GPs, Stop Putting Your Fingers In It!

Urologists call for GPs to stop doing DREs for suspected prostate cancer

The British Association of Urological Surgeons (BAUS) wrote a statement this week, backed by ProstateUK, calling GPs to stop using the ‘finger test’ or ‘rectal exam’ in patients with a raised PSA to investigate prostate cancer. Interestingly, they didn’t choose a medical journal or official medical account as the medium for communication, they chose The Times newspaper.

They are calling for an end to the routine practice of performing physical exams. They offer a clear message to GPs: Raised PSA? No need to do a physical exam - just refer for an MRI to rule in or rule out cancer.

The appeal is obvious. We know that rectal examinations are invasive and painful, and a deterrent for some men seeking help. Maybe this is about reframing public perception - with prostate cancer being brought back into mainstream attention with high profile cases such as the cyclist Chris Hoy.

The sensitivity of rectal exams for prostate cancer is also underwhelming. BAUS wanted to align itself with modern technology and research that confirms the accuracy of MRI and targeted biopsy such as the PROMIS trial. This message towards GPs had the tone of your eye rolling father who forgives you when you forget to follow his clear instructions.

A General Practice Lecture

GP’s will fire back by saying DREs are performed as they are still found within NICE’s Prostate cancer guidelines and their local urology dept referral form still insists that a DRE is done for the referral to be accepted. Calling GPs out of date is superficial messaging.

No one denies that MRI and biopsies are more accurate than rectal examinations, but they are also expensive and come with significant risks. We cannot afford to refer everyone. If BAUS wants change, start with NICE. Rewrite the referral forms. Invest in MRI capacity. Don’t tell GPs to stop using a tool they’re required to use.

Admits the messaging and bold headlines, some additional clinical nuance seems to have been forgotten in the messaging. There are countless GPs who will have a story of a hard, craggy prostate in a symptomatic patient (with a normal PSA) who went on to develop cancer.

If the PSA comes back as normal (as they do in 20% of men diagnosed with prostate cancer) and we don’t examine prostates, this may lead to false reassurance. This sentence should also find itself in the messaging.

Some GP’s also decide to examine the prostate is the initial consultation before PSA results are back, but this new guidance seems to suggest to wait for PSA results to return. This would, of course, mean booking the patient for a second appointment slot to examine the prostate if the PSA result returns back normal.

Robotic Surgery and The Future of Surgical Training

The robotic surgery revolution is here! The NHS has announced a major expansion in robotic surgical capabilities, with the aim of pushing up the 70,000 operations a year currently performed robotically to around 500,000 procedures by 2035.

Robotic procedures generally involve less blood loss and nearby tissue damage, and patients tend to recover faster.

Surgical training programmes therefore, need to make sure that they keep pace. Trainees must become proficient in robotic techniques, but not at the expense of open surgical skills. There will always be cases where converting to an open approach is necessary, whether due to unexpected anatomy or intra-operative complications.

If we train surgeons to operate only with robots, we risk leaving them unprepared for the moments when they need to rely on traditional methods.

These reports have all been passed on to Rachel Reeves, who will be nervously looking at the price tags of these robotic systems and the infrastructure needed to house them.

Unless the capital funding is present to pay for the robots, we risk creating a system of regional inequality where only some patients have access to robotics.

Medical Turf Wars: Boundaries & Power Struggles

What the turf war between Cardiology and Interventional Radiology can teach us…

We are told that the multidisciplinary approach underpins our profession, lined by a belief in collaboration and teamwork. Beneath the surface however, the territorial nature of medicine is very much still alive. Whilst patient outcomes are often at the heart of these debates, it would be disingenuous to exclude status and control as other variables at play.

Cardiac Lab Take-Over

Coronary angiography and angioplasty was created by interventional radiologists in the 1960s. Soon after, interventional cardiologists dominated the development and promotion of percutaneous coronary intervention, showing interventional radiologists the exit from cardiac labs.

The loss of coronary angiography from interventional radiology was the first ‘turf issue’ faced by interventional radiology. Cardiology was able to establish turf control by owning the full patient care pathway - from diagnosis to follow up, whereas the radiologist would be dependent on referrals to take on new work.

What can we learn from this about turf wars in medicine? Ownership of the patient pathway seems to be crucial. If you can self refer to your own speciality and follow those patient’s up afterwards, that gives you leverage.

Whilst radiologists may celebrate the fact they do not take ownership and therefore full responsibility of the patient’s care in their own hands, this factor seems to be a contributing reason why cardiology emerged as the turf war winner.

