Health professionals ignore their patients at their, and their patients’, peril

Good medical practice is about many things, one of the most important of which I reckon is simply listening. I can’t tell you the number of times individuals have told me they said something potentially important to their doctor, only for it to be either dismissed or simply ignored. Some patients end up being castigated for having the ‘temerity’ to perhaps suggest something (such as a diagnosis) that was not thought up by their doctor or was not consistent with the opinion he or she had already given. I’m not sure this makes for the best health care.

One of the first patients I ever saw when I started in practice was a diabetic who claimed that she could tell from her vision what her blood sugar levels were doing. She claimed that the amount of ‘mistiness’ of her vision correlated well with her blood sugar levels as measured using a meter. When she told her doctor about this he told her she was talking ‘rubbish’ and that this ‘just can’t happen’. But how could he have possibly known that, is my question. Of course he can’t: it’s an opinion, and in expressing it in the way that he did he also risked jeopardising his relationship with his patient too.

Now, in this specific instance, the effects of the failure of this lady’s doctor to listen to her and believe her were unlikely to be too dire. I mean the exchange may well have led to some irritation, upset and loss of respect, but it’s unlikely that the lady would come to much harm as a result of this. However, in healthcare failing to listen to patients can have significant negative consequences, and my blog today is specifically about an example of this. If you are a practising doctor or dietician, you may want to avert turn away now.

I saw a 4-year-old girl in practice this week, brought in by her parents. The mother did most of the talking. In the last year, the girl had developed chronic diarrhoea. The mother decided to keep a food diary and through this thought she had identified wheat as the cause of her daughter’s diarrhoea. She eliminated wheat from her daughter’s diet, and the diarrhoea resolved.

Meanwhile, the girl had been referred to a gastroenterologist. When they consulted him, he recommended that the girl be tested for coeliac disease (gluten sensitivity). The test came back negative, though there was some talk that because the child had not been eating wheat (wheat is the main gluten-containing food in the UK diet) at the time of the test, that the test might have missed the diagnosis (in other words, the test may have given a ‘false negative’ result).

The girl was referred by the gastroenterologist to a paediatric dietician. The mother gave the history again (wheat in the diet – diarrhoea, no wheat in the diet – no diarrhoea) and despite this, the dietician recommended a diet rich in grain including wheat. The child’s parents thought this was odd (given the history), but resolved that health professionals must know what they’re doing and went on to their daughter on the recommended diet. Loe and behold, the diarrhoea returned.

Not keen on the idea that she was knowingly feeding her daughter a diet that was clearly making her child sick, the mother matters into her own hands again and re-eliminated wheat from her daughter’s diet. Again the diarrhoea resolved.

After this, it was time to go back to see the gastroenterologist. The mother gave the story again, with the addendum that the dietician had recommended a diet which made her child sick, so she had reverted to the original diet and her child appeared to be well again. The gastroenterologist, instead of saying ‘thanks for doing my job for me’ berated this woman for being ‘irresponsible’ for taking her daughter’s diet and health into her own hands.

In a degree of desperation and confusion with ‘I’m a bad mother’ thoughts circulating in her head, the mother brought her to me to seek my advice. I pointed out that I’m not sure she needed my advice, as it was obvious (to me, at least) that she had handled her child’s health issue as logically and responsibly as any mother could.

She mentioned that part of the reason that she was unsure about whether she’d done the right thing is because she didn’t have a ‘scientific background’. I pointed out that both the doctor and dietician may be regarded as people with a scientific background, but look where that had got this mother and her daughter.

The fundamental problem here was that neither the doctor nor the dietician had listened to this child’s mother. She maintained to me she had given a very clear story to these people: wheat in the diet caused the child to have diarrhoea, while with no wheat in the diet the child was well. It’s not rocket science.

What is it, though, that causes health professionals to sometimes ignore what patients are telling them, even when it’s blindingly obvious the best thing to do is listen?

Some of the issue here, may relate to an inability to get out of one belief system and into another. If, for instance, someone erroneously believes that a diet rich in grain and wheat is healthy, then it can be a bit of a stretch for them put that to one side, even when sitting before them appears to be a classic exception to their ‘rule’.

Another issue that I think is all too common in medicine is the idea that we health professionals are the ones that know about health, and if someone encroaches on that we can feel like our position has been somewhat usurped. I, like some other practitioners, welcome suggestions from my patients. Not only is it an opportunity to learn, I’ve found they’re almost always right too.

Now just imagine for a moment what would have happened if this mother had, in the long term, taken the advice to feed her daughter the very food that is clearly provoking her diarrhoea? Not only do we have a sick child, but we now have a mother who may feel inadequate for ever doubting the opinion of the health professionals from whom she has sought advice. Not an ideal situation, at the root of which were a couple of health professionals who did a lot of talking but not a whole lot of listening. Fortunately, the mother in the end decided to do some selective deafness of her own.

There’s an addendum to this story I’d like to add. Near the end of the consultation the father of the child told me he had been appalled by the standard of medical care they had been offered (and rightly so, I think). He then recounted an interesting story: after the birth of their first daughter (the daughter with the wheat sensitivity was number two) the mother was quite unwell. She was extremely tired and lethargic, and was found to have some abnormal findings on her ECG (heart trace). The doctors were unable to find out what was wrong with her. The father, in desperation, ‘googled’ his wife’s symptoms and through this came up with a possible diagnosis of hypothyroidism (low thyroid function). He took the diagnosis to his wife’s doctors and asked them to test specifically for this condition. Sure enough, it turned out to be what was wrong with her. By the end of the consultation, I was beginning to wonder whether these parents in front of me had missed their vocations.

As I said, good healthcare is about many things, but I reckon an essential part of this is listening to and honouring our patients experiences and opinions. We health professionals ignore our patients at our, and our patients’, peril.

122 Responses to Health professionals ignore their patients at their, and their patients’, peril

  1. Catherine Collins RD 6 June 2008 at 8:23 pm #

    Ah, I wondered – given the amount of criticism levelled against you these past two weeks Dr Briffa – just when your next pop at dietitians would present itself. A depressingly regular occurence whenever critical attention is turned towards your very own personal interpretation of nutritional and medical science.

    If I recall correctly (and I’m sure you will kindly remind me if I’m wrong), the last blatant and persistent attempt to denigrate Registered Dietitians (lets not forget, the only legally registered nutrition professionals in the UK) was during a period of criticism against self-styled nutritionists such as Mr Patrick Holford and yourself (to clarify for readers, the only link between you being that you are a medically registered doctor who lectures on founder Mr Holfords Institute of Optimum Nutrition course).

    You make a serious point that the care of this child was compromised by the lack of two healthcare professionals, implying that neither professional undertook their clinical responsibilities correcty.

    I do hope that you recommended the parents report both the doctor and the dietitian to the GMC and the HPC respectively, so that their errant practices will be addressed and the care of this – and future – patients protected.

    Not to do so would surely breach your professional conduct as a member of the GMC also – would at least prove that your concerns are serious and not merely presented as a positive media puff to distract public attention from your recent postings on this and other sites and blogs.

  2. MinorityView 7 June 2008 at 12:48 am #

    Anyone remember Dr. Feingold who listened to the parents of his hyperactive child patients and figured out that food additives were causing problems? For many years his work has been discounted, but recently new research has indicated that food additives do cause behavior problems.

    And then there is Dr. Wakefield who listened to the parents of autistic children. His reward has been years of attacks and now a show trial.

    Perhaps listening to patients is too dangerous? To the practitioner’s career!

  3. Megan 7 June 2008 at 8:57 am #

    Our son was born 38 years ago, and by his second year I ‘knew’ there was something wrong. We took him to a succession of doctors, who referred us to a successioin of psychologists and psychiatrists, without success!

    No diagnosis was given by any of these, and when I tentatively asked if he could be autistic, I was shot down in flames. One psychiatrist steepled his fingers, looked at the ceiling, and said “In some cases it is the mother who requires the treatment, not the child.”

    By this time our son was four. I had been told by an experienced child psychiatrist that it was my fault.

    Our son was expelled from his first school, and his second school would only take him if he was a weekly boarder. This was so they could impose their discipline on him – obviously he had to be got away from his bad, bad mother.

    Whenever I spoke to any health care professional about him, I asked if he could be autistic, and still got the same response – I was a stupid woman for asking.

    By the time he was twenty-eight he was bigger and stronger than me. I was frightened of him and his rages, and was heading for a breakdown. As he was an adult I couldn’t do anything about his health care, but I could about mine.

    When I saw my (new) GP I was in tears – I told him my problems were caused by my son’s lack of diagosis, and begged that he do something.

    He did. He asked my son if he would take part in some tests at a local hospital, and my son agreed. He was diagnosed with Asperger’s! This stupid mother had been right all the time, but none of the professionals would listen to me.

    After twenty-eight years my son began to receive treatment. The improvement was so dramatic that he has lived in his own flat for six years now, obviously with a lot of support, but life is so much better for everyone.

    Am I angry and bitter? You bet I am! We all had a terrible life for almost thirty years, thanks to the attitude of the psychologist and psychiatrists!

    Sorry for the rant, but your article hit a nerve that’s still very raw.

  4. Dr John Briffa 7 June 2008 at 9:31 am #

    Catherine Collins RD

    Instead of engaging with the real issue (some spectacularly poor healthcare caused by an inability or unwillingness to listen and take a patient-focused approach) your comments focus not on the message, but the messenger (me).

    Can I draw you back to the real point at hand with regard to the dietitian concerned: the mother told the dietitian that wheat gave her daughter diarrhoea, and the dietitian recommended a diet rich in wheat products. As I alluded to, it’s hardly rocket science to perhaps conclude that a diet devoid of wheat might be the way forward.

    My opinion is that the dietician offered unthinking, illogical, substandard and inappropriate advice. In fact, the advice looks to have jeopardised the health of the child.

    You are the chief dietician at St George’s hospital in London, UK. Imagine for a moment that the events I described applied to someone in your team. Can I ask you to tell us honestly how you would react and respond?

    What would your opinion be of the professional competence of the dietitican concerned? And would you attempt to attack and discredit the person who brought the information to you?

    You describe me as a ‘self-styled nutritionist’. I do not claim to be a nutritionist, though I admit I do believe I have a good grasp of nutritional matters. Some dietitians may disagree with my views, though I note to date not one has been able to provide anything remotely ‘evidence-based’ to refute my claims. This is a matter of great importance, bearing in mind the fundamental impact diet can have on health.

    You go on to claim that I teach at ION. Can you provide evidence for this, please?

    You suggest that I am attempting to distract public attention from my recent postings. Why on Earth would I want to do that? The whole reason for writing them is for people to read them (otherwise I wouldn’t have written them in the first place).

    You make no sense. Just like it makes no sense that you resolutely refuse to engage with issues that have critical importance with regard to the health and lives of the people we serve.

  5. Frank 7 June 2008 at 9:32 am #

    Hi John

    do you think another reason some doctors just don’t want to listen to patients and deal with certain illnesses can be sometime partly because of their fear that they can related to what the patient is saying and don’t want to deal with their own fears, so by pushing away patients and not listening to them is just part of them pushing away their fears.

    by the way john,

    THANKS FOR LISTENING

  6. Apricot Stone (pseudonym) 7 June 2008 at 9:48 am #

    I spent several months with doctors, dieticians, paediatricians getting no help for my baby daughter’s wheat intolerance (I worked it out with a food diary myself). At the final appointment with the paediatrician he intimated that as she had evidence of bacterial infection (can’t remember which one) I was to blame, then said we’ll review her in 6 months. I also couldn’t understand that if I wanted a biopsy done she would have to eat wheat every day for 6 weeks. Why make a child more ill? I didn’t go back, it was a complete waste of time.

    This experience was the reason why I turned to homeopathy. It was a slow process of improving her general health but she no longer has wheat intolerance.

  7. MinorityReport 7 June 2008 at 9:59 am #

    You would think listening to patients is a simple courtesy, and beyond that, good clinical practice. But time and tempers are so short in the healthcare sector these days that the terms ‘evidence’ and ‘no evidence’ can be used to screen out the patient’s own report.

