GP Sceptics podcast 1: Big Soda


In the first of the GP Sceptics podcast series, Dr Justin Coleman and Dr Liz Sturgiss team up to dissect, analyse and sometimes trash medical research that is relevant to GPs.

This first podcast looks at the influence of Big Soda on health research. The good, the bad and the fizzy.


Relationship between Research Outcomes and Risk of Bias, Study Sponsorship, and Author Financial Conflicts of Interest in Reviews of the Effects of Artificially Sweetened Beverages on Weight Outcomes: A Systematic Review of Reviews. PLOS One, Sept 2016

Relationship between Funding Source and Conclusion among Nutrition-Related Scientific Articles PLOS Medicine 2007

Big Soda sponsored 96 health groups — a big conflict of interest, study says. Washington Post, Oct 2016

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Coffee – safe even if your heart is a bit dicky



Heart smart latte

Coffee drinkers with heart issues can breathe a sigh of relief. A new study shows coffee is safe for people at risk of arrhythmias, even if they have heart failure and are wearing a pacemaker.


It seems intuitive that caffeine intake should be limited or prohibited in patients with heart disease. No-one wants to die with a latte in their hand. On the other hand, for a coffee drinker, the idea of facing a lifetime of coffee-free mornings might seem more unpalatable than risking sudden death.

The beautiful news from this well-designed study from Brazil (where they know their coffee) is that this risk is non-existent after all. The heart keeps ticking along just fine, even as the morning fog clears.

The background

Evidence prior to this study had not shown that coffee was risky, but nor was there proof it was safe. Continue reading

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Do GPs ever regret referrals?

Je ne regrette rien

Je ne regrette rien

An Australian study (featured today in Medical Observer) has found prostate cancer patients are more likely to regret surgery than radiotherapy. This had me wondering; if my patient regrets surgery, should I then regret having referred them to a surgeon?

We would like to think our referrals are always based solely on the best outcomes, but can we really claim, as Edith Piaf did, Je ne regrette rien?

Or are we in fact sometimes swayed by factors other than outcomes – things like tradition, familiarity, friendships, or yesterday’s guidelines? It’s hard to identify any one referral as adamantly wrong, particularly if we self-reflect through rose-coloured lenses. But surely not every decision can be all La vie en rose.

If a GP refers to a surgeon in the private sector, the patient usually ends up getting surgery. Something about hammers seeing everything as nails?

So, radiologists advise further radiology and pathology begets pathology. Sure, some private urologists routinely consider re-referral for radiotherapy, but many don’t. This, despite a recent high-quality study showing both produce similar prostate cancer outcomes*. Continue reading

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Pharma targeting nurses for ‘education’



Who’s been talking to Nurse Jackie?

Pharmaceutical companies are increasingly targeting nurses when it comes to industry-sponsored events.

Although nurse-only events are still uncommon (5% of all events), nearly twice as many pharma-sponsored events in Australia now have nurses present than have GPs.


Research by the University of Sydney, published in JAMA Internal Medicine today, examined four years of industry-sponsored events to 2015. A total of 116,485 events were reported by pharmaceutical companies who were members of Medicines Australia.

Nurses were present at 40% of all events, GPs at 21%, while specialist physicians came in top, at 69%.

Of events aimed at a single profession, 5% included only nurses, 9% only GPs, and 18% only specialists.

Nurse-only events were decidedly cheaper for the sponsors:  The per-person cost was only 39% of the amount spent at doctor-only events. Events where nurses were present were significantly less likely to include a served dinner, or to be held overseas.

So, why is money being spent on nurses, at two in five events? Continue reading

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Deprescribing: a fancy word for ceasing?

DeprescribingWhat’s old is new again. Hipster beards are so in, they’re out, and where we used to simply cease medications—we now deprescribe them.

The art of commencing medicinal herbs dates back to Neolithic times. The art of stopping them began about a week later.

Probably why Hippocrates had to remind us to do no harm.

With this history, we gen-dinosaur GPs have recently been scratching our beardy chins wondering how we missed the memo that deprescribing is now a ‘thing’.

Mind you; old or new, learning how to stop medication is critical for patient care. And hopefully, now we have a word for it, tomorrow’s deprescribers will do it smarter and harder than we ever did.

Our generation received no explicit teaching, gleaning what we could from our mentors and, no doubt, from our mistakes.

A recent article in The Conversation highlights the dubious practice of using one medicine to counter the side effects of another. This is fine if the first medicine is vital and the second makes the first tolerable. But more often the medicine cabinet rivals a lolly shop, and vague side effects are ubiquitous.

For the 10 per cent of Australians over 65 years taking 10 or more medications, an antacid or antinauseant may just reflect that the stomach is coping with nine other pills. I’d argue sometimes even the antidepressant is a product of a similar prescribing cascade. Continue reading

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Eat like an Italian

Delicious  portion of  fresh salmon fillet  with aromatic herbs,

The jury is in: the Mediterranean diet saves lives, and plenty of them. Just this week at a cardiology conference in Rome (where else?) another large study confirmed it.

So why is it that I so rarely prescribe the Mediterranean diet for my patients?

To answer that, we must examine the dietary advice of GPs in general and, unfortunately, of me in particular.

But first, let’s look at the new evidence from the Moli-sani study.

A group of 1197 Italians with a history of cardiovascular disease were followed for eight years, and their degree of adherence to a Mediterranean diet was assessed on a 9-point score. The all-cause mortality was 37% lower in those who followed the diet (score 6-9) compared to those who didn’t (score 0-3).

