Tuesday, 7 December 2010

Things I Love About Medical School: The Feeling When It's Going Well

Today was my first day in A+E. I Clerked a patient, picked up all the salient points from the history, examined her and spotted a couple of subtle but important signs and came up with the most likely diagnosis all while a senior doctor was watching me.

I accompanied the same doctor to resus where a patient with sepsis was brought in by ambulance: I managed to put in a big cannula, take bloods and cultures from it and then take an ABG and successfully interpret it. 

This was all in the space of about 45 minutes. A few things went well and I felt ten feet tall.

Last week on ward-round I answered three questions wrong and almost tripped over my own stethoscope.

The ups and downs of medical school are not so good for your mental health.

Monday, 8 November 2010

Things I Hate About Medical School: FPAS

FPAS, The Foundation Programme Application System is (this year) the absolute bane of the final year student's existence. Last year it was called MTAS and no doubt something else before that just as it will almost certainly be called something else next year. As UK graduates we are (almost) guaranteed a foundation year 1 (FY1) job in a UK hospital however this year the UK FY1 market was oversubscribed by around 180 people. This did not help with everyone's tension. 

The basic premise is that all students apply through an online system where their performance at medical school, any previous degrees, awards or prizes are converted into points. There are then five white-space questions asking you to discuss the attributed of a good doctor in 200 words or fewer. These questions ask you either to give an example of when you have personified some value or other (specifically the ones the GMC think are important) or to ask you how you would deal with an hypothetical situation. The questions are released some time in October and you have 10 days to formulate your answers before submitting the application so the questions can be marked by an anonymous panel. Better answers add to your total score.

The application also requires the student to rank his or her choices of foundation school. These foundation schools correspond to around 20 chunks of the country where the student could work as an FY1. It is the system of matching students to foundation schools that is the real stinker. The matching system ought to be simple enough that everyone gets their first choice or, for those with weaker applications applying to more competitive foundation schools, their second or third choice. Sadly though, the situation is not that simple and generally if you miss your first choice then you miss by a mile and end up at your sixteenth choice. It is the assumption that any student would be so grateful to get any job that they would happily pack up and work anywhere that is offensive.

The old model of medical school was that everyone came in straight from school with no family, no partner, no baggage and could be sent anywhere. An increasing number of students are graduates with things like mortgages, partners, husbands, wives, that sort of thing. The system will only give you the opportunity of staying in one spot if you have children in school, are a carer for someone with a disability or have a health problem yourself that requires you to be near a specific hospital. If you don't like the system then that's fine; you just don't get to be a doctor, that's all.  

Thursday, 1 July 2010

Sick Taste

My girlfriend has multiple sclerosis. The woman I love and want to spend the rest of my life with is sick. I can say these things now of course; it helps that she's not that sick at all right now to be honest. 

All things considered it was a bit of a shock when one morning eighteen months ago she woke up and the world looked a bit fuzzy. Eight hours later she was blind in her right eye and she noticed some slightly sinister pins and needles. A bit of a shock certainly, but I managed. I was there for leaning on and the last thing I was going to do was let a silly thing like chronic disease worry me. 

MS comes in a couple of different shades of terrifying: one if these is the progressive avalanche of disability with its catheters and wheelchairs. The other, the relapsing-remitting kind, comes in fits and starts, sometimes the symptoms go away entirely after an attack, more often they leave something behind. Like scrubbing rioja from beige carpet. 

My girlfriend has been back to the symptom pick-and-mix several times since her diagnosis. First there was the eye then the eye got better. Then it was her legs then her legs got better, mostly. Not being able to walk all that well was a bit rubbish but the NHS and everyone helped out and we were able to get cheap taxis to hospital appointments so at least we weren't stuck indoors. A day out is a day out. 

Not that I'm complaining. Well I am really but stiff upper lip and all that. It's really not so tough for me. She's doing amazingly well at the present and, having nearly given myself an ulcer last year, I've learned to discuss my own stress and fears. It's nicer you know, sharing feelings instead of letting them erode your stomach. 

She's not quite a hundred percent on her legs yet and the NHS have got her something called a perching stool. Half sitting, half standing. The sort of thing she can use in the kitchen when her knees start to wobble. Now I'm probably being incredibly ungrateful but I've started now. I have never seen something so ugly in my life. It's a good job that people with disabilities lose their taste and self respect or she might think twice about wanting it in our home. Now I know it's functional and it only has to do it's job but so does an ikea chair and they're twenty quid and look really nice. Who designs this stuff? Crutches, walking sticks, grab-rails, the whole lot. I've met people who have been to design school. All with impeccable taste. All able to make something beautiful that also does the job. Thank god her sense of style has MS or she might notice something's up. 

I hope no-one else who needs a little help with their mobility starts thinking they've got some sort of right not to have an ugly home. Imagine if they started thinking they should be able to buy the same sort of stuff as us normal people ... Eugh. As for me I'm off to fit some handrails and try and make the decor fit around the new stuff. I wander if you can get emulsion in hearing-aid brown?

