Reflection

Vol 1 pp.200-286 | 30 April 2010 | thelsjm.co.uk | ISSN 1759-1236 | doi:10.4201/lsjm

Women in Surgery-Karen Daly Inside the Mind of House MD The Enigma of Dr James Barry Medicine, Motherhood and Me Is Breast cancer prevention a realistic prospect for the future?

Surgical training in the 21st century-should we be worried? lsjm 30 april 2010 volume 01

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FOREWORD

Reflection doi:10.4201/lsjm.ed.002

Sir William Osler is quoted to have said “Medicine is a science of uncertainty and an art of probability”. In this issue we explore the characteristic ideas and individuals that have brought traditional medicine and modern healthcare to the precipice of change.

The shift from a paternalistic approach to healthcare provision has been long coming but here in the UK it flourishes and is celebrated. The place of the woman in the medical team has experienced a parallel shift. An article on the life of James Barry tells the tale of a woman’s rise to the top of surgery in an era where women in health are epitomised by the contribution of Florence Nightingale. Several interviews in this issue explore the lives of high-profile women in surgery, medicine and health governance. Haastrup gives us insight into the job of Karren Middleton, the current chief health professions officer for England with the task of uniting professions allied to health.

Our surgery section showcases the work of students who attended the Scalpel conference 2010, the first of its kind. Together with an exposé on peer-led teaching, these initiatives commiserate the notion that the health trainee can and should play a bigger role in the training they receive.

Other agents have always had a role on how tomorrow’s health professional prepares for the task. For instance, the media has a wide effect on social and health policy. We as current and future health professionals are not exempt from this influence. Dr Gregory House of the popular television drama House MD is the infamous face of “TV Medicine”; Kharay interviews Dr Harley Liker to find out what makes this fictional though fantastic brain tick.

21st century medicine employs the use of new and fancy toys to train the future; Shaw describes his experience of this new training. The future is built on the past, Hague writes about the lessons learned from the historical analysis of paediatric cases.

Reflection (the image of the status quo seen in a mirror) is often useful in changing this status. We can however reflect on the past in our search to redefine the future. Healthcare is a science of uncertainty. To survive it, we must master the art of probability. The final issue in this volume hopes to cabinet these aspects of progress as healthcare marches deeper into the waters of change.

Kevin Owusu-Agyemang Editor-In-Chief

Kevin Owusu-Agyemang Co-Editor-in-Chief 200

Nana Seiwaa Opare Co-Editor-in-Chief

Helena Masters Acting Creative Director lsjm 30 april 2010 volume 01

30 APRIL 2010 VOL 01 ISS 03

Contents Page: 202 205 217

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Reviews Schizophrenia through history The mental health team in Britain: past, present and future What insights can historical analysis of case notes provide children’s healthcare today?

Familial hypercholesterolaemia

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Interviews with Women in surgery - Karey Daly Foetal cleft lip and palate repair - Professor Ortiz Monasterio The view from a bridge - the chief health professions officer

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Sections of the LSJM Surgery pg. 230 Editors- Milan Makwana & Jonathan Cheah Submit to: Surgery@thelsjm.co.uk Psychiatry pg.216 Editors- Alexander Ross and Samuel Ponnuthurai Submit to: Psychiatry@thelsjm.co.uk

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Global and Community Health pg256.

Editors- Harpreet Sood and Vishal Navani Submit to: gch@thelsjm.co.uk

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Health Law and Ethics pg.242 Submit to: hle@thelsjm.co.uk

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Medicine pg.270 Editors - Laura Vincent Submit to: medicine@thelsjm.co.uk

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Careers pg.206 Editors- Sonia Damle Submit to: careers@thelsjm.co.uk

The London Student Journal of Medicine (LSJM) is published by the LSJM Publishing Group, an independent non-profit organisation. The LSJM Ltd grants editorial freedom to the editors of the LSJM. Whilst the authors and editors have taken all reasonable measures to ensure the accuracy of the articles published and images used, they do not warrant that the information is complete, correct and or accurate. All articles published in this journal, are views of the authors and do not reflect that of the editors, organisation or institutions to which they are affiliated to or the LSJM unless otherwise specified

by Law. Acceptance of advertising does not imply endorsement. LSJM Ltd shall not be liable for the any loss, injury or damage caused by your reliance on any article published. For further terms of use, see www.thelsjm.co.uk. © the London Student Journal of Medicine 2009.

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Editorials An era of change No white space, no brain space?

The dark art of medicine

Special Report The role of reconstructive surgery in the management of urethral stricture: a case study Investigation into the association of Cancer Stem Cells and chemoresistance in breast, colon and prostate cancer cells Research The mental health of mental health staff: psychological distress and burnout in DSPD units Evaluating the impact of cigarette packet graphics on tertiary students What are the beliefs of adult patients on the prevention of adult obesity in primary care?

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Articles Inside the mind of House MD Manchester students make the case for peer-managed-peer assisted learning The enigma of Dr James Barry Should the private conscience of a health professional interfere with their professional duty?

“Not all sunlight is dangerous, just ultraviolet radiation” A discussion of drug-induced hyponatraemia

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Perspectives Medicine, motherhood and me Surgical training in the 21st century - should we be worried?

In breast cancer prevention a realistic prospect for the future?

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Profiles Miss Beryl de Souza

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Also in this issue Letter to Carlos Chagas News

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EDITORIAL

An Era of Change doi:10.4201/lsjm.ed.002

At theLSJM, we define medicine as the management of a patient’s health need that is realised through the application of an umbrella of services. From this medicine is not simply what the doctor does. It is rather a process that we implement as a wider health team, to meet any patient’s need.

1 2 3

Any definition put forward by a group of young minds from an even younger journal may seem bold and somewhat irrelevant. The dawn of change however rests over most of healthcare; with entities like the specialist nurse as a fore-glimpse of tomorrow’s medicine. Change is usually feared and often avoided for the waves of painful adjustments it sweeps ashore, which often reveal the great inadequacies of the status quo.

The commonest excuse to stifle progress (if not just change) is that it begs us to move out of familiar territories or be washed away.

To return to the clinical importance of this dawn, three case scenarios are employed: A patient attends the emergency services following a brief period of concussion after being hit in the temple with a baseball. The A&E nurse notes the patient’s GCS as 15 and triages him to minors to have his injury tended to. The doctor in minors finding nothing wrong with our patient decides to monitor him for a few hours before discharging.

The actions of this doctor save the patient hours later when he develops a headache, starts vomiting and his level of consciousness deteriorates.

A head CT reveals an extra-dural haemorrhage. Today, protocols on the management of head injury work to prevent such patients from slipping through the cracks and dying of preventable conditions.

A second patient reports to his diabetes nurse in a community review that he is experiencing severe epigastric pain. The nurse alerts the local general practitioners (GP), who reviews the patient, notes he is otherwise stable and recommends some ibuprofen and paracetamol. The GP advises the patient to attend A&E if it recurs or gets worse.

The case highlights the need for all health professionals to recognise their scope of expertise in patient care with freedom to treat or refer patients where appropriate to their needs. At present, GPs occupy the role of sentinel to the evolving view of healthcare. The office of sentinel is all too easily mistaken for that of the lighthouse. Primary care should prevent inappropriate referral to health services but should not replace specialist assessment.

The GP in the above case should have recognised this patient’s presentation as an acute abdomen and requested assessment by a trained surgical team. There is always the temptation to initiate management for complaints once a referral has been received. The patient subsequently presented with shock secondary to a perforated duodenal ulcer. The late presentation was partly due to a masking of his symptoms by the analgesics received.

Finally, a surgical registrar reviews a patient 6hours following an elective left hip arthroplasty. An epidural was sited to control pain during the operation and was recently removed. The patient initially reports some mild pain at the operative site. The pain increased after the epidural was removed but he is now happily pain-free and cannot feel both legs.

The surgical registrar in this case contacted the anaesthesist to discuss the potential of a complication following the epidural, arranges for imaging of the spine and seeks a neurosurgical review. His actions saved the patient from irreparable damage from cord compression secondary to a haematoma; a complication revealed after the catheter controlling a bleeding vessel is removed. Timely responses such as these have their place in traditional medicine and any changes to the practice of medicine have to safeguard it.

The cases highlight the need for the trainee to learn the most important skill of - all waiting. A reminder to the practiced clinician to refer, and the importance of the experience acknowledged. The lucid interval is the calm before a medical storm that all health practitioners should acquaint themselves with in order to avert disaster and deliver the best health outcomes.

Healthcare delivery and practice in the UK has undergone several overhauls; from GP contractual arrangements with government through to the continual reshuffle of appointment criteria of newly qualified doctors, and the extension of the power to prescribe to nurses. Patient care seems unaffected by these changes and in some cases sparse improvements have arisen. We compare this era of calm in healthcare to the lucid interval; the time before the tsunami hits the shore.

A new era is upon all of healthcare and it is time to lose the weights that anchor us down. The doctor has traditionally represented medicine; it is time for doctors to take their place as part of a wider team. The student stands in the shadows ready to succeed the more experience clinician; it is perhaps time he/she sat as part of the team that shapes tomorrow’s health practice. The student of healthcare is “tomorrow’s doctor”, tomorrow’s medicine. TheLSJM was conceived to encourage students to take more of an active role in shaping what tomorrow’s health practice is. Change can be good, it is usually better when forewarned. We must take measures to forearm ourselves.

Kevin Owusu-Agyemang, Editor-in-chief

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GENERAL MEDICAL COUNCIL

The General Medical Council registers and licenses doctors to practise medicine in the UK. Our purpose is summed up in the phrase: Regulating doctors, Ensuring Good Medical Practice.

The law gives us four main functions: • keeping up-to-date registers of qualified doctors • fostering good medical practice • promoting high standards of medical education • dealing firmly and fairly with doctors whose fitness to practise is in doubt

Office of the Health Professions Adjudicator (OHPA)

From April 2011, the adjudication of fitness to practise cases involving doctors will transfer from the GMC to a new body called the Office of the Health Professions Adjudicator (OHPA). OHPA is being established under the Health and Social Care Act 2008. It is being created to ensure clear separation between the investigation of fitness to practise cases and the process of determining whether a professional’s fitness to practise is impaired.

To begin with, the new body will be responsible for making decisions on fitness to practise cases brought forward by the GMC and, in time, the General Optical Council. Over time, other regulators of healthcare professionals may transfer their adjudication functions to OHPA. For more information about OHPA, please visit www.ohpa.org.uk The GMC will remain the regulator for doctors, continuing to set the standards for professional practice and receiving and investigating allegations about their fitness to practise.

Merger of PMETB with GMC

From 1 April 2010, (subject to legislation) the functions of the Post Graduate Medical Education and Training Board (PMETB) will be transferred to the GMC, creating a simpler and clearer framework for the regulation of medical education and training.

In February 2008, the Secretary of State announced that PMETB would be merged with the GMC, following a recommendation from Sir John Tooke’s Independent Inquiry into Modernising Medical Careers. Following the merger, all stages of medical education and training will fall under the GMC’s remit. For more information please visit www.gmc-uk.org or www.pmetb.org.uk

Podcast helps today’s medical students become tomorrow’s professionals

A major new initiative has been launched by the General Medical Council (GMC) to help medical students to develop and maintain high standards of professionalism throughout their training and careers.

Medical students on a new podcast describe how good clinical knowledge, patient confidentiality and smart dress are all attributes that help to demonstrate high standards of professionalism. Newly qualified doctors discuss the challenging issues they can face and how the professionalism training they received at medical school helps them to offer high standards of care to patients.

Professor Jane Dacre, GMC Council Member and Vice Dean and Head of Education at UCL Medical School in London, features on the podcast: “Doctors must demonstrate good clinical competence and be able to communicate complex information to their patients effectively.

We spoke to doctors and medical students who acknowledge on the podcast that this is one of the most challenging parts of a doctor’s role, especially when facing testing situations on issues like patient confidentiality”.

Throughout 2010 the GMC will continue a programme of work engaging with medical students alongside the podcast on professionalism and an e-bulletin to which medical students are encouraged to sign-up.

The e-bulletin updates medical students on what they need to know from their regulator. In this edition, the GMC updates students on developments in medical education and regulation, including the upcoming merger of PMETB with the GMC and new guidance from the GMC being launched this year. The GMC also asks medical students to get in touch about what ethical issues and guidance they want to hear about in the next e-bulletin.

Other planned activities during 2010 include reviewing and updating content on the student section of the GMC website and working alongside the Kings Fund and the Royal College of Physicians on a series of student roadshows.

GMC guidance Tomorrow’s Doctors sets the standards that medical students have to meet before they graduate. The guidance was published in 2009 and among other things highlighted the importance of communication skills and a good bedside manner as well as ensuring that medical students acquire the scientific background and technical skills they will need to be effective doctors. Tomorrow’s Doctors will be implemented by 2011/12.

To listen to the podcast and subscribe to the e-bulletin, please visit www.gmc-uk.org/students The GMC is also keen to hear your feedback on the podcast.

Further information for medical students is also available on the student pages ‘Information for medical students’ on the GMC website.

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Medical Scientist Physiotherapist

Cardiologist Nurse

Surgeon

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EDITORIAL

No white space, no brain space?

This year, several medical schools will be piloting yet another change to the Foundation Programme Application process.

Coming out of the recommendations made in the Department of Health’s document The Next Stage Review: A High Quality Workforce[1], the proposed changes will see the current ‘white space’ questions being replaced by ‘situational judgement tests’ written under the watchful eye of an invigilator.

The new method of assessment is an attempt to address concerns raised by the Department of Health review, which states that “new work needs to be undertaken to develop more reliable and valid selection tools for recruitment”.

But by removing what critics have often anecdotally called the ‘creative writing’ element of the Foundation application process, have the medical education chiefs taken a step backwards from their commitment to reflective practice?

White space questions allowed for the expression of reflective thinking about different facets of life – not just the healthcare experience. Offering candidates the opportunity to show that they have a range of interests, and asking them to demonstrate how their outside experience enhances their professional attributes is surely a worthwhile test of reflective learning?

Reflection seems to be the buzz word in healthcare education today, yet in other fields it is not a new idea. From the truisms of Confuscious in BC China to the theories of pre-war educationalist Dewey, self-reflection has been a key part of the learning process.

What does this mean for students today? Porfolios and projects have replaced the hours of rote learning and memorisation of anatomy and pathological processes. Yet, the evolution of medical education has not been so much a straight switch, rather a bolting on of added requirements, resulting in more hoops to jump through and more boxes to tick. Of course anatomy and pathology are not subjects to go without, so with all this additional reflective work to complete, when is there time to actually take stock of your progress, to take a longer, career-focused view - in short, to reflect?

This issue, Dr Harley Liker talks about his role as medical advisor on hit US drama House. Liker is also heavily involved in undergraduate medical education at UCLA and says that bringing a breadth of experience to the table is important for a fledgling doctor.

“I often encourage my medical students, mainly first and second years, to use their free time away from medicine because I think it makes them better rounded. So if you told me they had the opportunity to watch an hour episode of House MD or go see a provocative foreign film, I would say to them go do the latter as it’s going to broaden you. If they enjoy House then that’s great but I would not give it to them as an assignment.”

Given the demands of the Foundation Application process, if extracurricular, non-medical pursuits are to go unrecognised, will medical students end up narrowing their horizons too much?

More than two and a half thousand years ago, Confuscious said: “By three methods we may learn wisdom: first, by reflection, which is noblest; second, by imitation, which is easiest; and third, by experience, which is the most bitter.”

In order to learn by reflection, one needs time. By removing the white spaces and filling them with ever increasing hurdles and hoops, we reduce the opportunity to learn how to practice wisely.

Through our pursuit of reflective portfolios we become better at playing the game. Whether it makes us better doctors remains to be seen.

Sonia Damle Section Editor Careers References 1.

The Next Stage Review: A High Quality Workforce, Department of Health, June 2008

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ARTICLE

Inside the Mind of House MD Gurpreet Kharay Bsc(Hons) Year 5, King’s College London Gupreet.kharay@kcl.ac.uk doi: 10.4201/lsjm.car.006

Consider the humble physician - devoting time and attention to patients in need; maintaining a commitment to life-long learning to keep his or her skills up to date; upholding the Hippocratic oath; and reviewing scripts for a top-rated television drama in the heart of the Hollywood Hills.

Not expecting a doctor’s responsibilities to be so broad? Neither was UCLA physician Harley Liker MD. When Dr Liker entered the profession he was sure that medicine would be a varied and interesting profession; but no one was more surprised than he when he found himself working on the script of the award winning medical drama House MD. Access to and interest in medical matters has never been greater, and the advent of internet search engines such as google and wikipedia means that everyone can be a home-made medic. The international success of shows such as Grey’s Anatomy and House is proof of medicine’s popular appeal. Dr Liker, one of the medical technical advisors on House - the most watched show in the world[1] - agrees that medicine is something that we all can relate to.

Liker was the first medic to be brought on board the Emmy awardwinning show, and explains how he landed the job several years ago: “My son Jake was in preschool with the daughter of House’s creator, David Shore.

David and I would discuss new projects and one time he said ‘I’ve been asked to pitch this idea of creating a television show’. His idea was that he was going create a physician who was going to be edgy and solve mysteries; the term he used with me was ‘I want him to be like Sherlock Holmes’. I think few people know the show is called House as it bears resemblance to the name Holmes.”

At the time, a drama based on medical mysteries had never really been done before.

Shore, had a background in law but needed someone with medical expertise to get the show right. Liker recalls the early stages of getting the show off the ground where he drew on his experience in the profession to come up with the character credentials: “When it came to the characters and their professions I immediately said you’re going to need an oncologist’, so that’s what Wilson - House’s best friend - became. From an dramatic standpoint you want oncology to feature in the show. It’s life threatening and allows for emotional highs and lows and that’s drama.”

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“Also at the time of my discussions with David, the Anthrax scare was not too long ago and there was a lot of concern about bio-terrorism.

I said you need an infectious disease person because people get really sick from all kinds of strange organisms - so that’s what Dr House became. Furthermore you need a neurologist because that allows for dramatic signs such as seizures and directs interest to the brain which fascinates people and so we had Foreman.

“Chase became the pulmonary critical care doctor since there are bound to be really sick inpatients and you need someone with expertise to care for them too.

“Finally we thought rheumatology would work well because rheumatologic diseases can present in odd ways and some can actually be life threatening, like advanced Lupus. So Cameron became the rheumatologist on the team.”

Discussing medical cases amongst fellow physicians and health professionals is one thing but making medicine make sense to those from non-medical backgrounds is a whole other ball game.

And that includes the writing staff. Liker recognized some common misunderstandings stemmed from the medical jargon: “One of the things writers love to say is ‘give him an MRI’ and I tell them doctors don’t give patients an MRI, they order an MRI. Similarly David very early on knew he wanted Dr House to report to someone high up and he called Dr Cuddy the Dean of Medicine. I told him ‘it should be the Chief of Medicine’ but then the average person watching House MD is from a non-medical background so in a way whether it’s the Chief or the Dean it doesn’t matter.”

Liker forgives the writers’ errors, knowing that all but one, David Foster - a fellow physician - do not have the benefit of clinical experience to steer their ideas.

When asked who’s the real star of the show - the medicine or the drama - Liker is quick to explain: “It’s not really a case of one before the other. The show is ultimately about telling stories – hopefully highlighting human characteristics and emotions such as sadness, joy, betrayal that are universal.

So the show is much bigger than just the diseases. The medicine and the cases are the vehicles by which we can illustrate human nature. Then you have the arcs which is where the drama fits into the script. The nice thing about medicine is that it is very accessible and something everyone can relate to you can personalize it. It also makes us think about moral and ethical issues.”

But while the storylines and character development fall within the remit of David Shore and the writing team, Liker’s chief interests lie in the technicalities and medical nuances of the show, and he works hard to maintain accuracy, inviting specialist consultants in various medical fields to advise the show.

“I really leave what’s happening with the characters to the writers.

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ARTICLE

One of the recurring characters early on was a pharmaceutical company boss called Edward Vogler. My input was about the nature of the relationship between him and Dr House as I knew the ins and outs of hospital administration and hierarchy. For the most part, how the characters evolve is left 99.5 per cent in the writers’ hands.”

Liker is always on hand to point the writers in the right direction when it comes to ideas for diseases and cases, and he is keen to point out that the choice of condition is driven by dramatic interest rather than commercial ones.

“I was asked by an individual who was wondering whether the pharmaceutical industry had undue influence on the show. In other words where we paid to do product placement? Well, on the show we only use generic names and never the branded ones. We would say ibuprofen rather than use its tradename. So, just so the record is clear, the pharmaceutical industry has zero influence on the writers or the content.”

“This isn’t a show about coughs and colds or something that’s going to be easily diagnosed with the first blood test because there’s

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no mystery, no hook to keep the viewers engaged. I’ve given the writers some interesting websites that help guide them to some rare diseases and every year someone from a different field of medicine comes down to talk with and sit amongst the writers. The brief is simply to tell us about their most interesting and challenging cases.

“The nice thing about House is that there is a medical mystery to be solved and they’re typically complicated enough that a second or third year medic is not going to figure out, and so it can get their minds to think of differential diagnosis which is good.”

“The writers are constantly reading and they are hearing about strange poisonings that were not easy to detect. You want to find diseases that are similar enough to other diseases so it’s easy enough to go down the wrong path. You know the old saying ‘If you hear hoof beats think of horses not zebras’? Well in House we have them hear hoof beats, think of horses but ultimately it turns out to be zebras.”

The high value placed on medical accuracy is obvious, but does the often-idiosyncratic behaviour of the eponymous Dr House stem from similarly factual origins? Does his habitual use of Vicodin and his apparently dismissive attitude to his team and patients alike, have a basis in reality? Liker insists that House is purely fictional and emphasises that he is not aware of any doctors who conduct themselves in the manner Dr House does.

“The notion that I’m not going to see a patient and instead send my residents to see them while I sit and pop Vicodin and play with a tennis ball in my office is the furthest from the truth. There’s no question that I would ever conduct myself the way he conducts himself professionally or I would not have a practice! If you want to put me on the spot here and ask me whether I know of any doctors who get their interns or residents to break into patients’ homes - I most certainly do not...!”

While some of House’s more outlandish character traits may push the boundaries for the sake of entertainment, creator David Shore will often ask the writers to present medical literature that supports the disease they are working on for an episode, to make sure everything is as plausible as possible. If Liker feels the medicine is being pushed too far he will take a stand.

“The conflict for me is when I think that something is not medically possible - you can’t tell me you can take a kidney from a bird, put it in a man and that kidney is going to start working. The unwritten rule is - if it could happen or it’s happened at least once – it could happen on House.”

References: 1.

http://thecelebritycafe.com/features/28886.html

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INTERVIEW

Women in Surgery Prini Mahendran

Year 4, St George’s, University of London m0401028@sgul.ac.uk

Have you ever felt that your gender has ever impeded your career?

Actually I always felt it gave me a slight advantage - if getting noticed is important then being the only woman most of the time was definitely a positive. There were one or two senior consultants who genuinely doubted whether I could manage but I guess I proved them wrong anyway.

09/09/09 Pregnant Pause: Flash Mob

Some argue that groups such as Women in Surgery[4] have promoted positive discrimination by encouraging the appointment of female surgeons over their male counterparts. Is there any truth in this?

The role of Women in Surgery and groups like it is not to promote positive discrimination but to raise the profile of women in surgery. In that I think they have succeeded. I don’t believe that women have been promoted over men because of their gender, and I wouldn’t want that to be the case either. Surgery should be a meritocracy as that is the best way to maintain high standards.

Caption: Ms Karen Daly, a Children’s Orthopaedic Surgeon The existence of women in surgery is a relatively recent event.

It was the mid 1500s when Henry VIII united the Fellowship of Surgeons with the Company of Barbers to form the forerunner of the Royal College of Surgeons of England.[1] At that time, and for the next 300 years, the profession remained a male bastion, penetrated only by those such as Dr James Barry, in fact a woman who managed to pass as a man and have a successful surgical career. It was only after her death in 1865 that her gender was revealed.[2] Thankfully today women do not have to go to such lengths to pursue a career in medicine. In 2007, the majority of students studying pre-clinical medicine are women. [3] But are women given equal opportunities as their male colleagues in the surgical field? In the same year, more than 93 per cent of surgeons at consultant level were men.[3] Why is this still the case?

Consultant Surgeon Karen Daly has bucked the trend.

Qualifying more than 20 years ago, she specialises in Children’s Orthopaedics and Trauma at St George’s Hospital, London.

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Do you think that old boys’ network still exists?

If there is one, then they are way out of touch. It is no longer possible for a patron to get their trainee appointed. In fact we had a discussion not long ago about a trainee who was thought to be very good but had not be able to get a post through interview. My view is that good trainees will get there without us. We have all had set backs and bouncing back afterwards says a lot about someone’s resilience - which is a good attribute in a surgeon.

Do you think it is possible to balance family life and a career as a successful female surgeon?

I suppose you should ask my children that one! I have a full time consultant job and six children but I still feel I have a good work life balance - equally busy at home as I am at work! I know this isn’t necessarily the right thing for everyone. In order to run this sort of life, you do need a lot of stamina and an ability to organise oneself as well as others, as well as good childcare - which isn’t cheap! What is really important is to realise is that there are choices to be made and these are part of the active process that is career planning. There are so many variables that need to be taken into account - but if a woman has what it takes to be a surgeon then she can find a solution that is right for her.

References 1. http://surgicalcareers.rcseng.ac.uk/wins/history 2.

3.

4.

http://www.newscientist.com/article/mg19726462.000-histories- the-male-military-surgeon-who-wasnt.html http://surgicalcareers.rcseng.ac.uk/wins/research-and-stats/statistics http://surgicalcareers.rcseng.ac.uk/wins

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INTERVIEW

The View from a Bridge- The Chief Health Professions Officer Oluwatosin Haastrup Year 3 Medicine, St George’s, University of London m0700193@sgul.ac.uk

Karen Middleton is Chief Health Professions Officer for the UK Department of Health. As such she advises ministers and Department of Health officials on anything to do with the Allied Health Professions, an umbrella term which encompasses 14 disciplines including art therapists, physiotherapists and paramedics.

[1] Appointed in 2007, she is only the second person to have ever held this relatively new position, and is also tasked with bringing stakeholders such as the Royal Colleges on board with the Department's proposals for Allied Health. She also works to ensure that the policies made at strategic level translate to improve clinical practice.

What was your route to becoming the Government’s Chief Advisor on Allied Health?

