Breast surgeons rock

It takes a long time for medicine to embrace new ideas and change practice accordingly. Research, too, is painstakingly slow.

Surgery is slightly different, however. Surgeons can make small adaptations to standard operative techniques, adding their own refinements to existing procedures without absolute proof that their innovations are truly beneficial. They can merge procedures in the hope of improving outcomes for their patients.

When I was a medical student my mother was diagnosed with breast cancer. It was a fraught time as my little knowledge only served to make me feel utterly unable to guide her. She opted for a total mastectomy followed by immediate reconstruction, a major undertaking but one that was curative and the right decision for her. But that decision was not based on sound medical evidence, only her own preferences and the recommendations of her brilliant surgeons.

Now a unique audit into breast cancer surgery has produced the first national figures on how patients view the outcome of mastectomy and breast reconstruction surgery and has found that these innovations and adaptations made by the surgeons on the front line have paid off.

Eighty-eight per cent of women felt they had always been treated with respect and dignity while in hospital and 90 per cent rated the care they received as excellent or very good. More than 90 per cent were very satisfied with the competence of their consultant surgeon, and 85 per cent were very satisfied with the professionalism of the team.

More importantly, these data have finally confirmed that women prefer to undergo a breast reconstruction at the same time as they have their cancerous breast removed, so they never experience the trauma of seeing themselves without a breast and the fear of feeling less feminine. Eighteen months after reconstructive surgery, 85 per cent of women reported feeling confident in a social setting most or all of the time. Women who underwent mastectomy without reconstruction reported less positive results.

Women who chose breast reconstruction at the time of their mastectomy also reported higher levels of emotional and sexual wellbeing than those who underwent mastectomy alone.

When we are supposed to be practising only evidence-based medicine it is good to have confirmation that we are indeed getting some things right.

Losing the alcohol war

There seem to be many small rebel factions working against the Government. Alcohol has inspired the latest.

Six health organisations have walked away from the Coalition's new proposals to regulate alcohol designed to reduce drink-related illness and deaths. The deal is supposed to see supermarkets, pubs and drinks manufacturers all pledging to do their bit to reduce harmful drinking, for example by labelling items with the number of alcohol units.

The Royal College of Physicians, the British Liver Trust, the British Association for the Study of the Liver, the Institute of Alcohol Studies, the British Medical Association and Alcohol Concern have all rejected the deal. In my book, those are bodies that ought to be listened to.

One of their main concerns - to me, entirely justified - is that in formulating these plans the Government has allowed the drinks industry to drive the pace and direction of the policy.

It does look like a massive PR exercise on the part of the drinks manufacturers. They can now heavily publicise their apparent concern by making a noise about any minor changes they decide to make to alcohol levels or labelling of their products and so come out with increased sales to a hoodwinked public. It won't make

the slightest difference to our health, however.

The cost to British society occasioned by alcohol is estimated at £25 billion each year. That includes both health and crime and disorder costs. When I investigated this myself for a television programme it was clear that most drinkers have no idea how many units they consume at each sitting, or even how poisonous alcohol can be at high levels. It follows that clearly labelling cans and bottles with easy-to-read information about the number of units within them, safe drinking levels and a warning message about not exceeding these levels is a must, but it is not a solution.

The World Health Organisation has stated that action on alcohol must fall into three areas: affordability, availability and promotion. I'm not sure it is that simple. Look at countries that have strict alcohol laws and expensive drinks and it can be seen that the populations binge-drink more than in the UK and have high levels of alcoholism. The only difference is that levels of alcohol-related crime and violence are lower, almost certainly because the drinking is covert.

While I know it sounds pessimistic, I rather think we irreparably screwed up when we first legalised and promoted alcohol. It is a crippling example of exactly how hypocritical and ill thought-out our stimulants laws are. Just look at our drink-driving laws where the public has basically been told that a bit is OK, a lot is not, and left to try to figure it out for themselves. They don't, and people die. Sadly I fear that now it is too late, that we can never back-pedal fast enough to reverse the damage and that there is now no satisfactory solution to this problem.

Patients struck off in NHS budget reforms

The Government's reforms to the NHS are the biggest and boldest the organisation has seen since it was formed 60 years ago.

