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.  

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

Wednesday, 17 February 2010

New Evidence Links High Achievement in School with Bipolar Disorder

Researchers from King's College London and the Karolina Institutet in Stockholm have published data linking high academic performance in school with the mental illness bipolar disorder.

Anecdotally, high academic intelligence has often been linked with the disorder, also known as manic depression. This research however is the first to offer any support to such a theory but is unlikely to give the whole story.

First things first; Bipolar disorder is a very real and serious subject. It is a disabling mental illness with around half a million sufferers in the UK. These people live through periods of usually crippling, crushing depression coupled with periods of soaring mania. The depression that occurs in bipolar disorder is among the most severe that you can imagine. As a medical student I was lucky enough to spend six weeks of my psychiatry training in a mental health unit in East London. The patients I met were mainly those who had been held for treatment under one section or another of the mental health act. Many of these people lived with bipolar disorder and were receiving treatment during spells of this deep deep depression. It is worth remembering that bipolar disorder is one of the mental illnesses most likely to lead to suicide.

The depression aspect of the illness is not neccessarily what people are most interested in. Depression isn't exactly fun, but mania, especially when it comes with a spark of talent and imagination certainly sounds like it might be. The romantic notion of genius and madness being closely related has caught the imagination since the time of the classical philosophers and has a lot to do with the perceived flashes of wit and inspiration that are sometimes seen when people are manic.  Since Stephen Fry's excellent and moving 2006 documentary The Secret Life of The Manic Depressive bipolar disorder has had a somewhat higher position in the public imagination. One theme of this documentary was that people with the disease can, while living through a spell of mania (or its less severe cousin hypomania) have the most productive and creative times of their life. The documentary focussed on artistic types who found they were blessed with the ability to work extremely prolifically during manic spells. This presentation of the disorder is only one half of the story. When I've talked to people with bipolar disorder it has become clear that mania is not always (or even very often) about people who can't stop painting, or composing or writing poetry. I met people who had been walking the streets of the east end half-dressed in the middle of the night having unprotected sex with strangers and having to deal with the resulting pregnancies and infections. I met people who had given away or gambled all of their money. I met people, in short who were not having the greatest time of their life; people in desperate need of help because of their inability to keep safe. Mania is not a good thing.

The research from London and Sweden, published in this month's British Journal of Psychiatry was carried out by looking at Swedish school results. Between the ages of 15 and 16 young Swedes take compulsory exams similar to our GCSEs. The researchers took the results for almost a million young people taking these exams and, using the admirable Swedish national hospital records looked to see who ended up being admitted to hospital with a diagnosis of bipolar disorder between the ages of 17 and 31. The headline-grabbing result was that those with the highest grades had four times the risk of a hospital admission with bipolar disorder than those with average grades (a leap from 4 per 100,000 people to 16 per 100,000 people). This link was most apparent in humanities subjects, and less-so in the sciences. This seems to agree with ideas about creativity and bipolar disorder. However, another important result from the research is that having the lowest grades (in all subjects) gave people twice the risk of a hospital admission with bipolar disorder than their schoolmates with average grades. The research itself is meticulously conducted and it is likely that these numbers are pretty reliable and represent a real-life situation. I would suggest a couple of questions worth thinking about: This research identified that the average age of hospital admission with bipolar disorder was at around 21. Do your GCSE grades neccessarily reflect your intelligence or creativity at age 21? If bipolar disease does have a link with intelligence, then why isn't the relationship a linear one? Why are the lowest achievers at higher risk than those with average grades?

While there are doubtless famous artists, writers and for that matter scientists, doctors and lord-knows-who else who have managed to function well with bipolar disorder it's important to remember that most highly functioning people don't have it. Its very enticing to us however, this idea of the tortured genius. It appeals directly to our vanity on the one hand, the idea that those with a mental illness can be capable of greatness is a reminder that all of us, with our sub-clinical character flaws and foibles can at least have a stab at it. On the other hand, less attractively, maybe it has more to do with schadenfreude than aspiration; the flaws of the best and brightest validate our own.

Daniel James

Published in the London Student. March 2010

Saturday, 8 March 2008

Old Age, Who Cares

Everyone cares about old age, or at least everyone should. Old age is everyone’s problem; it is the ultimate destination of the vast majority of us and affects us all as individuals and as members of society. It is a problem not only because of the biological factors that make older people more likely to become unwell and the economic factors that are the result of a changing population dynamic but because of the simple fact that there is a large group in society (older people, the elderly, the aged) that is the victim of thinly veiled prejudice from all quarters. Ageism is defined as "prejudice or discrimination on the grounds of a person's age” and can include prejudice or discrimination directed towards people of any age. The specific problem of the treatment of older people is more usefully termed gerontophobia and is defined "a fear of growing old or a hatred or fear of the elderly” (1) this definition shows the Janus face that this problem presents with elements of i) fear of ageing, and ii) a sense of hostility towards the older generation. To understand this problem it is important to investigate both elements of this dichotomy; fear and contempt, which combine and develop until older people are pushed to the fringes of society and their poor treatment becomes normalised. This normalization is the wider problem of gerontophobia. 

