Faith in the medical profession may have waned a little since the era of my grandparents. In their day the GP’s word was gospel. Even so, the majority of the public today would probably place the recommendations of their doctors above that of a herbalist like me. Yet in the intervening years physicians have become increasingly out of step with the medical literature, and in many cases at a loss to deal with modern patients’ health issues.
In my last article I reported on a study demonstrating the remarkable benefit of a gluten-free diet in Tourette syndrome, which led to huge improvements in symptoms and quality of life. Yet, the idea of treating a Tourette’s patient this way would be wholly outside the thinking of pretty much any doctor or specialist in the country. More incredibly, I bet that even in ten years time this will still be the case, because doctors and specialists DO NOT READ THE RESEARCH!
Yes, I know that was written in shouty all-caps, but I’m at the point where I need to let off a little steam.
So, Dr Milton Packer, an old-school GP, has recently shared his horror at the illiteracy of his colleagues in an article published on MedPage Today. He explains that he remembers the days – not so long ago – when physicians kept up with the literature, by diligently subscribing to the leading 3 or 4 journals in their field. They managed to scan the titles of each month’s issue and read many of the abstracts. If a paper was particularly interesting they might read the entire text.
But, he bemoans, those days are gone. Physical copies of journals are no longer sent to physicians homes, but they instead receive email notifications of new electronic issues. Like most emails these get a cursory scan, before being passed over.
Dr Packer points out that whereas once a busy physician might pretend to be keeping up, they now openly admit they are not. The sense of guilt has gone. He describes the shocking response when he addressed these points at a meeting of nearly 200 young physicians.
I asked how many actually read an issue of any journal that was delivered to them, electronically or physically.
The answer: Zero.
Did they at least read the titles of the lead papers in the New England Journal of Medicine every week?
No one did.
Did they pick one journal in their field of interest and try to keep up?
Not a single hand went up.
Then I asked the most revealing question of all. When is the last time that you read any single paper on any topic from start to finish?
Shaken, I asked why no one was reading any papers. The answer was: We don’t know how to read them. And most papers will subsequently get contradicted by another paper published somewhere else. So it makes no sense to read any single paper.
This is an appalling state of affairs. It means there is a growing split between the research community – who are at least obliged to read the literature pertinent to their field of enquiry – and the physicians who this research is supposed to inform. The audience for research papers is diminishing fast, and in many cases papers are published that only get read by other researchers.
Consequently, any patient with a particular medical condition can go online to PubMed and look up dozens of pertinent papers that their GP will not have the first inkling about. With a couple of week’s research most members of the public with at least a modicum of scientific literacy can easily exceed the expertise of their GPs and even specialists.
For a practitioner like me who focuses on the nutritional aspects of disease the door is wide open: The links between diet and disease have become clearer and clearer in the last 20 years, so that by taking a functional-medicine approach I bring about dramatic improvements in my patients health (see my testimonials page for examples of these), and it’s all supported by a real evidence base.
For the majority who are blind to all this and place their trust in the presumed wisdom of their GPs, the outlook is often bleak. If their health problem is one of the growing number of multi factorial , autoimmune, complex syndrome-like conditions most physicians simply don’t have a clue where to start. Too often I hear stories of missed diagnosis or misdiagnosis, a failure to join the dots between symptoms, and a reluctance to undertake testing. Too many of my patients have been told by their GPs and consultants that ‘there is nothing more that can be done’ or that their condition is a mystery, or that the next step is to cut out part of their bowel… when there ARE alternatives IN THE MEDICAL LITERATURE. (Sorry, I’m getting shouty again).
Patients are even told – unbelievably – that they are imagining it. Yes really. Patients in serious long-term pain, are told they are ‘making it up’. It’s as if most doctors have been trained with a medical model from the 1960s; As if the research from the last 50 years had yet to arrive on these isolated and far off shores. How strange that the internet has made information both closer and further away!
So what is the evidence for my claim of their ignorance? The epidemic of metabolic diseases – what they vaguely call ‘lifestyle diseases’ – which have exploded in the last half century. If they had kept up with the literature would they be quite so impotent in the face of rising obesity, autoimmune disease and diabetes? Would they accept such poor outcomes for their patients leading to newspaper headlines like these:
In the NHS alone as many as 20 million people are living with two or more conditions and ineffective treatment is leading to escalating costs and early deaths.
To hammer home the points I am making, take a passage from our May 2018 News Round-Up:
Type 1 diabetes: Medpage Today (May 7th) reports on a study that surveyed 316 Type 1 diabetics and found that those who followed a very low carb diet (less than 50g per day) achieved excellent blood sugar control. Overall, 97% of these participants achieved the recommended glycemic targets of the American Diabetes Association.
Several points to note:
(1) The low-carb patients had excellent blood sugar figures. Very few diabetics under standard NHS protocols get anywhere near these results.
(2) Functional Medicine practitioners like me have been treating type 1 diabetes with a very low carbohydrate diet for at least 10 years*. Yet we have been up against it with diabetes nurses and endocrinologists working against this approach, even describing it as dangerous and frightening patients to ‘get back on the carbs’.
*See this 2008, fully referenced article, explaining how the Polish doctor Jan Kwasniewski, was successfully treating type-1 diabetics with a low-carb diet back as far back as the 1980s.
(3) Notice that this study was observational – they did not put patients on a low carb diet, instead they identified patients that had put themselves on the very low carb diet. In other words these patients had worked out what to do for themselves.
(4) Finally, a prediction: I bet that this paper will have ZERO IMPACT on the management of T1 diabetes in the National Health Service during the next fifteen to twenty years. I’d love to be wrong, but…
As well as losing touch with the research literature, the majority of physicians are losing their diagnostic and small surgery skills. I have heard this first-hand from a number of old-school doctors – ones that trained 20 years ago or more – who are frustrated that they can no longer use the skills they were trained in. They are barred from doing so. These functions have been passed to the specialist. Now a phlebotomist nurse takes blood, so the GPs no longer do. Likewise with small surgery: only one of the doctors in the practice carries out those procedures, so the other doctors lose those skills. Even once-routine procedures like taking blood pressure has been hived off to a nurse, in a room, with a machine. Not long ago, a GP was not only able to carry out all of these separate functions, but he used them within an integrated, holistic approach to provide a thoughtful, skilful, general medicine for patients that he knew. Half a century ago it would not have been uncommon for a family doctor to have treated three generations of a family and be aware of their familial health patterns and contributing circumstances. Few GPs today attend births, and few do home visits.
So, the ‘general’ in General Practitioner has withered away. GPs are now little more than policy men, policing the NICE guidelines; keeping on the straight and narrow; gatekeepers, regulating the flow of people who get to see the busy, busy specialists, who themselves are overwhelmed and impotent in the face of the modern epidemics because NONE OF THEM ARE READING THE LITERATURE. And even if they did, are any of them confident enough or free enough to implement what they learn? I doubt it very much. And I think they know it. Which is why they no longer bother to read the literature.
Hats off to Dr Packer for addressing this important topic. And hats off to him for keeping up with the literature: His personal area of focus is heart failure and he claims to read dozens of papers per day! Well that beats my efforts: I only get though a couple of dozen per month. Incredibly, though, that probably puts me well into the top 0.1% of physicians in the country!
Next time you need to visit a doctor remember they have taken the path of least resistance and become zen masters when it comes to the research literature… indeed ignorance is bliss!