For the first time, and amid considerable controversy, the vast majority of the NHS budget will be put into the hands of family doctors.

Health unions and royal colleges have already said that they have "extreme concerns" about greater commercialisation of the NHS but I am enthused. Surely if anyone is going to know where money is most needed and best spent it is the GPs on the front line?

But some of the other proposed changes have been nothing short of ludicrous. I have written already about my mistrust of the proposal that GPs offer email consultations, and now another money-saving suggestion has been made by someone who is clearly totally out of touch with reality.

Thousands of patients face being removed from GP practice registers if they have not seen their doctor for six months. NHS managers claim that this is to ensure lists are accurate and up to date but GPs are obviously concerned that many patients will be struck off without reason and then forced to re-register when they actually need to see a doctor. The scheme is to be tested in London initially but could be rolled out elsewhere if judged a success, something I hope is unlikely.

Everybody needs to be registered with a GP, even if always seemingly fit and healthy. The age group that will suffer most from this scheme are the twenty- to thirtysomethings who are rarely ill purely because of their age. This scheme may simply panic patients into popping along twice a year to take up an appointment slot for no reason other than to ensure they remain on the books.

I don't subscribe to the argument that everyone should be going in for an annual check-up anyway - this usually throws up more issues than it solves and will take considerable time and money.

Over and above this it is men, already notoriously bad at going to doctors in the first place, who will be most likely to be removed from lists.

Women have far more reasons to see GPs because of contraception, smear tests, breast exams and pregnancies. Men have none of these issues and therefore will rarely go to GPs before the age of about 50 when the prostate starts playing up. If the current proposals go ahead I would estimate that 75 per cent of men in the UK will be without a GP after a couple of years.

Counter-arguments include the theory that GPs keep "ghost patients" on their books in order to boost their annual income; doctors receive an annual payment of up to £100 for each person registered, regardless of whether they have had any treatment. Of course, I can see that there is a need to crack down on this and tidy lists up, but having a criterion of removing those who simply haven't been for six months shows a misunderstanding about how health services are accessed by the younger generations and will only serve to further alienate a cohort of patients whom we are only just managing to win over.

GPs can't spot every disease

Monday marked the fourth International Rare Disease Day, which saw patient organisations from more than 40 countries converging around the slogan "Rare but Equal" to stress the need for closer collaboration between patients and researchers and to shed light on the challenges rare disease presents to both patients and health professionals.

This clearly inspired the more depressing reports that quickly followed about how our GPs are missing one in four cancer cases, sending patients away having dismissed early warning signs as minor ailments.

It has long been reported that Britain has one of the lowest cancer survival rates in Europe.

Experts blame late diagnosis for the alarmingly high death rates.

More than half of those with the rarer cancers, which account for around half of all cases, have to see their GP repeatedly before they are finally referred to a specialist.

Rare cancers include kidney, thyroid and gall bladder cancers, and those of the blood and lymphatic system such as myeloma, leukaemia and lymphoma. They are difficult to diagnose as the symptoms are often vague or similar to many other more common conditions.

The reasons for this apparent failure are certainly multifactorial but include the simple fact that if you don't see a condition very often then you are highly likely not to think of it as a possibility. Coupled with a reluctance and dislike among doctors to have to diagnose something grim and break the news to a patient, and you can see why these results may be occurring.

These reports did initially cause me to briefly question the wisdom of what I have long considered to be the single most useful rule of thumb any doctor needs to know. First described by the 14th-century logician and Franciscan friar, William of Ockham, and known as "Occam's razor" it suggests that "entities should not be multiplied unnecessarily". A more useful interpretation for scientists is "when you have two competing theories that make exactly the same predictions, the simpler one is the better".

It means a common condition is probably more likely to be responsible for a patient's symptoms than a very rare one. This remains true for most cases that GPs see and will probably be the guidelines under which most practise, even if subconsciously.

By sticking to this adage doctors will be correct for most of their diagnoses, and only the few incidences of rarer disease may be missed.

Rare cancers can be hard to pick up, and the recent reports of patients who made multiple trips to GPs and to A&E and still failed to get diagnosed suggest that it isn't always the doctors who are at fault but the subtleties of diseases that we are still a long way from fully understanding.

