Partha Kar

Gastrointestinal symptoms and pancreatic exocrine insufficiency in type 1 and type 2 diabetes

Our review of clinical practice demonstrates that gastrointestinal (GI) symptoms were common in patients with type 1 and type 2 diabetes seen within our diabetes service. In those patients who are symptomatic, we observed that 42% had low faecal elastase 1 levels consistent with the diagnosis of pancreatic exocrine insufficiency (PEI). The presence of steatorrhoea and weight loss alone were insufficient to screen for PEI, and other GI symptoms (such as diarrhoea, abdominal cramps/pain and bloating) need to be additionally sought. Copyright

Differences in level of confidence in diabetes care between different groups of trainees: the TOPDOC diabetes study

BackgroundThere is an increasing prevalence of diabetes. Doctors in training, irrespective of specialty, will have patients with diabetes under their care. The aim of this further evaluation of the TOPDOC Diabetes Study data was to identify if there was any variation in confidence in managing diabetes depending on the geographical location of trainees and career aspirations.MethodsAn online national survey using a pre-validated questionnaire was administered to trainee doctors. A 4-point confidence rating scale was used to rate confidence in managing aspects of diabetes care and a 6-point scale used to quantify how often trainees would contribute to the management of patients with diabetes. Responses were grouped depending on which UK country trainees were based and their intended career choice.ResultsTrainees in Northern Ireland reported being less confident in IGT diagnosis, use of IV insulin and peri-operative management and were less likely to adjust oral treatment, contact specialist, educate lifestyle, and optimise treatment. Trainees in Scotland were less likely to contact a specialist, but more likely to educate on lifestyle, change insulin, and offer follow-up advice. In Northern Ireland, Undergraduate (UG) and Postgraduate (PG) training in diagnosis was felt less adequate, PG training in emergencies less adequate, and reporting of need for further training higher. Trainees in Wales felt UG training to be inadequate. In Scotland more trainees felt UG training in diagnosis and optimising treatment was inadequate. Physicians were more likely to report confidence in managing patients with diabetes and to engage in different aspects of diabetes care. Aspiring physicians were less likely to feel the need for more training in diabetes care; however a clear majority still felt they needed more training in all aspects of care.ConclusionsDoctors in training have poor confidence levels dealing with diabetes related care issues. Although there is variability between different groups of trainees according to geographical location and career aspirations, this is a UK wide issue. There should be a UK wide standardised approach to improving training for junior doctors in diabetes care with local training guided by specific needs.

Re-structuring diabetes education: the passport to success?

continues to be a huge issue for deliberation within the NHS. Despite all the recent structural changes, the focus has continued towards shifting the bulk of diabetes care management into the community. This has led to debate about appropriate health care providers, coordinated models of care and the possible redefinition of the role of diabetes specialists. Published data sets have expressed concerns about the quality of diabetes care being delivered in both specialist and primary care. This has raised questions about the quality of diabetes care against the background of recent health care policies focusing care for patients closer to home, not in monolithic traditional structures such as hospitals. A significant drive towards enhancing education for primary care has thus been noticeable (albeit often in a random ad hoc fashion) aiming to raise the overall profile and understanding of complex chronic diseases such as diabetes. In this article, we discuss opportunities for the delivery of education based upon our local experiences with consideration to altering the education portfolio for diabetes care at different stages within primary care training. The aim of this article is to challenge the status quo and encourage specialists to develop their educator role, acting as an appropriate support for primary care, thus potentially contributing to improved diabetes management closer to home.

Diabetes and general medicine: to couple or uncouple?

The ownership of general medicine continues to be a perennial issue within acute trusts. Over the years, there has been a steady progress towards specialism but, as the world has moved on, patients are older and have multiple disease morbidity; the recent clamour has been to move away from single organ disease to, once again, a more generalist approach. General medicine used to be reasonably simple with all specialists being part of the on-call rota, sharing out patients and using their general medicine accreditation. Though perhaps not enjoyed by all, it certainly generated a sense of camaraderie and the job was shared by all, not by a few. The direction started to change when cardiology as a specialism made the case for becoming a specialty in its own right – with doorto-needle targets becoming an important part of trust requirements. Over time, as has been borne out, this move has had its pros and cons. The pros indeed have been for all to see: better cardiovascular outcomes, especially in relation to myocardial infarction outcomes, and better resourced cardiology units across the country. The benefits for patient care have been many. However, the cons have included the break-up of a sense of camaraderie. Suddenly, one specialty was more special than others. Suddenly, the patient with a myocardial infarction or angina had preferential care, and their own specialist rota and carers; this was intrinsically different from, say, someone with a severe asthma attack or diabetic ketoacidosis. Not surprisingly, others started to follow suit. The gastroenterologists made their, not unjustified, case for ‘bleeding rotas’, the need to have hepatologists, and a separate gastroenterology rota. Elderly care physicians ran the risk of being consumed by the sheer volume of patients, with admissions starting to skew and reflect the ageing population; thus they began to set their own tramlines and criteria. The bond between all physicians appeared to have been broken. We all now existed in silos, wrapped in our own specialties – all correct in their own view, yet incorrect when the bigger picture was taken into account. In between all of this, there still existed the need to see and review patients who did not quite fit into any criteria, and the label ‘general medicine’ was used. That left the respiratory physicians and diabetes specialists being given the burden and the concept of being the teams who looked after patients beyond narrow specialism – and this started to grate as time passed by. The question, quite rightly, was raised about the patients of their own specialism – did they not deserve care better than or at least as good as that of a cardiology patient?

Respect, engage, change – it's time to end the white noise

The burning question at the moment is ‘What we can do to optimise delivery of diabetes care?’ Fundamental questions need be raised as to how far we respect each others professional positions, how far we actually engage with patients and what we can do to improve these vital relationships. We need to look at the power of social media, as to how it could help us engage with each other cutting across all boundaries, whether it be between professional ranks or patients. How can we genuinely put the patient in charge of services, be guided by them to achieve a higher quality diabetes service all across the country?