  8. Hilda 7 June 2008 at 10:46 am #

    It is true that professionals have their own ideas which are hard to budge, just as scientists of the day thought and held tightly on to the idea that the world was flat. Kuhn said that science proceeds not by one idea building on another but by revolutions in thinking. We are seeing one now.

    Dieticians do not think about the way wheat is now grown, the change in its chromosomes etc. They perhaps read the conventional textbooks but not the many well researched books books written for the general public. One such id ‘Dangerous Grains’ by Bral. It shows why we should not eat grains.

    I had aclient who suffered severe stomach oains when she ate pasta. I took her off wheat. They went away. Her friend said this was rubbish si she went on it again. Pains returned. Friend said she neede a test to see if she was intolerant. I told her that if she only gets pains when she eats pasta and they subside when she doesn’t that is a test in itself and it IS scientific.

    TRY THE BOOK. IT’s GREAT!

  9. Hilda 7 June 2008 at 10:49 am #

    PS. WHEAT is HIGHLY HIGHLY ADDICTIVE!

  10. Sue 7 June 2008 at 10:56 am #

    Shame on you Catherine Collins RD for your lack of concern and shame on your profession.
    Start giving some bloody up-to-date nutrition advice for a change. Read the new research. I would never ask a dietician for nutrition advice!

  11. colmcq 7 June 2008 at 10:57 am #

    “your comments focus not on the message, but the messenger (me).”

    hahahaaahahahaaaaaaaaa. My irony meter just exploded!

  12. ross 7 June 2008 at 11:33 am #

    Sue, read this again:

    “I do hope that you recommended the parents report both the doctor and the dietitian to the GMC and the HPC respectively, so that their errant practices will be addressed and the care of this – and future – patients protected.”

    Now does this show a lack of concern?

  13. Sue 7 June 2008 at 11:37 am #

    BTW – Catherine Collins RD – for a dietician you seem to be a little bit overweight!

  14. Dr John Briffa 7 June 2008 at 11:47 am #

    Sue – now that’s not fair! A lot of dietitians are overweight. ;-)

  15. Jackie Bushell 7 June 2008 at 11:55 am #

    My husband had IBS for years. It is now gone, ever since he visited a private specialist in nutritional and environmental medicine (there don’t seem to be any in the NHS but that’s another story). He put him on a Stone Age style elimination diet and identified wheat sensitivity, amongst other related problems. He now keeps to a wheat-free diet most of the time and the IBS stays away – unless he overdoes the occasional wheaty foods, when it comes back.

    My point is, what did the NHS gastroenterologist that he consulted around the same time tell him? That there’s no real cure but that he should follow a ‘healthy’ diet full of grain including wheat! Why, when there is so much evidence of wheat or other food sensitivities being at the root of IBS (and other problems) for many people, do such ‘experts’ in mainstream medicine not seem to recognise a modified diet as a potential solution worth trying out at least?

    It seems they are so blinkered by the high carb/low fat/grain and wheat-rich ‘healthy eating guidelines’ that they just cannot entertain the concept of the current ‘healthy eating diet’ not being healthy for some people at all. Or maybe, they do know about these ‘alternative’ beliefs, but do not dare to mention them to patients for fear of being hauled up before the GMC for heresy (yes, this IS happening. Dr Barry Durrant-Peatfield, working in the area of thyroid and adrenal problems, is just one example).

    Whichever the case, mainstream medicine is failing the patient. All of it is about internal politics and entrenched beliefs. Some of it is done in the name of ‘protecting the patient’ from charlatans and unproven treatments. In reality, very little of this actually helps the patient. Some patients manage to self-help themselves by querying what they are told by the ‘experts’, seeking out their own information and making their own informed decisions. Sadly, most still feel the ‘experts’ are God, don’t feel they can question their judgements, and continue to be ill.

  16. ross 7 June 2008 at 11:58 am #

    Dr B – did you recommend that the parents report the doctor and the dietitian to the GMC and the HPC?

  17. Dr John Briffa 7 June 2008 at 12:06 pm #

    ross
    No, it seemed the parents had already come to their own conclusions regarding this.

  18. ross 7 June 2008 at 12:09 pm #

    So they were going to?

  19. Dr John Briffa 7 June 2008 at 12:24 pm #

    ross

    Actually, I can’t say. And neither do I think this is important to the key issue here regarding what looks to me like very poor healthcare rooted in a failure to listen.

    Do you have any views on this?

  20. ross 7 June 2008 at 12:34 pm #

    Why can’t you say? The individuals are anonymous so there are no data protection issues, otherwise you wouldn’t have used them as an example on your blog.

    It may well be poor healthcare, although it is impossible to say as we are being asked to judge your account of the parent’s account of what happened. Often in these cases the situation is more complex so I wouldn’t like to judge this case based on anecdotes.

    I think the key message is that people who experience poor healthcare should be encouraged to complain to the regulators. That is what they are there for. Are you regulated by BANT?

  21. Dr John Briffa 7 June 2008 at 12:51 pm #

    ross

    “Often in these cases the situation is more complex so I wouldn’t like to judge this case based on anecdotes.”

    Yes, but I’m just asking you to judge the case on the account I have presented. What’s your impression?

    “I think the key message is that people who experience poor healthcare should be encouraged to complain to the regulators. That is what they are there for.”

    I wrote the piece, ross, and I can tell you that’s NOT the key message at all.

    “Are you regulated by BANT?”

    No.

  22. Sue 7 June 2008 at 12:52 pm #

    The key message is that people should not be experiencing poor health advice from so called experts – Registered Dieticians (lets not forget, the only legally registered nutrition professionals in the UK)!

  23. Dr John Briffa 7 June 2008 at 12:56 pm #

    Sue – that’s not fair! Don’t forget we doctors. ;-)

  24. pKate 7 June 2008 at 1:29 pm #

    Tell someone to make their or their child’s diet healthier by eating less fatty/sugary/high salt junk food such as cakes, confectionary, battered products, burgers, processed ready meals, highly processed grains etc and they will find a million and one reasons why they can’t possibly do this.

    Tell them to avoid dairy and wheat and dress it up in pseudoscientific claptrap and they will happily pay you for the advice and cut out all the rubbish in their diet at the same time as it’s pretty hard to find junk food without one of these ingredients in it.

    They will feel better and probably loose weight and hail the ‘discovery’ of a wheat/dairy allergy.

    Sadly they are then making it really hard work to have a well balanced diet by cutting out two major food groups and taking away the joy of an occasional fatty snack.

  25. Dr John Briffa 7 June 2008 at 1:39 pm #

    pKate

    “Sadly they are then making it really hard work to have a well balanced diet by cutting out two major food groups…”

    What do you think a child might be missing out on in wheat and dairy?

  26. Sue 7 June 2008 at 1:51 pm #

    pKate,
    I’m sure we can live quite happily and healthily without those two major food groups wheat and dairy.
    There is plenty of gluten-free junk food.

  27. Katrina Woodrow 7 June 2008 at 1:55 pm #

    I too have been patronised by Catherine Collins, some four years ago on the Johnnie Walker Show on Radio 2. I am a mere kinesiologist you see. We aren’t scientific enough for her ilk, even though we do tend to end up sorting out the dietary problems caused by the sort of advice dished out by nutritionists and doctors. The problem with nutritionists and dieticians is that they don’t treat each person as an individual. They seem to have learned by rote what is deemed to be good and bad for people and don’t take into account individual biochemical make up. When I mentioned the general lack of treatment of colonic candida by the medical profession, unless it is oral or vaginal, and said that I do successfully treat it, she said in a very disparaging tone “Oh, that is so alternative.” I told her it was only alternative because mainstream doctors refused to accept its occurrence and treat it. Her main talent seems to lie in self publicity rather than providing any useful help to people. She makes my blood boil.

  28. Jonathan Swift 7 June 2008 at 3:06 pm #

    I do not think that it is appropriate to make personal comments about Catherine Collins weight. This site is supposed to be about helping people not playground bullying.

  29. ross 7 June 2008 at 3:46 pm #

    “Yes, but I’m just asking you to judge the case on the account I have presented. What’s your impression?”

    That there’s probably more to it than you have presented. But that if the parents had a legitimate reason to think that the health care and advice they were given was wrong then they should have been encouraged to make a formal complaint.

    Why can’t you say whether the parents complained? The individuals are anonymous so there are no data protection issues, otherwise you wouldn’t have used them as an example on your blog.

  30. ross 7 June 2008 at 3:48 pm #

    Dr B, I seem to recall that you recommended applied kinesiology in one of your Observer columns. Do you think it is a useful diagnostic tool?

  31. Dr John Briffa 7 June 2008 at 4:50 pm #

    Jonathan
    Actually, I’m not sure that if Catherine Collins is overweight, that this is entirely irrelevant to the debate about the appropriateness of dietetic advice.
    Also, do please read Catherine Collins’ own comments and see if you can detect an element of bullying there.

  32. Dr John Briffa 7 June 2008 at 4:51 pm #

    ross

    “I seem to recall that you recommended applied kinesiology in one of your Observer columns. Do you think it is a useful diagnostic tool?”

    In selected individuals and with the right practitioner, yes.

  33. Robin 7 June 2008 at 4:54 pm #

    My No 2 daughter was eventually diagosed with ISB – Ulcerative Colitis – a good 10 years ago after a difficult period coping with the symptoms without understanding what was happening. She went to both her GP & the Company Doc (Consumers’ Association) and was given a number of wild suggestions. One was that her diarrhoea & bloody stools were caused by an anal fissure. She became so unwell that I went over to Hertford and brought her home to where we then lived. She was 30 at the time.

    She went to our large GP practice and fortunately received an immediate and sympathetic response from one of the GPs. The upshot of it all was that she was referred privately to her former consultant and we trotted off to a private hospital in Reading. Detailed examination and admission was swift (I had never been called “Sir” by any doctor!) as was the diagnosis.

    Drug-based treatment was effective in helping to manage the symptoms, but the key was the good old Internet (which, no doubt, an RD would despise) where our daughter found the Specific Carbohydrate Diet. Since implementing that approach (with sympathetic responses from later consultants) she has married and born two children and IBS is completely manageable.

    Dieticians that have given my wife & I advice about Type 2 Diabetes simply trot out the widely discredited (many studies) high-carb diet stuffed full of pasta, potatoes, bread, etc., etc. I wonder if these dieticians we see are working towards NVQ Level 1. They literally read from a crib-sheet.

  34. ross 7 June 2008 at 5:03 pm #

    “Actually, I’m not sure that if Catherine Collins is overweight, that this is entirely irrelevant to the debate about the appropriateness of dietetic advice.”

    Then why did you dignify Sue’s mean-spirited post with a response? Surely that would only encourage such behaviour?

    So what do you think the mechanism is for applied kinesiology? The evidence base doesn’t look too good and I can’t see a plausible mechanism by which it could work, apart from the ideomotor effect. (I’m assuming that Katrina is an applied kinesiologist rather than a kinesiologist, as they are very different things and I think it’s always a good idea to be accurate in these things.)

  35. Elizabeth 7 June 2008 at 5:58 pm #

    May I politely point posters to an ALSPAC* study published in the British Medical Journal maybe four years ago? The title was “Undiagnosed coeliac disease in a cohort of seven (nine?) year olds”, lead author P. Bingley. This study showed that, out of 5,400(?) children tested for coeliac disease, about 54 tested positive for sub-clinical coeliac disease, of whom only a handful were being treated for this condition. I’ve never claimed to be a statistician but I make that to be 1:100 of the population to be susceptible to/suffering from coeliac disease, mostly without a formal diagnosis except possibly that old catchall “irritable bowel syndrome”.

    I understand there to be a condition that doctors call “toddler diarrhoea” which I’d now like to suggest should be considered to be potentially coeliac disease, tested for, diagnosed and treated where appropriate. N.B. From my personal experience of listening to many parents of autistic children I can confirm that the percentage of autistic children who suffer from gluten and/or casein intolerance is far higher than 1:100. Before you ask, the last time I heard, the MRC wasn’t prepared to provide funding to test how the GFCF diet affected autistic children (please, please update me – I’d love to be proved wrong on this particular point).