I qualified as a chartered Physiotherapist in 1985. I have worked for most of my career in and around London and in 1996, I was seconded on an 18 month user consultation to look at services provided for people with severe physical disability. This was not something I was at all used to and it totally changed my career. I realised that until that point I had probably been meeting my own needs as a clinician and not at all what these people wanted. As a result of this I set up a multidisciplinary service, Disability Options Team which is still running today. From there, I went into managing until 2003 when I came to the Department of Health to advise on Allied Health and started this role in 2007.

How did you come to realise you might not have been meeting patients' needs?

Well, I was successful at what I did but I went out to meet these people in pubs, clubs, homes, hospitals but it suddenly dawned on me that we clinicians think we are providing the best healthcare possible but I wonder how much of it is actually to meet our need to be needed. Do we develop services because they interest us or are they genuinely centred around patients’ need?

The term 'patient-centred care' is used very often these days. If you think about it, a clinician’s purpose is to provide a service to patients so why do we need to invent the phrase ‘patient-centred care’? Most people go into healthcare to serve and yet so many of our services are organised to suit ourselves.

I’ll never forget meeting with a 46 year old lady who was disabled with Multiple Sclerosis. I asked what she would need to improve her quality of life and she simply replied...a window cleaner. “If I am going to sit here almost 24/7,» she said, «the only delight I get is watching people pass by. I would like clean windows and I am unable to clean them myself.”

At the time it only cost £8 a month for this but I had to go from service to service searching for an allowance to fund it. Fortunately,

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these days training is much more focussed on the patient's perspective and so we do not make as many assumptions about what people need.

Your present role involves encouraging different healthcare professions to work in an integrated fashion. How did you find the interdisciplinary approach was perceived when you were training?

When I trained at St. Mary’s Hospital, in London we had no interdisciplinary training and there was much more of a hierarchy, with clear demarcations between healthcare students. Nonetheless, I soon realised some integration was needed - some of the patients we saw had been visited by as many as fifteen professionals a day!

I started to appreciate the value of interdisciplinary working, as opposed to just multidisciplinary work - particularly in the areas where our roles overlapped significantly.

By embracing this overlap in roles, isn't there a danger that the distinction between roles will disappear? And doesn't this increase the risk of mistakes happening if people are uncertain where their responsibilities begin and end?

People worry that I am advocating for a ‘generic health professional’, but I'm not saying that the individuality and specificity of our disciplines should be eroded. In areas where there is a great deal of commonality between the professions, we can and should blur the boundaries to complement one another. For example when we learnt anatomy, you know, we could have done it with the medics.

Why on earth were we all doing it separately? We've already moved away from that a great deal and we will continue in that direction.

If we subscribe to the idea of ‘patient centred care’, as long as the professional is competent, and there are very many competencies that are generic, does it matter which profession does it?

How do you see the current relationship between medics and allied

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INTERVIEW health professionals?

The problem is of course that when you say Medicine, Joe public and indeed the clinicians - think doctors. We had a scenario recently where the Florence Nightingale Institute issued a lot of money for both nurses and Allied Health Professionals, but because of the title, people just didn t read on. And that is the case with the term medicine. But the new generation of health care professionals will change this.

Allied Health Professionals are only just becoming recognisable to members of the public. And while roles such as the Chief Nursing Officer or the Chief Medical Officer have been around for some time, there has only been one Chief Health Professions Officer prior to me.

On every board there will be a Director of Nursing, a Medical Director but not necessarily anyone at that level for Allied Health and that’s been one of my real campaigns. This needs to change, to allow Allied Health Professionals to have input to healthcare in this country at a strategic level.

A Leadership Challenge was run this year for the first time, particularly for Allied Health Professionals. I wanted to raise the profile of Allied Health Professionals as leaders of change, of transformation and improvement and raise their profile at strategic health authority level and give individual Allied Health Professionals the experience of working in management/ leadership positions to demonstrate how their inherent skills as clinicians are transferable to a leadership position. It gave them this very experience and they were amazingly successful.

Do you think people are otherwise unable to see strategic influence as a possibility for Allied Health Professionals?

I think your generation will be different, but people of my generation - where we all learnt separately and were not able to exert influence find it more difficult. I want us to get to a place of equal footing. On the whole, Allied Health Professionals just get on with their jobs. I want them to know that they can influence upwards too.

I care about relationships, about the vulnerable, and I think that is the driver for me. Although I am here for the Allied Health Professionals, I am only interested in the difference it can make to patient care; I am not interested in pushing for the movement of Allied Health Professionals onwards and upwards for their own sake.

Karen Middleton is married with two step children. Her many and varied personal interests include sailing, skiing, biographies and reading about politics, as well as spending time with her friends

Karen Middleton is a patron of the LSJM.

“

References 1.

http://www.dh.gov.uk/en/Aboutus/Chiefprofessionalofficers/ Chiefhealthprofessionsofficer/DH_075030

Most people talk about adding years to life for patients, I am interested in the quality we can add to that life, adding life to years.

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”

At 30 years old, my life seemed pretty settled. I was living in a North London flat with my long-term partner. We were pretty short of cash, but that was alright because, after years of secretly regretting not choosing medicine first time round, I had finally quit my job and got into medicine via the Graduate Entry Programme at King’s College, London. Now over a year into the course, and part way into the clinical years, consultants and colleagues had passed on a number of medical mantras.

“Common things are common,” they intoned on a regular basis.

Imagine my surprise then, when I found myself unexpectedly expecting.

I discovered that I was pregnant just over a year ago. Whilst I had always known that I wanted children one day, I hadn’t reckoned on that day arriving so soon. Taking a break so soon after starting clinical placements certainly wasn t part of the plan, but after the initial surprise had worn off, there was no doubt in my mind that I was going ahead with the pregnancy. I did worry about informing the medical school initially, but I really need not have done this was nothing they hadn t seen before and they left it entirely up to me to decide whether I wanted to take a year’s break before resuming my medical career. Although my baby was due just four days after the 3rd year exams, I decided that, if all went went, I could get through those, and then take a year-long hiatus.

As luck would have it, I had quite an easy pregnancy. There were a few times when I rushed in late due to morning sickness, but having informed the medical school and the head of my medical firm about the state of affairs early on, my occasional tardiness was met with nothing but understanding and support.

Of course, as the bump got bigger, it became a nice talking point with patients on the wards and in clinics. On one occasion, a patient who happened to be a retired consultant obstetrician managed to guess exactly how many weeks pregnant I was just by looking at me!

Having been an (albeit welcome) surprise, I was half expecting my baby to continue true to form and arrive early - slap bang in the middle of my exams! Fortunately, my due date came and went without any signs of labour, and I was able to sit my exams.

I even managed to have a few days to catch up on some much needed sleep afterwards. The last few weeks before exams were definitely hard - swollen feet, backache and disturbed sleep, my clinical partner admirably put up with a lot of complaints! In retrospect, studying right up until the end of the pregnancy was probably a nice distraction. It did mean that I didn t do much reading in preparation for the birth - although I am pretty certain that I managed to annoy the obstetrics registrar with my incessant

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PERSPECTIVE

Medicine, Motherhood and Me Asa Shetly

Year 3 Medicine, King’s College, London asa.lundstrom@kcl.ac.uk

09/09/09 Pregnant Pause: Flash Mob

questions (once the epidural took hold, that is)!

My daughter is now five months old and, finally feeling like I’m getting the hang of this parenting thing, my thoughts have turned to what it will be like once I go back to studying. I find myself trawling the internet for information and advice from others who have been in the same boat: what help is available to cover the cost of childcare? How will I ever find time to revise for exams with a baby to look after? What happens if, say, my daughter is ill and I have to miss teaching? How will I ever make it to the hospital for 8am ward rounds? Coming across the blog of a Swedish medical student who manages to combine her studies with pregnancy, looking after a toddler and studying for the USMLEs whilst still finding time to bake bread and make granola was undeniably scary, but thankfully there are plenty of other accounts showing that you don’t have to become Supermum to cope. A fellow KCL student shared her experiences of being a first-time parent and Phase 3 student in the sBMJ in 2003[1], and there are of course plenty of online forums where student parents can receive and provide advice – there is even a separate forum on New Media Medicine dedicated to parents at medical school[2].

Also, what happens after medical school? How will I cope with the on-calls of foundation training with a three-year old at home?

What if I want to have another baby? And what happens after foundation training – how do you combine specialty training with family life? As Annette Johnstone, an LTFT (less than full time trainee) SPR in radiology at Leeds Teaching Hospitals NHS Trust and mother of three boys under five has learnt, it is doable, albeit not always easy: ‘After having my children I really appreciate all the things I used to take for granted getting up and leaving the house at the very last minute, being able to go in for MDT meetings at 8am or staying behind for teaching or to sort out a patient. Now, I am much more organised although you have to be prepared to deal with the unpredictables that come with kids, like the nursery closing at 3 because of snow. You sometimes feel the world is against you!

A great resource on what to expect when combining motherhood with being a doctor is So you want to be a medical mum?[3], with advice on maternity leave, full time vs part time training and plenty of quotes from professionals from different specialties (and there is also a short chapter on having a baby as an undergraduate). Annette has chosen to train part time: ‘Having kids, you need to get the work/life balance right. I currently work 60% as an LTFT which means prolonging training, but I’ll never get this time back with the kids so I enjoy trips to the farm, swimming, parks and picnics while my full-time colleagues are racing through their training’. For me, well, time will have to tell.

Not having decided on a career change until the grand old age of 29, part time training could mean that I am still sitting exams well into my forties depending on which training route I go down, but then again, I don’t want to miss out on too much of my daughter’s childhood.

All things taken into account, how do I feel about it all now, five months down the road of parenthood? Well, considering that some days I’m not even organised enough to leave the flat, I do worry that the task of combining studying with parenting will prove too much. Still, I will certainly try my best and I am confident that the medical school will continue to be as understanding and supportive as they have been so far. Yes, there is the possibility that I will miss important teaching when my daughter is ill and yes, it might be that I never make consultant – but as I sit here by my computer as my baby daughter snoozes next to me in her cot, I mainly feel very, very lucky.

References 1.

2.

3.

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studentBMJ 2003;11:87-130 April ISSN 0966-6494 http://www.thestudentroom.co.uk; http://www.newmediamedicine.com/ forum/parents-medical-school/ Hill, E. (2008). Oxford University Press.

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ARTICLE

Manchester Students make the case for Peer-Managed-Peer Assisted Learning Ambrose Boles & Ben Amies Year 4 Medicine, University of Manchester ambrose.boles@postgrad.manchester.ac.uk doi: 10.4201/lsjm.car.007

The practice of peer-assisted Learning (PAL) can be traced back to the philosophers of Ancient Greece1. At its heart is the idea that students benefit from being taught by - and teaching - each other. For this reason, it is often informally used by medical undergraduates2 and other healthcare students. A recent international medical education conference described PAL as an “exciting and developing area in medical education”3.

Since 1993, PAL has enjoyed increased popularity, following the General Medical Council’s recommendation that medical graduates should have “appropriate teaching skills”2,4. At present at least 11 of 31 medical schools in the UK run a PAL programme as part of their core curriculum5. PAL is often used to complement existing medical curricula2, with benefits for both tutors and tutees widely described in the literature. It has been shown to deliver teaching comparable to that of an expert6,7, as well as offering some added unique benefits.

PAL sessions are more friendly and informal than expert-led teaching. Tutees regularly report that they find it easier to ask questions in this setting, without fear of judgement for lack of understanding8,9. There may also be additional benefits associated with the comparable curricular level between tutor and tutee. It has been found that tutees feel PAL is delivered at a more appropriate cognitive level than sometimes experienced with the more traditional teacher/student model of education6,9. Furthermore,

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the greater sense of camaraderie between tutor and tutee is believed to benefit learning10. Peer-tutors can also be excellent role models for younger students11.

It’s not only the tutees that benefit from this scheme. There are also benefits for peer-tutors. PAL provides a rare opportunity for students to develop valuable teaching skills, which are essential for future practice as a doctor4,6. In addition, teaching helps peer-tutors consolidate their own learning and increase their confidence2,12.

PAL programmes can be organised by the medical school (facultymanaged) or by students (student-managed). The majority are the former, offering students interested in becoming PAL tutors the chance to take modules on how to deliver small group teaching.8 The latter, such as the one run at the University of Manchester11, are organised and delivered almost entirely by student-tutors, with only some input from expert clinicians. Although both faculty-managed and student-managed PAL programmes share similar benefits9, there is evidence to suggest that student-managed programmes have additional benefits.

It has been proposed that one of the main benefits of studentmanaged PAL is that it gives students a greater sense of ownership over the PAL programme8,11. This results in peer-tutors taking greater responsibility for ensuring that their teaching is of a high standard, and promotes self-appraisal, which is essential for modern medical practice4,13. Furthermore,

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Another key advantage of student management of the programme is the opportunity for peer-tutors to develop organisational and team working skills. There is also significant interest from tutees in becoming future peer-tutors9. This allows the management of the programme to be passed down from year to year, thus making it self-perpetuating. Furthermore, by its nature student-managed PAL exerts little strain on existing teaching resources14.

A possible criticism of student-managed programmes is that peertutors do not have sufficient formal training in small group teaching to be able to effectively deliver small group teaching. This is supported by the finding that formal peer-tutor training improves tutee learning outcomes15,8. In the Manchester PAL programme, experienced peer-tutors informally train and advise new peertutors in techniques for delivering small group teaching. In order to further improve peer-tutor teaching skills, this process could be formalised. In addition, we have implemented an audit tool to help us assure the quality of our teaching.

In our experience, a student-managed PAL programme can be successfully run with results comparable to existing PAL literature9.

In addition, student-managed PAL has extra benefits over facultymanaged PAL programmes. These benefits include the promotion of student ownership of the programme, encouragement of peertutor self-appraisal, development of organisational and teamworking skills, and self-perpetuation of the programme. For these reasons, it seems that existing faculty-managed PAL programmes could benefit from devolving more management responsibilities to students.

Ambrose Boles is involved in running the PAL programme at Salford Royal Hospital, which is now in its sixth year. Ben Amies is intercalating in Medical Education and is involved in setting up a new PAL programme at the University Hospital of South Manchester. Both authors would like to acknowledge the hard work and dedication of their fellow peer-tutors, and in particular that of James A Giles.

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References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Topping KJ, Ehly SW. Peer-assisted learning. Mahwah, N.J.: L. Erlbaum Associates; 1998.

Ross MT, Cameron HS. Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30. Med Teach. 2007 Sep;29(6):527-45.

Anderson J, Varma B, Ross M. Spotlight on Peer Assisted Learning: a world of opportunity. www.amee.org/documents/Spotlight%20on%20Peer%20Learning.pdf.

General Medical Council. Tomorrow’s Doctors: recommendations on undergraduate medical education. London: General Medical Council, 2003.

Jayasinghe G, Evans DE, Horton D. Faculty development for peer tutors – what do we want? And how do we want it?. Poster session presented at: Association of Medical Education in Europe Conference; 2009 Aug 29 – Sep 2; Malaga, Spain.

Graham K, Burke JM, Field M. Undergraduate rheumatology: can peer-assisted learning by medical students deliver equivalent training to that provided by specialist staff? Rheumatology (Oxford). 2008 May;47(5):652-5.

Weyrich P, Celebi N, Schrauth M, Moltner A, Lammerding-Koppel M, Nikendei C. Peer-assisted versus faculty staff-led skills laboratory training: a randomised controlled trial. Med Educ. 2009 Feb;43(2):113-20.

Wadoodi A, Crosby JR. Twelve tips for peer-assisted learning: a classic concept revisited. Med Teach. 2002 May;24(3):241-4.

Giles JA, Boles A. Student-managed peer-assisted learning. Poster session presented at: Association of Medical Education in Europe Conference; 2009 Aug 29 – Sep 2; Malaga, Spain.

Knowles MS. Self-directed learning : a guide for learners and teachers. New York: Association Press; 1975.

For full references see thelsjm.co.uk.

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Self Harm

Personality Disorders

Bi-polar

Anxiety

Forensic

Schizophrenia

Eating Disorders

Dependence

Depression

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EDITORIAL

The Dark Art of Medicine

doi: 10.4201/lsjm.psy.011 Many medical students still regard psychiatry as the dark art of medicine. Even though Psychiatry now occupies a prized position as a compulsory module during the latter stages of clinical training at most medical schools many still leave wondering what a psychiatrist actually does for his patients. Although he often coordinates a team that discusses a patient’s treatment, how much time if any does he actually spend with the patients themselves?

For the medical student, early exposure to the schedule of a working psychiatrist undoubtedly sheds light on the role of a psychiatrist. But many are still left with the uneasy feeling that this is simply to assess patients at presentation, before passing them on to the other mental health professionals in the team. These other professionals are the ones that truly get to know the patient and his condition, that directly observe the effect, positive or negative, that treatment and his circumstances are having on him.

Psychiatrists are viewed simply as walking prescription pads, who aside from a basic understanding of psychopharmacology need only a copy of the ICD 10 or DSM close at hand to perform their roles.

This attitude poses an important question about the role of the psychiatrist. Has the demise of psychoanalysis as the main vehicle of psychotherapy resulted in loss of patient contact for psychiatrists? Since newer, evidence-based, therapies such as CBT are often provided by clinical psychologists and other health care workers, doesn’t this mean that psychiatrists are left with less and less actual time to spend with their patients? It’s not that we are arguing for the return of psychoanalysis, but the return of some of the time that this therapeutic role contributed to the patient-doctor relationship. A relationship that is surely vital for anyone making decisions about patient care.

The decline in therapeutic work is not for lack of training in psychotherapeutic theory and methods. Post graduate training, in the UK and USA, incorporates both technical and practical psychotherapeutic training. During the three “Core Training” years FRCPsych candidates, “must deliver basic psychological treatments in at least two modalities of therapy over both longer and shorter durations”.1 Since 2001 the US board responsible for accrediting post graduate training courses stipulated that those training in general psychiatry must show competence in five types of psychotherapy. 2 There is potential then for the new generation of psychiatrists to spend time with their patients using psychotherapeutic methods.

But is this training enough? Even if a psychiatrist wants to spend time with patients using evidence based methods like CBT, will this benefit the patient? Wouldn’t this time be better spent with someone, such as a clinical psychologist, who was better trained in the therapeutic method?

Unfortunately there is very little research on this topic, although the research that exists is not positive. A small study by Whitfield et al. asked a group of 51 Scottish psychiatrists who had received CBT training about their use of and training in CBT. 3 Although the majority said they used CBT type therapy in their practice less, than half received supervision in the method and less than half supervised others in their training. The main reason for not using or training in the method was lack of ‘protected time’ in their ‘job plans’.

Even in the US, where psychotherapy still forms a large proportion of training, there seems to be little motivation to develop these skills in younger psychiatrists. In a survey of 102 trainees, only 31% thought that training in psychotherapy was well integrated into their training with the number of patients actually treated and the level of assessment varying widely from course to course.4 Given these discrepancies in experience it is reasonable that psychological therapy is provided by those more experienced to do

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EDITORIAL so. However, it is difficult to see where and when a psychiatrist gets to know his patient as their treatment progresses. Certainly he will receive feedback from others, but as he is often the person responsible for integrating their care , is this ‘feedback’ enough?

The question that remains is whether psychotherapy still has a role in communication and care between patient and psychiatrist. The training of psychiatrists in psychotherapy may well be only to leave trainees with an awareness of these methods, but in using this training in this way aren’t we missing a chance to claim more ‘protected time’ with our patients?

Samuel Ponnuthurai & Alexander Ross Section Editor Psychiatry References 1.

2.

3.

4.

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Royal College of Psychiatrists. A competency based curriculum for

specialist training in psychiatry. London: Royal College of Psychiatrists; 2009. Available from http://www.rcpsych.ac.uk/PDF/Core_Feb09.pdf` Plakun, E. M. Finding psychodynamic psychiatry’s lost generation. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry. 2006; 34 (1): pp. 135 – 150.

Whitfield, Graeme, Connolly, Moira, Davidson, Alan, Williams, Chris. Use of cognitive-behavioural therapy skills among trained psychiatrists.

Psychiatric Bulletin. 2006; 30(2): pp. 58-60.

Khurshid, Khurshid A, Bennett, Jeffrey I, Vicari, Sandy, Lee, Karen L, Broquet, Karen E. Residency programs and psychotherapy competencies: A survey of chief residents. Academic Psychiatry. 2005; 29(5) : pp. 452-458.

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These questions relate to the ongoing debate between the biological model of mental illness and the psychosocial model – a debate we have tried to represent in previous issues of this journal. For those who stand wholly on the biological side of this divide, it must be difficult to see how such time can be well spent. Whilst for those who stand wholly on the psychosocial side it must be difficult to see how, given the current levels of training in therapy, and the time set aside for it in a psychiatrist’s job, a psychiatrist can actually usefully practice these methods.

But surely, we argue, there is a simpler matter at stake here.

Surely this time is also an important opportunity to get to know each patient’s specific circumstances and response to treatment. Surely this information is vital wherever one stands in this debate.

Is there method in madness after all?

It is an idea that first rose to infamy in the late 18th century with the Romantic Movement, and its appeal has cantankerously refused to dissipate. I am talking of course, of the link between madness and genius. The recent flurry of headlines has two root stories.

Psychiatrist Professor Michael Fitzgerald has been publicizing his new book, in which he claims luminaries as diverse as Kurt Cobain, Lord Byron, Clark Gable, Oscar Wilde and Picasso may all have been suffering from ADHD. He hopes that highlighting the possible positives of the condition, will help reduce stigma amongst sufferers.

Additionally, the researchers at the Karolinska Institute in Sweden in association with Kings College London, have found students who excelled at school age 16, were almost four times more likely to develop bipolar disorder as adults. The study carries particular weight as it is one of the first to survey such a substantial population, with a total of 713,876 study participants. It is thought the mild advantages of hypomania may account for this; hypomania provides a cognitive state of increased innovation and piquant wit, heightened emotional intelligence, and oft associated with an extraordinary stamina and boost in concentration. Researchers propose that these cognitive styles present a double-edged sword, improving school performance during adolescence but simultaneously predisposing students to significantly increased risk of bipolar disorder in later life. Another conclusion reached, however, will ground any Romantics firmly in reality. Students with notably poor school performance are at twice the risk of developing the condition compared to the general population, as a consequence of the darker cognitive styles of the disorder such as deep depression which is frequently accompanied by other disturbed behaviour such as substance misuse.

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PANELS PAGE

Psychiatry through the ages Nicola Hood

Year 4 Medicine, King’s College, London nicola.hood@lsjm.co.uk

Psychiatry is currently defined by the Concise Oxford English Dictionary as, “the branch of medicine concerned with the study and treatment of mental illness and emotional disturbance.” Whilst history suggests that madness in man is no modern affliction (note Shakespeare’s merry medley of meshuggenehs) the incorporation of psychiatry under the esteemed umbrella of medicine is more recent, as is the accompanying application of scientific standards to its theories and practise. Yet still, there is hesitation in the air. Public opinion lurches precariously from a heartfelt embrace of the American ‘therapist’ culture, in which we warble weekly about our issues, to a rejection of all mental illness as a problem of the weak, and dash it all chaps, thoroughly un-British to boot. This fickle mentality to an issue of such pertinence can no longer be tolerated. It is the duty of the next generation of medics to remember to respect our future colleagues equally, regardless of the specialty selection. Accepting the fundamental value of mental health maintenance is the cornerstone of whole-patient-centred-care, and we owe it to our patients to sharpen up our act. Psychiatry must not, cannot be belittled; ignoring its importance is nothing short of negligence.

Three News Items of Note

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Daring to Redefine- DSM V By the time you read this article the American Psychiatric Association will have released a draft version of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders- the psychiatrists’ Bible.

Whilst officially only diagnostic to America- where it defines not only diagnosis and treatment but who will pay for said treatment- it nevertheless has a trickle-down effect to the views of mental health held by society as a whole. The first DSM was published in 1952, and this version will not be finally released until 2013 (by which time this author hopes to be pacing the wards). Over time, the editions have reflected a flavour of what’s fashionable, drifting from a highly Freudian standpoint across to a more heavily biomedical approach.

Much has been written about concerns over transparency and the influence of the drug giants such as Pharma, but perhaps a more apposite debate should be had over the applications of the final product. The brain remains little-understood, people even less so.

The DSM does not diagnose, it is only an aid to diagnosis, and we need psychiatrists to carefully analyze and appraise each and every individual, before slapping on a label, which may remain with them for life.

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Banishing Baby Brain You might expect that new discoveries in psychiatry to relate to previously unknown biochemical mechanisms underlying common conditions, or perhaps novel aetiological factors. What is most unexpected is to read that a team lead by Helen Christensen from the Australian National University are declaring a condition does not exist at all. Colloquially referred to as ‘baby brain’ it has been traditionally thought that motherhood and pregnancy reduce women’s cognitive powers. The latest research though, banishes this belief as little more than another old wives’ tales, a superstition similar to swirling a wedding ring to discover if it’s a boy or a girl. The axiom may have wormed its way into the apple of popular culture but can actually be explained as a combination of a pre-partum change in women’s attributional style and an (evolutionarily adaptive) shift in attentional focus to the child. The researchers aspire that their results challenge the view that mothers are less effectual in the workplace than their colleagues, by dint of a change in attitudes of obstetricians, midwives and healthcare visitors, as well as the publication of their conclusions in the wider media.

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Schizophrenia through History Kaanthan Jawahar, BSc (Hons) Year 4 Medicine, King’s College London kaanthan.jawahar@kcl.ac.uk doi: 10.4201/lsjm.psy.009

Introduction Schizophrenia is viewed as a mental disorder, characterised by abnormalities in perception and expression of reality. Disturbances occur in thought, behaviour and emotion, and can affect all sensory modalities1.

Schizophrenia tends to occur equally amongst men and women, with a typical age of onset of 20 to 28 years in males and 26 to 32 years in females2. The point prevalence of Schizophrenia has been shown to be 0.46%, the period prevalence to be 0.33%, the lifetime prevalence to be 0.4% and the lifetime morbid risk to be 7.2%3.

Currently, there is no laboratory test to confirm a diagnosis of schizophrenia. Nor does a sign or symptom exist, which is considered to be pathognomonic of the disorder. Instead, a diagnosis is made using the DSM-IV-TR4 or ICD-10 criteria5.

The debate rages on over the aetiology of schizophrenia. Genetic predispositions, the dopamine theory, environmental factors, glutamate dysregulation and congenital factors all seem to play a part1. In the absence of a tangible pathological marker, one must question why these criteria are used. How did they come into existence and what is the underlying thinking behind them? To begin to answer these questions, one must look back at the initial conception of schizophrenia itself.

