Managing diabetes is not all about expensive medication

After 2 1/2 years, Dr Justin Coleman finishes as Editor of the Diabetes Management Journal. He will continue to remain involved with the DMJ, as a member of its Editorial Advisory Board. This is his final editorial.

Around 100 articles have hit this editor’s desk over the past 2½ years, journeying us through a hundred different aspects of managing diabetes.

The desk itself has gone on a journey too, when last year I transported it from Brisbane in the southern half of Australia (yes, check the map) to almost as far north as you can go. The Tiwi Islands just cling on to the nation, counterbalancing Australia’s only larger island—Tasmania—on the opposite edge.

In terms of diabetes issues, the people walking into my general practice have considerably more in common with East Timor to the north than with most Australians to the south. Here, type 2 diabetes (T2D) is so common that it is a general expectation.

My small community of 1600 includes 22 people on haemodialysis, with almost as many again waiting in the big city to ‘return to Island’ when a haemodialysis bed becomes free. Where I live, ‘new bed available’ has become a sad euphemism to mark the ultimate end-point of our diabetes and renal management.

So when an article lands on my desk discussing cutting-edge technology around the artificial pancreas, or a drug research breakthrough, I have to remind myself that most Australians live in surroundings where these advances will improve lives. This progress heralds an exciting future for those who are already effectively accessing what we have now, and many readers of the DMJ will soon be delivering it. Exciting stuff!

Yet in my time at the helm, I have also made sure to commission plenty of articles that go back to the basics, to ensure we do them well. After all, it is at the ‘blunt edge’ of medicine—far from the news headlines—that most health gains are made.

Primary health care, rather than the specialist diabetes clinic, is the health home of most Australians who have T2D. A few dip in and out of tertiary clinics and private hospitals offering advanced complex care, but it is the daily work of general practitioners, diabetes educators, dietitians and exercise physiologists—often generously supported by endocrinologists—that meets the bulk of the care needs for Australians with diabetes.

If asked to list the things that really matter, I’d note that diet, physical activity, weight loss and simple, cheap pharmaceuticals (hypoglycaemics and cardiovascular preventatives) carry the load. Management of these basic factors does not require much advanced technical knowledge, but absolutely requires skills around ‘what is likely to work’ for the individual with diabetes sitting in front of us.

Take something as simple, cheap and basic as physical activity. By any measure we know it is beneficial for people with diabetes; let’s not limit the claim—it is beneficial for life as a human!

For a sedentary person, the end-goal of ‘more activity’ is backed by more research than a health professional could possibly need, and has greater health benefit than any front-page medical advance this century.

Yes, the goal is obvious, but not so the solution.

After all, that same goal would equally apply to a Brisbane business executive attending a corporate health check and to a Tiwi man I opportunistically pluck from my waiting room. The real skill—the subtle art—is in finding the ‘solution’: an approach to management tailored to that individual.

The  exec may benefit from their GP having read DMJ articles about High Intensity Interval Training, tai chi (see p23) and barriers to exercise, while my clinic staff might take more note of DMJ features on poverty and diabetes, free community exercise programs and exercise with diabetes complications.

A sedentary lifestyle, a poor diet, and an obesity issue are all wicked problems that demand that the health professional has access to a kit full of evidence-based, low-tech tools. Selecting the right tool requires communication, trust and an ongoing relationship nurtured over time.

Sometimes the intervention will involve something new, exciting and shiny—wearable technology or a novel drug class—but don’t confuse the ‘thing’ with the ‘process’.

Diabetes management is no sprint race.

The Feb 2020 edition of the DMJ is available here.

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My perfect medical statistics day

I don’t know how others celebrated International Statistics Day, but I decided to dedicate an entire morning clinic to the cause.

If I’m honest, I usually drift into the old habit of seeing each patient as an individual, but for once I made a concerted effort to treat everyone as a statistic.

I didn’t want any atypical patients ruining my outcomes, so I worded up my receptionist Joan about who to book in.

“Please exclude anyone who has heart failure, doesn’t speak English or is on two or more medications.” She raised a dubious eyebrow. “Oh, and I want them allocated randomly.”