    * Avon Longitudinal Study of Parents And Children

  36. Gilly 7 June 2008 at 7:01 pm #

    I have just ploughed through this blog and felt compelled to respond. It’s sad to hear that individuals have experienced poor healthcare – I too have experienced this with my son when he developed a peanut allergy some 10 years ago.

    I also am ‘one of those’ registered dietitians and have been practising within the NHS for 20 years. I would like to stress that I do, as many of my colleagues do, listen to people. My whole ethos is that I treat people as I would want to be treated myself – a crucial part of that is listening. I train fellow health professionals on motivational interviewing and employ this in my daily work. This approach is based on a spirit of collaboration, evocation and autonomy and puts into practice all the basics of active lsitening skills i.e. open questioning, affirmation, reflecting and summarising. The principles of the approach are being empathetic, exploring ambivalence and accepting resistance. I do not read a ‘crib’ sheet to all patients – everyone is treated individually with all their circumstances taken in to account.

    I get the impression that this site has fallen in to two camps – one that slags off dietitians and one that won’t accept that perhaps there are other approaches to things. As registered dietitians we are bound to work from an evidence-base. Perhaps what needs to happen is that our nutritionist colleagues publish some evidence on their approaches and we could all work together happily. Or would this be too threatening to either party? I certainly am not precious about my profession but will be professional in my work at all times.

    As for the reported case that Dr Briffa speaks about – I completely agree with my respected colleague, Catherine Collins, that Dr Briffa had a responsibilty to report this substandard treatment. I certainly would – I have in the past pushed for an ex-colleague to undergo disciplinary proceedings due to incompetency and would not hesitate to do so again.

    Dr Briffa says that the issue of reporting the said health professionals is not the issue ( I would say that it should be a very important issue) but the issue was that the girl was advised to eat wheat. Was there any discussion that perhaps they wanted her to do this in order that they could make a definitive diagnosis? If she has coeliac disease – will she really know this now or is it sufficient for her and her parents just to assume it is a wheat intolerance – end of. As a mother I wouldn’t want to see my child suffer, however, I would prefer to have a diagnosis in order that I could ensure the best possible treatment/intervention/care long term. Surely most parents would?

    So Dr Briffa – I feel offended that you tar my entire profession with the same brush and don’t do what you claim to do with your patients i.e. treat them individually.

    It would be refreshing to see on your site perhaps some debate that didn’t involve such childish tactics by anyone – where perhaps that everyone treated each other with respect. Or is this too much to ask?

  37. Catherine Collins RD 7 June 2008 at 10:15 pm #

    Dr B

    You claim my comments focus on the messenger, not the message. I disagree. I commented on both.

    You repeat that the “advice looks to have jeopardised the health of the child” and asks what, as a dietitian, would I do about it. If I believed the comment above to be true, it would be breaching my HPC Code of Conduct to ignore it. How it would be dealt with (ie locally, or an official complaint to registrant bodies) would depend on the relative views of the parents and professionals ” bearing in mind the perceived accuracy of third party reporting.

    ION teaching. Your website claims ‘Lectures and seminars at the Institute for Optimum Nutrition in London’ http://www.drbriffa.com/about/, and contribute articles for the ION http://www.ion.ac.uk/archives/issue_index.html. ” but perhaps I have that wrong ” along with others such as Quackometer and Dr Aust http://www.quackometer.net/blog/2007/05/holfordism-understanding-patrick.html, and Dr Aust http://draust.wordpress.com/2007/09/22/hello-world/.

    I’m sorry ” your last paragraph makes absolutely no sense to me whatsoever. But I’m sure you’ll take time to explain

    And for all commentators – ‘When the character of a man is not clear to you, look at his friends’ (Japanese proverb)

  38. Hilda 8 June 2008 at 12:07 am #

    To Katrina Woodrow : Dieticians and nutritionists are very different. Usually nutritionists are more likely to take people off wheat and dairy. White flour is just sugar. Dr Briffa is more in line with the ideas of nutritionists.

    I cannot understand why dieticians keep on about high carb eating and the ‘food groups’. the ‘food groups’ groupings are arbitrary in that vegetables and fruits are carbs just like bread etc but more nutritious. I think they have some financial connection to the food indudtry but not sure in what way.

    I did find that one had told a multiple sclerosis patient to eat 3 tablespoons of margerine a day! This is one of the worst foods on the planet, is not unsat fat and is like nothing found in nature. It is a scandel.

    Also if it wasn’t for Patrick Holford, ION and his nutritionists many many more people would stil be ill today.

  39. Hilda 8 June 2008 at 12:12 am #

    PS HOWEVER, I was disgusted to see that someone had written that Catherine Collins is overweight. I do not know the woman but this sort of below the belt jibe is cruel and nasty and not scientific. There are many reasons why people might be overweight. I eat a great diet, am a nutritionist and am overweight as I have a low thyroid not low enough to be treated while my daugher eats twice as mucghas I do, gets less exercise and is a tall size 10.

    THis sort of jibe is fit for silly children and not intelligent adults.

  40. Sue 8 June 2008 at 3:07 am #

    Catherine Collins is mean spirited. If a dietician is overweight it really doesn’t look good. It makes you think maybe the diet advice they are dishing out is incorrect if they can’t even control their own weight.

    I think kinesiology is a good tool for the practitioner to use to confirm what she may be suspecting. It does not diagnose but gives a picture of the person’s constitution. It helps you to see where the person may present problems later in life if they do not look after themselves with a healthy diet and lifestyle.

  41. Dr John Briffa 8 June 2008 at 8:01 am #

    ross

    “Then why did you dignify Sue’s mean-spirited post with a response?”

    There was actually a serious point behind this: many dietitians are visibly overweight. And this does cause some to consider the appropriateness of dietetic advice. And it most certainly does not inspire confidence. This observation is rarely mentioned, but I think it has relevance here (it’s the ‘elephant sitting in the room’, if you will).

    “So what do you think the mechanism is for applied kinesiology?

    Regarding kinsesiology, I’m not aware that’s it’s been systematically studied, and therefore there does not seem to be good evidence either way. My experience, though, is that this modality can be highly useful, particularly with regard to diagnosis. It can sometimes seem to uncover information that can be difficult or impossible to obtain in any other way.

    I have a responsibility to my patients to do all I can to help them, and sometimes kinesiology does seem to provide an invaluable service to them. I actually think it would be unethical not to recommend it where appropriate.

    You ask about a ‘plausible mechanism’, but I’m not bothered with this. There’s lots of things I advise in practice the mechanism of which I wouldn’t necessarily be able to explain fully. This doesn’t matter much to me, and neither does it usually matter to my patients: they just want to get better, they’re not so much interested in why or how.

  42. Sue 8 June 2008 at 8:11 am #

    oops, I was talking about iridology!!

  43. ross 8 June 2008 at 8:43 am #

    “I have a responsibility to my patients to do all I can to help them,”

    Yes you do. So why refer them to a practitioner that will use a diagnostic tool that a) you have no idea how it works and b) haven’t considered the evidence base for? (“Regarding kinsesiology, I’m not aware that’s it’s been systematically studied, and therefore there does not seem to be good evidence either way.”)

    It has been studied and a cursory google would have told you that. A good summary (with references) is here: http://www.quackwatch.org/01QuackeryRelatedTopics/Tests/ak.html

  44. Dr John Briffa 8 June 2008 at 10:22 am #

    ross

    How do you know I haven’t considered the evidence? The question is, is the evidence relevant to my embracing of applied kinesiology in clinical practice?

    When I use kinesiology in practice, it’s chiefly for the purpose of identifying food sensitivities. The evidence cited on quackwatch does not constitute systematic study regarding this application of the modality.

    Also, applied kinesiology is, I think a modality in which there is wide variation in levels of experience and ‘skill’. I refer to an individual kinesiologist who I believe is highly skilled and in my experience provides highly useful information in the main. Even if we had good, relevant science that had been reproduced several times over (which we do not), its findings may not apply to the specific kinesiologist I refer to.

    I’ve already answered your question regarding kinesiology’s proposed method of action: in the main, that’s not an important consideration for me and my patients.

  45. ross 8 June 2008 at 10:40 am #

    I’m not sure why you refer to AK as a modality, as far as I’m aware it’s not a therapy.

    Do the studies referenced on Quackwatch give you pause for thought? Perhaps that there is ‘good evidence either way’?

  46. Dr John Briffa 8 June 2008 at 10:44 am #

    ross

    Pause for thought – yes.
    Change my clinical practice – no.

  47. ross 8 June 2008 at 10:55 am #

    So looking at the state of the evidence, you think that on the balance of probabilities it is likely that AK works as a diagnostic tool as its practitioners claim and it is unlikely that it is just quackery?

  48. Dr John Briffa 8 June 2008 at 11:28 am #

    Catherine Collins RD

    “How it would be dealt with (ie locally, or an official complaint to registrant bodies) would depend on the relative views of the parents and professionals ” bearing in mind the perceived accuracy of third party reporting.”

    Can I ask you to specifically answer the question I posed in my last comments to you which is: ‘And would you attempt to attack and discredit the person who brought the information to you?’

    “ION teaching. Your website claims ‘Lectures and seminars at the Institute for Optimum Nutrition in London.’”

    Here’s what my website states:

    ‘Further education and experience:
    Since qualifying as a doctor, Dr Briffa has taken a special interest in the area of nutritional and naturally-oriented medicine. He has attended a wide variety of training courses, seminars and lectures, which include:

    …Lectures and seminars at the Institute for Optimum Nutrition in London…’

    It appears you have deliberately misrepresented me.

    But this would not be for the first time. See here http://www.drbriffa.com/blog/2007/10/03/why-is-the-dietary-advice-given-to-diabetics-so-often-so-woefully-inadequate/ (comments 39 and 45) for another flagrant example of this.

    Once I had exposed this, you declined to contribute further. But now you’re back, and it seems you’re up to your old tricks too.

    Catherine, how do you think it helps the reputation of your profession to more than once deliberately misrepresent someone though selective quoting?

    “I’m sorry ” your last paragraph makes absolutely no sense to me whatsoever. But I’m sure you’ll take time to explain”

    My last paragraph states: ‘You make no sense. Just like it makes no sense that you resolutely refuse to engage with issues that have critical importance with regard to the health and lives of the people we serve.’

    The point being (although I think it’s as plain as day) that there appears to be serious issues within your profession with regard to the quality and appropriateness of dietetic advice. This has potentially grave consequences for the health of the people we serve. And you appear to be utterly unconcerned about this. Clear enough now?

  49. Dr John Briffa 8 June 2008 at 11:30 am #

    ross

    “So looking at the state of the evidence, you think that on the balance of probabilities it is likely that AK works as a diagnostic tool as its practitioners claim and it is unlikely that it is just quackery?”

    No, I am saying in selected patients with the right practitioner I find AK to be useful in clinical practice. Though I think I’ve said that before.

  50. ross 8 June 2008 at 11:36 am #

    So if you find it useful in clinical practice then it you must think it works? Yes?

  51. Dr John Briffa 8 June 2008 at 11:38 am #

    ross
    Can you qualify that question, please?

  52. ross 8 June 2008 at 11:40 am #

    You use AK. Do you think it works?

  53. Dr John Briffa 8 June 2008 at 11:45 am #

    ross
    That hasn’t qualified the question, I’m afraid.

  54. Hilda 8 June 2008 at 11:45 am #

    Why would teaching at ION be a problem? I trained at ION and my training was scientific. I am also a university lecturer at a very well respected comventional university and have taught research methods and data handling there so I am concerned about information being scientific. ION and Holford have put nutrition on the map . In another era I used to be a school careers officer. Then I had to do a project interveiwing dieticians. This was before ION. They said that no-one listened to what they were saying about diet and only doctors were ever quoted in the press.

    Both of us want to help people and I have helped many people who were told that no help could be given. I have seen eczema, and psoriasis clear up without drugs, seen fibromyalgia recede, also IBS, hyperactivity, indigestion which one lady had for 42 years, etc etc. A scientific response to a nutritionist’s work would be , ‘How did you do it?’ Not , ‘That’s rubbish’.

    What we have here is professional jealousy which has existed since there were professionals. Yes, we do not yet have registration. This is being worked on and we want it and want to be regulated. We are not keen on the fact that anyone can call themselves a nutrititionist.