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Early Views The earliest evidence of the disorder can be traced back to Ancient Egypt (circa 1500 BC). The Book of Hearts within the Eber papyrus, describes in detail disorders that resemble modern day depression, dementia and the thought disturbances found in schizophrenia6.

Brief descriptions consistent with psychoses and schizophrenia also appear in Hindu Ayurvedic texts (circa 1400 BC)7. In medieval times, hallucinations and delusions were interpreted as proof that the individual was possessed, leading to several women being executed on the assumption that they were witches6.

The 19th Century Wilhelm Griesinger (1817-1869) spoke of ‘einheitspsychose’ (unitary psychosis) and believed that all psychoses were caused by a single pathological process in the brain. A disorder of the ‘mental reflex’ resulted in the symptoms of psychosis (e.g. a retardation resulted in melancholia and a hyperactive state resulted in mania)8.

Bénédict Morel (1809-1873), a French physician described a disorder mainly affecting males in adolescence, in which withdrawal, odd mannerisms, self-neglect and mental deterioration were present, coining the term ‘démence precoce’ in 1853 (premature dementia). In contrast to Griesinger’s ‘einheitspsychose’, Morel wanted to classify disorders based on their cause, symptoms and outcomes9.

Karl Ludwig Kahlbaum (1828-1899) placed importance on the course and clinical outcome of the disorder. He differentiated between disorders with and without an organic aetiology and coined several new terms for newly described symptoms and syndromes, including paraphrenia, dysthymia, and cyclothymia10. Like Morel, Kahlbaum also described a psychosis in the young - ‘jugendliche irresein’ (juvenile madness). However, he is better known for his description of ‘katatonie’ (catatonia) – a disturbance in motor functionality as a phase in a progressive illness, comprised of psychosis and depression, commonly ending in dementia11.

Kahlbaum was also the mentor of Ewald Hecker. Together, their studies on psychotic patients at Kahlbaum’s clinic resulted in Hecker adding ‘hebephrenia’ (a disorder with an onset in adolescence and continuing mental decline – ‘hebephrenia’ literally translates as ‘silly mind’) and ‘cyclothymia’ (a cyclical mood disorder) to psychiatry12.

Emil Kraepelin & Dementia Praecox Emil Kraepelin (1856-1926) studied medicine in Leipzip and Wuerzburg between 1874 and 187813. Unlike his contempories, Kraepelin had little interest in identifying pathological markers in brain samples. Instead, he had a profound curiosity in human psychology as a dimension of psychiatric illness. He was a great admirer of the experimental psychologist Wilhelm Wundt. In 1882, he took up a post Leipzig to study with Wundt in his newly established psychological laboratory14.

In 1883 his work with Wundt spawned the first edition of his ‘Compendium der Psychiatrie’ (Compendium of Psychiatry), in which he argued that psychiatry was a branch of medical science and so must be subject to investigation and research like the other natural sciences. With respect to psychiatry, this involved identifying discrete disorders and then to map out a corresponding progression of the illness, taking into account individual differences in personality in the case histories15.

In 1890, Kraepelin took a professorship of psychiatry at Heidelberg.

It was here that Kraepelin was free to research as he had wanted, without the pressure to implement neurology14. Within 4 weeks of admission, patients were assigned a diagnosis and their progression

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REVIEW

was vigorously followed up. Kraepelin had all of this information on ‘zahlkarten’ (data cards) - each one unique to each patient and updated during each interaction16.

By focussing on clinical psychopathological research based on data about the course of an illness, Kraepelin aimed to define nosological boundaries in psychiatry.

Kraepelin found that a large proportion of his patients progressed through to dementia, despite their differing clinical presentations.

He postulated that one illness was the cause of this. Naturally, he pursued this finding to identify indicators for this new disorder17. With the use of his ‘zahlkarten’, he had created a database from which reliable data could be extracted and interpreted.

The fourth edition of Kraepelin’s ‘Lehrbuch der Psychiatrie’ introduced dementia praecox to the scientific community in 1893, under the category of ‘Psychic Processes of Degeneration’14.

Symptoms included auditory hallucinations, delusions, autism, abnormal thought associations, flattening of affect, lack of insight, stereotypy and negativism, with onset typically in adolescence18.

Kraepelin also felt that there was a definitive pathological cause of his dementia praecox and he was sure that it would be discovered in the future - a departure from his initial repulsion of biological psychiatry19.

The sixth edition of Kraepelin’s ‘Lehrbuch’ (1899) saw him split the vast world of psychotic disorders largely into two main groups. The first was ‘Manic-Depressive Psychosis’, whose central symptom was a disorder of affect and the course was cyclical, with patients often going into remission following acute episodes, and in some cases recovering completely. The second was ‘Dementia Praecox’, where psychosis was present in the absence of an affective component, with patients suffering from uniformly progressive cognitive decline.

Dementia praecox consisted of the catatonic, hebephrenic and paranoid types. The current DSM-IV-TR criteria speaks of these types as well (renaming the hebephrenic type as ‘disorganised’)20.

Kraepelin had initiated a change in the way that psychotic symptoms were interpreted. The presence and not the content of symptoms was now the focus.

Eugen Bleuler & Schizophrenia Eugen Bleuler (1857-1939) was a Swiss psychiatrist who followed Kraepelin’s work closely throughout his career. But his focus lay more on the mechanisms of the symptom formation in dementia praecox, as opposed to the prognosis. He coined the term ‘schizophrenia’ in 1908 (literally ‘splitting of the mind’) as he felt the underlying pathology was a cognitive loosening of association14.

He also felt that schizophrenia was a heterogeneous entity and, as such, had a variable course and did not inevitably enter a deteriorating progression. Complete recovery was also possible. In this way, Bleuler felt that ‘dementia’ was not appropriate21.

Bleuler postulated the existence of ‘fundamental’ symptoms and

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‘accessory’ symptoms. The fundamental symptoms have come to be known as the ‘four A’s’: Ambivalence, flattening of Affect, Autism and loosening of Associations. The accessory symptoms were the more positive, psychotic features of the disorder: hallucinations, delusions, catatonia, abnormal behaviours etc.9.

Bleuler felt that his four A’s were found in every case of schizophrenia, whilst the more overt accessory symptoms could be found in other disorders. If loosening of associations occurred in the individual’s mind, then the accessory symptoms would invariably ensue, resulting from the cognitive impairment. Therefore, one could argue that his fundamental symptoms were pathognomonic of schizophrenia22.

Bleuler’s views held sway for a substantial amount of time, especially in the USA. But his fundamental and accessory symptoms and his new categories (‘latent’ and ‘simple’ schizophrenia) led to problems in diagnosis, as discussed by Stefan et al:

“

... this confusion was confounded by the clinical heterogeneity of schizophrenia, the lack of clear prognostic features and the failure to discover any definitive pathological abnormalities, and led to an expansion of the concept of schizophrenia to the extent that it became a vague symptom for severe mental illness with different meanings in different countries3.

”

Kurt Schneider & 1st Rank Symptoms Kurt Schneider was born in 1887 in Württemberg, Germany. He studied medicine in Türbingen and Berlin. In 1945, he was appointed to the chair of psychiatry and neurology at the University of Heidelberg, where he stayed until he retired in 195524.

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Schneider was concerned with improving diagnostic methods in psychiatry. His beliefs were similar to that of Karl Jaspers (1883 – 1969), who believed that the essence of psychoses was that the content was ‘non-believable’ by normal individuals (i.e. they were unable to understand and relate to it). This made Schneider move away from trying to interpret symptom content and instead to understand the symptom form20. He argued that the content of psychoses were of little importance in diagnosis. Instead, one must look at the form of the psychosis (e.g. how a delusional belief is held and how a hallucination is experienced)20.

Schneider’s largest contributions to our understanding of schizophrenia were his ‘1st Rank Symptoms’ (auditory hallucinations, delusional perception, thought insertion, withdrawal and broadcast etc.)25.

Like Bleuler, Schneider wished to make a list of ‘fundamental’ symptoms. But Schneider’s focus was on clinically observable symptoms. He thought that the underlying component in schizophrenia was a loss of personal autonomy and the inability to distinguish between self and non-self 26.

“

Among the many abnormal modes of experience that occur in schizophrenia, there are some which are put in the first rank of importance, not because we of them as basic disturbances, but because they have this special value in helping us determine the diagnosis of schizophrenia... Symptoms of the first rank importance do not always have to be present for a diagnosis to be made26.

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”

Schneider had created a symptom cluster that can be reliably and objectively used to diagnose schizophrenia (much like the current DSM-IV-TR).

Schneider also spoke of second rank (negative) symptoms (e.g. flattening of affect, poverty of speech, social withdrawal), which he felt were highly suggestive of schizophrenia, but not specific to the disorder12.

DSM-III The Diagnostic and Statistical Manual of Mental Disorders 1st edition (DSM-I) was published by the American Psychiatric Association in 1952. Work had began for this in 1948, with the aim being to provide American psychiatry with a single national system of classification.

At that time, psychoanalysis was the predominant school of thought and this classification system reflected that. DSM-II became available in 1968 and further consolidated the psychoanalytical hold over American psychiatry27.

During the 1960s, Schneider’s 1st rank symptoms held sway in the UK and Europe, after British investigators translated his work20.

This global non-standardisation of diagnostic criteria prompted two studies to analyse if the differences had any implications. The US-UK Diagnostic Study28 compared diagnoses of psychiatric disorders between London and New York. A major finding was that schizophrenia seemed to have a much wider concept in the USA. Some patients, who received a diagnostic label of schizophrenia in the USA, would have been diagnosed with an affective disorder in the UK29. The International Pilot Study of Schizophrenia (IPSS – World Health Organisation)30 looked at several countries and concluded that broader criteria were used in the USA when compared to Europe.

Furthermore, it also suggested that a higher degree of consistency in the clinical picture of schizophrenia was found when using the strict diagnostic rules of Kraepelin and Schneider.

These differences were one of the main factors, which led to the creation of DSM-III and its publication in 1980.

The man in charge of the DSM-III task force was Robert Spitzer.

Born in 1932, and educated at New York University Medical School27, he sought to make diagnoses as precise as possible. His thinking was that all disorders had an underlying pathology and thus the use of stringent criteria for diagnoses would correspond better to an uncertain aetiology – a Kraepelinian way of thinking. The major innovation of DSM-III was the presence of a symptom checklist alongside the descriptive prose of the disorder. A patient would have to display symptoms on this checklist in order to be diagnosed31.

Spitzer had standardised psychiatric practice and research. He had created diagnostic criteria, which were nominally evidence based and had laid down testable hypotheses, which would ensure the continuing review of the criteria. DSM-IIIR (revised edition 1987), DSM-IV (1994) and DSM-IV-TR (text revision - 2000) have followed27.

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DSM-V DSM-V is currently being developed and is due to be released in 201232.

One would expect relatively few changes to be made to the diagnostic criteria, as they have remained largely unchanged since DSM-III. However, Van Os33 argues for a total overhaul of the existing criteria - “…scientific and societal developments point to a system of classification combining categorical and dimensional representations of psychosis in DSM and ICD. Furthermore, it is proposed to introduce…the diagnosis of salience dysregulation syndrome”.

In this syndrome, it is argued that positive psychotic experiences alter salience attribution (i.e. display other psychopathologies, such as mania and cognitive deficit). When these components rise above a threshold, intervention is required33.

This model is treatment based. It measures affected mental components and so provides therapeutic targets. It does not attempt to understand the underlying psychopathology, but it does not need to, as the underlying cause of Schizophrenia is still unknown.

Conclusion Mental illness has been present throughout time. Evidence of psychoses has been observed as far back as ancient Egypt. However, the concept of schizophrenia is a mere two hundred years old. The works of Griesinger, Morel, Kahlbaum and Hecker all made contributions, but it was Emil Kraepelin who changed not just our understanding of schizophrenia, but also our understanding of psychiatry.

He simplified the myriad of psychiatric disorders into two categories: manic-depressive psychosis and dementia praecox20. He felt that in the absence of pathological markers, one must make the diagnosis of the disorder as specific as possible – the same thinking of Robert Spitzer31 and DSM-III nearly a century later.

Bleuler and Schneider created lists of symptoms, which could be used to diagnose schizophrenia. Indeed, Bleuler’s beliefs were instrumental in DSM-I and DSM-II. But it is Schneider’s 1st rank symptoms25 that are present in the current DSM-IV-TR classification.

Before Kraepelin, diagnoses in psychiatry were largely descriptive.

He sought to add validity and reliability to psychiatric practice. With this new validity and reliability, psychiatric research became possible

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and served to increase our knowledge of disorders and subsequent treatment.

Even with the absence of definite pathophysiology and the arguments against diagnostic labels, nosology in psychiatry is needed for reliable communication in the research world. Without Kraepelin, we would not have this.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Kring AM, Davison GC, Neale JM, Johnson SL. “Schizophrenia” in Abnormal Psychology 10th ed. USA, John Wiley & Sons. 2007 Castle D, Wesseley S, Der G, Murray RM. The incidence of operationally defined schizophrenia in Camberwell 1965–84. British Journal of Psychiatry 1991;159:790–794 Bhugra D. The global prevalence of schizophrenia. PLoS Medicine.

2006;2(5):372–373 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 4th Edition Text Revision. Washington DC, American Psychiatric Association. 2000 World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders. Switzerland, WHO. 1992 Kyziridis TC. Notes on The History of Schizophrenia. German J Psychiatry, 2005;8:42-48 Lawrie SM, Johnstone EC. “Schizophrenia and Related Disorders” in Companion To Psychiatric Studies 7th ed. Johnstone EC, CunninghamOwens DG, Lawrie SM, Sharpe M, Freeman CPL (eds.). London, Churchill Livingstone. 2004 History of Psychiatry - Greisinger. http://bms.brown.edu/ HistoryofPsychiatry/griesinger.html. Accessed on 30/05/2009 Gelder M, Harrison P, Cowen P. “Schizophrenia” in Shorter Oxford Textbook of Psychiatry 5th ed. Oxford, Oxford University Press. 2006 Bräunig P, Krüger S. Karl Ludwig Kahlbaum, M.D. 1828–1899. Am J Psychiatry 1999;156:989

For references see thelsjm.co.uk.

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The Mental Health Team in Britain: Past, Present and Future Tariq Shafi

Year 4 Medicine, University of Nottingham tariqshafi@btinternet.com doi: 10.4201/lsjm.psy.008 The mental health team is, like any team in medical care, the crux of provision of care for, in this case, patients with psychiatric difficulties. The twentieth century has seen a great change in the provision of mental health care and, accordingly, the mental health team. This article will discuss how society impacts on mental health care, and compares the components of a mental health team from 50 years ago to that of today. It will also hypothesise what the mental health team will look like 50 years from now.

Impact of Society on Psychiatric Care There is little doubt that society affects not only science but healthcare. The latter half of the twentieth century saw a shift in psychiatric care from inpatient to outpatient care, a process termed ‘deinstitutionalization’. Immediately after the end of World War II, Britain underwent considerable economic and social change. The country was bankrupt after the war as a result many industries and services were nationalised, including the health service. The move to community-based treatments probably derived from a change in social philosophy, new and effective forms of psychopharmacology and the rundown state of the asylum buildings 1.

The Mental Health Team in 1960 Fifty years ago, society in Britain was markedly different than it is now. Television had hit British homes and the nuclear family unit was more commonplace than today.2 The majority of women did not work outside the home and the proportion of people attending church was several fold higher than today.3 On the political front, the great enemy was Communism and the threat of the atom bomb pervaded the air. The main autonomous source at that time, the BBC, paled in comparison with the independent and diverse media of today.

In 1960 the focus of psychiatric care was beginning to shift from long-term, often indefinite inpatient stay in an asylum to a more diverse, outpatient system of care. Physical treatments such as electroconvulsive therapy and lobotomy were relatively new and used commonly. Day hospitals had begun to be established, providing more flexible psychiatric services and reducing the number of hospital beds. The use of neuroleptic drugs allowed more patients to be managed in the outpatient setting. The focus from inpatient to outpatient care was also illustrated by the appointment of outpatient psychiatric nurses, first deployed in Warlingham Park Hospital in Croydon in 1954, whose role was to facilitate rehabilitation and help former patients seek jobs and accommodation. Furthermore, the Percy report in 1957

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recommended that, ‘the majority of mentally ill patients do not need to be admitted to hospital as inpatients. Patients may receive medical treatment from general practitioners or as hospital outpatients and other care from community health and welfare services.’4 The Mental Health Team Today Society today is almost unrecognisable in comparison to fifty years ago. Whilst wars are more numerous and prevalent today, Britain is not in its recovery phase from a world war. Stigma regarding mental illness is less prevalent, not least because information is more accessible in the Internet age. People are less reluctant to seek help for medical problems than previously, with GP attendances per patient increasing by 50% since 1971. 5 Today, many people with mental health problems never see a psychiatrist, and are managed by their GP who may prescribe medications or refer them for counselling/psychotherapy. The factors predisposing to mental illness are more fully appreciated than they were in 1960. A mental health team today addresses these areas such as relationship problems, housing problems or benefits, and as such are quite large. Most people recover from mental health problems without coming into hospital,6 and the mental health teams are thus called Community Mental Health Teams.

Psychiatrists today put greater emphasis on emotional problems than previously. Clinical psychologists are trained in psychological treatments. The number of clinical psychologists has increased four-fold since 1995.7 Community psychiatric nurses can give and monitor medicines, and many have special training in themes such as eating disorders or behaviour therapy. The community psychiatric nurse is commonly the care coordinator assigned to the patient. As the key worker, the community psychiatric nurse often also provides the role of the occupational therapist, helping people get back to doing things and regaining or gaining self-confidence; and that of the social worker, helping people with money, housing and childcare issues.

A greater number of staff without a professional qualification may work with the team because of their special experience. These include people who have experienced mental health problems, advocates, and workers from day centres or housing organisations.

Specialist old age psychiatry teams may include other professionals such as speech therapists or physiotherapists. Such workers may also see people in their own homes. Most teamwork is done outside hospital although the team may have a base in a clinic.

Families and friends are involved, and advocates can be employed.

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The patient has a greater role in his or her care, and whether they should proceed with pills or counselling.

The Mental Health Team in 50 Years It is always difficult to envisage what society will be like in the future, especially as distant as 2060. Technological advances may be overestimated, illustrated by films such as Back to the Future II where hovering skateboards and automated clothing were standard in 2015. Conversely, there may be a regression in society post a nuclear war, seen in films like The Postman and the Mad Max movies. However based on trends, it is predictable that in 2060 Britain will be almost entirely secular and less conservative. The question however, is whether this trend will apply to the stigma of mental illness?

Although recent research has shown that the older population have a more sympathetic view of mental illness and, although people are more aware of mental health issues, views such as people with mental illness having less right to a job than others and being more prone to violence are becoming more common.8 The Moving People campaign has had a considerable effect in counteracting stigma in Scotland, where it has considerable backing by the Scottish Executive.

I believe that in 2060 there will be several changes to the mental health team. A dietician is already a common component of the mental health team but is likely to play an even greater role if trends in diet continue. Obesity in both men and women increased by 10% between 1994 and 2004. Food not only affects physical appearance, but also psychological health. For instance, complex carbohydrates as well as certain food components such as folic acid, omega-3 fatty acids, selenium and tryptophan are thought to decrease the symptoms of depression.9 Furthermore, people with mental health problems are more likely to develop or compound a weight problem, due for instance in lethargy, a feature of depression. Weight gain, impaired glucose tolerance (leading to diabetes) and osteoarthritis may also be a side-effect of some treatments such as antipsychotics.

I believe there will be a greater input from expert patients who have been through mental illness. An expert-patient Self Management Training Programme has been in place for manic depression since 1998, with good outcomes demonstrated in an ongoing randomised controlled trial.10 There may also be a role of a geneticist, as genotyping may initially be introduced to inform more tailored prescription of psychotropic medications. For instance, research has shown that patients with genotypes giving rise to extremes of activity of a particular cytochrome had an alteration in response to certain antipsychotics.11 Alcohol intake has increased two-fold in the last 50 years 12 and is likely to rise further and substance abuse, although declining

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in recent years nevertheless had an incidence of 25% amongst young adults in a recent study.13 The high rate of homelessness and substance abuse are factors relating to patient non-compliance and an assertive outreach worker can play a key role in the mental health team.

Finally, in terms of targeting specific groups early intervention services will become more common. Comprised of the members of the community health team these teams are already placed to play a key role in diagnosing psychosis early, enabling a faster recovery and reducing the incidence and severity of relapses. Due to the additional roles in the future mental health team outlined above, I believe that the clinical psychologist will still play an integral but lesser role, cognitive behavioural therapy remaining the predominant method.

Conclusions Since the 1950s the focus of psychiatric care has shifted from the centuries-old system of inpatient care to care within the community.

There are more members of a mental health team than previously, and the mainstay of treatment focuses on pharmacological, psychological and social therapy and rehabilitation. We are approaching an age of gene therapy and awareness of the link of diet to disease, and practitioners expert in these fields as well as expert patients can be future members of the mental health team.

It is unlikely that psychiatric care will be practised entirely in the community but, like society, in time psychiatric care will bear even less resemblance to what it was like in 1960.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Turner T. The history of deinstitutionalization and reinstitutionalization.

Psychiatry 2004 Sep;3(9):1-4.

Office for National Statistics: http://www.statistics.gov.uk/cci/nugget.asp?id=1865.

London [updated 2007 Oct; cited 2010 Mar 19].

Whychurch.org.uk: http://www.whychurch.org.uk/trends.php [updated 2007 Apr; cited 2010 Mar 19].

Lord Percy. Report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency. London: HMSO, 1957.

Office for National Statistics: http://www.statistics.gov.uk/cci/ nugget.asp?id=827. London [updated 2004 Apr; cited 2010 Mar 19].

The Mental Health Team: http://www.rcpsych.ac.uk/ mentalhealthinfo/communityteam.aspx. London: Royal College of Psychiatrists [updated 2009 Dec; cited 2010 Mar 19].

Migration Advisory Committee Shortage Report – Clinical Psychologists, SOC2212. NHS Workforce Review Team, 2009.

Psychminded.co.uk: http://www.psychminded.co.uk/news/ news2007/July07/stigma003.htm. Leamington Spa [updated 2007 Jul; cited 2010 Mar 19].

Feeding Minds: the impact of food on mental health, p8. From http:// www.mentalhealth.org.uk/campaigns/food-and-mental-health.

London: Mental Health Foundation [updated 2007 Mar; cited 2010 Mar 19].

The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century. London: Department of Health, 2001.

For references see thelsjm.co.uk.

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The Mental Health of Mental Health Staff: Psychological distress and burnout in DSPD units Mohammed Al-Hairi,BSc (Hons) Year 5 Medicine, Imperial College School of Medicine mohammed.al-hairi@nhs.net doi: 10.4201/lsjm.psy.010 Clinical burnout and psychological morbidity amongst prison officers and mental health professionals in psychiatric institutions is at alarming levels. Emotionally exhausted and physically drained forensic staff harm the practitioner-patient relationship and the rehabilitative therapeutic climate. As part of the larger MEMOS project assessing the organisation of the nationwide Dangerous and Severe Personality Disorder (DSPD) programme, this exploratory cross-sectional study will investigate the levels of burnout and psychological distress in all frontline workers employed in the four maximum security DSPD units delivering the new service. Of the total 749 members of staff, 356 (47.5%) completed a questionnaire that assessed their psychological wellbeing. Perhaps surprisingly, data analysis revealed that, on average, care of violent offenders only provoked moderate levels burnout. However, a quarter of the workforce was experiencing some degree psychiatric distress, a minority seriously so, and many had a particularly low sense of work-related productivity and achievement. These results provide food for thought for programme administrators and an impetus for further research to explore potential supportive strategies.

Keywords: • Burnout • Forensic • Mental health • Psychiatric • Nurses • Prison officers • Maslach Burnout Inventory • General Health Questionnaire • Dangerous and Severe Personality Disorder 226

Background Stress and Burnout Occupational stress has been well documented across the spectrum of healthcare specialities 1. Generic organisational factors repeatedly highlighted as major workplace stressors include a lack of resources, responsibility without authority, limited role autonomy 2, 3 and most importantly the risk inherent in a deep emotional investment in the wellbeing of vulnerable patients 4. Forensic psychiatric professionals are presented with a particularly demanding work environment in both context and purpose. Numerous studies have demonstrated that the occupational stressors for correctional staff can be broadly categorised into the difficulties intrinsic in treating incarcerated psychiatric patients and those that revolve around perceived bureaucratic practices.

Delivering therapy in a forensic setting entails coping with, and adapting to, potentially stressful patient encounters. Sullivan showed that psychiatric nurses had to deal with challenging behaviours, untoward incidents and violent confrontations on a regular basis 5. Correctional nurses and officers who lack the necessary skills to intervene appropriately can begin to view their patients as untreatable, difficult behaviours as intractable and work demands as unmanageable. Such attitudes may lead to feelings of inadequacy, frustration and psychological exhaustion 6. Psychologist Herbert Freudenberger was the first to identify this phenomenon and coined the term burnout which is still used colloquially to this day 7.

Freudenberger’s pioneering investigations were advanced by Maslach who refined the concept and developed the Maslach Burnout Inventory (MBI) where burnout is conceptualised as a complex multidimensional construct defined by emotional exhaustion, depersonalisation and reduced personal accomplishment (Figure 1). Professionals suffering from burnout feel emotionally and physically drained, develop dehumanised, callous or cynical feelings towards patients, while their sense of professional productivity and achievement diminish 8. The burnout phenomenon has been eloquently described as an enduring sense of helplessness and hopelessness 9 and has been linked with absenteeism 10 high employee turnover, and even alcohol abuse 11. Healthcare work itself should not be psychologically hazardous and as such, burnout

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is increasingly being regarded as a major cause for concern for NHS policy makers.

Figure 1: Schematic diagram of the burnout phenomenon.

Chronic emotional and interpersonal occupational stressors instigate or exacerbate Emotional Exhaustion and Depersonalisation leading to diminishment of one’s sense of Personal Accomplishment.