 Thoughts and fears of our own mortality strike relatively early. While still shielded by youth and by caregivers we are confronted by the death of a much-loved pet, grandparent or someone else close to us. Questions are raised: What does ‘dead’ mean? Why do people die? Will Mum die? Will I die? Death changes from an abstract concept that robs us of Fluffy (the hamster) to a certainty that will affect us, and all of those we love. This arousal of awareness can be sudden and surprising or, if younger, more insidious; as though we have just become aware of an awkward hooded figure, clad in black that was in the room all along; wondering what to do with his scythe. It is the presence of death in our lives, coupled with our self-protective instincts that lead us to fear the end of life. The end of life, it appears, is the end of everything. Ageing is by the same token something that triggers fear; it is the outward sign of the inevitable.

On a gravestone in a Suffolk churchyard is the simple epitaph; Life’s work well done. And we are all aware that this is exactly what death should be about. There are those tragic deaths of course; talk of people struck down in their prime, with ‘so much left to give”, but really, we accept (and hope that in our own case) death is an ending of something good, a full stop to a well-written sentence. Metaphors of resting in peace, and life’s work well done suggest that life is for achievement, and the end of a useful life is the end of life. So those people who have lived beyond their productive years have, by extension of that argument, forfeited their place in useful society. Their continuing existence beyond ‘usefulness’ becomes a cause for contempt towards older people, as they become a drain on society.

In the 1989 book Age Wave (2), describing the ageing population in the USA towards the end of the twentieth century, Ken Dychtwald, a gerontologist and psychologist explored gerontophobia and described it in terms of seven markers:

·  If young is good, then old is bad
·  If the young have it all, the old are losing it
·  If the young are creative, the old are dull
·  If the young are beautiful then the old are unattractive
·  If the young are stimulating, then the old are boring
·  If the young are full of passion, then the old are beyond caring
·  If the children are tomorrow, the old represent yesterday

His markers neatly underline the feeling of an increasingly youth driven society towards older people. It is true that the problem seems increasingly severe; a view often expressed by the general public and newspaper columnists is that a culture characterised by a lack of respect for older people is a new phenomenon, this however is not the case. Literature suggests that a positive view of youth contrasted with a negative view of old age has been expectated for hundreds, if not thousands of years. If it is accepted that the central characteristic of gerontophobia is a fairly organic progression of fear and contempt then this seems logical.

Shakespeare observed, famously in As You Like It the “seventh age of man” as “second childishness, and mere oblivion” (3). In Hamlet, he observes that “old men have grey beards, that their faces are wrinkled, their eyes purging thick amber and plum-tree gum and that they have a plentiful lack of wit, together with most weak hams”(4). Modern literature of course continues the trend of broad generalisations when it comes to older people. In John Steinbeck’s The Grapes of Wrath: “Grandpa was still the titular head [of the family], but he no longer ruled. His position was honorary and a matter of custom. But he did have the right of first comment, no matter how silly his old mind might be”(5).

For the most interesting literary comments on old age that demonstrate older people are rarely been viewed as valuable members of society it is worth looking to Plato. In the opening words of Book I of The Republic written in 360BC Plato examined older people. The patriarch: Cephalus tells the philosopher (styled on Plato’s teacher) Socrates about his old age:

“… I cannot eat, I cannot drink; the pleasures of youth and love are fled away: there was a good time once, but now that is gone, and life is no longer life.  Some complain of the slights which are put upon them by relations, and they will tell you sadly of how many evils their old age is the cause.”(6)

Plato’s description is one of older people disappointed at the lack of respect afforded them by their families. The dialogue concludes that respect is earned not because of advancing years but because of the sum of a person’s achievements, their attitude and behavior. Cephalus himself, though an important man; is indulged rather than liked, and is not invited to take part in the dialogue on justice and society that makes up the bulk of the work. The roman philosopher and orator Cicero (who studied at the Academy Plato founded in Athens some 300 years before) observed that Cephalus, an old man, would have been out of place in such a philosophical discussion, “which he could neither have understood nor taken part in” (From Jowett’s introduction to The Republic (6)).

Plato observes that the poor treatment experienced by older people, and their nature to complain about said treatment “are to be attributed to the same cause, which is not old age, but men's characters and tempers” (6). This brings to light an interesting anomaly in a culture where gerontophobia is considered normal. This anomaly is the favoured position that certain older people can hold in society. The most interesting example here is the figure of the elder statesman, typified by Winston Churchill, who came to power at the age of 65 to lead the UK through the second world war. Where older people are seen as leaders, or particularly active or successful it is more likely that the public will identify with their more youthful characteristics and they will not be associated with old-age with its connotations of weakness and senility (7).