    The reason that dieticians cannot do more is that the practice is for the medical profession either exclude people or incorporate them and let them do very little.

  55. Hilda 8 June 2008 at 11:58 am #

    gain. Actually the proof of the pudding is in the eating or not eating. I would stand up against any dietician to see which way would help my patients the most.

    FOOD GROUPS : Can the dietician tell me who devised these food groups and how anyone in the state of nature would know about food groups and why we need them. They are just an arbitrary out of date classification. Also does she understand how bad PROCESSED FATS such as margerine (ALL) are and why do dieticians recommend them.

    CARBS : Does she not know that refined bread, pasta etc is basically sugar so why recommend these for diabetics . I would genuinely like to be able to have a rational, scientific debate with a dietician.

    SUE : Your comment about the dietician’s weight is called in logic an ARGUMENTUM AD HOMINEM, i.e. You attacked the person rather than the argument and this has no logical connection.

  56. Dr John Briffa 8 June 2008 at 12:05 pm #

    Hilda

    “Why would teaching at ION be a problem?”

    The issue is not this, but that Catherine Collins’ assertion that I lectured at ION was a clear misrepresentation of me through selective quoting.

  57. ross 8 June 2008 at 12:13 pm #

    Dr B, can’t you just answer the question: you use AK. Do you think it works?

  58. Hilda 8 June 2008 at 1:16 pm #

    To PKATE : Nutritionists do not tell people they have awheat allergy. At least I don’t. If you took the time to do some research and read some books you would see that it is the wheat itself and not the person that is the problem. Find out how wheat is grown and how this differs from the way it was grown in the past. If wheat can destroy the villi in some people it must have quite potent properties. Scientists have messed aabout with the chromosomes in wheat to give it a higher gluten content in order to make it more springy which is what the housewife wants. It is the gluten which is protein very difficult to digest.Wheat has been found to be implicated in autoimmune disorders such as thyroiditis, MS, etc. It is a relatively new food in Man’s time on earth.

    Furthermore white bread is NOTHING but starch ie sugar so calling this a food group is silly. White pasta is like ployfilla, fills children up with very little nutritional advantage.If we all gave it up tomorrow, we would all be better off.

    To reiterate: THE FOODS GROUPS ARE JUST ARBITRARY WITH NO SCIENTIFIC BASIS BEHIND THEM!

  59. ross 8 June 2008 at 5:31 pm #

    “I do not claim to be a nutritionist, though I admit I do believe I have a good grasp of nutritional matters.”

    Dr B – you may want to ask the Highgate Hospital to update its website. You are listed under ‘Nutritionist’ via the ‘Find A Specialist’ drop down menu and your speciality is listed as ‘Nutritionist’ here:

    http://www.highgatehospital.co.uk/content/static/consultants_forth.asp?ConsID=319&sub=Nutritionist

  60. Dr John Briffa 8 June 2008 at 5:44 pm #

    ross

    “Dr B, can’t you just answer the question: you use AK. Do you think it works?”

    No, I can’t.

    “you may want to ask the Highgate Hospital to update its website. You are listed under ‘Nutritionist’ via the ‘Find A Specialist’ drop down menu”

    Obviously, there can be a difference between how I describe myself and how I might be described. I am aware that I am sometimes referred to as a ‘Nutritionist’, but it’s impossible for me to correct all of these instances. I will speak to the Highgate Hospital though.

  61. ross 8 June 2008 at 5:52 pm #

    “No, I can’t.”

    Oh, OK.

    Care to take a crack at these? (It might be a good idea to set out your position on the matter.)

    In your opinion, and after weighing up the evidence, on the balance of probabilities do you think that the risks associated with the MMR vaccination outweigh the benefits of vaccination?

    You have stated that you do not advise parents not to vaccinate, do you advise parents to vaccinate? Or do you not offer any form of advice?

  62. Dr John Briffa 8 June 2008 at 5:58 pm #

    ross

    Can I ask what you believe the issue of MMR vaccination has to do with the focus of this blog post?

  63. ross 8 June 2008 at 6:03 pm #

    None, it’s just I asked the same questions on the other blog posts where it was relevant and I hadn’t heard back from you. As you were actively replying here I thought I’d ask. Not a problem if you want to revert to one of the other blog posts and respond there.

  64. Hilda 8 June 2008 at 9:15 pm #

    Ross. How can anyone answer your question about risks? The truth is that no-one really knows the answer. The parent should be informed and make up their own minds being mindful that measles can lead to brain damage. If all the dat are not yet in you cannot expect a doctor to make this decision .

  65. JC 8 June 2008 at 9:35 pm #

    I cannot believe the amount of negativity that Dr B has received by writing a well intentioned article about a patient who was not listened to by either a GP or a dietition. Anyone who has been advised by any professional can recall such an instance – doctors and other medical practitioners need to get off their pedestals and learn to listen, just as lawyers and other professionals need to. The amount of negative and defensive aggression received from Katherine Collins and “ross” (whose credentials we are not enlightened to) must be hiding some deep seated insecurity. Why the need to protect? Surely “science” is about not having a closed mind – this is what Dr B is talking about – Katherine Collins and “ross” show themselves to be so scared about opening their minds, they can only protect themselves by attacking those whose minds are open. That’s a sad thing to observe in so called professionals who have clearly lost the plot.

  66. Catherine Collins RD 8 June 2008 at 9:50 pm #

    Dr B ” you say
    “Can I ask you to specifically answer the question I posed in my last comments to you which is: ‘And would you attempt to attack and discredit the person who brought the information to you?”
    My answer is simple – of course not, assuming of course that said individual is capable of objective clinical debate. Once professional courtesies had been dismissed, however – for example by the ad nauseaum practice of hurling insulting and misleading abuse about another legally regulated healthcare profession and their practice through potentially hypothetical musings on patient care* – one must permit representatives of the denigrated profession the opportunity to discuss such accusations in a rational manner to the benefit of all concerned. It is your right, of course, to consider such rebuttal ‘discreditation’.

    Dr B – you say –
    “ION teaching. It appears you have deliberately misrepresented me”

    Have I? Readers will note my earlier post acknowledges the statement as being ambiguous, with many other sites infering the same (few of many links provided in earlier post). The journal education articles stand. One could be of the opinion you frequently find it easier to overlook rational comment in order to be affronted by your commentators.

    You further claim –
    “But this would not be for the first time. See here http://www.drbriffa.com/blog/2007/10/03/why-is-the-dietary-advice-given-to-diabetics-so-often-so-woefully-inadequate/ (comments 39 and 45) for another flagrant example of this. Once I had exposed this, you declined to contribute further. But now you’re back, and it seems you’re up to your old tricks too”.

    How odd, Dr B.
    I previously noted my comments (back in October, I think) as postings # 32 and #37. I had to GoogleCache just to be sure. Fortunately, I was correct ” and others have also noted similar ‘jumps’ in posts http://jdc325.wordpress.com/2008/05/30/more-briffa/#comment-1130 . I presume the current links will remain in place for ease of reference?

    If by “old tricks” you infer defending my profession against your biased, unsubstantiated and misleading insults then I am guilty as charged.

    If, however, your comments allude to some breach in my professional standing I will be happy to debate this with you in the legal arena. You make a point of stating my place of work on your postings, so I assume you will be able to send written comment to this address also.

    Dr B – you say
    “The point being (although I think it’s as plain as day) that there appears to be serious issues within your profession with regard to the quality and appropriateness of dietetic advice. This has potentially grave consequences for the health of the people we serve. And you appear to be utterly unconcerned about this. Clear enough now?”

    Absolutely, Dr B. Absolutely clear. It is clear that you failed to comprehend that my comments concerning poor patient care were aligned with yours.

    * and finally, if this post refers to an actual patient, your opinion that the doctor and the dietitian have clinically abused this patient are absolutely, crystal clear. So may I call your attention to paragraph 43 of the GMC’s ‘Good Medical Practice’? http://www.gmc-uk.org/guidance/good_medical_practice/working_with_colleagues/conduct_and_performance.asp. Your professional organisation is very, very clear about what you should do next as a registered member of the GMC.
    I am sure we will read about it in a future blog.

  67. Sue 8 June 2008 at 11:36 pm #

    I do believe that when someone is an expert in nutrition or a dietician then if they adopt healthy eating and a healthy lifestyle it will show in their body. I know that sometimes this is not so simple as there are other issues particularly hormonal that get in the way.

    It was a bit of a below the belt comment to Catherine Collins about her weight because quite frankly she infuriates me. I’ve googled her up and read some of the comments in aticles that she has made and it just makes me shake my head.

    Ross,
    You certainly are persistent. Why are you so concerned about what Dr Briffa thinks about AK?

  68. ross 9 June 2008 at 7:40 am #

    Probably best to deal with this on one of the other blog posts Hilda as it’s off topic, but I’ll stick my neck out and answer the question here. My GP can answer my question about risks. Dr Anthony Cox can answer my question about risks. I can answer my question about risks. It’s about probabilities and evidence. There is a lot of evidence out there, some of it very poor or discredited (for instance, that used in support of the claim that MMR causes autism) and some good evidence (for instance, that used to demonstrate that there is no correlation between MMR and autism).

    In my opinion, and after weighing up the evidence, on the balance of probabilities I think that the risks associated with the MMR vaccination (which are incredibly small and very very unlikely to include the risk that it could cause autism) do not outweigh the benefits of vaccination.

    it’s not a 50/50 ‘red ball / blue ball’ situation. The evidence is very clear and that is what public health policy should be based on.

  69. ross 9 June 2008 at 7:45 am #

    “You certainly are persistent. Why are you so concerned about what Dr Briffa thinks about AK?”

    Didn’t the link to Quackwatch give you some idae as to why a member of the public would be concerned about a medical doctor referring his patients to a practitioner of an unfounded and unproven diagnostic tool? I’m not the only one who is interested:

    http://holfordwatch.info/2008/06/08/dr-john-briffa-on-testing-for-food-sensitivity-applied-kinesiology-dowsing-and-igg-tests/

  70. cynic 9 June 2008 at 9:40 am #

    Just to lighten the mood, Hilda I know it may have just been a turn of phrase but maybe you should google “flat earth myth”

    “with extraordinary [sic] few exceptions no educated person in the history of Western Civilization from the third century B.C. onward believed that the earth was flat”

    http://en.wikipedia.org/wiki/Flat_Earth

  71. Megan 9 June 2008 at 10:04 am #

    Do you ‘professionals’ who are attacking Dr Briffa realise just how stupid you look to us, the patients, the general public? I’m sure you don’t, otherwise you wouldn’t have sunk to the petty attacks I’ve read on this blog.

    May I say to those who have insisted that wayward health-care professionals must be reported to the relevant authorities that we, the patients, are often too darned scared to do so!

    I’m sure that Dr Briffa isn’t perfect – he is, after all, a human being. Understand that you aren’t perfect, either, so stop pretending you are.

    I, as a mere patient, read and understood ‘the message’ in Dr Briffa’s article, hence my post. It was simple, and a ten-year-old would have understood it just as readily.

    I am disgusted at those ‘professionals’ who have deliberately misrepresented Dr Briffa, demanded answers to spurious questions, and who have, quite frankly, done their darndest to bully him on this page. You are beneath contempt.

  72. Megan 9 June 2008 at 10:07 am #

    To cynic: Try telling that to these people
    http://www.alaska.net/~clund/e_djublonskopf/Flatearthsociety.htm

  73. cynic 9 June 2008 at 10:08 am #

    Regarding comments about people’s weight, Dr B I really think you should have stepped in there and moderated that cheap and unnecessary comment from Sue.
    Instead a few posts later you seemed to defend it (& make a cheap crack) when you wrote:
    “There was actually a serious point behind this: many dietitians are visibly overweight. And this does cause some to consider the appropriateness of dietetic advice. And it most certainly does not inspire confidence. This observation is rarely mentioned, but I think it has relevance here (it’s the ‘elephant sitting in the room’, if you will). ”

    Didn’t you use to smoke? It was years ago I think, but you were certainly old enough to know it wasn’t good for you. Fair play to you that you very honestly blogged about it I think. But does that mean we should look at that fact & then judgingly conclude that because you participated in such a wilfilly unhealthy practice as smoking that therefore anything you say about preserving health or medicine is to be doubted.
    I don’t think so, and it’s same with someone’s weight.

    poor show all round methinks, cos otherwise was an interesting post

  74. Sue 9 June 2008 at 10:10 am #

    I don’t see anything wrong in referring his patients to a practitioner of AK.

