Doctors should be teachers

7 hours ago

8 min read

VAT TRAP · LIGHTHOUSE SERIES

A lighthouse rescues nobody. It stands where the danger is and tells you, permanently, what the water is doing.

We teach children to change a fuse. We teach them to check the oil, to put air in a tyre, to find the stopcock before the pipe bursts rather than after. Many of us learned to put out a chip pan fire and quite a few learned to restart a heart.

Dr Edward Leatham · Consultant Cardiologist

For busy people, or to tune in when on the move, a Google NotebookLM audio podcast is available as a story beneath.

Treating and teaching

I have spent most of my career treating people, and medicine is now remarkably good at rescue. We open blocked arteries in the middle of the night. We restart hearts that have stopped. Almost none of that existed in its present form when I started.

But rescue is what you do when the teaching has already failed, and it arrives at the most expensive possible moment — after the damage. The patients in this series were all rescued. Every one of them would rather have been taught.

Why this cannot wait for the clinic

The obvious response is that doctors should simply do more of this. I no longer think that is the answer, and it is worth setting out why.

Start with what actually gets measured. In the NHS your weight and your BMI are recorded routinely. Your waist almost never is — even though waist divided by height is the better guide to the fat around your organs, and it is the fat around your organs that does the damage. A basic marker of central adiposity is not part of the routine at all.

Then take cholesterol. Spend an evening reading health forums and you will find people arguing about it with real conviction and no agreement — and not only patients. The argument ran for decades and it was a genuine one. It has since been settled, and the settlement has not reached everybody, including some of the people giving advice.

Now suppose both of those were fixed tomorrow. Waist measured at every appointment; every clinician current on the evidence. Cases would still slip through, because they always do. Most clinics in the world would still not change their practice, because they have neither the time nor the equipment. And — the part that decides it — most people on earth do not go to a doctor when they feel perfectly well, which is precisely when this knowledge is worth having.

That is the whole problem in one sentence. The consultation reaches too few people, too late, and it reaches them in the wrong state: unwell, worried, and looking for treatment rather than instruction.

So the teaching has to happen somewhere else. It has to reach people while nothing is wrong, without an appointment, in a form they can act on with a tape measure and a cuff that costs less than a month of streaming. That is what this series is for.

Why a lighthouse

A lighthouse rescues nobody. It launches no boats and it comes out to no one.

It stands at the place where the water is not what it appears to be — where the surface looks like open sea and the rocks sit just beneath it — and it tells every ship that passes, permanently, without being asked. It is the most patient form of teaching there is.

A lighthouse is not built where the sea is calm. It is built where ships have been lost.

That is what these cases are. Each one marks a hazard somebody hit, and turns it into a fixed light on the chart for everyone who comes afterwards.

What each case teaches

A real patient, described as it happened, with identifying details removed. How they arrived, who they were before, and which of the four pillars had been quietly out of range for years before anything happened.

Then the lesson, because each case exists to teach one thing. What that pillar is. How you measure it. What the number means. What it costs to find out.

I am using stories rather than a list of thresholds because that is how people actually learn. Nobody remembers that the target waist-to-height ratio is under a half. Everybody remembers the marathon runner whose heart stopped on a Saturday morning, and why.

These are not exotic patients. Most of them had seen a doctor. Several looked healthier than the doctor did. In every case the information was sitting there, cheap and unclaimed, and nobody in the story — the patient included — knew to go and get it.

What has changed, and why now

Two things have happened that make this a different argument from the one I could have made twenty years ago.

The first is that the cholesterol question is settled. For most of my career the position was that it was complicated and contested, and a generation formed its beliefs during that argument. Studies using inherited genetic variation, and then the trials of the newer cholesterol-lowering drugs, ended it. LDL is not a marker travelling alongside heart disease. It is the principal cause of it. And what matters is not your number today but your number multiplied by the years you have carried it — which is why children with inherited high cholesterol are now treated as children. The medicine has moved. The news has not — which is why the forums are still arguing.

The second is that the measurements came to you. A blood pressure monitor costs less than a month of streaming, and any pharmacy will measure it free. A glucose monitor can be bought over the counter without a prescription. A cholesterol panel can be ordered online and posted to your door, or asked for by name at your surgery. A tape measure costs almost nothing.

And the standing of home measurement has completely reversed. Twenty years ago a great many doctors regarded a home blood pressure machine with suspicion — the real answer came from the clinic, or from a twenty-four-hour monitor the hospital lent you. Today measurement away from the clinic is what the guidelines ask for, home readings are used in trials, and a week of your own readings predicts what will happen to you better than the single one taken in a surgery with your coat still on.