Chronic Occupational Stressors:

Reduced Personal Accomplishment Depersonalisation Emotional Exhaustion Dangerous and Severe Personality Disorder The origin of the Dangerous and Severe Personality Disorder (DSPD) diagnosis can be traced back to a UK government “white paper” which described a putative criminogenic mental disorder for which broadened commitment criteria was proposed 12. The authors noted that “individuals who present a risk to others because of their severe personality disorder are rarely detained under the [existing] Mental Health Act 1983 because they are assessed as being unlikely to benefit from the sorts of treatment currently available in hospital” 13. Citing the importance of public protection, the government passed legislation that would eliminate this treatability criterion and enable the involuntary hospitalisation of severely personality disordered persons shown capable of causing serious harm and who presented an unacceptable risk to society.

The new proposals generated controversy almost immediately with leading psychologists voicing concern over the conversion of psychiatric facilities into instruments of social control without explicit therapeutic intent 14. Many remain unconvinced that these people are treatable or their antisocial behaviours amenable to change. As such, the issue of whether the government’s DSPD proposals strike the right balance between individual liberty and public safety remains open.

Nevertheless, as a result of the landmark publication four pilot DSPD units were opened; two within HM Prison Service (HMP Whitemoor and HMP Frankland) and two based in secure NHS psychiatric hospitals (Rampton and Broadmoor hospitals).

Ongoing concerns that working with this challenging population

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has an adverse impact on the health and welfare of staff lead to the creation of the Multi-method Evaluation of Management, Organisation and Staffing (MEMOS) project.

Study Objectives As part of the MEMOS project, this descriptive observational study will: Examine the levels of burnout and psychological distress in the DSPD workforce.

Compare the results between healthcare nurses and prison guards, therapists and non-therapists.

Materials and Method Design and Sample A self-report multi-variate cross-sectional survey utilising the Maslach Burnout Inventory (MBI) 15 and General Health Questionnaire (GHQ-12) 16 was administered to all frontline personnel employed in the four pilot DSPD units.

These units share common clinical guidelines and provide longterm residential psychiatric care to adult patients with a diagnosis of DSPD. Nurses, psychiatrists and certain trained prison officers deliver therapy sessions. Frontline employees were defined as “any professional who carries out therapeutic, medical or educational activities or is in regular contact with patients/prisoners in a supervisory capacity”.

The study was approved by NHS COREC (Central Office for Research Ethics Committees).

Instruments A demographic datasheet was included in the questionnaire pack with questions on personal details and occupational variables such as length of time in post and previous experience in a forensic setting. These where then treated as independent or explanatory variables.

The MBI is a validated 22 item self-report scale widely used in occupational studies of human services workers. It comprises three separate subscales examining Emotional Exhaustion (EE), Depersonalisation (DP) and Personal Accomplishment (PA).

Respondents are asked to rate items on a six-point Likert-type scale ranging from 0, ‘never’, to 6 ‘every day’ and mean scores are then calculated using these frequencies. While high scores for EE and DP indicate a high degree of burnout, the PA subscale measures a protective personal quality and so higher scores indicate lower levels of burnout.

The GHQ-12 assesses the current level of experienced mental

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RESEARCH stress of respondents. It includes items such as ‘Have you recently been feeling unhappy and depressed?’ and is rated on a four-point scale (scored 0-3). Total scores over 3 are considered above the threshold for psychiatric “caseness” and indicate probable psychiatric distress.

Procedure The survey was distributed with an information letter attached in which assurances of the confidential, voluntary and anonymous nature of the investigation were explicit. The questionnaires were unnamed but did include an identification code to enable researchers to follow up non-responders. Members of staff were instructed to return the completed questionnaire directly to the research team in the pre-paid envelope provided or post it into a sealed box on the unit for hand collection by the researcher.

To boost response rates, employees were reminded about the MEMOS project in staff meetings, organisational newsletters and directly by email. Negotiations with the line managers enabled unit wards to provide protected time during working hours to encourage

Gender Male Female Age 20 - 29 30 - 39 40 - 49 50 - 59 60 + Therapy?

Yes No

Prisons (%)

Hospitals (%)

Total (%)

68.3 31.7

47.4 52.6

56.3 43.7

15.4 28.2 32.9 20.8 2.7

19.4 38.3 27.8 13.3 1.1

17.6 33.7 30.1 16.7 1.8

61.8 38.2

60.6 39.4

61.2 38.8

Table 1. The demographic characteristics of the sample population by site.

Involved Therapy (%) 27 29 26

All Staff Prison Officers Psychiatric Nurses

Not Involved Therapy (%) 25 23 25

All Cases (%) 26 26 25

Table 2. The percentage of staff who crossed the GHQ-12 psychiatric “caseness” threshold for likely psychiatric distress

All Staff

Officers

Nurses

MBI Subscales Mean

SD

Depersonalisation

14.9

4.6

10.0

5.9

12.9

9.4

14.7

3.7

10.5

4.1

12.4

17.3

Personal Accomplishment

27.0

9.6

15.7

27.7

9.4

13.3

Emotional Exhaustion

% High Mean

SD

% High Mean

SD

% High

14.9

6.3

8.2

5.8

10.3

18.8

23.6

8.7

10.3

Table 3. The means and standard deviations of the 3 subscales of the Maslach Burnout Inventory for nurses, prison officers and the total staff sample. The proportion of participants who scored highly under each subscale is also listed.

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staff to complete the questionnaire. In addition, three follow-up letters were sent to all non-responders requesting consent.

Analysis The data collected was analysed using the Statistical Package for Social Sciences (SPSS) software, version 14. Chi-Square analysis was used to assess the significance of variation in subgroup proportions while differences between the mean scores on the three MBI indices was examined using the Students t-test.

Results Of the total 749 members of staff, 356 completed the questionnaire pack giving a reasonable if disappointing response rate of 47.5%.

This was fairly constant across all 4 sites (41% - 52%).

The sample comprised of 79 (20%) prison officers, 108 (28%) psychiatric nurses, 28 (7%) senior managers, 37 (10%) psychologists or psychiatrists and several other smaller healthcare specialities.

The demographic characteristics of the entire study population are summarised in Table 1.

Despite the greatest effort and numerous strategies to increase the return rate, only 50% of the eligible population participated.

While the sample obtained can be said to be representative as the proportions above correspond well with institutional records, the poor response rate may skew the results; professionals who feel particularly dejected or despondent or burned-out as a result of chronic work-related stress may be less inclined to participate.

Table 2 shows the proportion of psychiatric nurses and prison officers who fulfilled the criteria for psychiatric “caseness” on the GHQ-12. In total, 26% of respondents were suffering from some degree of psychiatric morbidity and this was similar for every discipline; there was no statistically significant difference between the nursing and security workforce or between staff involved and not involved in delivering therapy.

Maslach conceptualised burnout, and its constituent components, as continuous variables and categorised high, moderate and low levels based on the results of a normative sample of 730 mental health professionals 15. Using this breakdown, it can be calculated that 13% of staff employed in the DSPD service are positive for a high level of EE, 9% positive for high DP and 16% positive for an abnormally low sense of PA (Table 3).

There is a statistically significant difference between the mean PA score for nurses and prison officers (p=0.04), whereas the same cannot be said for the 2 other subscales, (EE, p=0.9; DP, p=0.07). Moreover, many more nurses and prison officers felt particularly depersonalised by their work than the total staff average, 17% and 19% fell in the high burnout level for DP compared to only 9% of the sample taken as a whole.

Further data itemisation and univariate analyses revealed a weak correlation between age and burnout, particularly EE (r=0.344), but this did not reach the level of statistical significance (p=0.245). Likewise, there was no significant relationship between age and GHQ-12 result, or between gender and the MBI subscales. Furthermore, and somewhat surprisingly, neither experience in a general forensic setting or on the DSPD unit itself correlated significantly with either one of the two assessment

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RESEARCH tools.

Discussion In terms of the concerns raised over the DSPD workforce, it seems that, on average, the care of violent offenders provoked only moderate levels of burnout. In fact staff appear relatively resilient to depersonalisation and emotional exhaustion despite the fact that are charged with the task of supervising and securing an unwilling and potentially violent population.

On the other hand, the majority of frontline forensic staff reported work as moderately stressful in all components of the MBI while about 13% felt physically and emotionally depleted (high EE) and almost one in ten had developed callous, indifferent and insensitive attitudes toward patients (high DP). This figure was a lot higher in psychiatric nurses and prison officers, at about one in five. Moreover, the overall prevalence of psychological distress in the DSPD workforce was high with approximately one quarter suffering from psychiatric ill health, a minority seriously so. This represents a major cause for concern in terms of the recruitment and retention of skilled staff.

The PA subscale of the MBI essentially measures ones belief in their work-related competence, and hence a low PA reflects a strong tendency to evaluate ones work negatively 17. In the context of the DSPD programme, the particularly low PA score, significantly in prison officers, may be attributable to the limited patient progress observed. “Burnout is most evident in work situations that inhibit mental health workers’ capacity to realise their values through their work” 18.The argument that personality and behaviour is largely immalleable in the DSPD population may be accurate.

Study Limitations The findings from this study must be treated with some caution since only 50% of the eligible study population participated. Differences between the sample group and the study population, beyond their demographic characteristics, are impossible to evaluate. The questionnaire method of data collection is particularly susceptible to recall bias and ignores the dynamic and idiosyncratic nature of workplace stress. Moreover it is likely that overall job satisfaction and burnout are influenced by unmeasurable local factors that are difficult to quantify such as leadership style, communication flow and organisational culture. Another important consideration is that sources of stress outside the workplace were not accounted for in this study. Domestic strains and traumatic life events can independently contribute to the experience of burnout or may make it more difficult for employees to function well at work and therefore represent a potential confounder 23.

In Conclusion, this study represents one of the first quantitative investigations of its kind with DSPD workforce and its results provide food for thought for the programme administrators. Overall, it appears that the emotional demands of human service provision combined with the significant challenges of the DSPD population have an adverse impact on the psychological health and wellbeing of many employees. In order to ensure the longevity of the DSPD service, the units must create a working environment that is considered healthy and secure by both prisoners and treatment staff.

References 1.

It is unclear why young and inexperienced members of the DSPD workforce reported the same levels of psychological distress and clinical burnout as senior colleagues. Many studies have reported young age and forensic inexperience as risk factors for occupational burnout 19; 20, while the effect of gender is uncertain 18. As DSPD units are perceived as the forefront of forensic psychiatry, they may attract the most enthusiastic, trained and skilled young professionals who are more resilient to the burnout process 21; 22. Another possible explanation is that the cross-departmental, multidisciplinary team approach in these units protects junior recruits from the most distressing aspects of patient care. Melchior discovered that work experience at the group level had a much higher association with burnout than that at single nurse level 19.

2.

3.

4.

5.

The importance of the practitioner-patient relationship on professional burnout has long been suggested. Maslach posited that nurses would develop clinical burnout if their patients did not respond to them on a personal level, give positive feedback or show progress 15. It has since been shown that burnout follows perceived inequity in the therapeutic relationship where nurses feel little improvement has been generated from the large emotional investment made 19. Indeed, working with psychiatric patients with a poor prognosis can lead to feelings of helplessness, weariness and frustration that can initiate the burnout process 6. Mental health professionals who work with long-term psychiatric patients need to recognise that such patients often have a limited potential for rehabilitation 19. Unrealistic expectations can lead to feelings of disappointment and dissatisfaction that exacerbate the damaging burnout spiral.

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6.

7.

8.

9.

10.

Weinberg, A., Creed, F., (2000). Stress and psychiatric disorder in healthcare professionals and hospital staff. The Lancet, 355(9203):533537.

Fagin, L., Carson, J., Leary, J., De Villiers, N., Bartlett, H., O’Malley, P., West, M., McElfatrick, S., Brown, D., (1996). Stress, coping and burnout in mental health nurses: findings from three research studies. International Journal of Social Psychiatry, 42(2):102-111.

Edwards, D., Hannigan, B., Fothergill, A., Burnard, P., (2002). Stress management for mental health professionals: a review of effective techniques. Stress and Health, 18, 203-215.

McGrath, A., Reid, N., Boore., J., (1989). Occupational stress in nursing.

International Journal of Nursing Studies, 4, 343-358.Bamber, M., (1991).

Reasons for leaving among psychiatric nurses: a two-year prospective study.

Nursing Practice, 4(4):9-11.

Sullivan, P.J., (1993). Occupational stress in psychiatric nursing. Journal of Advanced Nursing, 18(4); 591-601.

Moore, E., Ball, R.A., Kuipers, L., (1992). Expressed emotion in staff working with long term adult mentally ill. British Journal of Psychiatry, 161, 802-808.

Freudenberger, H.J., (1974). Staff burnout. Journal of Social Issues, 30(1):159-165.

Maslach, C., Jackson, S.E., (1981). Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press.

Sørgaard, K.W., Ryan, P., Hill, R., Dawson, I., (2007). Sources of stress and burnout in acute psychiatric care: inpatient vs. community staff. Social Psychiatry and Psychiatric Epidemiology, 42(10):794-802.

Neveu, J.P. (2007). Jailed resources: Conservation of resources theory as applied to burnout among prison guards. Journal of Organizational Behaviour, 28, 21–42.

For full references see thelsjm.co.uk.

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EDITORIAL

Welcome to this third issue of the London Student Journal of Medicine. It has now been a year since the LSJM’s inception and a continuing theme throughout this period has been new practices with the explicit aim of improving patient care. One example of this has been the wider topic of patient safety and specifically the World Health Organisation Surgical Safety Checklist which we introduced in our first issue1 and featured the role of the healthcare student in its dissemination in the second issue2. However, as has been recently discussed, there is still much to achieve within this rapidly developing sphere of medicine, bringing with it additional challenges such as how to incorporate these new ideas into the already crowded undergraduate curriculum of healthcare students3.

A further theme this year has been the future of surgery, both in terms of technological advances and as a potential career. This is continued in the present issue with a personal account of the use of a laparoscopic simulator, one of a number of new training tools to assist trainees. Additionally, we also feature two contrasting profiles of surgeons at different ends of their careers, a senior trainee in the United Kingdom advancing the cause for female surgeons and a distinguished professor of surgery in Mexico who truly pushed the boundaries of his specialty.

However, our work has not just included the review and selection of potential manuscripts for publication, but has also revolved around building relationships with stakeholders interested in the LSJM and this issue features the fruits of a successful partnership between the LSJM and Scalpel, the Surgical Society of the University of Manchester. The following pages contain a synopsis of their Undergraduate Surgical Conference, held in November 2009 and the abstracts of the winning submissions. The posters and presentations of the winning entries will be available online in the near future. Furthermore, we are pleased to announce a new partnership with the King’s College London Surgical Society and their forthcoming Trauma Conference. We are always interested in supporting undergraduate surgical events so please get in touch if you have any events in the pipeline.

As has been previously highlighted, change in Medicine is both necessary and inevitable and so is the case with the Surgery Section.

This will be our last contribution to the LSJM and a new leadership team is therefore sought. Application will be through the process outlined on the LSJM website (www.thelsjm.co.uk), but if anyone would like to discuss the editor’s position informally, please feel free to contact us at surgery@thelsjm.co.uk.

We concluded our first editorial by stating that our aim was for you, our readership, ‘to consider the LSJM as a place to publish your work and begin to make it part of your regular reading – hopefully’ our work over this past year has begun to realise this aim.

Jonathan Cheah and Milan Makwana Associate/Section Editors, Surgery Section

References: 1.

2.

Yuen S. What is the WHO Surgical Safety Checklist. The London Student Journal of Medicine {Surgery}. 2009;1:51.

Carson-Stevens A, Hafiz S, Bohnen J, Rose Jr. J, Gutnik L, Henderson D, et al. Transforming the Culture of Surgical Safety. The London Student Journal of Medicine {Surgery}. 2009;1:128-9.

3.

Donaldson LJ, Lemer C, Noble DJ, Greaves F, Fletcher M. Finding the Achilles’ heel in healthcare. Journal of the Royal Society of Medicine. 2010;103:40-1.

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INTERVIEW

Foetal Cleft Lip and Palate Repair Priyanka Chadha

Year 3 Medicine, Imperial College, London priyanka.chadha06@imperial.ac.uk Pioneer Professor Ortiz Monasterio speaks about the ethics and realities of his foetal repair surgery many years ago

Fig 1: Professor Ortiz Monasterio

Cleft lip and/or palate is the most common congenital malformation of the head and neck and accounts for 65% of all head and neck anomalies. Foetal cleft lip and palate repair became a reality after the advent of high resolution ultrasound imaging allowed an anomaly to be identified prior to delivery. The benefits of this type of operation were numerous and included the inherent characteristics of foetal wound healing, which is scarless at mid gestation, in contrast to wound healing in adults. In addition, the ability to prevent damaging consequences of the malformation, for example maxillary growth restrictions should no longer occur and there would be a decreased need, or no need at all, for additional treatments or other after care.

Professor Ortiz Monasterio (figure 1) attempted the first foetal cleft lip repair in humans two decades ago. His initial attempt of foetal lip repair was in rats and a successful outcome of scarless wounds was achieved. He then moved on to primates. Using high resolution ultrasound, his team were able to identify the gestation period of each foetus. They operated, through an open approach, on a total of 38 foetus. The team entered the uterus, whilst avoiding the placenta, and removed a section of the upper lip from the foetuses, sutured it back together and observed the behaviour of foetal wound healing and general physiology through into adulthood. Through these operations, Professor Monasterio learnt to operate “fast and well” and was confident enough to attempt a foetal repair in a human.

PIC

Was operating on human foetuses an easily attainable goal?

Following the Declaration of Helsinki in 1975, (ed. a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data), operations of this type became very complicated. I discussed all of the risks with the mother, for example, the risk of premature labour, loss of life, the possibility of hysterectomy, bleeding etc. After all of this information the mother consented to the procedure and it was possible to go ahead with it. Although the child was born prematurely, it was viable. However, it was born with a scar much worse than those seen in post-natal repair.

Although similar research was being done with regards to foetal repair for congenital diaphragmatic hernia, the laboratory in San Francisco doing this had much more money, many more resources and a larger team to help.

It was much more difficult for me. I was just a craftsman trying to develop a technique. I can do nose operations now, on babies

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who are two months of age, beautifully. It is much easier and the technical difficulties found in foetal repair are not there. In 1965, 65% of our cleft lip and palate repairs (as done by the whole team, including the residents) had velopharyngeal insufficiency (failure of the soft palate to reach the posterior pharyngeal wall, often resulting in defective speech – VPI). This reduced to 25% in 1985 and in 2003, 7% of my own, private patients, solely operated on by me, had VPI. It is through a lifetime of dexterity that I have been able to achieve such results (figure 2).

This illustrates the great progress that is being made in the field of cleft lip and palate repair without the need for risky surgeries, such as foetal repair.

Do you think that foetal repair is realistic in the future, with more accurate ultrasound scanning and a more precise gestation period identified for scarless healing?

No, it’s not attainable. It’s just too risky. It involves very difficult and complicated techniques in open surgery and feto-endoscopic surgery. It is technically very hard. Even with the advent of fetoendoscopic surgery, of which there is very little evidence, one is still manipulating intricate structures inside of the mother and this itself is very difficult. Placental bleeding is still a very real possibility as are all of the other risks. There’s no concrete evidence for regeneration. It’s just wishful thinking unfortunately.

Never shall the evidence of scarless wound healing outweigh the risk of premature labour.

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INTERVIEW Do you think that it is ethically viable to attempt to continue with these operations and that the benefits may outweigh the risks?

What benefits? There is no evidence. It is not ethically acceptable.

The benefits simply don’t outweigh the risks. The main advantage Fig 2: Current cleft lip and palate surgery, performed by Professor Monasterio

great risks and is very complicated. Closing the skin and aligning the orbicularis oris muscle is very difficult. Cleft lip and palate repair is an exciting adventure and currently, we are limited by bioethics, costs and benefits. If you’re talking about congenital diaphragmatic hernia, then of course, this is different. It is life saving and therefore much more justified. This condition is something very different.

Are you still enjoying your career?

Of course! I am still enjoying it. I graduated 63 years ago and I am still operating but I think I should stop! I like to try and pass my experience on to the residents. I try to communicate experience. I have enjoyed my life to the full. I originally did my general surgery residency in Mexico, I then did my plastic surgery training in the U.S. In 1955, I returned to Mexico and my time here led to the first full time residency in a specialty, which was plastic surgery. Now, there are over 50 residencies in varying specialities. People came to us for a cleft lip and palate repair very late in their lives. We wanted to find people who required a repair and so we organised a mobile unit to travel to rural areas. We provided free health care, with a team and recruited people of all ages for cleft lip and palate repair. In total, our group has performed around 24,000 cleft lip and palate repairs in just over 50 years!

now of early post natal surgery is that the shock for the family is diminished. But with proper psychological support, the family are able to understand the child’s condition more. Foetal repair has

Do you have any regrets? Would you repeat the decisions that you’ve made?

I have no regrets. None. I am an adventurous surgeon and I have no regrets about my previous work. There is nothing to regret – one does operations and learns from them and the information gained whilst performing them, and then one moves forward.

, At the LSJM

Su r g ery is only one

asp

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ne i c i d f Me

PIC

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PROFILE

Profile of: Miss Beryl de Souza Interviewed by: Niyati Lobo Year 3 Medicine, King’s College London niyati.lobo@kcl.ac.uk I probably did but was too thick-skinned to ever notice when it did happen. Certainly, the discrimination was never overt.

Can you describe a person that has had the most influence on the way you practice today?

I do not think there is just one person I can describe. My training has been influenced by various people who have trained me over the years.

You’re married to a surgeon. Was he initially supportive of your surgical aspirations or did he want a more traditional wife who would have more time to raise a home and family?

Because I went to medical school as a graduate student, I met my husband who was already along the surgical training pathway. He was aware of what I wanted to do as a career and has always been very supportive.

Current Post Senior Registrar in Plastic Surgery, Chelsea and Westminster Hospital, London Joint Honorary Secretary, Medical Women’s Federation BMA Council Member Undergraduate Studies BSc (Hons) Biochemistry, Chelsea College, University of London Postgraduate Studies MPhil Royal College of Surgeons of England, University of London 1987 MBBS St Bartholomew’s Hospital, University of London 1992 FRCS Royal College of Surgeons of England, University of London 1998

What made you decide to pursue a career in surgery?

I did a degree in biochemistry and undertook a period of research at the Royal College of Surgeons prior to entering medical school.

My project involved investigating different substances as matrices for peripheral nerve regeneration. The microsurgical techniques I learned during this time encouraged me to pursue a surgical career with a view to specialising in plastic surgery.

During your years as a trainee, did you ever experience discrimination by your male counterparts for being a female surgeon?

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How do you balance raising a home and children with working in a highly demanding field?

Well, we have to be very organised which is difficult. We have to ensure that we’re not on call at the same time and we need to have back-up. I’m lucky as my parents live nearby and are very supportive. I also have a group of friends who I can rely on to help us out when needed.

Did you take a lot of time off work when you had children?

No, I didn’t as my specialty is very competitive. For my first child I took 6 months off and for my second child, I took 3 months, which may be less than most people do. I do regret not being there and spending much time with them when they were growing up. But it’s very, very difficult to get the balance quite right.

Describe a typical day.

There is no such thing as typical day! I usually wake up around 6am and leave for work almost immediately. I arrive at the hospital between 7 and 7:20am and have breakfast in the mess. The morning is spent either on ward rounds or in theatre. I spend my afternoons in theatre or in clinics consulting and assessing patients for surgery. On average, I finish between 5 and 6pm, unless I’m on call!

What would you say to those who believe it isn’t possible for a woman to combine a surgical career with being a mother?

I would say it’s not impossible, but certainly requires resilience and support from your partner, friends and relatives. Determination and the ability to persevere is key. However, the most important thing is that it is not impossible. It may be more difficult along the way because you want to balance your responsibilities as a mother and as a surgeon. In addition to that you have exams to pass,

lsjm 30 april 2010 volume 01

NEWS Access to Obesity Surgery In a recent conference at the Royal College of Surgeons, it has been said that ‘access to NHS weight-loss surgery is inconsistent, unethical and completely dependent on geographical location’.

A survey carried out before the conference found that 66% of surgeons said that patients eligible under NICE guidelines are refused surgery in their centres and that the criteria for surgery varies depending on geographical location. The Department of Health has been called upon to ensure that equal access to treatment for all patients is implemented. (For more information see www.rcseng.ac.uk) papers to write, research to do, teach, etc.

You are an honorary secretary in the Medical Women’s Federation (MWF). Can you tell us a little more about this organisation and how it relates to female medical students?

At the moment, 60% of medical school intake are women. This means that, in the coming years, the workforce will change and women will have to make certain choices in order to keep the workforce in a condition whereby all specialities are filled.

Inevitably, some women will end up choosing harder specialities just to fill in posts. The recent report by the Chief Medical Officer (Women Doctors Making a Difference) has made certain recommendations for female doctors. The MWF campaigns for the very same recommendations, these being primarily to do with leadership roles, mentoring, flexible training and childcare facilities. I would urge female medical students to get involved with the MWF for the camaraderie and support that is provided.

Aspirin and Breast Cancer Survival J Clin Oncol 2010 Feb 16. [Epub ahead of print]

What is the most important thing you learned as a student?

It is important to be both able to relax and exercise discipline with regards to studying during your time at medical school. Things don’t get easier once you qualify, so it is important to learn this skill as a student. I am still trying to achieve a healthy work life balance!

Gastric Banding for Obese Teens JAMA 2010;303:519-526

American researchers have sought to evaluate aspirin’s effect on breast cancer following animal studies suggesting that the agent may inhibit breast cancer metastasis. Over 4,000 nurses were observed prospectively for diagnosis of breast cancer and length of time on aspirin via questionnaire. The relative risk for breast cancer mortality was decreased among women who used aspirin for 2–5 days/week (0.29, 95%CI 0.19–0.51) or 6–7 days/ week (0.36, 9%CI 0.24–0.54), compared to non-users. Distant recurrence was also reduced with regular aspirin use. The authors concluded that aspirin use was associated with a decreased risk of distant recurrence and breast cancer death.

PIC

Do you have any tips for aspiring female surgeons?

Decide early on what surgical specialities you’re keen to pursue.

Once you’ve done that, look in detail at the career structure for those specialities so you have an idea about the jobs that will be available to you. Make use of career websites such as the Royal College of Surgeons and the Department of Health. Find out whether you would be able to tick the boxes required in order to overcome the competitive nature of surgical posts. Audit work, research, publishing and presenting and skills training at an undergraduate level are all useful.

A recent randomised controlled trial has sought to elucidate if obese teenagers lose weight better through lifestyle modification involving diet, exercise and behaviour modification or surgical intervention. 50 14-18 year olds from Australia with a Body Mass Index of greater than 35 were assigned to supervised lifestyle intervention or gastric banding. During the two year follow up, significantly more teens in the banding group than in the lifestyle group had lost at least half their excess weight (84% vs. 12%).