  75. Dr John Briffa 9 June 2008 at 10:47 am #

    ross

    “Didn’t the link to Quackwatch give you some idae as to why a member of the public would be concerned about a medical doctor referring his patients to a practitioner of an unfounded and unproven diagnostic tool?”

    How much of conventional medical practice do you think has been ‘proven’ to be beneficial?

  76. John Stone 9 June 2008 at 11:13 am #

    I had not really been paying attention to this correspondence, but looking at it as an outsider I cannot understand why Catherine Collins took this article as a professional attack.

    I do, however, suspect that many in the medical take the tautolical view of Prof Jowett of Balliol College that “What I don’t know isn’t knowledge”.

  77. ross 9 June 2008 at 11:28 am #

    “How much of conventional medical practice do you think has been ‘proven’ to be beneficial?”

    Dr B, I’m not sure that that has anything to do with the point I am making, we are considering the evidence for a specific diagnostic tool. Is ‘there’s no evidence base for lots of other stuff, why should I worry about what practitioners I refer my patients to?’ really your argument?

    If you are to follow that line of argument then I would suggest that you look at ‘conventional’ diagnostic tools & tests so you are comparing like for like (remember, AK is not a modality). Mammograms, ECG’s, blood tests, X-rays, MRI scans etc.

  78. Dr John Briffa 9 June 2008 at 11:35 am #

    ross

    How about clinical experience as a ‘diagnostic tool’? Does that have any merit in your book?

  79. ross 9 June 2008 at 11:44 am #

    It depends. The clinical experience of homeopaths leads them to believe that water is healing their patients. They do not concede the possibility that they could be mistaken and that what they are seeing is regression to the mean or the placebo effect. I think it’s the same for AK. So it’s as well to check the evidence base and make sure that more plausible mechanisms than chi or meridians don’t account for the effects the practitioners see. In your clinical experience does AK provide accurate results?

  80. SkepTicTacToe 9 June 2008 at 12:12 pm #

    Cynic (post 73), The obesitylevel of dieticians and nutritionists is VERY pertinent. First, let us use Google’s definitions here:-

    - a dietician is meant to “help promote good health through proper eating”

    - a nutritionist is a “health specialist who devotes professional activity to food and nutritional science, preventive nutrition, diseases related to nutrient deficiencies, and the use of nutrient manipulation to enhance the clinical response to human diseases. They may also advise people on dietary matters relating to health, well-being and optimal nutrition.”

    In this regard they are quite specialised compared to a doctor. If a dietician/nutritionist is obese, it makes me think one of two things:

    – they are following their nutritional advice but it is plain wrong, or,
    - their nutritional advice is impractical at some level as they cannot follow it themselves – in which case it is similarly useless. (That advice can be difficult to follow is one thing but if the advice causes considerable discomfort is another. A case in point is with conventional calorie restricted diets where the patient is asked to persist in a state of chronic caloric deficit – because a patient at some time or other will ALWAYS given in to appetite).

    None of us would chose to be obese here, including dieticians and nutritionists. It is barely credible that they should give advice if a) they cannot follow it themselves, or, b) it is poor advice to start with.

    The analogy with a smoking doctor breaks down in that the doctor is not telling you HOW to smoke, he is telling you NOT to smoke. Evidence for smoking related illness is irrefuteable unlike the evidence for what constitutes an optimal diet.

  81. Dr John Briffa 9 June 2008 at 12:16 pm #

    ross
    “In your clinical experience does AK provide accurate results?”

    In selected patients with the right practitioner, yes. (yawn).

  82. ross 9 June 2008 at 12:20 pm #

    OK. It’s just that I said:

    “Dr B, can’t you just answer the question: you use AK. Do you think it works?”

    Then you said:

    “No, I can’t.”

    So, now you have stated that in your clinical experience, in selected patients and with the right practiotioner, it provides accurate results. How do you know?

  83. Hilda 9 June 2008 at 12:32 pm #

    Ross. If A GP advised a patient not to have an MMR and the child got measles then encephalitis, then brain damage what then? All a GP can say is that this is what we know and this is what we don’t know and let the parent decide. I’m just so glad that that I do not have to make this decision. I do not know whether giving the vaccines separately is safer but if measles was to become epidemic again would this be a good thing?

  84. Hilda 9 June 2008 at 12:49 pm #

    Skeptictactoe

    As someone who has treated and researched obesity for many years I can tell you quite categorically that there is not a clear relationship between healthy eating and weight. If you look at TV programmes eg Gillian McKeith they make it seem as though all who are overweight eat pies, chips, junk etc. This is not the case. There are many reasons for weight gain such as:

    Thyroid problems : If the T4 level range goes fro 11 to 28 (still considered normal and not treated at low end) and a person’s T4 is 12, compared to someone whose T4 is 27, they are at a disadvantage and will find it impossible to lose weight unless they so little as to become ill. Many people are low thyroid and one reason is that tap water contains fluorine and chlorine which displace iodine needed for the thyroid. They are two of the halogens and more reactive than iodine.

    Genetics : If you have done GCSE biology you will see that animals adapt to their environment in terms of climate and food availability. Polar bears are large. There is definitely a genetic component in weight. Rats have been bred to put on weight with a very low calorie intake.

    Candida : This is a yeast which can attach to thyroid receptors blocking its action

    Polycystic ovarian system: This is related to insulin resistance and can cause weight gain. It is getting more common.

    The soil on which food is grown which is deficient in chromium, zinc and magnesium needed to process food correctly.

    Admittedly there are many people who are overweight because they eat too much of the wrong foods, but weight gain is a more complex problem than you might think. Read Taubes book ‘The diet delusion’.

    One last point : Just as the social work profession does not like to train people who have no experience of life, a dietician who is naturally slim would have little idea about the difficulty of losing weight. One that is struggling or has struggled is in a good position to understand others.

  85. Katrina Woodrow 9 June 2008 at 1:35 pm #

    I actually practice Classical Kinesiology which is based on Applied Kinesiology. I trained to practice this as a result of the dramatic improvement in my own health after consulting a kinesiologist. Having dragged myself through my 30s feeling absolutely drained but just being told by doctors that of course I was tired, I had young children, I was desperate and in the same situation as most of the patients who come to see me.

    People need answers for why they feel so bad and when the medical profession can’t help them they turn to complementary therapists. Kinesiology actually helps identify what is going on in the body without invasive procedures.

    I wish I had a good explanation for how kinesiology works, the best I found was in a book by Ellen Cutler MD (note the MD) who believes it works in the opposite way to the ‘fight or flight’ mechanism. When the brain registers a physical danger it sends blood and energy to the muscles and extremities to help a person either defend themselves or run away. When a more subtle danger is recognised, the brain sends blood and energy to the vital organs to protect them, thereby temporarily weakening muscles.

    As someone has pointed out already, if something works, do we actually need to know how it works? My patients can feel the difference when their arm weakens in response to a test and they can feel when it remains strong. I make sure they do so they know that I am not trying to pull the wool over their eyes.

    I hate being regarded as a quack just because kinesiology does not have a degree course to back it up. It still took me 3 years of training and I am still studying so that I understand in greater depth whatever I am treating.

    My patient who had had chronic gastritis for many years, who suffers only the occasional period of discomfort now, really doesn’t care how it works, she only knows that life is worth living now where she was beginning to think that it wasn’t until she came to see me (at the recommendation of my husband who is a very sceptical pharmacist).

    I tend to credit kinesiology with her improvement rather than me, as without the kinesiology we couldn’t have identified the candida, helicobacter pylori, hypoglycaemia, parasites and many food intolerances which had been plaguing her. Her doctor had told her to get some Gaviscon and learn to live with it. This lady’s gratitude is touching and it gives me a lot of satisfaction to know that I have brought about this change for her. She is only one of my patients but she came to see me this morning so she is fresh in my mind.

    If kinesiology didn’t work to bring people back to a healthy state I wouldn’t bother to practice it as I have a conscience and couldn’t take money from people if I didn’t know it would help them. It doesn’t matter a jot to me that Quackwatch don’t approve, how many people have they directly helped get better?

    What seems to be missing in the general treatment of patients is the acknowledgment that they are individuals with different genetic and biochemical make ups. We are not ‘cookie cutter’ people, we are all unique and need to be treated that way rather than being pigeon holed and given a bog standard treatment.

    It is all very well knowing that oranges and peppers are a great source of vitamin C, if those same foods go on to give you heartburn are you really going to benefit? That is one example of where kinesiology helps, we identify the foods which upset that particular person so they can avoid it and not have to take Gaviscon or similar treatments. Using kinesiology I also used Ellen Cutler’s Allergy Elimination Technique so that patients can re introduce offending foods back into their diets.

    If I had a heart attack or broke my leg, I wouldn’t think of going to a kinesiologist because that is where doctors excel. If I had digestive problems or felt tired all the time, a kinesiologist would provide a far better chance of getting better. I am living proof.

  86. SkepTicTacToe 9 June 2008 at 2:29 pm #

    Hi Hilda, I have read Taubes’ “Good Calories, Bad Calories”, which I think is “Diet Delusion” under a different badge. it is an excellent book, and through personal experimentation amongst myself and friends, can attest to the validity of a ‘paleo’ approach to nutrition.

    I am quite skeptical about blaming thyroid or genes – hell everyone obese person I have spoken to about wieght has a reason for why they are overweight – and guess what, it is NOT their fault – it is thryoid/genes/blah blah blah.

    As for deficiencies in soil nutrients, heck I reckon fat people buy their gorceries from Tesco/Saisnbury’s, the same as me, so why am I not affected?

    How is it that we cannot trust our appetite to tell us when we are full? Who here eats as much as they need and then thinks, “You know what, I am going to eat some more!”. What evolutionary advantage can there be to eating ‘more than you need’ such that you can eat yourself in to a state of immobility?

    As Taubes observes, it is not a case of balancing calories in and calories out – but I hear few nutrition experts nailing this one. Diets should not be (and is not) a complex issue. Chronic hunger will always win over ‘restraint’. Too many in the nutrition business are trying to fix a symptom rather than the cause.

    Ultimately if you are a fat dietician your advice is either does not work, or is such that you cannot follow it.

  87. ross 9 June 2008 at 5:09 pm #

    Hilda, I agree that obesity is not a cut and dried issue, which is why I find it surprising that Dr B made those comments despite writing the following on 9 November 2007:

    Well, one thing is for sure: being ‘overweight’ according to the BMI scale does not mean someone is ‘fat’. That ‘additional’ weight may be, after all, the result of muscle, bone or whatever. And even if there is a bit of ‘padding’ present around the body, is this necessarily a bad thing? It might be a sign of greater ‘nutritional reserve’ which can be drawn on in times of need. Which, by the way, may reflect an evolutionary adaptation that has helped to ensure survival during times when food supply was limited. While starvation is less of an issue for the population analysed in the recent JAMA study, what may be relevant is that individuals of higher weight have been found to be at reduced risk of death in certain circumstances including critical illness and surgery.

    Whatever the explanation, I believe there is now abundant evidence which shows that the conventional advice given to individuals around maintaining or attaining a ‘healthy’ BMI is simply not justified. So, until it seems we have good evidence to the contrary, my suggestion that we do not urge people to strive to conform to a body weight that may be quite unattainable and perhaps even detrimental to their health.

  88. Dr John Briffa 10 June 2008 at 8:57 am #

    Catherine Collins RD

    I claimed you misrepresented me regarding lecturing at ION. You, in response said: “Have I? Readers will note my earlier post acknowledges the statement as being ambiguous…”

    Let’s just remind everyone reading this what you actually wrote:

    “…you are a medically registered doctor who lectures on founder Mr Holfords Institute of Optimum Nutrition course”.

    Now how ‘ambiguous’ is that do you think? The answer of course is, not at all.