Wearables have moved the other pillars too, though unevenly, and it is worth knowing where the line falls. Continuous glucose monitors are sold over the counter. Watches detect atrial fibrillation well enough to send people to a cardiologist. But blood pressure from a wrist, without a cuff, is not there yet — the American Heart Association's position is that these devices still need proper validation. For the first pillar you still need a cuff, and it still costs less than a month of streaming.

Neither was true twenty years ago. Arguably neither was true five years ago. Together they make the case for teaching this now rather than continuing to dispense it one appointment at a time.

Do not wait to be called in

Here is the habit I would most like to break.

Most people treat their health as something that happens to them at appointments. You go when something hurts, or when a letter arrives, somebody measures whatever is on their list that day, and if nothing is said you assume all is well.

But the list is not the same as the four pillars. Take the simplest example: almost every surgery records your BMI, and almost none records your waist. BMI cannot tell the difference between muscle and fat, or between the fat under your skin and the fat around your organs — and it is the fat around your organs that does the damage. Waist divided by height is the better guide, it costs nothing, and you can do it yourself in ten seconds.

Nobody checks your tyre pressures for you between services. Nobody is going to keep your four columns for you either.

So I would turn the whole thing around. At the moment people go to the doctor in order to find out. I think it should be the other way round: you know your four numbers, and you go to the doctor when one of them is wrong. That is a different transaction entirely — and it is the one we already accept everywhere else in life. Nobody drives to a garage to ask whether their tyres are flat.

DR LEATHAM'S OPINION

Know your numbers

My view, and it goes further than current practice: from the age of twenty everybody should know these four, and should know them the way they know how to change a fuse or check the oil.

• Waist ÷ height — a tape measure, ten seconds, target below 0.5. Learn this one in place of your BMI.

• Blood pressure — averaged over several mornings at home, not a single reading in a surgery.

• LDL or non-HDL cholesterol — one blood test. Most people have never had it explained to them.

• HbA1c, or a CGM profile — from twenty, and sooner if you are carrying excess weight or have symptoms.

I would teach this in schools, alongside basic life support from sixteen. Two lessons. One of them tells you how to restart somebody else’s heart; the other tells you how to look after your own.

And if a number comes back wrong, that is not a catastrophe — it is information arriving early enough to be useful. Glucose and visceral fat in particular respond well to what you eat, how you move and how you sleep. Blood pressure and cholesterol may need more than that, which is exactly when you take the number to your doctor.

A personal position, informed by the evidence but ahead of routine practice. Not a screening guideline, and not a substitute for your own clinician's advice.

The part you can use

Every case comes with the four pillars drawn as a figure — four columns holding up a tablet, one for each measurement — set to that patient's real numbers, so you can see what was standing and what was not.

The figure is live, not a picture. Move the numbers and the columns change, which lets you ask the question nobody asked at the time: what if this had been found, and what if it had been dealt with?

Then the step that actually matters, and it takes about a minute: put your own numbers in instead. Most people discover they have had one or two of the four measured and have never thought about the others.

And if a column is not where it should be, that is when you go to your doctor — with numbers in hand. It is a different consultation from waiting to be found.

The tool is free and there is nothing to sign up for.

A word about hindsight

It is easy to look backwards at a catastrophe and find the moment it could have been stopped. I am not writing these up to say that a colleague missed something, or that the patient should have known. In most of these cases nobody did anything wrong — the measurement was not part of the routine, and the patient had never been told it was theirs to ask for.

Nor am I claiming that finding the problem earlier would certainly have changed the ending. Nobody can say that about an individual. What can be said is what measurement would have permitted: years in which something modifiable could have been modified. That is a smaller and truer claim than prevention.

But there is one thing I will say, and it is about you rather than them. They were never taught this. You are being taught it now. From here the four columns are yours.

The first case

The first Lighthouse Case publishes alongside this post: a man in his early forties, a marathon runner, lean and a lifelong non-smoker, who had an out-of-hospital cardiac arrest during a weekend run. Three of his four pillars were in excellent order. He had built them himself, over a decade. The fourth had never once been measured, and he had inherited it from a father who died at fifty.

The tool is free and there is nothing to sign up for.

→ Check your own four columns

→ Read the first Lighthouse Case

This article is part of The VAT Trap educational series by Dr Edward Leatham and is intended for educational purposes for patients and clinicians. It does not constitute individual medical advice. The clinical cases described are anonymised with all identifying details removed. All treatment decisions should be made in partnership with a qualified healthcare professional.