Regular GP refresher courses about the more infrequently seen conditions have been suggested as a possible solution but I certainly wouldn't like to be the one who has to sell this idea to our already overstretched doctors.

Red meat - what's the beef? Dr Christian Jessen

Red meat is again arousing strong - and conflicting - passions in those with opinions about what's good for us. On the one hand, the Department of Health is warning Britons to cut down on our red meat consumption because it increases our risk of developing bowel cancer.

Under its new guidelines, adults are advised to eat no more than 500g a week. On the other hand, last week the British Nutrition Foundation claimed that most adults ate "healthy amounts" of red meat and the link to cancer was "inconclusive".

Finally, nutritionists have got in on the act and declared that lean red meat such as steak is healthy and one of the best sources of iron, and that women in particular are shunning it at the risk of developing anaemia.

So what should we eat? Well, I side with the nutritionists on this one. We need red meat, we evolved to eat it, and women in particular benefit from including it in their diets. The great flaw in all the above arguments is that taking a single food group in isolation and reporting on its benefits or deficiencies is nonsensical.

Foods work together, in combination, to provide their benefits. It's why we advocate a balanced diet with plenty of variety. There is a good reason why we drink a glass of orange juice with our breakfast cereal in the morning. The vitamin C in the juice helps our guts absorb the iron in the cereals.

The truth is that some foods people have traditionally believed to be iron-rich, such as spinach, are not. Despite Popeye's claims, spinach is one of the poorest sources of iron I can think of. Not only does it start with low levels in the first place but it also contains a compound called oxalic acid, which inhibits iron absorption by the gut.

If you add the fact that high-fibre foods such as fruits and vegetables contain chemicals called phytates that can slow down iron absorption, you can see how people avoiding red meat and relying on plant sources of iron are at significant risk of becoming anaemic. In fact, iron deficiency is the commonest nutritional deficiency in Britain.

Red meat isn't perfect. The problems come from two main sources. Its fat content, particularly saturated fat, does increase the risk of heart diseases and cancers, and the chemicals produced when the outside of the meat is charred during the cooking process are indeed carcinogens.

So the solution is very simple: buy lean cuts of meat, don't burn it when cooking, and eat it in moderate amounts. It's an important and nutritionally valuable part of our diets.

Hypnosis is the new way to give birth painlessly

In the middle of huge cutbacks and extensive NHS reform any newly emerging techniques that promise to save money will be welcomed with open arms.

One such proposal seems sound enough: hypnobirthing. An 18-month NHS trial study aims to teach expectant mums how to hypnotise themselves before giving birth as an alternative to painkillers. This will involve learning how to attain a trance-like state during labour in the hope that they will not need costly treatments such as epidurals. First started in the US, it uses self-hypnosis, relaxation, visualisation and breathing techniques to prepare for birth.

Currently as many as 60 per cent of mothers have epidurals and many more use other forms of pain relief, the safety of which has often been questioned. Many mothers enter the delivery suite intending to have a "natural" birth, then understandably demand drugs when the true might of their contractions kicks in.

Hypnosis is successfully used in many other areas of healthcare, including dentistry, well known for its association with pain and fear, and fear here seems to be the key. Most mums experience anxiety and fear about the impending birth, in part due to our society's highly medicocentric approach to birthing, implying that it is a dangerous, painful and scary experience.

Hypnotherapists believe that a lot of the pain of childbirth comes from fear acting on the body to cause tension and muscle constriction. If women can relax and release muscle tension, this causes less pain, more effective contractions and often a shorter labour. It certainly sounds plausible, and the feedback from women who have used it has been consistently positive.

It's even been backed up by several relatively large-scale studies, one of which found that self-hypnosis during childbirth eased some of the pain of labour, lowered the risk of medical complications and reduced the need for surgery. Another study found that hypnotherapy shortened the first and second stages of labour. For women having their first babies, the first stage was reduced from an average of 9.3 hours to 6.4 hours, and the second stage from 50 minutes to 37 minutes on average. The differences for women having their second or later children were less dramatic, and it is here the financial benefits may be seen.

I can certainly see the downsides; this technique will not work for all women. I also worry that medical staff may attend less often seemingly self-sufficient labouring women, so putting them more at risk of complications going unnoticed.