Furthermore, the banding group experienced improved quality of life although 8 revision operations were required.

Reducing Post-surgical Infections N Engl J Med 2010;362(1):18-2 To determine the effectiveness of pre-operative skin preparation in reducing post-operative infections, American researchers randomised 849 patients to either chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. The 30-day infection rate in the chlorhexidine-alcohol group was 9.5% compared 16.1% to in the povidone-iodine group (P=0.004). Additionally, chlorhexidinealcohol was superior in both superficial- and deep-incisional infections. The researchers state that ‘preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated surgery’.

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SPECIAL REPORT

Scalpel Undergraduate Surgical Conference 2009 The Scalpel Undergraduate Surgical Conference was held on 7 November 2009 at Wythenshawe Hospital. It was the first national conference of its kind, and drew medical students from all over the country. The event was held in collaboration with The Royal College of Surgeons (RCS), The Association of Surgeons in Training (ASiT) and Doctors Academy.

The conference was attended by 120 medical students from as far away as Dundee and Peninsula Medical Schools. It provided a platform for students to present their original research, audit or case reports at a national level to other students and a select panel of surgeons with a passion for teaching and research. The best presentations were awarded prizes, which were generously sponsored by Mr Peter Richardson, Mr Rory McCloy, and the London Student Journal of Medicine.

The day was chaired by our local eminent surgeon, Professor Gus McGrouther. Speakers included Professor Nanchahal from Imperial College London, whose fascinating lecture covered the advancements in plastic surgery research. Professor Stanley, a local orthopaedic surgeon, discussed the role of the surgeon and shared wisdom from a full and varied career. The keynote address came from Miss Helen Fernandes, a consultant neurosurgeon from Cambridge and the Chair of Women in Surgery. Her talk covered the history of surgery, as well as her experiences as a female surgeon and the aspects of neurosurgery that drew her to choose it as a career.

A fantastic array of workshops was available, kindly supported by Doctors Academy and the RCS. This was a great opportunity to learn some practical surgical skills or ask expert advice about getting into surgery. A lively evening dinner was held at Red Chilli restaurant, which allowed delegates to relax and share their experiences of other UK medical schools.

The conference was the climax of a triumphant year for Scalpel, which has been gaining momentum since it’s re-launch in 2006. A second conference is planned for 2010, which promises to be even better than the last!

Elspeth Hill

President and Ambrose Boles, Conference Co-ordinator Scalpel Surgical Society, The University of Manchester scalpelmanchester@gmail.com

Audit

Incidence of MRSA colonisation and subsequent risk of infection in orthopaedic elective surgery Emma Murphy

Fourth Year Medical Student, University of Dundee ezmurphy@dundee.ac.uk doi: 10.4201/lsjm.surg.012 Background The incidence of methicillin-resistant staphylococcus aureus (MRSA) colonisation is continuing to increase in UK hospitals with the incidence of MRSA-positive orthopaedic patients, at the time of their admission, considered to be around 5.3%. A previous study has shown that the risk of developing MRSA surgical site infection (SSI) post-operatively in orthopaedic trauma patients colonised with MRSA is 2.5 times greater than that of the normal population, but the risk of developing a MRSA SSI in elective orthopaedic patients has yet to be determined.

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prophylactic antibiotics used during the procedure and subsequent development of a SSI in the year following surgery.

Purpose The aim of our study was to determine how effective screening and treatment of MRSA colonisation in all elective orthopaedic patients was on the subsequent risk of developing a MRSA SSI.

Results From January 2005 to April 2008, there were 5,933 admissions for elective orthopaedic inpatient surgery to our unit. 108 of 5,933 (1.8%) were MRSA colonisation positive with 5,825 (98.2%) MRSA colonisation negative. Seven out of 91 (7.7%) patients who were MRSA colonisation positive had a SSI within one year of surgery (95% CI 3.1%, 15.2%). Of these, deep sepsis occurred in four (4.4%) patients and superficial infection in three (3.3%) of the 91.

Deep sepsis rates, in lower limb joint replacements, were high in the previously MRSA colonisation positive group, with two SSIs out of 28 total hip replacements (7.1%) and two out of 29 total knee replacements (6.9%).

Methods We analysed all orthopaedic elective patients screened for MRSA who were admitted between January 2005 and April 2008. For colonised MRSA positive patients, we determined the site of MRSA colonisation, if colonisation was eradicated before surgery, patient’s risk factors for MRSA colonisation,

Conclusions Our study indicates that patients colonised with MRSA at their pre-op assessment are at increased risk of developing MRSA SSI and that this risk is significant for total hip and total knee replacement patients. Where infection develops MRSA is the most likely causative organism.

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SPECIAL REPORT

The Role of Reconstructive Surgery in the Management of Urethral Strictures: a case study

Case Report

Hussein Taki

Fourth Year Medical Student, University of Bristol ht6031@bristol.ac.uk doi: 10.4201/lsjm.surg.009

Background The management of urethral stricture disease in men is a relatively common issue faced by practising urologists. Urethral strictures occur for many reasons including congenital, iatrogenic, idiopathic and inflammatory causes. Stricture disease is responsible for as many as 5,000 hospitalizations and 1.5 million outpatient visits per year in the USA and has an annual cost of $200 million.

Figure 1: Incision and mobilisation of Neo-Urethra, Urethra Sutured at a wide diameter, and Closure and wound dressing.

Stage two of urethroplasty.

Case Report Mr. A is a 45 year old man suffering from a long standing problem with urethral strictures, caused by the inflammatory condition Balanitis Xerotica Obliterans (BXO). This was previously treated with a topical steroid cream and several unsuccessful dilatation surgeries, home dilatation, as well as an urethrotomy. Passing urine was painful and he suffered from urinary retention, for which he had to self catheterize. As a result he underwent reconstructive surgery to relieve his strictures. This involved a two stage Urethroplasty using a buccal graft to reconstruct the urethra (fig1 &2). The two operations were 6 months apart and appear to be successful, having recently completed the second stage operation. Mr A’s urinary flow rates and Urethroscopy will be performed in outpatients every 3 months to monitor the risk of re-stricturing. He is recovering well after the surgery and is looking forward to resolving his long standing problem.

Discussion This case study discusses the aetiology of urethral strictures as well as their investigation, highlighting the role of the “reconstructive ladder” in their management. It also discusses whether in more severe cases the less invasive steps of the reconstructive ladder should be bypassed in favour of the more effective and invasive urethroplasty.

Figure 1: Ventral Midline Incision, Incision into urethra and Stricturotomy, all as part of a urethroplasty

Conclusion Most surgeons believe that urethroplasty should only be indicated after urethrotomy. Urethrotomy works best on small proximal strictures. Urethroplasty has a success rate as high as 96%. Repeated Urthethrotomy and Dilatation is neither clinically effective nor Cost Effective in longer strictures. For longer strictures where urethrotomy is expected to fail a primary urethroplasty is both cost effective and clinically effective. 2 References 1. Rourke. K. (2004) Urethral Stricture Disease: contemporary management; presentation at university of alberta.

2. Wright. J.L (2006); Urology 2006;67:889

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SPECIAL REPORT Rsearch

Impact of pathologic re-evaluation of core needle biopsies in patients undergoing radical prostatectomy Eoin Dinneen

Fourth Year Medical Student, University of Bristol Ed4798@bris.ac.uk doi: 10.4201/lsjm.surg.010

Objectives Gleason sum from prostate biopsy (bGS) is an important tool in classifying severity of disease, ultimately influencing clinical management. Commonly, outside laboratory pathology is reevaluated prior to surgical intervention. We evaluated agreement of bGS with prostatectomy Gleason sum (pGS) and the impact of regrading on prediction of true underlying tumor architecture.

Methods A retrospective analysis was conducted of men who underwent robotic prostatectomy (RARP) by two surgeons during the period 2005-2009. Initial trans-rectal ultrasound biopsy demonstrated carcinoma by an external laboratory. Specimens were re-evaluated by our Genito-Urinary pathologists prior to surgery and biopsy data were correlated with pGS. Statistical analyses were conducted on positive core bGS and percentage carcinoma involvement to assess inter-laboratory agreement. Kappa (ะบ) statistics for agreement and linear regression analyses were used for categorical variables and coefficient of concordance used for continuous variables. This data was also correlated with the final surgical pathology Gleason Score.

Figure 1: Trans-rectal Ultrasound Guided (TRUS)

Results 100 patients had 331 positive core needle biopsies. Agreement (ะบ) for bGS between outside laboratories and internal pathologists was 0.55 (p<0.001). Internal readings were twice as likely to upgrade vs. downgrade the original bGS (23% vs. 11%). When reevaluation resulted in a change in bGS, agreement with pGS was ะบ =0.29, vs. ะบ=0.04 for agreement of initial (external) bGS with pGS. When no change was made to bGS agreement with pGS was ะบ=0.40 (p<0.001). No effect was seen on accuracy with increased time to surgery though data suggests a relationship between increased number of biopsies and improved accuracy.

Conclusions Good reproducibility of bGS seen between external laboratories and our institution. Internal pathology re-reads correlated better with pGS than original external bGS. When re-evaluations result in a change in bGS, there is a marked improvement of prediction of underlying tumour architecture

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SPECIAL REPORT

Investigation into the association of Cancer Stem Cells and chemo-resistance in breast, colon and prostate cancer cells

Research

Hardip Gendeh, BMedSch (Hons)

Fourth Year Medical Student, University of Nottingham mzyahsg@nottingham.ac.uk doi: 10.4201/lsjm.surg.011

Susan Watson PhD Professor of Pre-Clinical Oncology, Division of Pre-Clinical Oncology, University of Nottingham

Figure 2: IHC of AP5LV lung metastasis with significant expression of CD133 CSC marker (brown)

Rajendra Kumari, PhD Senior Research Fellow, Division of Pre-Clinical Oncology, University of Nottingham Background The Cancer Stem Cell (CSC) theory suggests that tumours are heterogeneous, consisting of a small proportion of highly tumourigenic cells with similar properties to normal stem cells, in terms of yielding a heterogeneous cell population and proliferation. Evidence suggests that CSCs are highly tumourigenic in mouse models, with increased metastatic potential and chemo- and radio-resistance. They are emerging as key targets for new therapies and detection providing prognostic information. CSCs express specific surface marker panels, CD44 and CD24 in breast cancer, CD133 in colon cancer and CD44 in prostate cancer.

Purpose To demonstrate that CSC markers are over-expressed in human cancer cell lines, associated with chemo-resistance and enhanced metastatic potential.

Methods The chemo-resistance of MCF-7 breast and C170HM2 colon cancer cell lines was assessed by a tetrazolium-based, colorimetric cell viability assay. Enhanced chemo-resistance cells were subjected to immuno-fluorescent staining for the expression of CSC markers. Breast (MCF-7 and MDA-MB-231), colon (C170HM2 and AP5LV) and prostate (PC3M) xenograft tissue from mouse models of metastasis were subjected to immunohistochemical staining for the expression of CSC markers.

Figure 1: IF of MCF-7 (ADR) with significant expression of CD44 CSC marker (green) with nuclei (blue)

Results MCF-7 adriamycin- and paclitaxel-resistant human breast cancer cell lines were confirmed to be resistant and were found to express higher levels of CD44 than chemo-sensitive MCF-7 cells both in vitro and when grown as xenografts in vivo. CD133 expression was enhanced in AP5LV lung metastases compared to the primary tumour injected in the peritoneal muscle wall.

Overall CD133 and CD44 expression were elevated in the poorly vascularised subcutaneous sites compared to well-vascularised sites including prostate (PC3M), peritoneal cavity (C170HM2), mammary fat pad (MCF-7) and peritoneal muscle wall (AP5LV) suggesting they may be up-regulated in response to stress.

Conclusions CD44 is a robust marker of chemo-resistance in breast cancer cells in vitro and in vivo whilst CD133 is less discriminative.

CLINICAL RELEVENCE & FUTURE WORK Current chemotherapeutic agents have broad and non-selective cytotoxic effects, hence killing only the proliferative cancer cells and sparing the highly tumourigenic CSC. Although tumour de-bulking is achieved, CSCs are not eradicated and may result in re-emergence. Thus future chemotherapeutic agents should concentrate on specifically targeting CSC, hence preventing the tumour to be sustained. An optimal panel of CSC markers are required for all cancer types to provide a prognostic marker, act as a biomarker of chemo-resistance and to guide new treatment specifically targeted at CSC.

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ARTICLE

Surgical training in the 21st century-should we be worried?

Benjamin Shaw, BSc (Hons) Year 4 Medicine, University College London b.shaw@ucl.ac.uk For the vast majority of medical students interested in a surgical career, the closest we get to ‘actual’ surgery is holding a retractor, suctioning or if we’re lucky, tying a suture or two. It is puzzling how we can choose a career in surgery without knowing whether we have the skill, aptitude and precision to become competent and successful surgeons.

This issue becomes even more pertinent when considering the relationship between the recent reforms in surgical training and the advancement in surgical technique. The European Working Time Directive restricting a doctor’s work to 48 hours a week, combined with the Modernising Medical Careers initiative to reduce the length of surgical training has meant a significant reduction in a surgical trainee’s education. Furthermore, political and economical factors including patient safety, the implementation of quality assurance targets and time demands, are also contributing to limiting a surgical trainee’s operating experience.1,2 At the same time, continual advancement in surgical techniques, such as minimal access surgery, has necessitated an increased need for skills such as enhanced hand-eye coordination and meticulous manual dexterity.3

These factors raise a number of concerns about surgical training in the twenty-first century. As surgical trainees have less time to develop the necessary skills to become competent surgeons, will ‘natural ability’ become more important in the success of a surgeon? With medical students only performing the most basic of surgical tasks how can students with a ‘naturally ability’ be selected? Additionally, will the reduction in training compromise on quality and as a consequence put future patients at risk? What can be done to prevent this bleak prospect and aid surgical training?

Surgery in 21st century

Currently there are a variety of training techniques that have been introduced to combat the reduction in surgical education allowing trainees to gain experience outside the operating theatre (Figure 1).

These techniques include static bench models whereby trainees can practise basic procedures such as suturing and tissue dissection, live animal models enabling trainees to operate on ‘real’ tissue, video box trainers and virtual reality (VR) simulators where trainees can develop laparoscopic surgical skills.4 This year I was fortunate enough to be given the opportunity to use LAP mentorTM (Figure 2), a laparoscopic VR simulator by

Figure 1. Surgical training adjuncts currently in use 4,5

Skill Training Model Bench models

Video box trainers Animal models

Virtual reality simulators

• • • • • • • • • • • • •

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Advantages

Readily available Suitable for basic skills training Inexpensive Use of real surgical instruments Moderately inexpensive High fidelity Physiological tissue response to surgical manipulation Similar anatomy High fidelity Physiological response to surgical manipulation Suitable for procedural training and selfpaced learning Objective assessment Evidence of skills transfer

• • • • • • • • • • • • •

Disadvantages

Low fidelity Models not available for all procedures No feedback to the trainee from model Low fidelity Limited feedback to trainee from model Limited availability High costs Infection concerns Moral and ethical issues High costs Limited availability Simulators not available for all procedures Not all simulators provide tactile feedback

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ARTICLE of training such as video box trainer training, no training and standard laparoscopic training in surgical trainees with little or no prior experience in laparoscopic surgery. Although many of the included trials had a high risk of bias, the review demonstrated that those trainees who trained with VR simulators showed superior performance with increased accuracy and completed tasks in a shorter period of time compared to the other groups.6 So can VR simulators resolve the concerns listed above?

Image: Simbionix.com

Due to the demonstration of skills transfer resulting in superior performance compared to standard training6 it is likely that in the near future more surgical trainees will have access to VR simulators.

This can only be beneficial in combating the reduction in surgical education. Although VR simulators cannot completely replace the experience obtained on ‘actual’ patients, by utilising VR simulators as a training adjunct, trainees can develop many of the skills necessary for surgery outside of the operating theatre and therefore make the most of their precious time in theatre.

In addition, as VR simulators facilitate self-paced learning, surgical trainees of all ‘natural’ abilities can develop the required skills at their own pace and practise on the simulator as much as they require to achieve proficiency. This will ensure the next generation of surgeons have the necessary skills and experience to provide the best care possible for patients.

Figure 2: The LAP mentorTM Simbionix (http://www.simbionix.com/LAP_Mentor.html).

During my session on the machine I worked through a series of basic laparoscopic surgical skills such as cutting, clip applying, camera manipulation and object translocation. I then finished off my session by performing part of a simulated laparoscopic cholecystectomy.

Getting first hand experience on a VR simulator illustrated to me the benefits of these machines compared to the other forms of supplementary training in surgical education. VR simulators provide normal physiological tissue response to surgical manipulation e.g. the VR ‘tissue’ bleeds when cut. In addition, the simulator I used provided tactile feedback by utilising haptic systems thereby imitating real life. VR simulators also facilitate self-paced learning and assessment by measuring objective data on specific tasks such as time taken to complete the task, instrument path lengths and economy of hand motion. I found this feature particularly useful as a way of improving my usage of the instruments and monitoring my progress. It should be noted that VR simulators are not without limitations. Although there are simulators for a wide variety of laparoscopic operations there are not simulators available for all surgical procedures. Furthermore, due to the high cost involved in acquisition and maintenance, there are a limited number of these machines in the UK. Not all VR simulators have tactile feedback and as a consequence some surgeons have questioned their ability to replicate reality, with some describing their function as primarily visual rather than motor training.4,5 Despite reservations from some camps, there is encouraging evidence in the literature demonstrating skill transfer from simulator to the operating theatre, particularly so with laparoscopic surgical skills. A recent Cochrane review of twenty-three randomised clinical trials compared VR training to other forms

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Using simulation-based training, such as VR simulators, to ensure safer care for patients has been endorsed by the Chief Medical Officer, Sir Liam Donaldson. In his 2008 annual report, he highlighted the success of utilising simulation-based training as a surgical training adjunct and its potential use as a valuable method of filling the skills gap resulting from the recent reforms to surgical education. He recommended that “simulation-based training should be fully integrated and funded within training programmes for clinicians at all stages”.7 In an ideal world VR simulators would also be available to medical students. This would enable students to begin to develop the skills essential for surgery and help to ascertain whether they feel they have the aptitude to pursue a career in surgery. Unfortunately, the prospect that all medical schools will make VR simulators available to students remains doubtful due to economic confines.

Furthermore, even those institutions with VR machines will have to give priority to surgical trainees and so access to medical students will be limited.

I feel privileged to have been given the opportunity of experiencing a VR simulator first hand. I thoroughly enjoyed my session on LAP mentorTM and the experience reinforced my aspiration of becoming a surgeon. If given the chance, I would highly recommend that other medical students make use of VR simulators. Apart from the enjoyment of ‘operating’ it gives deeper insight into what surgery actually entails.

Acknowledgements The author would like to thank the Department of Obstetrics & Gynaecology and the Screen-Based Medical Simulation Centre of the Royal Free Hospital for giving the opportunity to access the laparoscopic simulators.

For full references see thelsjm.co.uk.

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I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art. I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. But I will preserve the purity of my life and my arts. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

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ARTICLE

The Enigma of Dr James Barry Alice Wilson

Year 4 Medicine, University College, London a.wilson@ucl.ac.uk doi: 10.4201/lsjm.hle.009 The Wellcome Collection exhibition Identity questions the concept of a personal identity. Acknowledging the amalgamation of innate and acquired traits, it questions the oversimplification demanded by official PIN numbers. Given that the deeper question of “Who, really, am I?” remains much harder to get at, this is approached through particular protagonists whose lives open up identity debates. One such figurehead in this exhibition is April Ashley who was one of the first people in Britain to undergo a full sex-change operation. Born a boy – George Jamieson – in Liverpool and growing up there in the Second World War, he went on to join the Merchant Navy travelling to Paris and taking to the stage of the Carousel night club, famous for its male impersonators. Following hormone treatment George changed to April Ashley in May 1960 and subsequently became a campaigner and friend of the stars. But although her ‘chosen gender is important to her, it is far from the sum of her parts.’1

the archaic view that ‘very little benefit will result from the best–devised means of prevention until prostitution is recognised as a necessity’,3 Dr Barry was revolutionary in her determination to provide for the civilian population so affected by the vices of Military occupation. Dr Barry was in fact brought to General Court Martial on 24 November 1836 for her precocious correspondence and for ‘behaviour unbecoming to an officer and a gentleman’,4 but eventually having been acquitted she added a triumphant postscript to the court notes: ‘Subsequent to this ... the Lords Commissioners of HM Treasury ordered the Commissariat Dept to provide for the Civilian branch of the Hospital by contract the same as for the Military- by which means the Government saved considerably and the patients were better provided for.’5 This is affirmed by Sir Henry Stork’s writing to the Commission in 1865 citing Malta, another of Barry’s postings, as an example of successful monitoring of VD.6

Dr James Barry(1789-1865) features briefly in the exhibition, because she too came to be defined by her chosen gender, despite the fact that the sum of her parts amounted to much more than a gender debate. After death, Barry was found to be female by her charwoman Sophia Blake, but she had lived her life as a male. Having graduated from Edinburgh University in 1812, James Barry went on to become a Surgeon in the RAMC. From 1816 she would not return to England for more than two years together, until ill health necessitated retirement in 1859. During her career James Barry was notorious for her obstinate nature, but this voracity was to pay off in reforms she enacted. Whilst placed in South Africa Dr Barry carried out ‘probably the most interesting Caesarian section of all time.’2 This occurred fifteen years before the first successful one in England, with vastly inferior resources, and what is more both mother and child survived; the grateful parents named their son James Barry Munnik.

In her letters and through subsequent reports Barry comes across as a fiery character. When she crossed paths with Florence Nightingale during the Crimean war, the latter noted:

In addition to pioneering surgery, Dr Barry approached medical subjects which others shunned. When Principal Medical Officer of St Helena the issue of Venereal Disease (hereafter VD) became paramount. Whilst nominally reputable men upheld

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Winner of best dissertation prize from the Wellcome Trust for History of Medicine 2009

“

(He) kept me standing in the midst of quite a crowd of soldiers, commissariat servants, camp followers etc. etc, every one of whom behaved like gentlemen during the scolding I received while (she) behaved like a brute. After (she) was dead I was told she was a woman.7

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ARTICLE

Speculation about Barry’s ‘true’ sex has produced ‘proof’ for her being male, hermaphrodite and female. The death certificate signed by Major McKinnon and verified by Sophia Blake details sex as male,9 Barry lived and corresponded as a male and she was in two of the most archetypically male professions: medicine and the military. Of the biographies and research carried out on Barry, the most adamant of male sex was Professor P R Kirby who wrote a series of articles in the 1950-60’s to counter the ‘allegation that Dr James Barry was a woman’10 and dismiss her being female as an entertaining legend. He criticises the main biography by Isobel Rae11 for willingly accepting the charwoman’s statement and accuses the Lancet series of correspondence12 as full of ‘misstatements’.13 He also takes rumours about sexuality to make the case that Barry was so male she was homosexual. In terms of timing, Kirby argues that it was only after death that rumours began, and that at no point did the military authorities deign to make a statement.

To account for Barry’s notoriously effeminate appearance Kirby posits that she was a type of male hermaphrodite who possessed feminine breast development, external genitalia and testicular feminization syndrome with absence of hair. The first written suggestion of this was by Major McKinnon: ‘my own impression was that Dr Barry was a Hermaphrodite’.14 In the following years Edward Bradford backed this up but with absolutely no evidence, and Price reached the conclusion through a dubious process of elimination, concocting tales of grandiose heritage and the need to hide this specimen of a ‘third sex’. Most recently Rachel Holmes has argued more convincingly for hermaphroditism: Firstly through anecdotal evidence ‘three pillows of a particular description necessary to me under the peculiar circumstances in which severe accident have placed me’15 which she sees as trusses for an inguinal hernia or testes (though Rose contests that these were pads for menstruation). Secondly, Barry’s choice of thesis and studies are proof of an obsession with genitalia and the imperfections of the human body.16 Lastly Holmes perceives her behaviour as secretive and indicative of an empathy with other less fortunate people.

However, recently Hercules Michael du Preez wrote a seminal article ‘Dr James Barry: The early years revealed’17 which is tantamount to proof of Barry’s female status prior to studying medicine at Edinburgh. Following Barry’s death Sophia Blake approached Major McKinnon and he claimed: Following wind of this in the Manchester, Ireland and London daily newspapers, it soon sparked a widespread dialogue. Numerous biographies have been written on the premise of Barry’s female sex including those by Olga Racster and Jessica Grove, June Rose and Isobel Rae. As a result of the latter’s surmising, much written about Barry’s early years has ‘not been substantiated from primary sources but through frequently repeated speculation acquired the simulacrum of truth.’19 Du Preez’s remit was thus to categorically determine the point at which James Barry came into being. He

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“

Amongst other things she said Dr Barry was a female and that I was a pretty doctor not to know this…

She then said that she had examined the body and it was a perfect female and farther that there were marks of her having had a child when very young. I then enquired how have you formed that conclusion? The woman pointing to the lower part of her stomach said From marks here. “I am a married woman and the mother of nine children and I ought to know.”18

”

found, through tracing genealogy and cross-referencing letters between Mary Ann Bulkley, her brother James Barry R.A. and a solicitor in Edinburgh, Daniel Reardon, that James Barry started life as Margaret Bulkley, born 1789 in Cork, Ireland.

On researching the fascinating tale of this enigmatic character, it seemed that the sex of Barry was not the most interesting point, rather, the written dialogue stemming from it, which was such a reflection of the context in which it was written.

Shortly after Barry’s death in 1865 the Sunders News letter and Daily Advertiser concluded ‘The motives which led to this misrepresentation of sex and the time at which it began are both shrouded in deep mystery…I strongly doubt that even Miss Braddon could dare to make this person the heroine of one of her romances.’20 Novels were at this time in vogue, with gothic romances an outlet for those confined by domestic ideology, and the world of Sherlock Holmes imbuing the nation with an investigative spirit. Other excerpts reflected the misogyny directed against spinsters21 and the uneasy attitude to hermaphroditism concluding ‘this small and naughty doctor had always been, in body as in mind, a monstrous person’. 22 Attitudes to women and gender changed most significantly towards the end of the nineteenth century at which point

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Image: Wellcome Image

As a woman in a man’s world, it is unsurprising that Barry acquired a fierce and ostentatiously alpha male persona, seen frequently in the history of Amazons.8 These fighting women have a long history, and Barry is by no means unique in that respect. But despite Barry’s incredible lifetime achievements, since her death on 25 July 1865, it has been her sex, not her success, that has raised eyebrows.