Saturday, 8 May 2010

Things I Hate about Medical School: Fainting

The worst part of medical school for me is feeling faint in operating theatres and around blood, needles and knives in general. Before I came to medical school I feared I would have this problem as I've never been keen on needles when it comes to my own arm/my own blood. 

The first issue for me was watching an angioplasty in my first year/on my first ever visit to a hospital. It was the cardiologist cannulating the radial artery and using increasingly large plastic dilators to make room for the catheter he needed to pass. Looking back it wasn't the blood that made me go, nor was it the needle or anything else; it was the force needed to open up a hole through the soft tissue over the artery with essentially a blunt instrument. Now in all honesty this was the only time I've ever fainted in hospital but it gave me a real feeling for the warning signs. It feels terrible. You sweat and feel hot then you feel cold, then your vision closes in and you know it's time to make a polite excuse, step back from the table and have a sit down and some water.

So while I haven't actually fainted again; knowing exactly when it's about to happen is almost as bad because it still stops me doing what I need to. 

In the last three years (my clinical years) of medical school I have spent most of the working week in hospital and have now graduated from being scared at the prospect of the simplest procedures to being able to take venous and arterial blood samples, cannulate and watch some of the roughest operations in theatre (things like hip replacements and caesarian sections). It's still a waste of a perfectly good gown to let me scrub-in though; that's a little too close for comfort. 

Happily I have no desire or interest in becoming a surgeon but the fainting thing remains a weakness that really irritates me. Hopefully my continuing aversion therapy will do the trick one day. Perhaps in time for me to retire.

Wednesday, 31 March 2010

Analysis: Why are gays excluded from some clinical trials?

Gay men and lesbians are routinely excluded from clinical trials for new treatments for sexual dysfunction according to research published last week. The question is whether this is a case of discrimination or just questionable experimental design.

In the New England Journal of Medicine last week Dr. Brian Egleston and colleagues from the Fox Chase Cancer Centre, Philadelphia wrote that 15% of all US trials of drugs and treatments for sexual problems specifically excluded gays and lesbians from participating. Most of the trials in question looked into treatment of erectile dysfunction.

Clinical trials come in several flavours depending on how they are conducted and how much is already known about the treatment being studied. Phase I and II trials are when a few people are given the treatment to see if it works and is safe. Phase III trials are when thousands of patients are recruited to study the treatment in more detail. Dr. Egleston's work showed that 73% of phase III trials listed on the US National Institute of Health's clinical trials database explicitly insisted upon patients being heterosexual and, usually, in a stable relationship. Phase I, II and other types of trial were affected to a lesser extent. This exclusion is mainly confined to trials concerned with sexual function.

It is important to realise that this does not represent gay people being denied access to standard healthcare. It is troubling however that a straight patient who has had no luck with existing treatments can be invited by his doctor to participate in a trial where a gay patient won't have the same opportunity, and won't even be aware his sexuality is a barrier.

The US National Institute of Health, which monitors clinical trials in the USA, has guidelines which specifically state that people must not be excluded on grounds of sex or race (unless this is appropriate to the research), currently there are no rules about sexuality but this is currently under consideration. Essentially exclusion criteria exist to ensure that trials are safe and ask the right questions. So it would be fine to exclude vulnerable groups where there is a question of drug safety. Likewise for trials of erectile dysfunction treatment, obviously only men are included. Rules about exclusion criteria in the UK are less clear but they are likely to be reviewed on a case-by-case basis by local ethics committees.

So in a situation where hundreds or thousands of gay men with sexual problems are missing out on the opportunity to try new therapies one would assume there is a valid medical or safety reason why. I contacted Professor Gerald Brock from the University of Western Ontario, currently the lead investigator in a trial of viagra in men with diabetes to ask why his trial explicitly excluded gay men. He explained that in the case of this trial, "the end points used were questionnaires" these questionnaires ask specific questions about sex with a female partner and are only "validated for vaginal intercourse". 

This would seem like a sensible reason if not for the fact that a great many trials take place which do not use straight-men-only methods. I put this suggestion to Dr. Egleston who told me about "a measure of sexual function for men" that was used in research in his unit "that can be used in heterosexual men, gay men and even single men".

The more troubling issue then is why some doctors and scientists choose research techniques which make it impossible to include gay and lesbian participants in their trials when clearly there is a precedent for more inclusive methodology. In an interview last week Dr. Egleston stated that "there was no indication that people running the trials intended to discriminate against gays or lesbians" but suggested that it was more likely that people were using the less inclusive methods out of convention, referring to it as a "copy and paste issue". Indeed Professor Brock agreed that convention was part of the reason he used such methods but he also believed it produced the highest quality evidence.

In the west there are still areas where inequality exists between gay and straight people but it is generally taken for granted that healthcare isn't one of them. While drugs once tested and licensed are generally made available on prescription to anyone who needs them there is still real disparity where gays are denied the opportunity to participate in clinical trials. If this occurs as a consequence of using old-fashioned methods in the name of convention then researchers must take care in the future before questions are asked about what would look like discrimination to some.