    “I previously noted my comments (back in October, I think) as postings # 32 and #37. I had to GoogleCache just to be sure….I presume the current links will remain in place for ease of reference?”

    What is the suggestion here Catherine? What have the numbers of the comments got to go with this? The fact remains, that it appears from your comments and my response to them that you have deliberately misrepresented me, as you appear to have done here. This is the important issue, and everything else is a diversion.

    “If by “old tricks” you infer defending my profession against your biased, unsubstantiated and misleading insults then I am guilty as charged.”

    No, by “old tricks” I am referring to your apparently deliberate attempts to misrepresent me. ‘Dishonesty’, I think is another way of putting it.

    And how very ironic that you mention the legal arena. I don’t know, but on this showing, Catherine, my feeling is that a judge would conclude you to be a very ‘unreliable witness’ indeed.

    One can only imagine what the general public will make of this Catherine. But I reckon your attempts to uphold the reputation of your profession are back-firing spectacularly.

  89. cynic 10 June 2008 at 9:16 am #

    Hilda in your post#84 above, among the “many reasons for weight gain” you listed:

    “Many people are low thyroid and one reason is that tap water contains fluorine and chlorine which displace iodine needed for the thyroid. They are two of the halogens and more reactive than iodine”.

    This is a fascinating idea. Could you please post some links to some evidence for this?

  90. annemarie 10 June 2008 at 9:41 am #

    just a little comment about the weight issue

    Once I had an overweight patient enter my room looking highly agitated. She looked at me, sat down, realxed and said “if I had walked in and you had been a young, slim lady I would have walked right out again”
    Sometimes looking a little human makes our patients feeel at ease.

    As for the listening, I always get comments from clients that at least they are listened to in my consultations. I feel quite proud of that.

  91. Dawn 10 June 2008 at 6:32 pm #

    I think Dr B’s article was intended to draw attention to how ill thought out advice can do harm to patients who rely on it over and above their own experience or instincts. The case in the article describes an instance where the mother basically knew what the cause of her daughter’s symptoms was but probably wanted to have professional advice and to rule out anything serious ” perfectly normal. The fact that she received substandard advice is sad but is not restricted to dieticians or gastroenterologists or any particular category of health advisor. I don’t think that the poor advice was the only problem. Why did the mother put her daughter back on wheat? I would argue that she should have had more faith in her own observation (is this a subversive and dangerous thought?). The reason of course that this is often not the case is that we are supposed to trust our health professionals – in fact they demand our respect, our compliance even (as highlighted by the fear mongering and reprimand by the gastroenterologist). Well I say they should earn our respect because respect is a two-way thing ” where was his respect for her observation of the cause or her concern for her daughter not to be suffering?

    I think that the problem with giving advice is that sometimes it will simply be incorrect and unsuccessful for that particular patient at that time, especially if it is a very prescriptive and one-size-fits-all treatment based heavily on the advisor’s particular learning and leanings. I am including non-mainstream NHS funded treatments here too.

    In my view it is imperative that doctors and anyone giving health advice listens to their patients fully and expects their patients to take some responsibility for their own health. For anything where the cause is unclear including for example many digestive or allergy complaints the advisors need to start listening and involving the patients 100% in order to seek out and treat the root cause of their patients’ ills and maximise treatment success.

    I appreciate your stance in this article Dr B and if it threatens people then I wonder whether it is intellectual arrogance that casues such reactions.

  92. Cathy 11 June 2008 at 1:34 am #

    I suspect that Catherine Collins is labouring under the illusion that the pap she hocks is based on “science” rather than the rantings of Puritanical fundamentalist vegans.
    The absence of endomysial or antigliadin antibodies does not rule out a diagnosis of celiac disease and it certainly cannot diagnose wheat intolerance. Ms Collins might do something favourable for her patients if she acquainted herself with other antigenic lectins present in carbohydrate food ” especially wheat.
    The trouble with medicine today is the tendency to “treat the tests” rather than “treat the patient”. These “highly technological” tests are not 100% accurate and should NEVER replace good clinical skills – and listening is crucial.
    Rendering the issue down to whether Dr B should have reported these health professionals (and I did not miss the veiled accusation Ms Collins made that Dr B was lying) is essentially moot; officially these people “did their job” in that they relied upon the accepted tests for celiac disease and dismissed what the patient’s parents were telling them. In 25 years of health care I have seen MUCH worse misdiagnoses than this (often resulting in death) go completely un-addressed because “the ECG/the blood test/the X-ray was normal”. In Ms Collins’ attacks on Dr B’s position methinks the lady doth protest too much, and it reeks of the defensiveness common to those desperately trying to shore up an outdated, and patently defunct paradigm. Anyone feeling the need to defend a profession as a single unit displays the utmost insecurity, and unfettered disregard for the people they are paid to serve.

  93. Gilly 11 June 2008 at 11:55 am #

    Ross

    “So, until it seems we have good evidence to the contrary, my suggestion that we do not urge people to strive to conform to a body weight that may be quite unattainable and perhaps even detrimental to their health.”

    As someone who practices in weight management, I never advise/urge individuals to strive to conform to a weight that is unattainable or detrimental to their health.

    There is a lot of evidence now which shows that modest weight losses of 5-10% of original weight are beneficial. Often people find that this is a perfectly acheivable, sustainable target to aim for.

    As for comments made by others about dietitians being overweight or not – there can be pros and cons either way when it comes to advising/treating overweight people. Ultimately if the individual is treated as exactly that – an individual – and feels listened to and valued then surely this is more important than if the person treating them with respect is overweight or not.

  94. Gary Shaw 12 June 2008 at 3:24 pm #

    For anyone that stumbles upon this article and isn’t quite sure about the point of it (it’s clear that some of them haven’t judging by the comments), then the main point is in the title:

    “Health professionals ignore their patients at their, and their patients’, peril”

    – Great article and some very interesting debate too.

  95. Catherine Collins RD 12 June 2008 at 10:48 pm #

    Cathy – I really have no idea what you are alluding to with statements such as “under the illusion that the pap she hocks is based on “science” rather than the rantings of Puritanical fundamentalist vegans.” – unless you are referring to the R5Live interview of a couple of nights ago?

    Coeliac disease is diagnosed by one or all three current methods: anti-TTG or anti-EMA (antibody testing) and duodenal biopsy to look at intestinal morphology. It is usual for the biochemical tests to be confirmed by pathology – or vice versa, given the extensive nature of lifelong dietary restriction with a positive diagnosis. This is not a diet to be adopted frivolously for effect – Coeliac disease is an allergy to certain fractions of protein – different ones found in wheat, barley, and rye. The excellent Coeliac society website will confirm that this is not ‘pap’..

    It has absolutely nothing to do with lectins, ubiquitous plant chemicals that generate potential intolerance issues (but not all carbs as you state- refined sugars possess none).

    It is sad that you feel free to comment on the practice of professionals whilst demonstrating your negligable knowledge of dietitians work – their client interaction, knowledge base, or recommendations.

    I do not like to disabuse you but diagnosing health conditions by ‘horse whispering’ technique is inappropriate and irrelevant in the presence of defined ill-health – and morally bereft in exploiting vulnerable people.

    Dr Briffa made a very strong assertion that this child was harmed by these so called ‘professionals’. If you care to read my entries carefully you will see that I suggest in every single post my concern that Dr Briffa should report such shoddy practice to the relevant health bodies.

    Do you think that he should not?
    Do you think it is acceptable for him to ignore his GMC professional code of medical practice that urges him to protect future patients by reporting bad practice? And if you think its acceptable then your paradigm works outside the ethical and legal framework protecting the general public from clinical harm – hardly a recommendation.

    Now, if Dr Briffa is refusing to report both, one has to wonder why. Could it be that there was some grey area regarding the report? Perhaps – like another dietitian suggests- the child was recommended to include wheat in order for antibody or morphology tests to not generate a false-negative result?
    Perhaps on reflection there was really no real ‘abuse’ at all. It all was just an interesting subject diversion bigged up – for whatever reason – for good copy.

    At the risk of doing a Cherie-style ‘Did Leo Have MMR Jab’ can I ask Dr Briffa –

    Have you reported what you consider these two inept professionals?

  96. Katrina Woodrow 13 June 2008 at 5:38 pm #

    Would reporting two closed-minded medical professionals result in their minds being opened up to new possibilities and a change in their approach in the future? I think not.

    If it seemed worth the effort I suspect that Dr Briffa would report them, but witnessing the usual response of the medical profession for many years it probably wouldn’t make one jot of difference.

    Your mind does not seem to want to accept more than you were trained to do originally. As the old saying goes, “There is more than one way to skin a cat.” And it might not be a strictly scientific approach.

  97. ross 13 June 2008 at 6:42 pm #

    “If it seemed worth the effort I suspect that Dr Briffa would report them”

    Well I hope my GP finds it ‘worth the effort’ to follow his professional code of practice and not ignore the bits he finds a bit tiresome.

  98. Dr John Briffa 14 June 2008 at 9:32 am #

    Catherine Collins RD (Chief Dietitian at St George’s Hospital in London)

    “Have you reported what you consider these two inept professionals?”

    Let’s get this out of the way first, lest you continue to use it as a diversion from the actual case. I haven’t reported the ‘professionals’ concerned. And the reason for this is the parents declined to give me the relevant details. The matter of reporting these individuals to the relevant bodies rests in the parents’ hands now.

    “Perhaps – like another dietitian suggests- the child was recommended to include wheat in order for antibody or morphology tests to not generate a false-negative result?
    Perhaps on reflection there was really no real ‘abuse’ at all. It all was just an interesting subject diversion bigged up – for whatever reason – for good copy.”

    At no point did the dietitian say that this was her thinking. So, sorry Catherine, it looks just like an inability to listen properly and some dunderheadedness and on her part that is at root of the advice she gave.

    Also, I suppose it’s worth pointing out to you that even if after challenge with wheat/gluten, the tests for Coeliac disease proved negative, this does not preclude some problem with wheat. I mention it because it does seem to be something you are unaware of despite it being a really very basic nutritional concept.

    And finally, you make no mention of my claim that more than once you have deliberately misrepresented me (see comment no. 88 above). Why so?

    I reckon most impartial observers here may view your apparent tactic as unprofessional and lacking in honesty and integrity. I have given you an opportunity to explain yourself but you have not. I’m giving you another opportunity here. Do please give us your explanation (if you have one) of why you think it’s appropriate for a ‘Chief Dietitian’ to appear to deliberately misrepresent someone so flagrantly?

  99. ross 14 June 2008 at 10:29 am #

    Ross – “Dr B – did you recommend that the parents report the doctor and the dietitian to the GMC and the HPC?”

    Dr B – “No, it seemed the parents had already come to their own conclusions regarding this.”

    Ross – “So they were going to?”

    Dr B – “Actually, I can’t say.”

    But now it’s ok for you to say?

    “I haven’t reported the ‘professionals’ concerned. And the reason for this is the parents declined to give me the relevant details.”

    Why the need for secrecy?

    “At no point did the dietitian say that this was her thinking.”

    Well according to the anecdote you relate, you are dealing with the parent’s account of what happened so can you be sure that this is the case? It’s not uncommon for people to forget or misunderstand things, particularly when they are in stressful situations. Did you call the gastroenterologist or the dietitian to try and clarify this?

    Listening is very important, I agree, but so is talking.

  100. Dr John Briffa 14 June 2008 at 11:14 am #

    ross

    “Did you call the gastroenterologist or the dietitian to try and clarify this?”

    Before asking this question, you acknowledge that I had previously written: “I haven’t reported the ‘professionals’ concerned. And the reason for this is the parents declined to give me the relevant details.”

    It seems you’re suggesting I should have called people whose identity I do not know. ross, come on, that’s just stoopid.

  101. ross 14 June 2008 at 12:16 pm #

    “It seems you’re suggesting I should have called people whose identity I do not know. ”

    It would have been a good idea to ask the parents for the identity of the gastroenterologist and dietitian so you could call them and clarify the situation. As you hadn’t spoken to the dietitian, how can you state with any certainty that “At no point did the dietitian say that this was her thinking” ?

    You have assumed you had the full story from the parents. What I’m actually suggesting to you is that making this assumption might make for a good anecdote but probably doesn’t make for good clinical practice.