But in general it's harmless, proven in studies, and empowers women to have more control over the birthing process, unlike other ill-thought-out proposals the NHS comes up with.

Marathons can hurt you in the long run

Every year around this time several of my habitually unfit patients march in to my clinic and proudly announce that they have decided to do the London Marathon to get fit. My heart sinks. Running the marathon will not make them healthy, it will probably do quite the opposite.

People forget that the marathon is an extreme event. Even running intensely for an hour a day puts your body under so much stress that it will begin to break down. There is a very good reason why so many committed marathon runners look like they are suffering from fatal diseases.

The intensity of some training regimes, and the lack of efficiency of others, mean that the body will either be seriously damaged during training or totally annihilated by the main event. Here's an analogy: drinking water is a generally healthy thing to do, drink too much and it can kill you.

Some people are built for long-distance running and others aren't, but this is never taken into account. They may be able to push themselves by training and just about manage to finish the course, but will do their bodies no good at all in the long term.

Researchers from the Heart and Stroke Foundation will back me up. By MRI scanning hearts of runners they found that without proper long-term training marathons damaged the hearts of less fit runners. The exercise-induced injury is reversible over time, but could take up to three months.

Poorly prepared runners were also found to become more dehydrated and show greater loss of function of important areas of their hearts.

I fully expect to be bombarded with criticism for writing this, so let me just make what I'm saying absolutely clear: if you want to run a marathon, then do so, especially if you can raise some money for good causes along the way. But make sure that your training regime is suitable or you will almost certainly do yourself more harm than good.

Simon Cowell lacks the pecs factor

Recent photos of Simon Cowell on the beach have been less than flattering, mainly down to the emergence of a bust many women would be proud of.

Surprisingly, given his alleged vanity, his man boobs, or moobs, don't appear to bother him but, according to new research, he is in a minority.

The latest figures show that men are queuing up to get rid of their moobs - in fact, the operation to remove them was the second most popular cosmetic procedure last year, showing a 28 per cent increase on 2009.

Only nose operations had a greater appeal among men.

Men get a drubbing in the media - not to mention down the pub - if they undergo cosmetic procedures but the fear of mockery seemingly isn't putting them off.

Clinics reported a seven per cent increase in men signing up for cosmetic operations last year, compared with five per cent in women.

And moob removals are among the most popular treatments - so what exactly are they?

There are two sorts of moobs. One sort is caused by a condition called gynaecomastia, commonly seen in teenage boys. Firm, tender glandular breast tissue grows under the nipples, under the influence of hormones, and is usually caused by rising oestrogen levels that occur during puberty.

These moobs disappear without treatment within a couple of years. In adults, however, their occurrence is not normal. They are often caused by the conversion of testosterone into oestrogen via the enzyme aromatase.

Affected men may also notice a reduction in muscle mass, a more feminine fat distribution, tiredness and loss of libido. Taking anabolic steroids, certain medicines or using cannabis can also upset hormone levels, causing gynaecomastia, and occasionally it may be due to a tumour or hormonal disease of the pituitary gland, liver or testes.

The more common type of moob is something entirely different, most frequently observed in the middle-aged male.

They are, to be blunt, just fat, caused by poor diet, lifestyle and lack of exercise. This "false gynaecomastia" does not involve any real breast gland growth, and none can be felt. The breast tissue simply feels as it looks: loose and flabby.

Moobs are the stigmata of modern working life, ushered forth by the all-too-commonly encountered combination of stress, booze, lack of exercise and poor diet, and can be tackled by a good overhaul of lifestyle.

But there is a certain degree of crossover between the two types of moobs because testosterone is converted to oestrogen primarily in the fat cells, so the fatter you are the more likely you are to
develop them.

It can all seem very amusing and if you want some alarming examples of man boobs, look at the top 10 page at manboobs.co.uk. If yours look anything like these, it really is time to do something about them.

Moobs can actually signal the impending onset of heart disease, stroke, high blood pressure and diabetes. So it's not that funny at all really.

GP patients have to be seen

The NHS has been in the news a lot recently. Big changes are afoot, and about time too. While I am very aware that it is blasphemy to say so, the NHS no longer works well in many areas, and needs to change. It's a constantly evolving being and the way it is managed needs to evolve along with it. Unfortunately this hasn't happened.