Daniel James

First Published at Pink News

Monday, 15 March 2010

Chilean Earthquake Knocks Earth Off Its Axis ... A Bit

The earthquake that hit Chile on 27th February and killed more than 700 people was so powerful that it shifted the earth's axis according to NASA scientists.

The 8.8 magnitude quake, the seventh strongest ever recorded was examined by Richard Gross, a geophysicist working for NASA's jet propulsion laboratory in California. Earthquakes of this strength involve millions of tonnes of rock moving significant distances fundamentally changing the way the mass of the earth is distributed. This alters the way the earth spins. “The axis about which the Earth’s mass is balanced should have moved by 2.7 milliarcseconds (about 8 centimeters)" according to Dr. Gross who mapped the changes in the earth's tectonic plates by computer simulation.

A knock-on effect of this change is that days on earth will become shorter. There's little need to worry though since the calculations show that the difference is only 1.26 microseconds, slightly more than one millionth of a second. 

The effect of large earthquakes on the spin of the planet is not a newly observed phenomenon. The massive earthquake that struck Sumatra in 2004 supposedly took a whopping 6.8 microseconds off the length of a day according to NASA.

Daniel James

The Prince and The Professor

Professor Edzard Ernst, who holds the only chair in complimentary medicine in the UK is facing the closure of his department following funding problems and a conflict with the prince of Wales's office.

Professor Ernst is a practitioner of complementary and alternative medicine (CAM) who left his native Germany to start practising in the UK in 1999. In 2002 he was appointed the UK's first professor of complementary medicine at Peninsula Medical school, University of Plymouth. While there is no shortage of published literature where CAM practitioners make claims about the effectiveness and safety of their remedies, Professor Ernst and his team are unique in studying the subject using a rigorous scientific approach. In the last eight years he has published work debunking homeopathy (finding it to be no more effective than placebo or sugar pills) chiropractice (suggesting it doesn't work and may cause harm) and iridology, the diagnosis of systemic disease by examining the iris - the coloured part of the eye. Professor Ernst has campaigned publicly for the use of scientifically-proven therapies and has written books and a weekly Guardian column on the subject. His view is that "there is no such thing as alternative medicine. There is either medicine that is effective or not, medicine that is safe or not. So-called alternative therapies need to be assessed and then classified as good medicines or bogus medicines. Hopefully, in the future, the good medicines will be embraced within conventional medicine and the bogus medicines will be abandoned". The Professor's team have published a catalogue of high quality evidence supporting the use some CAM treatments such as St. John's wort for mild depression and acupuncture for nausea and chronic pain. The CAM lobby, one would think, would be thrilled to have a scientist on board who can add legitimacy to their practice.

He has been particularly critical of homeopathy, the prescription of extremely dilute preparations of herbs, vitamins, minerals and occasionally poisons usually diluted to the point where no molecules of the original substance are present. Following extensive primary research and examination of existing publications he has described it as one of "the worst examples of faith-based medicine" and suggested that a "belief in homeopathy exceeds the tolerance of an open mind. We should start from the premise that homeopathy cannot work and that positive evidence reflects publication bias or design flaws until proved otherwise". 

In 2005 Prince Charles, a vocal supporter of CAM, commissioned a report to be written by the economist Christopher Smallwood and the consultancy firm FreshMinds. The Smallwood report made a number of suggestions regarding CAM treatments, in particular that they be made more freely available on the NHS. While reviewing the report in a professional capacity Professor Ernst made very public criticisms calling it  "outrageous and deeply-flawed" pointing to "hair-raising ... bad science" and suggested that the prince may have "over-stepped his constitutional role" by attempting to influence government policy. Following these comments the Prince's private secretary Sir Michael Peat wrote to the University of Plymouth to express grave concerns over a perceived breach of confidentiality. Professor Ernst was subject to a year of disciplinary procedures and investigation before being cleared of all wrong-doing. The conflict between the Professor and the Prince of Wales, manufacturer of Duchy Herbals Detox Tincture, continues. Professor Ernst's opinion on the Prince's own brand of CAM: "Prince Charles contributes to the ill-health of the nation by pretending we can all overindulge, then take his tincture and be fine again . . . he thus promotes a 'quick fix' and outright quackery". The Prince's foundation for integrated health has since received a £900,000 grant from the department of health to continue its research. 

Clarence house must be a fairly smug place as the Peninsula medical school department of complimentary medicine faces an uncertain future. Professor Ernst identifies the royal row as "a turning point" in his, and his department's fortunes. “I can’t prove that there’s cause and effect, but I suspect I was so much persona non grata that the university began to look forward to getting rid of me. Now in about a year we will close the unit unless a miracle happens". The professor's testimony and evidence on homeopathy to the house of commons science and technology committee was instrumental in their ability to deliver the verdict that NHS money spent on homeopathy is wasted. 

If Professor Ernst and his department disappear it will be a great loss to evidence-based medicine. The UK desperately needs this man to continue debunking the myths of CAM, exposing quackery and highlighting those treatments which actually work.

Daniel James