That 37% is huge, by the standards of most medication interventions. In comparison, taking a statin (cholesterol medication) reduces mortality by around 25%.

Ah, but association is not causation, you rightly insist! The study can’t show that the diet is the actual cause of the reduction in deaths. Yet in this case, it probably is.

Continue reading

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Diagnostic health apps: coming soon to your smart phone.

illustration of latest smart phone isolated in white background.

In case you missed the news, last week saw the launch of the smartest medical investigation tool in the world. Or, if not that, then at least last week’s biggest health claim in the world.

Ada, a smart phone app designed in Europe but yet to be launched there, is being tested on New Zealanders and Australians first. The makers suggest it is more than just an app (not a literal claim – it is indeed an app), and instead describe their product as a virtual companion.

The underlying concept is clever. This app is the first to tackle health diagnosis on such a grand scale, and its market penetration will be closely watched by Google, Facebook and perhaps startup companies hoping to access a portion of the trillions spent by US medical insurers.

Everything about its design is big, from the team involved (said to include a hundred doctors) to its capacity to eventually integrate with medical video consultations. It even aims to build a picture of the user’s medical history over time, which will presumably adjust the weightings given to each branch of its diagnostic algorithm.

The RACGP and AMA have both issued warnings about diagnostic apps, pointing out the dangers of relying on their results. The app’s marketers have tried to pre-empt this criticism by building in a function where the app can send a copy of its output to the user’s chosen GP.

Technology enthusiasts may be tempted to dismiss RACGP concerns as doctors trying to keep robots off their turf, but the warnings are salient. The issue isn’t as simple as getting the diagnosis right or wrong.

In algorithmic approaches, the risks of both underdiagnosis and overdiagnosis are high. The former can lead to false reassurance with dangerous consequences for the individual, but the latter is the bigger risk at a population level.

Continue reading

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Paracetamol and pregnancy: what’s the fuss?

1. pregnancy

Could paracetamol be linked to ADHD? Photo by

Yesterday’s study linking paracetamol use during pregnancy with behavioural problems in childhood has hit news headlines around the world, and this morning ranked first among Australian health news stories, according to Google trends.

[Clarification: paracetamol brands include Panadol and Tylenol. In the US, the chemical name for the drug is acetaminophen.]

What is the fuss about?

A study published yesterday in JAMA Paediatrics analysed data from 7796 mothers from Bristol, England, who were part of a prospective birth cohort study in 1991-2. The self-recorded data included maternal use of paracetamol during pregnancy (at 18 and 32 weeks) and five years later, and the presence of behavioural issues when the child was seven years old.

The study found an association between antenatal paracetamol use at 32 weeks gestation and behavioural problems for the 7-year-old children, as measured by a high score on a conduct disorder scale (RR 1.42, 95% CI 1.25 – 1.62) and hyperactivity scale (RR 1.31, 95% CI 1.16 – 1.49).

A Relative Risk (RR) of 1.31 means that 7-year-old children in this study were 31 per cent more likely to score highly on an ADHD scale if their mother said she used paracetamol during pregnancy. Smaller RRs were found for paracetamol use at 18 weeks gestation.

The perfect media storm?

Continue reading

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Does complementary medicine equal anti-vax?


Do any complementary practitioners defend Castle Vaccine?


Ever since Wakefield’s flawed MMR-autism study was published in the Lancet – surely that journal’s biggest regret – attitudes to vaccination seem to have become a litmus test for ‘science’ versus ‘non-science’.

The opposing camps are broadly assumed to lie on either side of a river, with mainstream medicine’s castle on one bank battling alternative health practitioners on the other.

But just how clean is that divide?

A review in the latest Vaccine (by Wardle et al. University of Technology Sydney) looks at all studies that examine vaccination attitudes of complementary medicine practitioners and their clients.

Results from the 39 papers reveal a mixed bag of results that mire the waters; the imaginary river turns out to be more a muddy meeting ground.

The authors point out, “There is no default position on immunisation by complementary medicine practitioners or parents who use complementary medicine themselves, or for their children.”

Attitudes vary depending on different populations, but also on what question is being asked.

A UK survey found that, when asked for email advice, no homeopath and only 5% of chiropractors actively recommended MMR.

In contrast, a Canadian study found that two thirds of all chiropractors in Alberta with children had arranged for their own child to be vaccinated. While this is considerably lower than the national average, clearly not every alternative practitioner is helping fortify the anti-vaxxer camp. Continue reading

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Pharmacy business model: consumers at risk

conflict of interestAustralia’s first comprehensive pharmacy review in two decades, released this week, asks the important question:

“Is it confusing for patients if non-evidence based therapies are sold alongside prescription medicines?”

Let me save the reviewers some trouble: the answer is “yes”.

The harder question, of course, is “What, if anything, should be done about it at a regulatory level?” I don’t pretend to have an answer, but doing nothing at all will be a poor outcome for consumers.

The Review of Pharmacy Remuneration and Regulation (the ‘King review’) can be found here (pdf).

I spend a lot of effort highlighting potential conflicts of interest when it comes to doctors’ prescription decisions being swayed by marketing rather than evidence. But this is merely fine-tuning within a system already ensuring most doctors gain no direct financial reward.

The community pharmacy model is, necessarily, far more prone to financial conflicts of interest. Arguably, this could loosely apply to any business with a cash register, but the health industry requires particularly careful oversight. Continue reading

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