I think some of the new proposals are very sensible. Surely if anyone is going to know where money is most needed and best spent it is the GPs on the front line? I hope this plan works and I welcome it.

There is another idea being touted, however, that I don't think is sensible. In fact, it makes me very concerned indeed. The Government is planning to offer patients email consultations with GPs. People will be able to directly email their GP through a new Communicator tool, part of the secure personal health organiser website originally set up to allow patients to view their records online. Remember what a disaster the NHS IT system was to set up? Doesn't bode well, does it?

It's a move the Government claims will improve access to primary care. The word to pick up on is "access". It may well be improving access but it is certainly not improving care. It may possibly work for issuing repeat prescriptions to those with chronic but well managed conditions, or getting results from home test kits such as blood sugar or BP, to update records, but beyond this? No chance.

There is a very good reason why tradition has dictated that doctors bother to see their patients in person, to talk to them, ask them salient questions and maybe even lay on a hand. It's because patients are not generally very good at telling you what is wrong with them. They need help, and it is not always what they say that gives you the answer. Being able to see them, to read their body language and hear the tone of their voice are vital parts in diagnosis. I'll give you an example: chest pain. "Dear doc, I have pain in my chest, comes and goes, maybe a bit goes to my left arm as well. Should I be worried?"

Chest pain can have many causes, heart attack being one, acid reflux another, but it could also be a simple chest infection or even depression manifesting as a pain. Never could this be worked out from an email without either much back-and-forth correspondence (taking up at least as much time as a face-to- face consultation) or a very informed, educated and impartial patient relating the exact relevant symptoms correctly. It won't happen.

I have had good personal experience of this long before any pilot schemes were tried out. Since my TV shows have aired I have been inundated on a regular basis with emails from people all over the world wanting help, advice and diagnoses. I can confidently say that few are easily or quickly answerable, and few give enough information for any sort of useful reply to be given other than "Better go and see your doctor".

Given that the public is spending £2 billion a week on the health service I think it a very sad state of affairs for medicine if a face-to-face appointment with a GP becomes not a right but a luxury.

Cash for eggs: there are so many issues

Fertility and its management is always an emotive subject that polarises opinion. The views of the public are currently being sought on surrogacy - in the spotlight again following Nicole Kidman's announcement that her second daughter was carried this way - as well as the use of donor eggs and sperm to enable infertile couples to have a baby. More ethical issues are being explored, including whether close relatives should donate eggs or sperm to each other, and if it is acceptable for a baby to be born, through egg donation, to a woman who is also its grandmother.

The debate follows a high court ruling that may have opened the way for surrogate mothers to be paid, a practice which had been banned. If the public concede, then women could be set to receive thousands of pounds for donating their eggs. Currently, British clinics are banned from paying for eggs and sperm directly but can pay up to £250 in expenses - which hasn't exactly filled potential donors with a desire to go through with the process of donation.

The problem with the "cash for eggs" proposal will not be with the well-meaning majority but the unscrupulous few, who will lure in women by making egg donation seem like an easy way to earn money - without any explanation of what actually is involved. Worrying, too, is the possibility of "designer genes" being offered to couples prepared to pay exorbitant fees for the perfect combination of brains and beauty; the higher your exam marks and the better your bone structure, the more your eggs could be worth.

I'm not sure money is the main issue, however. While it's mainly the small amount of cash currently offered to donors that has been blamed for the shortage of eggs, I suspect a greater problem is the recent change in UK law which requires the identity of sperm or egg donors to be revealed to their children - the idea of a load of "surprise" children showing up years after donation undoubtedly puts off many would-be donors.

Maybe the issue is being looked at from the wrong angle, in London at least. The stats for maternal age show that in the UK London has the lowest number of births per 1,000 women aged 25 to 29, and the highest birth rate for women aged 35 to 39. This implies London women are leaving pregnancy until much later, a known risk for fertility issues and the need for donor eggs or even surrogacy. Many have argued that more should be done to cure infertility and to encourage women to have children when they are young and their eggs are still in good condition, instead of worrying about turning body parts into tradable commodities.