Though the dynamic of our population is changing, as diseases that kill people in their fifties and sixties become easier to treat and the percentage of older people increases, older people in society have been a significant group in society throughout history (8). Age at death is determined largely by our genetic makeup, maximum age therefore can be thought of as a relative constant; with developments in medicine serving to increase the percentage of the population who live to that age. In terms of illness being more common in older people, Hippocrates listed common diseases of ageing in great detail (9) and he is rightly honoured as a great observer, who learned from a great many older patients. Aristotle formulated a theory of ageing which explained it as a loss of heat as unscientific as this now sounds nobody really examined ageing in greater detail or wrote anything better in the 2000 years that followed (10). The common view among physicians until the 17th century was that ageing was largely an irreversible process of decay and increasing illness (7). Francis Bacon was one of the greatest (and loudest) opponents to this point of view, he proposed that ageing was not necessarily a homogenous process within a population (or across different populations), he suggested an epidemiological investigation of the different effects of ageing on different populations and of the different lifestyles on longevity (8).

It was eventually the work of Ignatz Nascher (who coined the term Geriatrics in 1909) in the USA that sparked scientific and sociological research into the process of ageing (11).  The medical side of geriatrics developed in the UK with the founding of the NHS in 1948 though geriatrics (as a medical specialty) was first born through the work of Marjory Warren, a physician at the West Middlesex hospital who was confronted with an influx of 714 older patients when that institution merged with an adjacent county workhouse in 1935. While reviewing the older patients from the workhouse wards, Dr Warren was able to discharge a great many, by ensuring they would receive proper care and the use of appropriate equipment (such as mobility aids) outside of an institution. She observed a great many differences in disease states in the large group of older people under her care when compared to younger patients as was able to adapt and modify the wards to their advantage (12). In landmark papers in 1943 (13) and 1946 (14) she called for dedicated geriatric departments in hospitals, specialist doctors to staff those departments and for medical students to be trained specifically in the diagnosis, treatment and care of older people. The Medical Society for the Care of the Elderly (later the British Geriatrics Society) was founded in 1947 and the first consultants in geriatrics were appointed shortly after the founding of the NHS (15). Geriatrics today is, sadly, characterized by a lack of funding and a poor image. A report on old age and health care from the Wirral hospital NHS trust published in 2003 suggests that gerontophobia is widespread within the health service, underlining negative attitudes (both held and displayed) towards older people, poor care environment, insufficient workforce capacity in geriatrics, inequalities in access to healthcare and inadequacies of essential nursing care as the particular problems with the care of older people (16).

If there can be any conclusion from this exploration of old age, then it must be that gerontophobia is a real, widespread problem that has become normalized and so has pervaded everyday life since the dawn of culture. It is worth note that gerontophobia is one of the most unusual of all forms of prejudice in that it discriminates against a group of people that the vast majority of society will end up in. Gerontophobia is perhaps most concerning in the provision of medical care where paediatric wards that employ clowns and play specialists, and ensure the healthcare of the young is holistic and discharge-focused can exist in the same building as drab geriatric wards where wheelchairs, televisions and any form of activity are in short supply (16). While gerontophobia in all its forms will never be eradicated from society it must be addressed and challenged unreservedly particularly in the healthcare setting, surely with the ultimate aim of stamping it out entirely.

An original Entry for the 2008 Joy and David Long (Essay) Prize in Medicine.

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2. Dychtwald K, Flower J 1989. The Age Wave: How The Most Important Trend Of Our Time Can Change Your Future. 1st Ed. 1989. Bantam (New York).
3. William Shakespeare c1599. As You Like It. Popular Classics Ed. 1994. Penguin Books (London).
4. William Shakespeare c.1601. Hamlet. New Penguin Classics Ed. 1980. Penguin Books (London).
5. John Steinbeck 1939. The Grapes Of Wrath. Penguin Classics Ed. 2000. Penguin Books (London).
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13. Warren MW 1943. Care of Chronic Sick. A Case for Treating Chronic Sick in Blocks in a General Hospital. British Medical Journal 2: 822-823.
14. Warren MW 1946. Care of the chronic aged sick. Lancet 2:841-843.
15. Barton A, Mulley G 2003. History of the Development of Geriatric Medicine in the UK. Postgraduate Medical Journal 79:229-234.
16. Davey B, Ross F 2003. Exploring Staff Views of Old Age and Health Care in The Wirral Hospital NHS Trust. King’s College London Nursing Research Unit: 01.11.2003. Available Online: www.kcl.ac.uk/content/1/c6/01/94/98/WirralReport.pdf Accessed: 30.01.2008.