Joan’s eyebrow went decidedly bell-curve. “Randomly how?”, she protested. I gave her a coin to toss and a friendly wink. She means well.

The first patient on my list was “Baby 4136 (gender blinded)”. Joan had received my memo about de-identification.

Continue reading
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GP Sceptics podcast 13: Nurses’ conflicts-of-interest


Few ever talk about it, but it’s not just doctors who are courted by the medical industry. Nurses are also frequently targeted when it comes to promoting pharmaceuticals and medical devices.

Barely anyone except Quinn Grundy talks about it, in fact, so Liz Sturgiss and Justin Coleman point the microphone at this registered nurse who did her PhD on that very topic.

The extent of what Quinn reveals will surprise you…it most certainly surprised all the nurse managers who were sure she would find nothing when she started digging.

From surgical devices to wound dressings and pharmaceutical purchasing committees, it turns out nurses have far more influence on where money gets spent than most people assume, not least the nurses themselves.

The only ones not surprised are the companies who have been pouring substantial resources into reps educating nurses, thereby ensuring their brand features prominently when it comes to spending taxpayers or patients’ money. Unlike marketing to doctors, there are no legal restrictions to marketing to most nurses, and few health services have even considered the issue.

I know nurses at my general practice continue to see ‘educational’ reps who promote expensive wound dressings, glucometers and other devices, a full 10 years after our GPs stopped seeing reps altogether.

The discussions around the ethics of this seem to be a decade behind, within a nursing profession which is otherwise such a champion at the forefront of promoting best practice.

Dr Quinn Grundy is a postdoctoral research assistant at the Charles Perkins Centre at the University of Sydney, soon to assume a faculty position at the University of Toronto.

She has just launched her wonderfully titled book Infiltrating Healthcare: How Marketers Work Underground to Influence Nurses   [The code DNB290818 gives a 15% discount]

Quinn mentions the dataset Pharmaceutical industry payments to healthcare professionals which is my go-to database for discovering the degree of links between doctors quoted in media articles and the pharmaceutical industry. That dataset was almost going to sit on my website here, actually, after a friend of mine collated all the reports mandated under the Medicines Australia transparency arrangements. However, I figured the University of Sydney had better lawyers and thicker skin, so I facilitated its publication there.

Also in the podcast, Liz delves into the Therapeutic Guidelines series and finds they come up clean as a whistle when it comes to independent expertise. Such a fantastic evidence-based resource for prescribers! Justin interviewed Susan Phillips, the CEO of eTG, at the recent GP18 conference.

In the final segment we look at the latest controversy from wonderful troublemaker John Ioannidis who has dreamed up a world where professional associations don’t get to author their own guidelines.

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A textbook case walked into the room


Textbook rash with a ponytail, by Ben Sanders

Four days ago, a textbook case of pityriasis rosea walked into my room. Well, technically it was the girl who walk in…the rash was just a hanger-on. But to me, the rash was everything.

The more I looked, the more textbook it became. It was as if a Murtagh’s patient education handout had grown legs and a ponytail.

The lesions weren’t just red—they were salmon-pink. Salmon-pink, I tell you.

If an Atlantic salmon had leapt into her T-shirt and flopped around in a “Christmas tree” pattern for a few minutes before being sustainably released back into the ocean, those lesions could not have looked more classic.

“And I don’t suppose that oval patch on her back appeared 7-14 days ago did it, Dad? Goodness, see how the scales attach to the outer border of this herald patch like a collaret? Your daughter has become a thing of rare beauty Mr Smith! A textbook case.”

Note to self: it is more exciting to diagnose a textbook case than to father one. Beauty, as it turns out, is only skin deep.

Addendum: the modern man neither knows nor cares what a collaret is, which is somewhat of a shame. The dapper legacy of the early dermatologists has been supplanted by the drab business tie.

Back to textbook cases, however. Have you noticed how few there are about, these days?

Not just rashes, but all the classics seem to present rather half-heartedly. Continue reading

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Vitamins: mostly harmless, mostly profitable

VitaminsVitamin D is mostly harmless. Sure, it can cause toxicity (mainly hypercalcaemia), but usually at megadose levels of around 60 capsules per day.

