is wrong, explain what they have got then work back to why they may have this problem via medical history, podiatric history, testing if necessary, referral onwards if beyond my scope of practice or GP intervention required. I find robust patient involvement is key to every diagnosis I make.
Going back to my inability to detect monofilament - leather like soles needing more emollient, occasional sciatica partly due to RTA many years ago and poor posture at work. Think I can detect very hot and very cold, but the temp differentials we use in the clinic situation, no chance. Also being 50, a touch of the old arthritis here and there in the feet may have reduced sensitivity. Never tried a neurothesiometer but seiffer tuning fork, I just can't detect. Blood glucose test, fine - tested 6 weeks ago on a routine visit to GP.
Thankfully alcohol consumption is under control - although one can celebrate with the rest. Never smoked.
PTP
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