  102. ross 14 June 2008 at 12:22 pm #

    Just to try and make this clearer. “Did you call the gastroenterologist or the dietitian to try and clarify this?” was a rhetorical question, as it was clear you hadn’t. As you hadn’t, you can’t be sure you had the full picture, which was my point.

  103. ross 14 June 2008 at 12:33 pm #

    Also Dr B, as an impartial observer I really can’t understand why you are so upset about why you think you have been ‘deliberately misrepresent[ed]…so flagrantly’. Catherine Collins said she may have been mistaken about you lecturing at ION and that this misconception is common on other blogs.

    But why do you view this as such an egregious slight on your professional reputation? You’ve attended lectures and seminars at ION, surely being thought to have delivered lectures and seminars there would not be detrimental to your reputation? OK, the description may be inaccurate but so was the Highgate Hospital’s description of you as a ‘nutritionist’, which given its unregulated status is a term that could be perceived as being detrimental to a qualified medial professional.

    Perhaps it’s easier to focus on this point than the science?

  104. Gilly 14 June 2008 at 3:37 pm #

    “It seems you’re suggesting I should have called people whose identity I do not know. ross, come on, that’s just stoopid.”

    I’m intrigued then Dr Briffa that you don’t feel it necessary to get a full background history from medical colleagues in order to inform your own practice. Given that this child had been seen by a gastroenterologist and had undergone investigations surely it would be good practice (and at the very least professional) to have some sort of communication or dialogue. Would you not agree?

    p.s. it’s stupid not stoopid!

  105. Catherine Collins RD 14 June 2008 at 6:28 pm #

    Dr B –
    At the risk of sounding political, in answer to your mewlings that ‘I misrepresented you’ may I draw the honourable gentleman to the earlier replies?

    Post 88 (yawn) has already replied to your accusations (yawn)

    Thank you for clarifying that you did not report said professionals – or dietitian dunderheads as you so politely put it.

    So I take it that you consider the evidence of the parents inadequate or unqualified enough to justify your scathing comments in the original post.

    thank you for clarifying

  106. Dr John Briffa 15 June 2008 at 7:59 am #

    Gill

    Gilly, focus if you will on these words for a moment and contemplate their meaning: “I haven’t reported the ‘professionals’ concerned. And the reason for this is the parents declined to give me the relevant details.”

    You are now going to explain to me how I was going to get the speak to the practitioners involved if the parents declined to tell me who they were. When you’re ready, Gilly….

    As regards the spelling of ‘stupid’ as ‘stoopid’, it seems irony is completely lost on you.

  107. Dr John Briffa 15 June 2008 at 8:05 am #

    ross

    “You have assumed you had the full story from the parents. What I’m actually suggesting to you is that making this assumption might make for a good anecdote but probably doesn’t make for good clinical practice.”

    Yes, oh what an idiot I must be for listening to my clearly intelligent and thinking patients and taking them at face value. What a very bad doctor I am!

    Hey, ross, I’ve got a question for you: “After weighing up the evidence here, what do you think that the probability is that the parents of this child know more about the medical and dietetic management of their daughter than you?” Ha ha ha ha.

  108. Dr John Briffa 15 June 2008 at 8:10 am #

    ross

    “Just to try and make this clearer. “Did you call the gastroenterologist or the dietitian to try and clarify this?” was a rhetorical question, as it was clear you hadn’t. As you hadn’t, you can’t be sure you had the full picture, which was my point.”

    Oh, so in previous posts it wasn’t a rhetorical question but now suddenly is. You have made things clearer, ross: it’s getting clearer and clearer you haven’t grasped the fundamentals of this case and are desperate to make anyone wrong (me, the parents) rather than accept this girl’s management was inappropriate and inadequate.

  109. Dr John Briffa 15 June 2008 at 8:14 am #

    ross

    “I really can’t understand why you are so upset about why you think you have been ‘deliberately misrepresent[ed]…so flagrantly’”.

    I accept that no everyone will share my views, but I do have a problem with people who attempt to divert from the issue at hand and discredit me by telling what appear to be downright lies. Now, ross, I accept that you may not have a problem with distortions of the truth, but I do. This is one of the differences between you and me, I suppose.

    “Perhaps it’s easier to focus on this point than the science?”

    Just to remind you, ross: wheat in the diet ” diarrhoea, wheat out of the diet, no diarrhoea. What ‘science’ is necessary here? ‘Science’ is almost certainly some of the reason why this girl was given wholly inappropriate advice.

    “as an impartial observer.”

    Impartial? That’s a joke, right? Ha ha ha ha.

  110. Dr John Briffa 15 June 2008 at 8:23 am #

    Catherine Collins RD and Chief Dietitian at St Georges Hospital in London

    “Post 88 (yawn) has already replied to your accusations (yawn)”

    My comments there only serve to highlight what looks to be your dishonest attempts to misrepresent me. You haven’t answered the charges at all. Instead of doing the decent thing of holding your hands up, admitting the crime and apologising, you continue to pretend that crime was never committed. How honourable and how professional! And this from a ‘chief dietitian.’

    “So I take it that you consider the evidence of the parents inadequate or unqualified enough to justify your scathing comments in the original post.”

    What’s this I see, an attempt to blame this situation on the parents by suggesting their account was somehow unreliable?

    Do please remember that this post is about the need for we practitioners to listen to our patients. And your ultimate response is that we can’t rely on what our patients tell us. How very ironic (and sad).

  111. Catherine Collins RD 15 June 2008 at 12:08 pm #

    Dr Briffa

    “My comments there only serve to highlight what looks to be your dishonest attempts to misrepresent me”

    why not “admit your crime” Que?
    What on earth are you referring to, Dr B???

    iThis is getting a tad tedious.

    Dishonest? How?
    ‘Crimes’ – What?

    Every post has supported your concern about this medical/dietetic ‘abuse’ and hope you will do something about it – instead of which the post appears nothing more than an opportunity to bluster and brag about your superior medical/nutrition practice as illustration of a ‘patient saved from conventional healthcare’.

    Lets state once again for the record – If I, as a Registered Dietitian (lets leave aside my work based position and location, unless of course you are hoping for your supporters to indulge in a little snailmail goading) was SO concerned about the treatment of an individual I would report them to the HPC. My code of conduct suggests I can breach patient safety ‘by act or omission’ – so, by ignoring the issue i have not acted in a professional manner. Your GMC ‘Good Medical Practice’ says similar.
    My position at St Georges has absolutely no bearing on my debate with you on this site.

    ‘Dishonest’ in stating you have previously manipulated comments on your blog – for reasons unknown?

    Others have experienced the same problems. Hardly dishonest to state this – then ask why this occured – even though the posts are apparently restored now. That evidence is found here:
    http://jdc325.wordpress.com/2008/05/30/more-briffa/#comment-1130 .

    I’m not sure why postings should disappear into the internet ether to resurface at a later stage, but you have to admit that loss of selective postings seems rather odd. And even more strange, that they were posted from dietitians. Perhaps your site has an intolerance or – dare I suggest – a previously unrecognised allergy to the opinions of those who challenge your views. Either way, the fact they are now restored does not neutralise the fact they were removed for a time – duration unknown but I’m sure those familiar with the internet could find the full details.

    FWIW I think your site showcases your knowledge and attitude towards patients/clients/healthcare professionals perfectly.

    I only wish you would adopt the same receptive approach in reading comments on your blog that you exhort from healthcare professionals when listening to patients – which, incidentally, as dietitians we do very well.

  112. ross 15 June 2008 at 12:58 pm #

    “Yes, oh what an idiot I must be for listening to my clearly intelligent and thinking patients and taking them at face value. What a very bad doctor I am!”

    To accept what anyone says at face value, regardless of their intelligence, is just a bit, er, naive.

    “After weighing up the evidence here, what do you think that the probability is that the parents of this child know more about the “medical and dietetic management of their daughter than you?”

    There’s not enough evidence to base an opinion on. But medical professionals do tend to know more about the medical and dietetic management of their patients than parents.

    “Ha ha ha ha”

    Something funny?

    “Oh, so in previous posts it wasn’t a rhetorical question but now suddenly is.”

    It was always a rhetorical question, I just thought I’d make the point I was trying to make clearer. You should try it sometime! (Just kidding!)

    “discredit me by telling what appear to be downright lies.”

    How can being thought (erroneously) to lecture at an institution where you attend lectures discredit you?

    “Now, ross, I accept that you may not have a problem with distortions of the truth, but I do. This is one of the differences between you and me, I suppose.”

    Oh, I do have a problem with distortions of the truth. Why are you suggesting I don’t? That’s a very odd thing to say.

    “Just to remind you, ross: wheat in the diet ” diarrhoea, wheat out of the diet, no diarrhoea. What ‘science’ is necessary here?”

    Well, some things are just not that simple. From the account you have given (which I don’t take at face value) I think it likely that the wheat was reintroduced to preclude the possibility of a false-negative test result. And without talking to the health professionals concerned I would not be 100% sure that this explanation could be discounted. And nor could you. Did you ask the parents to check this with the dietitian before recommending a course of action?

    “Impartial? That’s a joke, right?”

    I’m not a dietitian or a nutritionist or a practitioner of integrated health.

  113. John Briffa 16 June 2008 at 12:05 pm #

    Catherine Collins RD

    “iThis [sic] is getting a tad tedious.”

    And so is you not being able to admit that you seem to have deliberately misrepresented me on more than one occasion.

    “…the post appears nothing more than an opportunity to bluster and brag about your superior medical/nutrition practice as illustration of a ‘patient saved from conventional healthcare.”

    In your mind maybe. In mine, though, this post was and remains to be about the problems that can ensue when practitioners don’t listen properly to their patients and respond appropriately. See the title ” there’s a clue in there for you.

    “’Dishonest’ in stating you have previously manipulated comments on your blog – for reasons unknown?”

    Others have experienced the same problems. Hardly dishonest to state this – then ask why this occured – even though the posts are apparently restored now. That evidence is found here:
    http://jdc325.wordpress.com/2008/05/30/more-briffa/#comment-1130 .”

    The accusation here is that I deleted posts. I have never done that. Comments go into moderation, and then I decide to allow them or not. There’s nothing unusual here. It seems some (including some dietitians) like to give the practice of comment moderation some sinister undertone, when there’s nothing sinister or unusual about it at all. It seems to be yet another cheap and baseless attempt to discredit me and deflect from the real issue at hand.

    “I only wish you would adopt the same receptive approach in reading comments on your blog that you exhort from healthcare professionals when listening to patients – which, incidentally, as dietitians we do very well.”

    Just to remind you, Catherine: wheat in the diet ” diarrhoea, wheat out of the diet ” no diarrhoea. And the advice given by the dietitian in question: eat a diet rich in grain including wheat. Does this suggest the dietitian in question was really listening to you?

  114. Carolina 17 June 2008 at 5:20 am #

    Dr. Briffa, what I don’t understand is why you would bother arguing with morons. I think it would be more effective if you simply wrote your articles, accepting serious questions possibly by email, but disallowing comments.

    People certainly have the right to disagree with you, but I dislike the disrespect shown here by many. I am not saying that because you are a doctor you are perfect, but this is your blog, and whether one is a doctor or a chef or a char, one’s own blogs should be sacred ground. They are meant for sharing the thoughts of an individual, right or wrong, and shouldn’t be up for discussion by others.

    Of course, here I am violating my own feelings on the matter by commenting myself, but I just wondered why you allow it. I don’t allow comments on my own blog, although I do accept questions, etc. which I do not publish but answer individually IF they warrant an answer. I write to share what I know, or feel, and if someone else disagrees, then they can write their own blog.

    I came here because I am interested in your ideas, and I don’t care to read what others may think about it. I can make up my own mind without the input of other people, of whom most are no more qualified than myself to make medical judgments. In this case the article was not specifically about the science of medicine, rather its practice, but you were still sharing your feelings about the WAY it is practiced in many cases, and why would you allow argument about that? Anyone who would quibble with that is simply looking for an excuse to be seen on your blog.

    Yes, I know I have been rather long-winded for an ‘anti-commentator’, so I will go now, and never express another opinion on someone else’s blog again. Still, I wonder….