Vitamin C is also mostly harmless. My parents, advised by the medical zeitgeist when I was a child, gave us one citrus-flavoured tablet every day during winter.

And extracted fish oils are mostly harmless, except of course to the extractees: the fish.

Another thing these three supplements have in common is that they are all wildly successful products of health marketing. Marketing that uses ordinary doctors to amplify the message…doctors like you and me.

Arthur Dent (upon reading the description of planet Earth in The Hitchhiker’s Guide to the Galaxy): “Is that all it’s got to say? Harmless! One word?”

Ford Prefect: “I managed to transmit a new entry off to the editor. He had to trim it a bit, but it’s still an improvement.”

Arthur: “And what does it say now?”

Ford: “Mostly harmless.”

Douglas Adams

As highlighted recently the US has seen almost a tenfold increase of vitamin D sales in the last decade compared to the previous. Yet a recent meta-analysis  of 33 randomised trials showed that vitamin D or calcium supplementation has no effect on the incidence of fractures.

After years of venerating the “D”, it seems the vitamin is more often a marker associated with an illness rather than its cure. Continue reading

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Post-truth therapy: alternative medicine with alternative facts



Sweeping out the dirt


Being a medical sceptic is a hard gig, these days. Our negativity cops bad press; we lack the faith of traditional healers, the chutzpah of health bloggers and perhaps even the imagination of Donald Trump.

Lift the carpet to scrutinise the evidence for surgical procedures or pharmaceuticals, and detractors will point out that at least western medicine eventually responds to scrutiny – so how about first sweeping out the badlands of alternative medical practices?

But, take a broom to the dust at the foundation of so many complementary medical claims, and devotees will tell you to first get your own house in order.

We critics get used to sweeping criticism.

So, when the RACGP approached me last month to write their official submission to the Senate Report on the TGA reforms, I keenly obliged.

Over the last couple of years I had written the RACGP Choosing Wisely recommendations, aimed at reducing unnecessary procedures and treatments. Or, if some staunch traditionalists are to be believed, conspiratorially aimed at undermining the very basis of our rights as doctors to order whatever we want.

Having disturbed the peace at home, the TGA submission was a chance to kick up some dust over at Alternative House.

“More than a thousand claims…the majority are unscientific”

The issue is the bill before the senate that will allow manufacturers of complementary and alternative medicines to make therapeutic claims for their products without pre-approval. Marketers will be allowed to choose a claim from a selective list. Continue reading

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Drug seeker basted me like a turkey

Turkey, by Ben Sanders

Illustration: Ben Sanders

This month I got done over by a drug seeker. Tattoo Man basted me like a Christmas turkey, peppered me with garnished praise and slow baked his way through my seasoned outer crust. Bugger.

Usually, when it comes to slamming the script pad shut, I’m all Fort Knox.

Reception deliberately sends all hopeful newcomers down dead-end street to my brick wall. Five minutes later they exit, loudly proclaiming to the waiting room that, in effect, my clinical decisions are being influenced by the rather unlikely combination of both my genitalia and distal GI tract.

Funnily enough, those occasions are relatively easy. My patients in the waiting room know me well enough to guess what might have happened. And everyone knows their role: the receptionists blame me, as instructed, and I blame our Practice Policy—the only thing I’ve ever written which remains unsigned.

“Sorry madam, I’d love to help now that your grandmother mistook your oxycodone for pot plant fertiliser, but Policy says no. Those bureaucrats in Canberra are blighters, aren’t they!” Continue reading

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48-second GP consultations

Less is less

A recent BMJ study highlighted the remarkable degree of international variation in how much time GPs spend with their patients.

In Pakistan, a patient with a laceration would barely have time to explain how it occurred, let alone have it sewn up.

Whereas in Scandinavia, by the time the consultation ends, the wound has already healed by secondary intention.

Of the 67 countries studied, Australia ranks pretty much where you would want it – our 15 minute slots put us in the top quarter. Generous enough for a country that can afford it, without being inefficient.