ARTICLE medicalisation of homosexuality and the surge of feminism caused shifts in public perception. Ellen Clayton argued that if women could fight they could vote. By this dictum Barry upheld feminist principles and this can be seen in Racster and Grove’s conclusion that Barry ‘successfully competed with men on their own ground a hundred years ago’.23 Conversely, although Magnus Hirschfield believed war sexually freed heterosexual and lesbian women alike, in fact taboos still abounded. With ongoing concerns over a ‘third sex’ Racster and Grove exemplify that ‘connotations of a person of indeterminate sex in theatre and literature could be ignored by imbuing the warrior heroine with romantic or innocent motives’24 so they fictionalise Barry’s impetus to join the army by imagining her evading ‘My husband’s spies’.25 Given that war can act as a solvent and a stimulus, in the 1950’s there were considerable tensions between women in nontraditional spheres of activity and men already there. These tensions were negotiated in two ways: either women became honorary men (like James Barry), or conversely femininity was emphasised to reduce male hostility by underlining differences between the sexes. This is reflected in the dialogue between Isobel Rae and Prof Kirby. Much of their writing has a personal slant with Prof Kirby patronisingly accusing Rae of making Barry female to qualify her use of an ‘enticing title’.26 He disregards Barry’s female status through an assumption of female incapability in a duel, echoed in Price’s similar assumption of female medical incapability.27 By the 1970’s male masculinity was giving way to homosexuality and the flowering of feminism. With this as a backdrop, June Rose wrote The Perfect Gentleman. In the preface she, like Rae, rejects Kirby’s misogyny ‘His obsession with the specifically sexual identity is typical of a…predominantly male…assumption that a woman by nature would have been incapable of sustaining the

masquerade and attaining professional prominence’.28 In recent years, the exponential increase in literature on crossdressing, women in medicine, hermaphrodites and general social history has provided a much richer tapestry within which to understand James Barry’s story. Patricia Duncker and Rachel Holmes are two authors who have woven exotic novels out of her story.29 Perhaps the most interesting response of late has been the discussion prompted by du Preez’s article within the transgender world. Whilst the 1970’s was a time for feminists to reclaim their history, it seems now transgender people are doing the same and taking James Barry as their figurehead.30 In conclusion, Dr James Barry (1789-1865) was an enigmatic character enacting profound change in many areas of military medicine and surgery. After death her achievements were subsumed under sex/gender debates, which reflected the changing social mores more than facts of Barry’s life. Du Preez’s recent research, with the benefits of modern technology and data-basing, seems to have solved the mystery of birth. However, it remains to be seen whether attitudes to sex and gender have really changed in the last 150 years, since as a whole the historiography of Dr Barry indicates an ongoing inclination for the binary division of identity, and the marginalisation of anyone challenging this.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

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‘I Am’ leaflet for Identity exhibition, Wellcome Trust, 26 Nov 2009-6 April 2010 Mr A Dickson Wright, ‘Caesarian section’ from St Mary’s Hospital Gazette 1968 Jan-Feb. Wellcome Library: RAMC 748.

Sir Henry Stork, Letter to the Committee. Report of the Committee appointed to enquire into the Pathology and treatment of the Venereal Disease with the view to Diminish its Injurious Effects on the Men of the Army and Navy with appendices and the Evidence taken before the Committee, London: Harrison and Sons, 1868. The Women’s Library General orders, 7 December 1836, Malta. PRO CO 247 52 8572. Wellcome Library: RAMC 455 James Barry, note appended to the General Orders 7th December 1836, PRO CO 247 52 8572. Wellcome Library: RAMC 1264 Stork, op.cit. note 3 above, p(xliii) Florence Nightingale, undated letter about James Barry, From the collection of Sir Henry Verney. Wellcome Library: RAMC 801/6/5 June Wheelwright, Amazons and Military maids, London, Pandora 1989 D.R.McKinnon, Death certificate, 26th July 1865, General Register Office, Marylebone District War Office Personal Files No.14651/1 Dr.James Barry, Inspector-General, A.M.S. Wellcome Library: RAMC 373 Professor Percival R Kirby, ‘The centenary of the death of James Barry, M.D., Inspector-General of Hospitals (1795-1865) A Re-examination of the facts relating to his Physical Condition’, Africana Notes and News, June 1965, Vol 16, No.6 Wellcome Library: RAMC 455/item2.

For references see thelsjm.co.uk.

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REVIEW

What insights can historical analysis of case notes provide children’s healthcare today Shajheda Haque, BSc

Year 5 Medicine, Imperial College, London shajheda.hague04@imperial.ac.uk doi:10.4201/lsjm.hle.010

Abstract This paper is a historical analysis of 20th century paediatric case notes to reflect on clinical practices of children’s health. Many historians have used clinical case notes to reflect on medical activities, but none have used them as representations of patients and disease. Thus, this study is original in its centralised focus on: (1) 20th century paediatrics to explore the additional factor of the parent and the rise of social care in the doctor-patient relationship, trends which may run contrary to the standard view on the decline of patient narrative and doctors' attention to patients as whole persons; (2) the changes in record-keeping styles; challenging conclusions of previous work on use of diagrams in case notes; (3) revealing and tracing the use of consent forms before the Nuremburg code and thus challenging the “historiography” of consent as being mainly a post-WWII procedure.

To date, detrimental consequences can be seen through practice of poor communication skills, clinical skills and history taking.

Therefore, exploring the historical development will enable an appreciation of careful history taking and the evolvement of children’s care.

Introduction Medical records document ongoing events and communication between the patient and doctor.1 As Risse identifies, they help in understanding the practice of medicine, revealing intricacies of hospital life and-reconstructing medical life.2 By further study of these under-investigated areas, we can reflect on why it is important to understand the history to appreciate and build on furthering the goals in patient care.

Since the 1980’s, historians have been using medical records to reveal past medical activities, but records have not been explored nearly as rigorously as they could. I will be using these resources to analyse the changes undertaken between periods 1900 to 1975, in the context of children’s hospital practice. The 20th century was significant in the advent of medicalisation of children’s-health, demonstrated by the-vast-rise in opening of children’s hospitals.4 In

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particular, this paper will address on changes in record keeping via exploration of use of diagrams, clinical history taking and-consent.

What was the focus for a children’s doctor in the 20th century? How did they interact with the parent/patient?

The methodology of this study is through investigation of clinical records from 1881 Brompton Hospital notes, 1894 London Hospital, Queen Elizabeth Children’s Hospital in Hackney (QEH) from 1900, 1915, 1924, 1935, 1938, 1939, 1946, 1968 and 1975. (Table 1) Primarily, I observed the notes based on what was held at hospital archives first, then analysed my findings. In order to strengthen the-analysis of my findings I had the privilege to gain an oral history through interview with a retired Paediatric Consultant, Dr.-LeonardSinclair.3 Through his reflections of working at QEH in the 1950’s he was able to provide insight into his experiences.

Although, clinical records can reveal changes in clinical practice, they may not be representative of all doctors’ practices or hospitals, I will reflect further on the limitations of the-sources andpossibilities for future research in-the-conclusion.

The revelations of practices of medical record keeping One of the most important developments of the 20th century saw improvements in medical records.1 This was initiated in America

by Cannon who suggested using records as a tool for educating medical staff.5 This highlighted the necessity of the value of keeping accurate and complete records. However, many physicians did not see the need to record all details as they viewed note-taking simply to jog-their-memory. Physicians soon changed their outlook on records viewing them as a vehicle to reflect and-evaluate their care. Although, such changes were orchestrated in some hospitals, others still needed reminding to complete notes. Thus, the first 25 years of the 20thcentury were hugely important in initiation of changes in the medical record, to benefit both patients and medical staff.5 At-QEH practices of the early 20th century records reflect-similar concepts. Many-lacked details, for example ‘presented unwell’, identifying incomplete history taking. However, findings of temperature charts, treatment and-pulse were always complete.3

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REVIEW Table 1.

ESTIMATIONS

OF CLINICAL

RECORDS

BROMPTON NOTES

LONDON HOSPITAL

QEH MANY PHYSICIANS

QEH

QEH

DR SYDNEY OWEN

DR WILLIAMS 1881

DR.MACKENZIE

DR HELEN MACKAY 1935-39

1900- 2 volumes

1894 ~> 100 cases

~> 50 cases

~> 200 cases

1915,1924,1935,19381939,1946 Each year ~> 100/150 cases,1946~10

Use and discontinuation of diagrams in clinical-records Interestingly, one apparent change has been the use of diagrams in medical records. Why-might this-be?

I will be focusing on the first diagram I came across in the notes: ‘ the thorax skeleton diagram’. (Fig 1.)

Figure 1. ‘ the thorax skeleton diagram’

Early 20th Century textbooks justified the-consequential use of diagrams as a means of interrupting narrative flow to enable clear representation of clinical findings.7 Evidently, recordings identified loss of resonance on percussion where depth of shading increased with degree of dullness.6 Notably recordings on vocal fremitus, breath sounds, voice sounds and asymmetry were noted on the side rather than on the skeleton. Any adventitious sounds such as

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~Each year >100 cases

dry rales were indicated by ticking and-smaller/larger solid dots, denoted moist rales. Additionally the diagram was used to denote areas of cardiac, liver and spleen pathology. For cases without diagrams, the same information would be presented in continuous prose; ‘Abscess-in-thoracic-cavity, dullness-on-left-side-anteriorlyextends-down-to 5th rib, dullness-extends-laterally to mid-axillaryline posteriorly-about 2 inches from middle line on left side, percussion-note-tympanic...’3 This signified-the-level of detail demonstrated in case notes and-the focus on physical examination.

This brings us to the forefront of questioning; why was it used in the first place?

In order to analyse this I looked at case notes from Brompton Hospital 1881, London Hospital 1894 Dr Mackenzie, QEH 1900, [1915, 1924, 1935; Dr Owen] & 1935 Dr Mackay.3 Amongst these cases for each year I identified cases where the diagram was used, so mainly for respiratory cases; thus am presenting a sample from each year. The estimations of respiratory cases or cases where it was used represented approximately a 1/3 of the notes from each year. The diagram when used illustrated areas of pathology and abnormal findings on examination in combination with inclusion of narrative findings. The early 19th century Brompton notes show use of an additional diagram involving scapulas, using a gridline to mark out the distance of pathology from the scapula. This information was still evident in 1900 & 1915 notes ‘chest impairment on left side as height as 1 before left scapula’.3 The 1900 case notes used the diagram; however the majority of respiratory cases did not use this as part of the formality of history-taking, using written format instead. The 1915 case notes compiled by one physician showed use of the diagram was consistent and so was found in all respiratory spleen and-liver pathology . Amongst this compilation, there were also a few diagrams to symbolise no abnormalities in cases such as dyspepsia so stamped with no annotations, ‘chest NAD’.3 However, from 1924 onwards, use of this diagram was discontinued.

These notes demonstrated much wider use of chest radiography with written findings from the chest-examination. Moreover, X-Rays were more widely used during this period as accounted by Howell; which we will explore further.8 Thus, the issue of diagram discontinuation in these notes is hugely important.

Discontinuation of the diagram Figure 2.

REVIEW Historian Howell researched the effect of technology on patient-care in hospitals; one focus being the effect of X-Rays in record-keeping at Pennsylvania Hospital and New-York-Hospitals.

His findings acclaim that the reasons for use of diagrams were due to the increasing use of x-rays during this period.8 However, my sources show a very different history and yield opposite conclusions.

In-fact, Howell’s findings are misleading as evidence clearly underpins that diagrams were in use from before the period of use of the x-ray machine. The discovery of X-Rays in 1895 was received with mixed reception. Clinicians felt that it was an unnecessary investigation and-physical examination would remain superior.6 Additionally, limitations existed as use of machinery was expensive, dangerous and-required technological expertise.

However, despite radiation hazards from 1905, most physicians and patients ignored advice to use X-Rays cautiously.8 Many physicians were enlightened by the fact that they could evaluate pathology in a group and-that ‘sight offered much more satisfactory agent of-information-than-hearing-or-touch’ especially in specific to lung disorders.6 Thus, it became more commonly used by the 1920’s, coinciding with the period of discontinuation of diagrams on medical-records.

Reasons for discontinuation may be that radiography was sufficient graphic-representation of the clinical findings. As clinician Gordon identifies paediatricians were trained in radiology so would be more likely to-use-X-Rays-for diagnosis.9 In support of my findings, Reiser highlights concepts of physicians having to conjure up mental pictures of anatomical defects thus, explaining the tool of using the diagram.6 Another factor to consider for the apparent differences in findings could be due to disparities between US & UK hospital practice.

Significantly, the case notes from as early as 1881 & 1894-5 London Hospital Records show use of the diagram to record findings from the chest-examination, illustrating standardisation of records appeared earlier than Howell’s findings. Following his analysis of use of X-Rays on forms, it is correct that this period of the-1920’s/30’s led to huge changes in record keeping. However, his findings identify drawings evolved in 1912 and a standardised stamp in 1917. Clearly his conclusions that diagram use was concurrent with the increasing use of x-rays during this period are unrepresentative of the records within London Hospitals.8 Indeed, my findings suggest an-alternative-history, reopen the question-and-make clear the need for further research.

An Example of Patient Consent Forms in Use before the Second World-War and the Nuremburg Code One of the earliest references to duties of physicians stems from Hippocrates where emphasis is placed on building trust.10 Amongst the revelations of post WWII was recognition of informed consent.11 Following the 1947 Nuremberg trial, American judges laid down principles stressing the professional duty to inform of hazards to avoid unnecessary ‘physical and mental suffering.’ The Nazi experiments were symbolic of war crimes, against humanity, emphasising principles to act morally towards patients.11 Hence, I will be investigating the-practice of-consent through analysis of consent forms.

Consent forms Consent forms have been seen to serve a variety of purposes not limited to-ethical -requirements. One of the purposes is for documentation of events which took place. Primarily the goal

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should be to protect the interests of the patient; a formulatory device in the dialogue between doctor and patient.12 Additionally, legal documentation may protect physicians from liability in some jurisdictions. Although it may serve as defence from battery it cannot protect against disclosure unless the form includes information about the risks. Therefore, through reflection of the proposed intervention the signature is seen as reinforcement of understanding the presented information.12 Origins of Consent Many historians agree on the-issue-that there is paucity of information on consent practices prior to the 1960’s, thus records at-QEH allow insight into this practice.13 As Berg identifies that early ‘simple consent’ was valid by interchange between physician and-patient12. Although, American Law in 1932 made it a general law to obtain consent before operations and, if needed, in exceptional circumstances it could be implied.12 Many early 20th century case laws influenced the emergence of informed consent. The courts had an influential role dealing with consent before 1957, so already had an enforced structure before that of medicine.13 Particularly, the 1950’s Salgo case was fundamental where aortography resulted in paralysis; the-physician was sued for negligence and physician’s failure to disclose crucial information.13 Later in 1953, ethical guidance was issued by the Medical-Research-Council, expressing the importance that new-procedures should be made ‘amply clear’, distinguishing the difference in granting consent and-explaining the procedure.12 Also, the guidance addressed the need to be empathic towards patients subjected to novel treatments. On the other hand, doctors felt that the need to ask for ‘permission’ was acceptable but ironically viewed that having to sign a form would only cause mistrust.11 These fundamental events refined the definition of consent to include the need to understand all the necessary information about procedures, yet the courts were still hesitant to mandate full disclosure by physicians.13 Around this time Nazi-atrocities and-cases of abuse in medical research drew light on the trustworthiness of the profession.11 Initial propositions of informed consent were outlined by US physiologist Andrew Conway Ivy in-1946 who recommended voluntary consent and need to inform of all potential hazards.11 This identifies Ivy’s draft code as fundamental in shaping the events of the Nuremberg Trial.11 Further, developments were made by a neurologist who expressed that if patients could not make an informed decision, consent should be obtained from next of kin/guardian.11 Many physicians became aware of the-need-to-obtain-consent but, no universal application of the practice was present till the law was formulated in 1970’s through combination of battery and malpractice cases and the Nuremburg Trial.12 How physicians reacted to the formalities is unknown, but possibly many feared that, through disclosure, patients would be deterred against operations. Certainly, Pappworth provides extensive proof of thedomineering influence of Doctor’s taking advantage of patients.14 Significantly, subjecting children to experiments was seen as less justifiable, leading to debates over parental rights in deciding what may/may-not-be morally correct.14 An important question drawn was, ‘did patients give ‘informed consent’/‘blanket’ consent’?

Consent practices at QEH Evidence from QEH, shows practice of obtaining patient consent was formalised from as early as 1932.3 Consent forms were used

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REVIEW in all cases, as prior to the consultation with the doctor, parents/ guardians would consent to any necessary procedures. This is in disagreement with Evans’ conclusions that informed consent was a phenomenon of the post second world war period11. However, in reflection on the underlying principles of informed consent in 1970, we may argue the extent to which these cardinal principles were applied. This is indicated by a heartbreaking case in 1938 where a child had a large cavity compressing the brain’. The mother gave consent for surgery. However, 2 hours into the operation, the ‘child dies on the table’. The surgeon removed the ‘large cavity with yellow, soft caseous material. But, ‘at this point, respiratory difficulties were encountered, given Cocamine subc, and artificial respiration for ½ hour-given, blood-transfusion given, patient died’.3 Correspondence from the child’s mother indicated the consent form was signed (Fig 3). But, through reading this letter we can question whether the mother was really ‘informed.’ Although, it is undeniable that she was grateful for the care and attention her child received. It seems that she was under the impression the operation would lead to complete recovery, therefore not prepared for the risks of the procedure.

This explains her emotions and disbelief at the loss of her son.

‘I am desperately upset and cannot believe I shall never see him again’, ‘…terrible blow to me’. The impact of this correspondence identifies that the reasoning behind consent forms may be a way of protecting the doctor from any allegations of malpractice, rather than a focus on acting in the best interests of patients. This was identified in 1929 minute books where acknowledgment that, if the procedure were known, it ‘would deter patients’. In 1933, King Edwards Hospital suggested that QEH should change the design of their consent form; however there were no details with regard to how they should change. Minutes show that QEH were content with their Form and decided to ‘continue with existing form for the time-being’.3 Consent forms from 1932-1949 illustrate this concept, that is of ‘blanket’ consent. Here, agreement is obtained before admission which presents a sense that there is no drive to educate parents about procedures and no real choice for the parent. At QEH, parents consented to five scenarios before-hand: operation/fever or other hospital/post-mortem parents responsibility for burial/immunisation, cutaneous or intradermal tests.3 Figure 3.

The situation in 1968 identifies a better sense of the fulfilment of definition of ‘informed consent’ where the incorporation of the words ‘nature and effect explained by’ implies intentions to

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of both doctor and parent further-are-a-confirmation-of-a-unified discussion. This again highlights QEH may have been ahead of legislation of informed consent as Evans states that the 1970’s was the period of accepting this regulation.3 Thereby, through history of consent documentation one can see that inclusion of information in simple form is beneficial, to address patient concerns or confusion. One of the presenting practices of child-health is that younger children have less autonomy and individual rights, so parents act on behalf of them.15 If children are under-16 years of age, the Gillick principle now applies where if they have sufficient understanding they can give legally effective consent independent of parents’ wishes.16 This now highlights that doctors have to consider parents and patients in decision making.

Doctor-Patient Relations in Paediatrics: Patient Narrative, Parents & Social-Issues There is existing historiography on patient narrative but I have taken a un-investigated-spin on this, looking instead at how paediatrics presents parents narrative. Fissell argues that the middle of the 18th century saw transgression of patients’ narrative.

Thus, by this omission, common ground of the doctor-patient relationship was eroded.17 ‘increasing medical autonomy patients’ narrative of illness was made utterly redundant’.17 Fissell’s findings that hospitals an 18th century invention directed doctors’ focus on ‘signs, symptoms and-disease orientated diagnosis’, ‘the body, disease became the focus of the medical gaze, not the patients version of the illness’.17 Jewson is in agreement where he expresses greater social distance in context, to a change from the era of bedside medicine to hospital medicine; where the doctor has more control.18 Paediatrics is perhaps different in the sense there may be a greater need to engage with the child to ensure they co-operate, therefore, incorporating a doctor-parent and doctor-patient relationship. In light of this, communication skills are tested more in paediatrics than other specialities.15 Paediatricians have to assess the situation whether the patient is able to give a history.

In particular, obtaining the co-operation of 2/3 year olds may-be challenging.19 Views of History taking One influential clinician who draws on concepts of clinical history taking in 1920 is Robert Hutchison.20 It is clear as paediatrics established as a speciality in 1915 there was still room for establishing practices.20 He likens ‘paediatrics’ to be similar to veterinary work, where because the-patient is unable express their symptoms he believed the-focus-should be entirely based on observation; signifying-great-reliance-on-examination.20 He addresses the need to be precautious of ‘anxious mothers’ perceptions and concerns which may stem from ‘neighbours worrying her’.20 This is illustrated in 1915 notes ‘mother says child never healthy, as believes from birth something wrong with heart’.3 Additionally, his view of mothers as ‘loquacious persons’ further support a sense that he is not willing to rely on this part of the history.20 Through, examination of notes from 1900-1975 what is clear is the impact of parental involvement and disuse of Hutchison’s theories.

The earlier notes of 1900-1939 present a greater

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REVIEW involvement of the parents’ history. The presenting illness would be incorporated with parents’ comments and ideas such as ‘had always been delicate’, ‘developed rash’, ‘poisoned by plums’. This identifies a sense that the doctor would ask the parent what was wrong, to which the parent would continue and everything wouldbe-documented. Furthermore, focus was on what happened prior to the symptoms and observations rather than finding out about current symptoms for example, many accounts of cough were described briefly as dry/wheezy etc with no further details.

Although from 1894 there is a stark difference, where complete lack of focus on patients-symptoms is evident ‘patient does not know what is wrong with him.3 ’Shorter’s conclusions identify reasons why the long winded story of what happened prior to being unwell was a part-of-the-history-taking.22 He reflects that doctors were hugely reliant on the psychological dimension, as therapeutic perspective was poor the focus of the doctor was to concentrate on understanding the disease and-diagnosis; hence adopting-a cathartic consultation.22 Contrastingly to other fields of medicine as Hutchison mentions, observations are important, but don’t take precedence as he believed20. Thus consistently, physicians passed comments; ‘child miserable’, on appearance; ‘well nourished’, ‘child looks awful’, on mental thinking; ‘backward’ ‘very bright’, on personality; ‘lively’ ‘quiet’, and emotions; ‘child playfully happy’.

Occasionally, this would be an initial presenting statement; ‘very thin poorly nourished child, pale not puffy’, ‘fretful or tired’, but frequently was categorised into the ‘condition on admission’. This is significant in envisaging the state of mind of the patient and doctors interpretation on children’s non-verbal communication; ‘child semiconscious, knees drawn up’.3 It identifies combination of observation and examination cemented a close physical rapport with the patient.20 Yet there were no recording of the child’s views. The mothers influence was certainly evident; ‘mother says he is very disobedient at home’ for a boy presenting with chronic constipation. In cases of rickets, histories were orientated towards diet and home conditions; ‘neglected child’.3 Although, analysing the same diseases in 1935 by two different physicians identified differences in the extent of comments they made on patients.

Transitions of history taking Alterations in emphasis on parents’ narrative in 1968 records are apparent with more detailed focus approach on symptoms. ‘bad cough…..non productive’, ‘keeps him awake at night’.

Notably, diagnosis was written at the end rather than at thefront of the-notes, asserting that through careful history-taking and-investigations, an-accurate-diagnosis could be obtained.

Although, observations of patients remained; ‘looked unwell’ … ‘fussy with food’…..looks peaky; ‘lively little girl’ ‘very irritable girl, resenting examination’.3 In reflection, historiography analysis identifies parents narrative was predominant in periods 1900-1939 and altered in emphasis on medical detail in 1968. This view is in conflict with historians such as Fissell who found doctors to be greatly focused on the disease rather than the patient in the-mid-18th century.17 Similarly to my findings, Shorter found 1930’s was a period of strong reliance on listening to the patient as therapeutics was poor. But changes arose in the 1950’s where there were views of doctors being uninterested in patients.22 This marked the-period where therapeutic-perspective was much greater; which may be a cause for less influence of the parents’ history within the 1968-notes;

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expressing historian Warner’s’ view that therapeutics was core to the-doctors’ profession.23 Increasingly, patients felt doctors were too preoccupied in treating diseases rather than listening to them. This was supported by the noticeable abbreviated style of history taking.22 Additionally, Dr Sinclair a retired paediatrician who also felt many professionals very much focused on investigations and-treatment; acting as ‘authoritative figures’.3 This not only created a greater barrier, it flawed the patients trust in the doctor. Furthermore, paralleled by the apparent effect of media and knowledge from experiences of families and communities, the-parent became more questioning against doctors wishes; ‘patient well but still referred’.3 Shorter addresses ironically how this period saw high rate of court suits for malpractice.22 Social-Issues In 1938, Dr Mackay shows elements of concern for social care when she was faced with issues of neglect under the care of a-neighbour. She even goes as far as to say that the ‘history is unreliable’, and observed, ‘the child was undernourished, pale, tired, seems unhappy’.3 Through hospital admission she noted the child was much happier. They traced the mother at a-mental hospital to arrange alternative care with family, thus indicating the extent of care that happened at this hospital where the doctor had to engage in all elements of care. This was further confirmed

by Dr. Sinclair’s observations where doctors had to do their best for the patient and had to ‘take matters into their own hands’.3 It draws on the beginnings of needs of social care of children which appeared in the 1940’s.24 Importantly, this again conflicts to an extent with historians such as Jewson and Fissell’s findings of doctors’ attention to patients as test results and examples of a disease. Indeed, the integration of the-social elements is evidence to show doctors concern for the patient’s well-being.

Discussion: What insights can we gain into practices of 20th century children’s health using clinical case notes?

It is essential to reflect how practices of medical record-keeping changed in order to appreciate the medical record as it is today.

Primarily, Warner and-others used medical-records to reconstruct medical practice.23 Ultimately, my approach is unique in focusing on changes in the records themselves-as representations of patients and disease.

Furthermore, the discussion focused on three-main-aspects drawn from the case notes use and discontinuation of diagrams, consent forms and practices of record keeping in relation to the patient and parent as persons (rather than only disease cases) with individual and social characteristics. This is significant in relation to history of medicine where these issues have not been addressed in a collective sense and towards paediatric care.