  115. Gilly 17 June 2008 at 12:40 pm #

    “Gilly, focus if you will on these words for a moment and contemplate their meaning: “I haven’t reported the ‘professionals’ concerned. And the reason for this is the parents declined to give me the relevant details.”

    You are now going to explain to me how I was going to get the speak to the practitioners involved if the parents declined to tell me who they were. When you’re ready, Gilly….”

    I find your ‘explanations’ of why you didn’t go down a route of action very bizarre. You rant on about listening to patients as if no-one else does it better than you yet you don’t afford your patients the full holistic approach that they surely merit by ensuring that you get a full and complete picture of what has gone on before. You say it’s because they declined to give you information – I find this very strange indeed – perhaps they were also being very selective in other information they were giving you.

  116. Dr John Briffa 17 June 2008 at 5:24 pm #

    Gilly

    So, the parents give a full and frank account of the care of their daughter, but decline to give me the names of the practitioners involved. Now, you’re claiming that my failure to report or refer to these practitioners is ‘bizarre’. What are you suggesting I did in the circumstances: force them to give up the names? Is that really what you are suggesting?

    And then you suggest that the parents may have been very selective in the information they were giving you, suggesting, as others have done before, that the problem was created by them, and not the practitioners concerned. Oh dear, it seems you’ve been able to learn nothing from this blog post at all…

  117. Cathy 18 June 2008 at 6:54 am #

    Catherine
    I’m sorry to burst your ego-bubble but I’d never heard of you until I found this thread through another blog. RD5 ” Radio 5? Registered Dietician 5? Sorry, never heard of that either.
    Duodenal biopsy is not done unless one of the antibody tests comes back positive, but you have confirmed your propensity to “treat the tests and not the patient”. Poor clinical skills in my book; the raison d’etre for Dr Briffa’s post is the lack of listening skills ” Catherine ” take the bananas out of your ears.
    You don’t need to patronise me and explain with baby words what coeliac disease is ” I would have thought it apparent from my previous post that I am a health professional (I even trained at your current stomping ground). Your ignorance in assuming lectins cause “intolerance” further reinforces the idea that you have an innate inability to absorb any new information ” lectins are glycoproteins ” and they cause antigen-antibody reactions ”meaning ALLERGY ” not “intolerance”. And you don’t appear to know gluten is the protein component of gliadin ” umm, a lectin. The fact that you think the Coeliac Society’s website is “excellent” only demonstrates they follow the same flawed paradigm as you do and as such cannot prove you don’t peddle pap. Instead, why don’t we get a bit scientific and you cite me the original papers on which the USDA diet pyramid were based? Or some evidence of why a low-fat, low SFA, high carbohydrate diet is beneficial to health?
    Yes, I know very well how dieticians work and that’s why my opinion is less than favourable (oh, I’ve only been in healthcare since 1983). Your tactics here on this thread only reinforce that opinion.
    What vulnerable people am I exploiting here? What “horse whispering” nonsense are you alluding to? “Morally bereft”? ” the charge goes entirely to you; not only do you base your practice on an outdated and thoroughly debunked paradigm, but you stubbornly continue, with the bananas in your ears, to damage your patients with your pseudoscientific beliefs.
    My research is based on the literature; if you claim the same I have to assume you had a paper bag over your head whilst doing so ” as evidenced by your ignorance on lectins.
    Implying dark motives appears to be your tacky but tiresome M.O. ” don’t you have another hat?
    Should Dr Briffa have reported these health professionals? ” I covered this point in my previous post ” try reading it again, with your finger following each line, and speaking the words out loud, and you might comprehend what I said. Despite Dr Briffa explaining quite clearly that the names of the health professionals were not furnished you chose to keep those bananas in situ and use his explanation to further “allude” to yet another dark motive. What was he supposed to do ” crack out the waterboard?
    There are bad nurses, bad doctors, and bad plumbers, but according to your defensive diatribe, no bad dieticians. By your egotistical self-appointment to Defender of all Dieticians you only further sully the profession to which you belong.

  118. Gilly 18 June 2008 at 8:39 am #

    “Oh dear, it seems you’ve been able to learn nothing from this blog post at all…”

    I would beg to differ – I have indeed learned from this blog. I have learned that whilst some health professionals claim to put great importance on listening to people, in their actions towards others they do not demonstrate the whole spirit of this approach. It would appear to be very selective. I find it very sad that my colleagues working in health choose instead to snipe at one another and do not treat each other with respect.

  119. Catherine Collins RD 18 June 2008 at 12:08 pm #

    Cathy -

    The high prolamine and glutamine content of gliadin (and rye secalin, and barley hordein) renders these proteins fairly resistant to breakdown by digestive enzymes. It is the incomplete digestion of these prolamines and peptide fragments that generates the recognised toxic response that damages the bowel surface in coeliac disease.

    Studies on the aetiology of coeliac disease demonstrate NO evidence for lectin-like components in wheat gluten, despite the (quite plausible) theories now 15 years old. The confusion seems to be two-fold:

    1. Some studies have shown that gliadin reacts in a similar way to lectin towards a binding protein in the body called Mannan-binding lectin (or MBL) – hence the plausible proposal that gliadin was a lectin. Research (since 1993, onwards, if I recall) has since disproved this theory.

    2. In sensitive individuals, samples of tissue from the small intestine show a particular profile of damage when exposed to lectins. In coeliac disease, the pattern of damage is different in one area of the bowel which has lead researchers to conclude that although similarities are present, gliadin may exhibit lectin like ACTIVITIES, but is NOT a lectin.

    3. The coeliac society has evidence that compliance with a gluten free diet – lectin content variable and dependent on dietary choices – is the key approach to ensuring nutrient absorption and lowering the health risks associated with non-compliance. Lectins are clinically irrelevant in the management of coeliac disease

    4. Lectins from wheat may of course be associated with wheat intolerance – a very different condition to the allergy of coeliac disease. This requires different dietary considerations.

    5. UK dietitians don’t use the ‘Food Pyramid’ model of the US – a flawed design amended (you judge the success of this) by Walter Willett and colleagues. We use the ‘Eatwell Plate’ model of the FSA, which actually does include carbohydrate foods. This is aligned with what we know is the ‘Optimum’ diet for health – the Mediterranean Diet.

    6. I have absolutely no idea why you insist – like Dr B – that dietitians promo ‘high carb low fat’ diets for each and every patient – but to set the matter straight, thats another incorrect statement.

    Just like your one about ‘defending dietitians’. I suggest you adopt the reading practices you recommend to me in re-reading the submissions. All, bar this one, recommend Dr B make an official complaint about the dietitian and the doctor.

    The difference being, of course, that we don’t use hearsay to berate colleagues- just actual facts. It would be nice a similar knowledge base applied here.

  120. Peter 18 June 2008 at 1:19 pm #

    Hi Cathy,

    We have a question of semantics here, Catherine Collins states:

    “Coeliac disease is diagnosed by one or all three current methods: anti-TTG or anti-EMA (antibody testing) and duodenal biopsy to look at intestinal morphology”

    This is the definition, in the UK at least. No anti tissue transglutaminase or anti endomysial antibodies, or if you get a biopsy that missed the villous atrophy area, then you do NOT have coeliac disease. This is intrinsic to the definition of coeliac disease in the UK. You have to tick the boxes.

    Certainly in East London it’s even narrower because you won’t get biopsied if you are antibody negative, hence you MUST be anti-TTG or anti-EMA antibody positive to stand any chance of a diagnosis by biopsy. This is just how it is. No boxes ticked means no coeliac disease. It doesn’t matter how long you spend on the loo after eating wholemeal bread at your dietitian’s recommendation, you do not have coeliac disease.

    So a Catherine Collins is correct on this.

    Unlike her statement on the roll of lectins. Technically I believe “lectin like” applies more correctly to gluten (it’s wheat germ agglutinin which is the true cytotoxic lectin in whole grain wheat). WGA produces changes in the gut similar to those of early coeliac disease in rats, without antibody production. Rats do not have the HLA-DQ2 or HLA-DQ8 antigens unless transgenically engineered to possess them.

    http://www.ncbi.nlm.nih.gov/pubmed/3768964?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    Other groups consider WGA to have a roll in coeliac disease independent of antibody production:

    http://www.ncbi.nlm.nih.gov/pubmed/6895878?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

    Gluten also appears to act through the NKG2D receptor on natural killer cells to prime them to induce coeliac disease. It’s not clear whether this latter effect is a result of the lectin structure or simple recognition of peptide sequences in gluten. It does not involve antibodies, so is not technically “allergy”.

    http://www.ncbi.nlm.nih.gov/pubmed/16698443?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    But overall the suggestion that lectins are not involved in coeliac disease is, to quote someone else on this thread, bizarre. Certainly for someone giving dietary advice.

    But never forget, without anti-TTG or anti-EM antibodies, it’s NOT coeliac, in the UK anyway. Semantics. You still sit on the loo for a week or two after wheat. But it’s not coeliac. Keep saying it.

    Catherine Collins’ fervent desire for the dietitian and gastroeneterologist to be up for disciplinary action is commendable. Her approach is execrable. So too appears to be her knowledge of the immunology of gluten.

    Peter

  121. Cathy 18 June 2008 at 11:30 pm #

    Hi Peter ” thanks muchly for clarifying that

    Catherine
    What is this pathological fixation you have with things legal? “Hearsay”? This isn’t a court of law; it’s a blog. Dr Briffa has merely shared an experience that might give health professionals pause to think. He hasn’t defamed anyone in particular so why on earth do you take it so personally?

    You step into your own stereotype each time you commit finger to keyboard; you are still “treating the tests” with the attitude ” if we can’t test for it, it doesn’t exist. I have witnessed that patronising attitude many times among your profession: “Oh, so and so was negative for coeliac but the ignorant bugger has self-diagnosed wheat intolerance and against my highly important advice, consigned himself to the HELL that is wheat avoidance.”
    You want him to go home and gorge on whole-grain bread because “you know better”. You don’t care that he will suffer horribly as a result, that this advice could lead to gross nutrient deficiencies that will cause other seemingly unrelated medical problems and possible death because at the end of the day Catherine, ” you were seen to “do the thing right” rather than “do the right thing”; your “legal” obsession confirms this in spades.
    The anti-TTG might be better than the older antibody tests but it still isn’t 100% – no test ever is. The UK Coeliac guidelines admit that false negative antibody tests occur in 5-10% of patients and recommend duodenal biopsy in patients with ongoing symptoms but as Peter has explained above, this doesn’t seem to happen. Certainly the system failed the child described above.

    I’m allergic to pine ” it gives me gut anaphylaxis if I ingest it (and you’d be surprised what foods it lurks in). One particularly bad episode landed me in hospital with a diagnosis of sub-acute bowel obstruction. The GI surgeon wanted to do a laparotomy ” I told him it was a food allergy and he looked at me like I’d escaped from Bedlam. I signed my own discharge and found myself an allergist. With only 3 questions he pinpointed the problem and patch testing confirmed it. He also told me that he had numerous patients that had undergone unnecessary laparotomy because gastroenterologists don’t understand food allergies or intolerance (nor do dietitians it seems).
    I don’t consider unnecessary laparotomies good clinical practice Catherine ” do you?

    In 1934 a mother (with no formal medical training) insisted there was something wrong with her children. Luckily for her and countless children since, the good Dr Folling actually listened and observed the children (for hours). This was the discovery of PKU disease. How many children have been saved from severe mental retardation thanks to the intuition and persistence of one mother?
    Just think about that for a moment Catherine. And remember to take the bananas out of your ears.

  122. Sherrie 18 June 2008 at 11:55 pm #

    Dr Briffa, I think 99% of patients out there totally hear what you’re saying. I have had the same problem with Dr’s and for now have just given up until I feel like beating my head against a brick wall again.

    One thing though regarding the girl, you mention that they tested for coeliac disease but what about fructose malabsoption? Fructose malabsorption is very common, I think I read a figure of around 40% of Europeans suffer from it?

    Anyway as well as the obvious intolerance (fructose) there is also fructans, fructans are found in wheat, onions, asparagas, artichokes, green beans and probably more. All you need is a breath test so if she hasn’t been tested might be a good idea.

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