Half of the world’s population—predictably, the poorer half—spend less than five minutes with their primary care doctor.

A couple of minutes is all you get in Nepal or China, regardless of how long it took you to travel to the surgery in the first place. I suspect there’s not much chit chat about the family.

KahnemanReading about consultations long and short made me think of the book ‘Thinking fast and slow’. Its author, Daniel Kahneman, won a Nobel Prize in Economics, so presumably he can think pretty fast when he has to. Continue reading

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‘Junior’ doctors: what’s in a label?

junor doctor

Image: ITV News

When is a junior doctor not a junior doctor?

The answer is not ‘When they grow up’, but ‘When they work in the UK’, according to England’s chief medical officer.

The ‘junior’ descriptor was flagged last week by an Oxford professor as being ‘unjust, progressively inaccurate and detrimental to self-esteem.’ Chief medical officer Dame Sally Davies agreed with him that hospitals should consider updating their nomenclature for doctors who have only recently graduated.

However, the online response from the not-senior-doctors themselves has been less supportive.

Some noted that delineations in levels of medical responsibility already do exist, for very good reason, so obscuring them with a more cryptic title helps nobody. Tell it like it is!

The ‘junior’ debate is merely the latest in the endless series of quandaries about naming groups of people. If there is one, universal rule about labelling for any population that is a minority or vulnerable, it is this: after a decade or so, the name gets on the nose.

I recall being amazed as a medical student when I discovered ‘spastic’ referred to muscle tone. Hard to believe it had once been an acceptable description for a disparate group of people whose care needs were defined by reduced mobility.

In my schoolyard, of course, the term was pure insult, and had been replaced by the far kinder ‘disabled’. Kinder for a decade or so, until that descended into the same sociological mire, to be superseded by ‘person with a disability’. Continue reading

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GP Sceptics podcast 12: Doctors’ resilience


By Kat Ritchie


What keeps a doctor resilient, when dealing with a high-pressure job helping patients who are distressed and traumatised?

How can doctors balance empathy with self-care? Does easing a patient’s burden imply carrying it for them?

Dr Genevieve Yates teaches the art of resilience to doctors around the nation, and here we distil one podcast-worth of her wisdom.

Listen to it after a long day at work, or when you’re feeling vulnerable.

Even better, listen in bed, where Justin’s soporific opinions will guide you towards a replenishing sleep. Look after yourself, folks.

In Liz’s Special Source, Liz takes a look at the funding and influences behind ‘Therapeutic Guidelines’ — hint: it comes out clean.

Liz reveals her pin-up nerdy-researcher boy (Justin’s is Ben Goldacre), and we invite Dr Google into the GP surgery.

All this and more, in our final podcast for this ‘RACGP Year’ (October to October).

NEXT UP will be our live podcast at the annual RACGP conference in Melbourne. (Yes, that IS Justin’s photo on that link page. My, doesn’t he look worth listening to!) 

We invite all of GP17 to join us in an hour of fun as we go live for the first time on the Saturday morning, at GP Sceptics live podcast – Interpreting media headlines.

Our Guest:

Dr Genevieve Yates is a multi-talented GP who does a little bit of everything. She is the RACGP Queensland Censor, teacher for MDA National, facilitator for the Black Dog Institute, was previously Assoc Director of Training for NCGPT, and has won Australia’s Medical Educator of the Year. She is an accomplished author, plays violin in the Australian Doctors’ Orchestra, acts on TV and on stage, and co-wrote GP the Musical. Quite frankly, she makes us sick.


Balme E, Gerada C, Page L. Doctors need to be supported, not trained in resilience BMJ Careers, Sept 2015

Kearns H, Gardiner M. The Ultimate Time Management Guide for GPs (and in fact anyone in general practice) Published by Thinkwell

Beyond Blue National Mental Health Survey of Doctors and Medical Students 2013

Heneghan C, Goldacre B, Mahtani K. Why clinical trial outcomes fail to translate into benefits for patients 

Interesting reading: 

Doctors’ Mental Health Program A Beyond Blue program for health services

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