Paediatrics differentiates from other specialities by the need to build a relationship with parent and patient, so we have been able to gain an insight into the doctor-parent element. Thus, Shorter’s concepts in the doctor-patient relationship illustrate reasons for my findings. The modern 1930’s period highlights the psychological role of the physician; evident by a greater influence of the parents’ history and the post modern 1950’s period; with medical advance in treatments evident by emphasis on medical symptoms with social issues referred to the relevant Children’s Officer. 22 Concerning the availabilities of hospitals’ notes, there was a

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REVIEW good range and quantity from 1900-1930’s, fewer notes for the 1940’s, no notes for the 1950’s, and-few in 1960’s and 1975. I have provided estimations of notes as guidance of the amount of records I analysed.3 Moreover, such limited availability of notes was a presenting feature in-this research. Access to records from other institutions was not practicable within the time-scale and some were destroyed by environment or-too fragile. Thus, comparison between QEH and other children’s hospitals could provide a better insight into these elements.

My research was largely focused on using clinical case notes, I understand that they may not be representative of all hospitals and I appreciate that physicians’ practice may vary. Yet it is an avenue for historical investigation to investigate discrepancies between clinicians.5 Indeed Paediatric Medicine is a branch where clinical skills are tested to the utmost in terms of maintaining a relationship between parents and children and to be flexible in dealing with the range of ages. Through using the trend of clinical case notes, we have been able to draw on a range of practices that depicted twentieth century paediatric care, fundamental to shaping the branch as it is today.

Sinclair for his time in providing an insight into his own experiences of paediatrics

Acknowledgements: Many thanks to Dr Andrew Mendelsohn, Jonathan Evans and Dr Chris Derrett for all the guidance, advice and support. I thank Dr

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For references see thelsjm.co.uk.

References 2.

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Weed,L(1971) Medical Records, Medical Education and Patient Care, Ohio Press case western reserve Risse,G. Warner,J(1992) Reconstructing clinical activities patient records in medical history, Society for the Social History of Medicine 5(2):183-205 Case Notes from Volume 1and 2 1900/ Dr Helen Mackay 1935,1938,1939/ Dr Sydney Owen1915,1924,1935,1938,1939,1946 /Microfilms Clinical files 1968,1975 Queen Elizabeth Children’s Hospital, Royal London Hospital Archives Centre and Museum, QE/M/11,QE/M/11/27, QE/M/11/41,QE/ M/11, QE/M/13 Dr Mackenzie 1894-95,Royal London Hospital Archives Centre and Museum, London Hospital, Royal London Hospital Archives Centre and Museum LH/M/13/1-3 Dr Williams Royal Brompton 1881, Royal London Hospital Archives Centre and Museum BH/M/1/20 Parents admission consent register,1932-34,1935-37,1937-38,193840,1940-42,1947-49, Royal London Hospital Archives Centre and Museum QE/M/8 Minutes of the QEH Medical Committee (subsequently Medical Advisory Committee 1881 – 1981, Royal London Hospital Archives Centre and Museum QE/A/5/71 - 91. Minutes 1928 - 1935 Royal London Hospital Archives Centre and Museum QE/A/5/74.

Minutes of the hospital’s House Committee. 1929 - 1936 Royal London Hospital Archives Centre and Museum QE/A/4/26-27 Dr.Leonard Sinclair,Personal Communication,30th April 2009 Retired Paediatrician Chelsea and Westminister Hospital 4Viner,R Golden,J (2000) ‘Children’s Experiences of Illness’ In: Cooter,R (ed) Medicine in the 20th century, Amsterdam,Harwood Academic pp.575

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Should the private conscience of a health professional interfere with their professional duty?

Uaama Sheik

Year 4 Medicine, University of Leeds um06uqs@leeds.ac.uk doi:10.4201/lsjm.hle.011

Abstract: Many doctors believe that in modern medicine, central to which is patient care, there is no room for the doctor’s conscience. At the same time, more and more doctors choose to assert their right to a conscience when faced with contentious issues such as abortion.

Under current professional body guidelines, a conscientiously objecting doctor must refer their patient onto a doctor who will provide the service. This complicates matters for doctors who feel that the referral could be construed as a step in the facilitation of an unethical act.

There are several possible ethical justifications for both views and I aim to look at the arguments surrounding this issue.

What is conscience?

The idea of conscience has different connotations for different people. For some it is an inner sense of right or wrong, evoked only when they are faced with a difficult decision, whilst for others this same sense continually guides their judgement and therefore defines the way they live their life.

A person’s experiences, beliefs, upbringing and religion can shape their conscience, and also the extent to which they use it in decision making. This demonstrates the fact that a person’s conscience is part of their individuality and identity. It is because of this that we all hold different views and opinions, allowing us to be independent, autonomous individuals.

The current stance on conscientious objection Conscientious objection is currently permitted by professional bodies, and in some instances, the law. The General Medical Council regularly updates guidelines on this issue, through its core guidance, Good Medical Practice. These guidelines specify that doctors always have to make the care of their patient their first concern. Therefore, physicians are not allowed to discriminate against their patients based on their own views, even if these conflict with patient’s personal views.

However, in spite of this, doctors are permitted to refrain from carrying out procedures which conflict with their moral or religious beliefs, as long as some criteria are met. Conscientious objection is disallowed in the case of an emergency.

In practice if a doctor is faced with a situation to which he conscientiously objects, the patient must be asked to see another physician. It should be confirmed that the patient has the relevant means to do so. Otherwise, arrangements should be

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made for this to occur on their behalf – the patient must never be left with nowhere to turn.

The GMC does not stipulate to which procedures these guidelines apply, although the most common are abortion, abortifacient contraception and end of life decisions such as withdrawal of care.

This guidance applies only to performing the actual procedures and the doctors are not exempt from undertaking medical care of the patient before or after the procedure (1).

Furthermore, in 1993 the British Medical Association adopted its current policy of supporting doctors who wish to conscientiously object to certain procedures (2). The BMA stress that doctors who do object should not be professionally marginalised in any way.

Although the above are professional body guidelines only, a doctor’s right to not participate in abortion is currently protected under UK law in section 4(1) of the Abortion Act, 1967.

Protecting the doctor’s right to conscience There are many reasons a doctor might object to performing an abortion. The most common is the belief that life begins at fertilisation and that an embryo is a ‘potential person’ – that it is able to develop into a human being. Killing the embryo removes its potential to develop into a human being and this equates to killing which is morally wrong, as no one has the right to take life.

Historically, the doctor’s right to a conscience and therefore conscientious objection has been maintained. Part of the reasoning behind this is that the proposition of conscientious objection is that an allowance is made in exceptional circumstances only. It does not mean that doctors who exercise their right to conscientiously object do so to anything they find distasteful or unpleasant. Rather, it is a mechanism to uphold their convictions, guided by their conscience, in cases where they are asked to perform procedures they find to go against their moral judgement.

The simplest argument to support this view is that if it is possible to accommodate the views of doctors, then why shouldn’t we? As the current system stands, the continuity of care is ensured, and no options are withheld from the patient. This means that their health does not suffer in way, other than perhaps the patient being inconvenienced in having to go to another doctor.

It is important to consider that whilst abortion is legally allowable, it is not always true that what is legal is ethical, in the same way that what may be ethical is not always legal. Asserting one view onto everybody can be considered unfair. Many of those opposed

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to conscientious objection argue that doctors should not let their conscience affect the care of individual patients, and should instead raise this objection at a national or legislative level (3).

However, most conscientious objectors realise that not everyone holds the same views and that it is perfectly acceptable to have opinions which differ from others’. Therefore, these doctors are happy to respect their colleague’s views, in return for their own views being tolerated.

This diversity of opinion is also important because it allows the medical profession to reflect some of the views inherent in society.

Abortion is an issue towards which different people have different attitudes, and for the medical profession to reflect this can only be a good thing. It is not entirely inconceivable to imagine a pregnant woman, who conscientiously objects to abortion, wishing to seek out a like minded obstetrician.

Finally, although it can be argued that doctors with moral views against abortion, religious or otherwise, are likely to impose them onto their patients, there is nothing to suggest that the same isn’t true of doctors without such beliefs. It is not possible to be fully impartial when advising patients on any matter, and learning to suppress ones own convictions to respect the views of others is a skill, one which is unrelated to conscientious objection.

As previously mentioned, religion can be a major influence in the formation of conscience. As such, many strict Christian, Jewish and Muslim doctors may be against abortion where there are no necessary medical grounds. If the right to conscientious objection was revoked, competent doctors may be driven out of their roles.

In addition, revocation of this right may lead to conscientiously objecting doctors to avoid entering specialties like obstetrics and gynaecology or general practice, even though abortion may only make up a small part of the job. At a more extreme level, capable students may refuse to enter the medical profession if there is no allowance for contentious objection, negating the GMC’s desire of a “diverse medical student population” (4). This would be a great loss to the medical community, because these students and doctors may otherwise have good qualities which lend themselves well to the profession.

As mentioned previously, a person’s conscience is shaped by their beliefs and values. Therefore by applying their conscience to their work, these doctors are seeking to treat their patients in what they believe to be a moral way. It is impossible to apply this ideology in an inconsistent manner depending on the treatment being provided. To dissociate conscience from the practice of medicine for the purpose of patient care is either impossible or problematic.

For example, withdrawing the right to conscientious objection, which equates to removal of the doctor’s personal conscience, may be the first step in the path to doctors becoming subservient

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to the state. If a doctor loses the right to make decisions based on their own best judgement, they are reduced to mere automatons, in place solely to follows orders. The patient places their trust in their doctor and hopes that their best interest will be kept at the heart of the doctor-patient relationship. If there is no allowance for the doctor to deviate from set guidelines, patient care may suffer.

In relation to this argument, if a doctor has no conscience, it becomes much easier to lose other virtues such as integrity and honesty, which are essential to the practice of medicine. It is not difficult to imagine that few patients would want to be treated by a doctor without a conscience.

Withdrawal of the right to conscientious objection would create a discrepancy between the United Kingdom and other democracies.

In the developed world, wherever there are contentious issues, there are opt-out clauses or the right to conscientious objection, such as with physician assisted suicide in the US state of Oregon (5) or with euthanasia in the Netherlands (6).

No room for conscience in medicine Although there is no harm in having a conscience or using it to make decisions, in medicine, the patient’s requirements, beliefs and best interests should be central to the doctor’s actions.

Medicine revolves around the principle of beneficence, doing what is best for the patient, disregarding the interests of the doctor or anyone else. Conscientious objection complicates this.

Arguably it is not in the best interest of a pregnant woman wanting an abortion to wait to be referred to a different doctor because of the beliefs of her current one.

Furthermore, by allowing conscientious objection, we are forced to accept the views of others, for fear of offending them. If this continues, will anyone speak up if conscientious objection borders on discrimination? After all, one person’s conscience may be another’s prejudice.

A doctor’s conscientious objection may cause distress, anxiety or even offence to the patient. In the case of abortion, a doctor’s refusal to perform the procedure may cause the patient to have doubts over their decision, and may leave the patient unwilling to see another doctor.

Objection towards abortion could also harm the doctor-patient relationship and the patient may no longer feel comfortable coming to the same doctor, even for an unrelated problem. This may be especially true as some patients might feel that they were judged by the doctor because of their personal, religious or moral beliefs.

Furthermore, by opting out of abortion training and not participating in the procedure, doctors could be left in the dark about some important aspects of abortion, post-intervention care

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pregnancy is an increasingly common procedure and doctors will come into contact with countless patients who will have had an abortion in the past. Those who have conscientiously objected may not be able to provide the best care possible to such a patient, having never been exposed to the issue before.

The decision to conscientiously object also affects colleagues. It leaves them to carry out more of the tasks which may be considered unpleasant or objectionable; this inequity may lead to indignant coworkers. At this point, it is also important to consider the reasons for conscientious objection. A doctor who refuses to perform abortions on religious grounds alone is more likely to have his views respected, whereas a secular doctor with just as scrupulously thought out reasons against abortion might not have his objections regarded as highly.

A rising numbers of conscientious objectors could soon mean that there will not be enough doctors to carry out the increasing numbers of abortions demanded. In 2007, the Royal College of Obstetricians and Gynaecologists issued a statement highlighting the concern regarding potential future shortages of doctors to carry out abortion (7). Increased waiting times to have an abortion are hardly in the patient’s best interest. In some parts of the world, such as southern Italy, abortion is often unavailable to patients seeking it, because even though it is legally allowable, the number of conscientiously objecting doctors is too high (8). Should the current pattern of more doctors choosing to not perform abortions continue in the UK, the same situation is not entirely

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unimaginable.

It has also been documented that women undergoing abortion have been refused services by many individuals such as nurses, pharmacists and even hospital transport and catering staff (9). It seems logical that if there is allowance for conscientious objection in one group of professionals, namely doctors, then it is reasonable for these other groups to demand similar rights. This would cause an increase in the number of staff refusing their services, further exacerbating the shortage of abortion services described.

In addition, there is little official monitoring of the reasons that doctors use to object to abortion. It may simply be that many doctors who find the procedure distasteful use conscientious objection as a way of not having to perform it. Having parity across the board by disallowing conscientious objection altogether would remove this potential problem.

A doctor who conscientiously objects to abortion will never be able to provide impartial advice to patients on this matter.

The powers of persuasion are always likely to be at play, even if subconsciously. This again negates the principle of beneficence, as the best interests of the patient will not be the main concern of the doctor.

It can be argued that if a doctor feels particularly strongly against certain procedures, he should make every effort to choose a career path which does not come into contact with these procedures.

Medicine encompasses a wide range of specialties, some of which are unlikely to present with morally debatable issues like abortion.

Doctors can minimise problems for themselves, their colleagues and their patients by choosing their speciality wisely.

Some ethicists, like Julian Savulescu, suggest that conscientious objectors should raise their objections at a national or legislative level (3). If someone strongly believes that abortion is morally unacceptable, they should believe this regardless of who performs it. Therefore, instead of continually letting their views impinge on their relationship with patients and colleagues, they should aim to seek a long-term resolution by engaging in debate with the public and the government with a view to alter policy.

Clash of rights Ultimately the argument over conscientious objection simplifies to a conflict of rights - the rights of the patient to receive the healthcare they require and the rights of the doctor to not do anything against their moral judgement.

On the one hand, the patient is simply exercising their right to receive healthcare which is in their best interest, without feeling discriminated against or judged, a right enshrined in law. After all, one of the founding principles of the NHS was providing care that meets the need of patients, shaped around the patient’s preferences (10). The doctor, paid by public funds, has a duty to

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fulfil the requirements of the patient.

Conversely, the doctor too has a right to make decisions regarding his actions and it seems unjust to compel him to do something to which he is opposed. The patient is provided full freedom of choice regarding treatment they do or do not receive, and the same should be applied to doctors with regards to which treatment they do or do not provide. The European Convention on Human Rights serves to protect freedom of thought, conscience and religion (11); rights which extend to doctors too.

It can be argued that a balance can be reached as the patient is presented with the option to receive the same healthcare elsewhere. For this reason, in this situation, the law and professional body guidelines side with the doctor’s right.

Doing Wrong vs. Facilitating Wrong As previously discussed, the current guidelines for conscientious objection to abortion state that provisions must be made for patient care to be handed over to a doctor who is willing to perform an abortion. This leaves open the matter of facilitating wrong.

By objecting to perform an abortion, the doctor has acknowledged that he wants to be exempt from an act which will cause the death of the foetus, which is he considers to be an immoral act. As many ethical decisions are made using the principles of intention, it is fair to suggest that this principle can be applied to the situation of abortion too. By referring the patient on to someone else, the doctor is facilitating, in his own view, an unethical act. Although facilitating the unethical act is not the same as doing it, arguably, the difference is minute. In this scenario, the doctor may not have had the direct intention of killing the foetus, but the doctor’s action is one of the contributing factors which will eventually lead to the abortion. I therefore think that in this situation, the difference between doing and facilitating wrong is not a large one.

Some might argue that the gap between doing and facilitating wrong widens if the facilitation is not certain to lead on to the immoral act. This does not seem to apply here, simply because if a patient has come to a doctor for an abortion, it is likely that she has already made her mind up, and in the time that she waits to see another doctor, she is unlikely to change her mind.

Consequently, I am led to believe that where abortion is concerned, facilitating wrong can be just as morally questionable as doing wrong. It seems that it would only be morally acceptable if the doctor refused outright to be involved in the abortion procedure; this however contravenes the professional guidelines set out by the GMC and the BMA, and also the law.

Conclusion Conscience is an important aspect of our individuality, and at first sight it may seem that it should not be constrained in any way.

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However, not all conscience is the same. As with anything else, in private matters no one has a right to interfere with an individual’s conscience or the decisions that individual makes with respect to their conscience.

However, when the impact of a doctor’s decisions starts to impinge on the care provided to patients, we need to reconsider the right of the doctor to unrestrainedly conscientiously object.

There may be a case for allowing conscientious objection in some situations, such as outlined below.

For example, some argue that conscientious objection is only acceptable when the “ethical values on which it is based correspond to values in medicine” (12). In the case of abortion, this may be relevant to doctors who feel that abortion for social reasons is equivalent to killing. Undeniably, this is indeed in conflict with one of the intrinsic values in medicine. However, it is feasible that some objections may not correspond to values in medicine in any way, but are still just as strongly felt by the objector, and so personally, I feel that this view of conscientious objection is incomplete.

Another situation where conscientious objection should be permissible is where the doctor has a well founded claim for objecting to something in conflict with their moral or religious beliefs. Here, the objection should be respected, so long as the individual is able to substantiate their claims to prevent misuse of this allowance. It must also be ensured that the correct protocol is followed with regards to ensuring continuity of care.

Various sets of criteria have been set out by different ethicists to judge conscientious objection; one such criterion suggests that the objection should be serious, sincere and consistent. Also, the objector should reciprocate similar respect by accepting others’ views (13). Such a system may be a good starting point towards a standard which must be fulfilled before a doctor can object to performing a procedure.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Personal Beliefs and Medical Practice. General Medical Council; 2008.

Conscientious objection and doctors’ personal beliefs. British Medical Association; 2008.

Savulescu J. Conscientious objection in medicine. British Medical Journal.

2006;332:294-7.

Rubin P. Core Education Outcomes: GMC Education Committee. 2006.

The Oregon Death With Dignity Act: A Guidebook for Health Care Professionals. 2007.

Termination of Life on Request and Assisted Suicide Act (The Netherlands).

2002.

Abortion crisis as doctors refuse to perform surgery. The Royal College of Obstetricians and Gynaecologists (RCOG); 2007.

Dickens BM, Cook RJ. The scope and limits of conscientious objection.

International Journal of Gynecology & Obstetrics. 2000;71:71-7.

Beal MW, Cappiello J. Professional Right of Conscience. Journal of Midwifery & Women’s Health. 2008;53(5):406-12.

National Health Service: Core Principles. Available from: http://www.nhs. uk/aboutnhs/CorePrinciples/Pages/NHSCorePrinciples.aspx

For full references see thelsjm.co.uk.

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EDITORIAL

Dear Readers Having explored what is “unhealthy” and how medicine “innovates” constantly in our opening issues, we now sit back (though not on our laurels) for our third offering to “reflect” on health and science.

In my previous piece I spoke about issues that spanned nations and peoples, races and continents. We touched on the changing outlook of multinational pharmaceutical conglomerates and the scale of death due to preventable diseases in the forgotten places of our world.

Today I want to reflect on something as important, but infinitely closer to our daily practicing lives: Relationships and advice The American physician Martin H. Fischer said “In the sick room, ten cents’ worth of human understanding equals ten dollars’ worth of medical science,” and in dynamic 21st century Western healthcare where investigations can be definitive and cures may seem instant, aspiring physicians would do well to keep this in mind.

The first lesson I learnt in clinical school was to always stand up and walk out to greet and receive your waiting patient. The elderly clinician offering these wise words went on to add that by doing so one was afforded an opportunity to asses gait, balance and locomotor functioning instantly, saving precious NHS time. Furthermore he said it would prevent the development of obesity, diabetes, hypertension and all manner of other ailments that accompany our often-sedentary profession. What he failed to mention, was that this simple act allowed us to begin the all important doctor-patient relationship, on an equal footing, echoing Fischer’s words. A footing of kindness and compassion, where as a healer we rise to meet our patients as a manner of respect so that we can both move forward together. There is no cure without a willing patient that complies with our recommendations.

We are taught from day 1 of medical school that the most important tool the physician has to reach a diagnosis is the history. The exchange of between patient and doctor will almost always have within it the offending disease. As important as the initial words spoken by the patient are the recommendations given by the physician. The advice we give, as healthcare professionals is crucial. Doctors remain one of the most trusted professionals in today’s society, and our counsel is often sought and followed.

To this end the interesting discussion piece on previous “gold standard” advice for avoiding skin cancer being perhaps outdated is well worth a read. Vitamin D is now thought to play a vital role in the immune response and keeping out of the sun may indeed prevent us getting melanomas but instead predispose us to M. Tuberculosis! Furthermore the illuminating research article on the effect of the advice on cigarette packaging in helping smokers to quit in Australia further goes to show the immense power of the spoken word and the visual graphic (something doctors and health authorities would do well to remember during a global recession, the spoken word is infinitely less expensive than the manufactured tablet).

Our final piece deals with the sequelae when a doctor-patient relationship goes awry, namely due to the conscientious objection of a clinician with regards to a procedure. It is a significant work as we often find in our daily lives that the course of a consultation and treatment often never runs smooth.

I hope that you find this section challenging, interesting, enjoyable and above all stimulating. I hope that you leave it with the knowledge that for whatever you may prescribe or cut, it is often what you say that heals most.

With best wishes Vishal Navani Vishal.navani09@thelsjm.co.uk

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ARTICLE

“Not all sunlight is dangerous, just ultraviolet radiation”

Professor JLM Hawk

Shreedhar Krishna, Ajoy Bardhan Year 6 Medicine, Imperial College, London shreedhar.Krishna@imperial.ac.uk doi: 10.4201/lsjm.gch.008 Dermatologists are human. Therefore, there will be an inherent individual variation in the quality and content of advice provided to the public. However, for the purposes of this essay (as well as being a source of British sunlight policy), the validity of elements comprising the SunSmart message will be examined.

The SunSmart Message2 Spend time in the shade between 11 and 3 Make sure you never burn Aim to cover up with a t-shirt, hat and sunglasses Remember to take extra care with children Then use factor 15+ sunscreen In order to examine the efficacy of the advice provided, it is necessary to begin with some statistics.

On the face of it, this data seems to support SunSmart’s cautious approach to sun exposure. However, it is not currently known how sun exposure leads to melanoma. Adults who work outdoors as well as children who play outdoors are less likely to develop melanoma than those who work or play indoors.,4 Furthermore, work on a black population showed that melanoma was more common on the lower legs and soles of the feet5 - not prime sun-exposed areas. Clearly, the relationship between melanoma and sunlight is not simple.

The Tightrope Advice on sunshine is aimed at achieving ‘optimum’ sun exposure.

However, there is no general consensus on the balance between adverse and beneficial effects.

Physicians walk a precarious tightrope: Prescribe too much sun and there is a greater susceptibility to skin cancers; too little leads to vitamin D deficiency. Complicating matters further, there are large variations in what is considered a sufficient vitamin D level for health. Moreover, proximal factors such a skin pigmentation or traditional dresswear mean that there cannot be one universal optimum exposure for all.

Although UV radiation is prominently associated with the above diseases, it is worthwhile to note that “99 of every 100 British people won’t develop melanoma during their lifetime, and nine of 10 will be free of nonmelanoma skin cancer.”

The Facts Table 1. Age-standardised malignant melanoma incidence rates, Great Britain, 1975-20053 Conversely, lower intensity UVB exposure is linked to cancers far more prevalent than those affecting the skin. Lending credence to this argument, Giovannucci et al. showed an increase of 17% in total cancer incidence and 29% in mortality with a decrease of 25nmol/L in serum 25(OH)D3.6 Thus, other than for high skin cancer risk groups (e.g. individuals with large numbers of melanocytic naevi),7 the benefits of thorough sun exposure far outweigh its dangers.

Vitamin D deficiency has been linked to myriad other conditions, many of which are much commoner than skin cancer. These include multiple sclerosis, schizophrenia, diabetes and cardiovascular disease.

Using the value proposed by Zittermann (100-150 nmol/L), darkskinned children and the elderly are especially at risk of vitamin D deficiency.

The worryingly low levels reported in the UK elderly population are woefully insufficient for health throughout the year and are Over the last 25 years, the incidence of malignant melanoma (MM) associated with osteomalacia, muscle weakness and a tendency to has increased more than for any other common cancer in the UK. falls and consequent fractures.

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ARTICLE Table 2.

Serum 25(OH)D nmol/L

Summer

Winter

UK children

80

52

Dark-skinned UK children

36-42*

Teenagers

71

21

Young adults

70

30

UK Elderly

35

23

*(not differentiated by season The SunSmart Message The UK SunSmart message is derived from an earlier Australian campaign.8 Australia, however, has a considerably greater intensity of sunlight as well as the highest melanoma incidence in the world.9 SunSmart was thus developed in view of Australian objectives to reduce skin cancer; while its message is rational in temperate climates, it is somewhat unsuitable for the UK for a number of reasons:

spend more time in the sun.

1.

Therefore for those seeking sun protection, it would be perhaps more prudent to emphasise the generous use of sunscreen rather than a specific SPF. Furthermore, advice on re-application of sunscreen after swimming or significant sweating must be disseminated.

The British maritime climate produces substantial cloud cover even at the height of summer.

2. People in England and especially Scotland obtain minimal vitamin D from sunlight between October and March.10, 3. Individual exposure to sunlight demonstrates that Australians are exposed to considerably more UVR than the British.

It is important to note that the SPF is phototested at an internationally agreed application thickness of 2 mg/cm2. Unfortunately, evidence suggests that consumers apply sunscreen more sparingly, typically between 0.5 – 1.3 mg/cm. Stokes et al. suggest that the actual protection conferred is between 20-50% lower than the SPF on the label. Additionally, there are likely variations in application technique which have not been accounted for.

Conclusion Thus rather than covering up, we should be opportunistic in obtaining sun exposure, while taking care not to burn.

S UVB exposure causes the provitamin D3 to be isomerised to previtamin D3. During continual exposure to sunlight, the pre-vitamin converts via photo-isomerisation into vitamin D3. Critically, only UVB exposure initiates vitamin D synthesis. Thus, the recommendation to stay in the shade around midday, may be ensuring that sun exposure is to UVA wavelengths – increasing skin cancer risk with minimal vitamin D synthesis.

