‘Realistic medicine’ for diabetic foot patients

Each year at the Annual Meeting of the Irish Endocrine Society (IES), the prestigious McKenna Lecture is delivered by a distinguished invited guest. This year’s lecture was delivered by Dr Hamish Courtney, Consultant Diabetologist, Belfast Health and Social Care Trust, who spoke on the theme ‘Making changes for diabetic feet: One step forward’. The lecture was introduced by IES President Prof Steven Hunter, who acknowledged Dr Courtney’s significant contribution to clinical research and practice.

He discussed common complications and presented data on diabetic foot, emphasising the need for compassion in care and the importance of avoiding unnecessary procedures or aggressive management where it is not strictly necessary.

“I am very drawn by the initiative in Scotland of ‘realistic medicine’, which is supported by the Royal College,” Dr Courtney told the conference. “I think we miss out on a lot of this in our day-to-day practice and I think we really have a role as physicians in taking leadership in ‘realistic medicine’. So often, I think we defer to the surgeons and they make the [treatment] decision, but it is our job as physicians to understand the natural history and the burden of comorbidity, to make decisions about realistic medicine for these patients.”

He continued: “These elderly patients come in to the foot service and rather than see them, we have a ‘huddle’ and discuss them beforehand, and we are able to avoid many of these elderly people coming in an ambulance. We have been able to avoid 90 per cent of attendances at our service – a more compassionate and realistic approach is in place, rather than an aggressive medical or surgical approach. I am really passionate about physicians taking leadership in managing these old people who come in, for whom foot disease is perhaps part of the terminal process, rather than something active that needs to be managed in perhaps the way we manage other [conditions].”

He also touched on the cohort of patients who do not engage with diabetes services, which equates to up to 60 per cent of admissions. With these patients, there is a need to aggressively treat hyperglycaemic-driven complications; those with foot disease that is not being driven by diabetes, but by other factors such as smoking or hypertension, are less suitable candidates for secondary diabetes services. Dr Courtney presented case studies to illustrate this point and said for a patient whose foot disease is not being driven by hyperglycaemic-driven complications, “in a resource-limited world, I’m not sure we need to see this patient,” he said. “Somebody needs to look after his lipids and blood pressure, but it may not be us…. Of course, most of the patients are in-between [these two examples], and there is a developing experience in our centre as to who we should or shouldn’t see.”

He concluded: “It’s important to have a clear course for where we’re going, but it’s also important to be flexible enough when change is needed, depending on what happens… for our journey in Northern Ireland we are making changes, one step forward and hopefully not two steps back.”