The rise of endovascular technology has led to a similar tension between vascular surgeons and radiologists. As open surgical procedures declined, more vascular trainees spent time undergoing fellowships in endovascular skills. US figures show that the number of endovascular procedures increased from 340,000 in 1996 to 750,000 in 2005. There is clearly an abundance of work out there that seems to only be moving in one direction.

Not all turf wars are procedural either. The discovery of Helicobacter Pylori and it’s pharmacological treatment with proton pump inhibitors in the late 20th century effectively ended a century of surgical practice in peptic ulcer disease. A genuine turf war never arose from this discovery however as the patient outcome data was unequivocal.

PPIs improved outcomes on almost every data point, preventing life threatening complications and the prospect of surgery. It would seem therefore that when the data suggests a clear benefit for patients, turf wars don’t ensue.

Could we see a similar story play out with the advent of semaglutide treatments like Ozempic, causing a shift of the caseload of obesity away from bariatric surgeons and to the endocrinologists?

Factors Controlling Turf Wars

Ultimately, patient outcomes still seem to serve as the rationale for which speciality claims a clinical space. But this alone doesn’t tell the full story. We can’t forget the importance of narrative and who owns the patient’s story.

If a speciality is able to take ownership over the full patient pathway, (self-referral ability and long-term follow up as two examples) then it has a logistical and economical argument for asserting its dominance over a clinical area.

Interventional procedures are a modern marvel and are one of the most innovative frontiers in medicine today. It is a speciality that will continue to grow in the near future. One may look at this expanding workload and claim that there should be plenty of work for all parties involved, if the egos involved allow for it.

“Always appreciate the pre-op note reminding me to avoid hypotension, hypoxia, and acidosis — Thanks, was personally thinking of letting the patient become hypotensive and hypoxic”

“We have a crazy taxation system where the eligibility for free childcare means anyone who has young children and is (lucky enough) to be earning £105k is many thousands of pounds WORSE off than someone earning £99k, leading to big incentives to going part time or using salary sacrifice schemes - How is our taxation system like this?” (IFS report here)

“Was on nights and didn't realise senior in ED was an ACP until the point they asked for a CT abdo for ?perf/?malignancy. When I asked them to repeat their exam & Hx with specific questions/pmhx fact finding - I ended up doing CT mesenteric angio for ischaemia/angina which was proven. This is where a well rounded and knowledgable Radiologist is paramount.”

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Some things to review when you’re off the ward…

• Hospital consultants and SAS doctors are voting in an indicative BMA strike ballot—joining resident doctors. The government’s 4% pay offer has been labelled "an insult" amid demands for 35% increases to match inflation and restore real terms. (The Independent)

• Doctors everywhere still struggle to get their head around clinically differentiating between Type 1 and Type 2 Myocardial Infarctions - well the guys at JAMA are here with a fantastic and honest article titled: ‘Differentiating Type 1 vs Type 2 MI: Still More Art Science’.

• Six senior figures in England’s Medical Profession wrote a letter to The Guardian regarding resident doctor strike action: ‘In our view the NHS is at a more perilous state than at any time in our careers. A doctors’ strike would further diminish the ability of the NHS to deliver, and play into the hands of those who don’t believe in an NHS – publicly funded [and] based on need not want’.

• Rachel Reeves’ spending review is out and some are saying that Defence, NHS and social care are the only real winners. Reeves has announced an extra £29bn per years for the day to day running of the health service. Our health service now has a budget the same size as the national income of Portugal.

Weekly Poll

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Would you encourage or discourage your child from studying medicine?

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The Chancellor’s Spending Review: Now or Never For The NHS

The Chancellor’s spending review was released last week with many claiming that the NHS, social care and defence were the only clear winners. Other departments such as Environment, Food and Rural Affairs and Culture, Media and Sport received outright budget cuts. Reeves boasted an additional £29 billion per year for the day to day running of the health service along with a 50% boost to the NHS technology budget - but as written in the IFS this week, one still has to wonder whether this will be enough for our NHS.

Some political commentators call NHS funding a ‘black hole’, as it seems to take up a greater proportion of our budget whilst approval ratings fall. The NHS is so vast and economically complex, there is a worry one could continually pour money into it with little to no outcome to show for it. Perhaps this recent sentiment is a hangover from ten years of austerity measures and repeated cuts to the NHS between 2009-2019, damage that may take just as long to undo.

Wes Streeting has promised plans to make the NHS fit for purpose. For this government and the NHS, it feels like it is now or never.