M Sunburn is especially linked with melanoma and basal cell carcinoma; its avoidance can only be a good thing.

T “While regular sunscreen application can prevent the development of cutaneous dysplasia in sunny countries like Australia without compromising vitamin D levels, daily use of skin products containing UV filters in the UK, which is not known for its sunny climate, is unnecessary and may be potentially harmful.”11 Professor Diffey The sun protection factor (SPF) is defined as the ratio of the least amount of UV energy required to produce minimal erythema on skin protected by sunscreen to the amount required to produce the same erythema on unprotected skin. Paradoxically, individuals who regularly use high factor (SPF ≥ 15) are more likely to report sunburn than those who do not. This suggests that these individuals have misplaced confidence in their sunscreen and consequently

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 Other than for individuals at high risk of skin cancer, adopting certain behaviours prescribed by SunSmart is unwise and will likely lead to vitamin D deficiency.  For the general public, the benefits of thorough sun exposure outweigh the increased risk of skin cancers.  Thus, advice should encourage opportunistic sun exposure, while still taking care to avoid sunburn.  Due to proximal factors such as skin pigmentation, the ‘one size fits all’ approach of SunSmart is not suitable. Rather, advice should be individualised to fit the patient – not the other way around.  Certain groups, such as dark-skinned people and breast-fed babies are at greater risk of vitamin D deficiency and must be advised accordingly.

References 1.

2.

3.

4.

5.

6.

Hawk JL. Sunlight and health. Not all sunlight is dangerous, just ultraviolet radiation. BMJ (Clinical research ed.) 1999; 319(7216): 1066-7; author reply 1068 http://www.cancerresearchuk.org/sunsmart Statistical Information Team, Cancer Research UK Kaskel P, Sander S, Kron M et al. Outdoor activities in childhood: a protective factor for cutaneous melanoma? Results of a case-control study in 271 matched pairs. British Journal of Dermatology 2001; 145(4): 602609 doi:10.1046/j.1365-2133.2001.04432.x Crombie IK. Racial differences in melanoma incidence. British Journal of Cancer 1979; 40(2): 185-193 Giovannucci E, Liu Y, Rimm EM et al. Prospective study of predictors of vitamin D status and cancer incidence and mortality in men. Journal of the

For references see thelsjm.co.uk.

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LETTERS

Letter to Carlos Chagas Insights into Chagas disease Jan Man Wong

Illustration: Rhodnius prolixus

Year 2 Medicine, University of East Anglia j.wong@uae.ac.uk doi:10.4201/lsjm.gch.009

I am a second year medical student, who had the opportunity to get involved and know more about Chagas disease in a studentship last summer. As I looked more into the research, I feel obliged to give you a summary on the development of your disease in the past century and its way forward.

Past For your reference, the American human trypanosomiasis that you discovered has been now named as Chagas disease, paying tribute to your unique triple discovery 101 years ago. As it has been overshadowed by other priorities such as HIV/AIDS (a viral infection causing immunodeficiency reported in 1980s) and Malaria by the media, governments and organizations, it is currently regarded as a Neglected Tropical Disease. To date, Chagas Disease has an incidence of 500,000 per year1 and a prevalence of 1.4%2. It is estimated to infect 8-14 million people in 18 Latin American countries3, with 667000 disability adjusted life years (DALYs)2.

Concerning the pathogenesis, on top of the vectorial transmission of T cruzi via Triatoma infestans you proposed, transfusional, transplacentary transmissions and food and beverage contamination have been the new emerging means4. Through clinical experience, physicians generalized that the acute phase involves pyrexia, swollen lymph glands and inflammation of the eye. Though patients have high parasitaemia during acute phase, they usually go undiagnosed, as it is not uncommon that they are asymptomatic. 10-30 years after initial infection, about 30-40% of the patients develop chronic Chagas disease involving cardiac or gastrointestinal complications. 5 Regarding treatment and management, Uruguay, Chile and Brazil had declared that they are free of T cruzi transmission due to intensive insecticide spraying.6 Benznidazole and Nifurtimox have been the two main drugs prescribed for children, which has up to 62% seroconversion rate in 3-to-4-year follow-up7. However, they have not been compliant due to long-term treatment (30 to 60 days) and lack of accessibility. They are also reported to have severe gastrointestinal, dermatological, neurological and haematological adverse events limiting the use.8 There are blood bank screenings to monitor and guard against transfusional transmission although vaccination development is at its infancy.

Present One might be delighted to be informed that the World Health Organization (WHO), a specialized agency coordinating authority on international public health started 14 years after your death, proposed a ‘New global effort to eliminate Chagas Disease’ in 20079. It was initially welcomed but received some criticism on the lack of strategic plans6. I have, therefore, tried to investigate three of the ‘five-pillar strategy’ and analyze the situation as a basis for the insights into way forward in the next section.

Monitoring and estimation of burden of disease It was suggested that Chagas disease should be integrated into the health monitoring information systems of Latin American countries.

The development of representative, reliable and valid surveys to estimate domestic manifestation, incidence, prevalence, disability, population knowledge, prevention and control was needed6. I have to admit the development of these tools is slow, if not non-existing.

However, researchers from Pan American Health Organization (PAHO) had pioneered an estimate of 12755 T. Cruzi-infected Hispanic pregnant women to migrate to the States, with 166 to 638 infected newborns. They also gave information in specific states to monitor, giving a good start for surveillance.10 Identify diagnostic test for screening and diagnosis Prior to the campaign WHO set up, there was a multitude of procedures, including immunosorbent assays, immunofluorescence antibody tests, radioimmune precipitation and PCR based assays serving the purpose of screening and diagnosis. There was an urgent need for a standardized detection. I am happy to inform you that the WHO had looked into it and evaluated the serological assays. They had concluded in the research that radioimmunoprecipitation assays (RIPA) could be considered a gold standard for evaluation of other assays and that the sensitivities and specificities of seven enzyme-linked immunosorbent assays (ELISA) enable them to be used solely for screening and diagnosis.11 Evidence has shown that the reliability of assays is not affected by the origin of samples.12

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LETTERS Promote consensus on adequate management As aforementioned, as the two main drugs have high toxicity, short supply and issues regarding efficacy and availability, development of new drug is deemed necessary5. A non-profit product development partnership, Drug for Neglected Diseases initiative (DNDi), tried to link Research and Development to drugs. They have projects in three time phases, ranging from reformulation for children (short-term) to combination treatment (medium-term) to drug discovery (long-term)13.

Regarding the two existing drugs, Marin-Neto and his colleagues outlined a rationale and design and recruiting for a randomizedcontrolled trial (RCT) assessing Chagas cardiomyopathy, the BENEFIT trial14. Coura had also proposed combination treatment with Allopurinol for new pharmacological regimes15. The All-Party Parlimentary Group on Malaria and Neglected Tropical Diseases from the UK announced in its report that a vaccine has been tested and an antifungal agent has been proposed as a second-line treatment16.

Adding to the good news, the Medecins Sans Frontieres (MSF, aka Doctors without Borders) had published a paper recently, proving the viability, feasibility and necessity of diagnosis and treatment programmes for the disease in four different rural areas in Latin America, given the collaboration between governments and the organization.8 Future Agreeing with Reithinger and colleagues, a clearer strategic plan for new operational activities is crucial6, especially when renewing the ‘New Global Effort to eliminate Chagas Disease’ this year. With the insights from multiple studies, I have suggested the following: Elimination of vectors As seen from the statistics from Ministry of Health in your home country, Brazil, most of the Chagas cases were transmitted by vectors4, a more stringent and sustainable insecticide spraying is needed. Insecticide spraying is often reported to be irregular if not absent. Insecticide resistance should be monitored and alternatives considered. Insecticide-treated bed nets or dog collars, change of insecticide and expanding spraying areas are other ideas to be considered6. WHO should take the initiative to re-iterate the importance of sustainable spraying and other complimentary practices to governments.

Establish diagnostic and screening protocols As the WHO evaluation on serological assays only included those prior to year 2000 11, they could take a step forward and assess the results from other studies of similar sort. After sufficient data is obtained, it would be best if the WHO or other dedicated research institutes could consolidate the data and develop a meta-analysis, which could serve the basis for a ‘gold standard’ protocol for screening and diagnosis.

Development of treatment / management consensus It is important that an independent agent, such as WHO, ensures that the BENEFIT trial and combination treatment trial is well implemented with sufficient resources. It is also good news that Japanese company Eisai had agreed to develop first new compound, E1224, for Chagas disease with DNDi. This anti-fungal may reduce the non-compliant issues due to its long half-life when come to market earliest in 201417.

The MSF diagnosis and treatment programme had six components including information, education and communication, vector control, health staff training, screening and diagnosis, treatment and compliance and logistics8. Although there are areas that are subject to improvement, such as diagnostic tools, it has a number of advantages. The programme in itself helps training health staff, which compensates for the lack of trained front-line staff due to decentralization of health systems. The component of vector control could, in turn, help the government in surveillance of the disease. With these advantages, it is advised that the WHO, after careful modification, could publicize it as a universally agreed ‘treatment strategy’.

All in all, numerous institutes including DNDi, MSF, PAHO have worked towards the elimination of Chagas Disease, long after your death. A uniting body is needed to ensure these efforts are efficient and meet this goal. At present, the WHO is the defacto lead for such efforts. Let us hope that the renewal of the global effort would not only look good on paper but also practical in implementation.

I sincerely hope to have delivered a succinct but thorough report of progress in this area; with the vigorous input received after this to serve as a stimulus to review the report in the future.

Yours sincerely,

For full references see thelsjm.co.uk.

Medical Student

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PERSPECTIVE

Is Breast cancer prevention a realistic prospect for the future?

Katie Griggs

Image: Getty Images

Year 3 Medicine, University of Leeds um07klg@leeds.ac.uk doi:10.4201/lsjm.gch.010

Breast cancer is the most common carcinoma affecting women in the UK, making up 31.5% of new female malignancies in 2006.1 It is the leading cause of mortality in women aged 40 to 552, with 11,040 female deaths attributed to the disease in 2005.3 This essay aims to explore the issues surrounding the prevention of breast cancer by reviewing current literature on the topic, and to come to some conclusion as to whether it will ever be possible to completely eradicate the disease.

There are some known risk factors which may contribute to a person’s chances of developing breast cancer - although these are by no means definitive indicators of those who will develop the disease.

These include genetic4 and hormonal factors5,6,, age7 and various lifestyle factors8,9.

Assessing a person’s risk Based on the risk factors mentioned above, it is possible to work out a woman’s chance of developing cancer, and use this in deciding whether to carry out preventative measures. As some methods of preventing breast cancer have quite severe effects on a woman’s life it is important to decide whether the risks are large enough for

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sacrifices to be made elsewhere. In order to calculate a woman’s risk several mathematical models have been created. The Gail model is the most generally applicable, although it does neglect to take into consideration some factors (such as detailed family history) as effectively as others, notably The Claus Model10. The Gail model produces a figure which represents a woman’s five year risk of developing breast cancer, and preventative measures or treatment decisions are often based on that information.

Preventative Measures Hormone related prevention It has been found in studies on animals that oestrogens can be involved in the formation and proliferation of breast tumours and that removal of ovaries or administration of anti-oestrogenic drugs has an opposite effect. 11 In pre-menopausal women it is possible to suppress ovarian production of oestrogen. This process is known as ovarian ablation and can be carried out in various ways: oophorectomy, by use of radiation, or treatment with an LHRH (luteinizing hormonereleasing hormone) analogue. It has been proved that bilateral prophylactic oophorectomy offers a protective influence against

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PERSPECTIVE

breast cancer – women who had the operation before the age of forty had a 45% reduced risk of developing the disease compared to women with a natural menopause between the ages of 50 to 54.12 There are however downsides to this procedure which need to be carefully considered before the surgery is carried out. Factors associated with an early menopause (hot flushes, anxiety and depression13) may have a significant effect on a woman’s life. There are also long term risks of osteoporosis and decreased libido.

A slightly controversial method of breast cancer prevention – but perhaps the most successful - is bilateral prophylactic mastectomy.

It has been found that this procedure in women with the BRCA1/2 mutation reduces the risk of breast cancer by approximately 95% in women with prior or concurrent bilateral prophylactic oophorectomy and by approximately 90% in women with intact ovaries10. However, the effects of such a drastic cosmetic procedure can be vast. Women who have had mastectomies without actually having cancer have reported problems with body image, anxiety and depression as well as psychological distress.14 Because of the negative effects associated with such procedures they are currently mainly utilised by those who are considered to be at a high risk of developing breast cancer. If similar successful outcomes could be found in the future through methods which would not have the extreme cosmetic and psychological effects there could be a great uptake of prophylactic treatment in women at low or moderate risk who might otherwise avoid it.

Chemoprevention A more preferable method of breast cancer prevention without such radical effects is chemoprevention; the use of drugs which aim to interrupt carcinogenesis and thus prevent the formation or development of tumours. Selective Oestrogen Receptor Modulators (SERMS) work by blocking the effects of oestrogen on breast tissue. Tamoxifen is the most widely used SERM15 and its use in order to reduce the risk of breast cancer in women with 5 year risk of at least 1.66% (as determined by the GAIL model) has been approved by the FDA16. The NSABP P-1 Study which began in 1992 and recruited 13 388 women who had an increased risk of breast cancer found that tamoxifen in the dose of 20mg per day reduced the risk of invasive breast cancer by 49% after a median follow up of 54.6 months (p<0.0001)17.

There were significant downsides to the use of tamoxifen as a preventative measure; the 6681 women who took tamoxifen as opposed to placebo had 21 additional endometrial cancers (RR 2.53), and were exposed to higher risks of developing pulmonary embolisms (RR3.01) and deep vein thromboses (RR1.60)18. The balance between the benefits and the risk of adverse effect of tamoxifen were different

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in each patient depending on their individual risk profile, with younger women benefitting most and experiencing fewer negative effects19.

Raloxifene, another SERM which is approved as both a treatment and preventative agent in postmenopausal osteoporosis20, has been found to have a significant effect in reducing breast cancer risk in postmenopausal women. In the MORE study it was found that raloxifene reduced the risk of oestrogen receptor-positive invasive breast cancer by 84%21. In the largest breast cancer trial ever conducted22 on postmenopausal women at high risk of developing breast cancer, raloxifene was found to be as effective as tamoxifen at reducing breast cancer incidence22. Its benefits also included a lower risk of developing uterine cancers and cataracts when compared to tamoxifen23. However, because these results have been so significant only on postmenopausal women, further research is required to ascertain the benefits of Raloxifene on pre-menopausal women, or to find another SERM that is suitable for treating them.

In making the decision to use prophylactic treatment for breast cancer it is important to take into consideration the number of people who will have to be treated in order to prevent one case (NNT). The results of the NSABP-P1 trial found that 56 women would have to take tamoxifen for 5 years in order for one person to experience prevention of an invasive carcinoma over that period and the next seven years17. The MORE study found raloxifene had an NNT of 125 over four years24. There is little evidence to suggest that tamoxifen or raloxifene are effective in preventing breast cancer in women at low or moderate risk25. This fact, the NNT values and the negative effects associated with treatment with these drugs imply that it would not be practical for the population as a whole to be treated with either of these SERMS as a preventative measure.

In the future, an ideal SERM would have similar or increased ability to reduce breast cancer risk – without the significant downsides that are present in the current SERMs used in prophylactic breast cancer therapy. There are current trials into a ‘new generation’ of SERMs which have the potential to fulfil these requirements, and bazedoxifene, arzoxifene and lasofoxifene have been found to be promising26, although these treatments are not without problems, and further research is required.

For full references see thelsjm.co.uk.

Post-menopausal women do not produce oestrogen in the ovaries.

Androgens are synthesised in their adrenal glands and converted to oestrone by the aromatase – a cytochrome enzyme.2728 This process can be interrupted by treatment with aromatase inhibitors (AIs).

AIs are currently used as a breast cancer treatment, often alongside SERMS like tamoxifen, and have found to be very successful in this role29. There are trials currently underway to investigate the use of AIs as a chemo preventative measure, and data from pre-clinical studies has been promising.30 31Results from the IBIS-2 randomised

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EM of Breast Cancer cells- Wellcome Image

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phase III trial – which is a trial of the use of anastrozole in 6000 postmenopausal women with an increased risk of breast cancer - are expected in 201232. Results from this and another major study – the MAP.3 phase III randomised prevention trial33, have the potential to change the methods and success of chemoprevention drastically in the future.

For full references see thelsjm.co.uk.

As SERMS and AIs are not without their faults, there has been research into the use of retinoids (derivatives of vitamin A which are known to play a role in cellular and tissue differentiation) as a possible chemoprevention method. Many retinoids produce toxic symptoms that are not acceptable as a risk reduction side effect16, however a less toxic analogue34, fenretinide, has been the subject of several chemoprevention trials. A phase III trial of fenretinide on women with a history of stage I breast cancer found a 35% reduction of contralateral breast cancer in premenopausal women 35. This was found to be linked to levels of plasma insulin-like growth factor-I (IGF-I) levels. Based on these findings, significant research is underway in establishing the role of IGF-I in breast cancer risk36, and the potential implications for retinoid treatment in premenopausal women and those receiving HRT are also areas being researched.

Prevention of ER negative breast cancer Although there have been promising results from trials of SERMS and AI in reduction of estrogen receptor positive (ER+) breast cancer, these treatments have no effect on ER- tumour formation37. As around a quarter of breast cancers are ER-38, there is a considerable effort being made to find a way of preventing such malignancies. There are several potential molecular targets that are currently under investigation, and preclinical results have found that rexinoids, tyrosine kinase inhibitors and dual kinase inhibitors, and COX-2 inhibitors prevent the development of ER-negative breast cancer in transgenic mice37.

Other targets being investigated include ligands for peroxisome proliferator-activated receptor γ, retinoic acid receptors, vitamin D3 derivatives, VEGFR, and histone deacetylase inhibitors16. If any of

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the methods currently being tested are found to prevent ER- breast cancer, there could be a potential for chemoprevention of both ERand ER+ cancers by treating patients at risk with a combination of these methods and SERMS/AI. Conclusion Based on the literature reviewed in this essay, it appears that breast cancer will never be absolutely preventable, due to the impossibility of eliminating all methods of carcinogenesis. The fact that not all breast cancers result from the risk factors mentioned earlier in the report38 means that many cases cannot be anticipated and prevented.

Prophylactic treatment options that are currently available have fairly severe side effects. These effects would not be willingly tolerated in those who do not consider themselves at a high risk of developing breast cancer and thus by avoiding treatment these people are left unprotected. It does however seem that breast cancer incidence could be considerably reduced through developing techniques of prevention. Preliminary results of studies into several new methods of chemoprevention which may have reduced side effects have been promising. Thus in the future there could be the potential for a virtually harmless preventative measure to be given to everyone, regardless of their risk. This would have a significant effect on breast cancer incidence and mortality.

References 1.

2.

3.

4.

5.

6.

7.

8.

Cancer Statistics Registrations 2006 – A National Statistics publication. Series MB1 No.37, 2008 ISSN 0143–4829 (Accessed online on 19/01/09 at www.statistics. gov.uk) DEVITA, V.T, HELLMAN S., ROSEBERG S.A., AUSGABE G., Principles and Practice of Oncology (Periodicals) Lippincott Williams & Wilkins, Dec 2000, page 1651 Mortality Statistics- Review of the Registrar General on deaths by cause, sex and age, in England and Wales, 2005. London: Office for national statistics.

Series DH2 No.32 ISSN 0140-2587 (Accessed online at 01/02/09 at www.statistics.gov.uk) McPHERSON K, STEEL CM, DIXON JM, Breast cancer— epidemiology, risk factors, and genetics British Medical Journal, September 2000: 321(7261) Pages 624-628.

HENDERSON BE, FEIGELSON HS. Carcinogenesis, Oxford University Press- March 2000 Vol. 21, No. 3, Pages 427-433, The collaborative group on hormonal factors in breast cancer, breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53297 without breast cancer from 54 epidemiological studies. (No authors listed) Lancet 1996, 347 Pages 1713-27.

Cancer statistics 2005- Cancer Research UK Website. (Accessed online on 01/02/09 at http://www.info.cancerresearchuk.org/ cancerstats/types/breast) VAN DEN BRANDT PA, SPIEGELMAN D, YAUN SS et al, Reversal of relation between body mass and endogenous oestrogen concentrations with menopausal status. Journal of the National Cancer Institute 1996; 88: Pages 756-8

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RESEARCH

Evaluating the impact of cigarette packet graphics on tertiary students Ling Chen, Courtney Chun Hai Lai, Jessica Tin Yan Lai, Joanna Hong-Meng Tai Year 5 Medicine, Monash University, Australia Monash University Medical Students Smoking Reseach Group ling.chen.11@gmail.com doi:10.4201/lsjm.gch.011 Abstract Objective: This evaluation measured the initial impact of graphical health warnings within a tertiary student population aged 18---29.

Method: A cross-sectional study was conducted in Melbourne, Australia in August 2006 through a self-administered survey.

415 surveys were returned using convenience sampling from a university, a technical college and a suburban shopping centre. Of these, 373 were considered eligible.

Results: 81.4% of participants noticed the graphics. Graphics recognition and recall was greater in current smokers compared to past smokers or non-smokers. A greater number of past smokers quit smoking in the six months following the release of the graphics compared with the previous six months. Cost, family/household and friends were the most common factors contributing to attempts or thoughts on smoking cessation.

Conclusion: Cigarette packet graphics appeared to encourage smoking cessation within the study population. However, further research is still required into the long term effects of the graphic health warnings and other avenues for smoking cessation.

KEY WORDS: Australia; Health knowledge, attitudes, practice; Product labelling; Smoking; Smoking cessation; Students

new cigarette packets in order to inform, encourage cessation and discourage uptake.11 This follows similar actions in Canada, Brazil, Poland, Singapore and Thailand, with many other countries having implemented these graphics since.12 An evaluation of the graphical warnings in Canada found positive correlations between thoughts regarding the images, quitting intentions, and the increase in quitting attempts.13 Studies in Brazil, Greece and New Zealand showed graphical warnings to encourage cessation and prevent uptake.14---16 In Australia, these health warnings

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Image: Wellcome Image

Introduction Teenagers and young adults have the highest proportion of current smokers compared to any other age group in Australia. People aged between 18---24 and 25---34 have a smoking prevalence of 23.1% and 27.6% respectively according to the National Health Survey 2007---2008.1 Although this prevalence is slowly declining in Australia,2 this age group has generally been inadequately targeted in anti-smoking interventions.3, 4 Cigarette smoking can cause numerous deleterious health effects, notably within the respiratory and cardiovascular systems.5, 6 Both active and passive smokers face major health risks,7 with smokers having an increased ratio of mortality compared to never-smokers.8 Smoking cessation can reduce the risk of subsequent adverse smoking-related health effects.9, 10 Many public health promotion campaigns are aimed at discouraging smoking uptake and encouraging cessation, including text-based cigarette packet warnings and media advertising campaigns within Australia. From 1 March 2006, the Australian Federal Government has mandated graphical health warnings on

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RESEARCH Table 1: Graphics recognition and recall by smoking status Non-smoker

Past smoker

Current smoker

TOTAL

Noticed packet change (%)

121 (66.9)

80 (80.0)

73 (85.9)

274 (74.9)

Noticed presence of graphics (%)

139 (76.0)

86 (84.3)

77 (89.5)

302 (81.4)

Mean number of graphics recalled (min, max)

1.82 (0, 6)

1.83 (0, 6)

2.56 (0, 6)

2.01 (0, 6)

had similar effects including deterring school-aged adolescents from smoking and doubling the number of calls to the Australian Quitline.17---19 However, despite the high smoking uptake in the tertiary student population (aged 18---29), no study has been previously undertaken to examine the impact of cigarette packet graphical health warnings on this group.3

Holmesglen Institution of TAFE and 34 from The Glen Centro Shopping Centre. Participants were considered eligible if they provided information on smoking status, were aged 18---29 and studying at a tertiary institution. Surveys completed by more than one individual were excluded from analyses.

Unanswered questions were excluded from analyses. The data was analysed using SPSS (version 14.0) and Microsoft Excel (version 10.2614.3501).

Objective This evaluation measured the initial impact of the graphical health warnings within a population of tertiary students aged 18---29 in Melbourne, Australia, through their reported smoking status, time of cessation and influences on smoking cessation, .

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Method A cross-sectional self-administered survey assessed the impact of the new cigarette packet graphics through 18 multiple choice and four short answer questions (see Appendix 1). The survey elicited participants’ demographic data, smoking status and habits, awareness and thoughts about the new campaign, and changes to beliefs or behaviours. The survey was approved by the Monash University Standing Committee on Ethics in Research Involving Humans and piloted on a small group of young adults before distribution.

Smoking status was categorised by “I have never smoked a single cigarette”, “I have previously smoked” or “I currently smoke”.

Previous smokers were further classified as having stopped within the last 6 months, between 6---12 months or more than a year.

Identification of cigarette packet labelling as an influencing factor in a past smoker’s decision to quit was determined by rating “health warnings on cigarette packets” as having at least “a little” effect.

Participants’ written responses were categorised independently by two researchers as either positive (encouraged cessation or continued avoidance of smoking) or non-positive and disagreements were resolved by a third researcher.

Convenience sampling of young adults in the vicinity of the researchers were approached and invited to participate in the survey which was carried out during August 2006. An explanatory statement was issued with the self-administered survey, which was returned to a sealed box. Smoking and non-smoking participants were recruited from the Clayton campus of Monash University, the Chadstone and Waverley campuses of Holmesglen Institute of TAFE (Technical and Further Education), and a suburban shopping centre.

A total of 415 participants were surveyed of which 373 were considered eligible: 179 from Monash University, 160 from

Results There were a total of 373 eligible participants with 183 nonsmokers, 102 past smokers and 88 current smokers. The participants’ recognition and recall of the graphics on cigarette packets are shown in Table 1. Graphics recognition and recall was greater in current smokers compared to non-smokers or past smokers.

Amongst the 102 past smokers, a total of 34 people had ceased smoking in the six months after the release of the graphics compared to 13 people who quit in the previous six months.

Of these 47 past smokers, those who identified health warnings on cigarette packets as an influencing factor were significantly more likely to have quit in the six months following the release of the graphics compared to the previous six months (odds ratio 7.1, 95% confidence interval 1.31 to 38.8; p=0.023). However, the most common factors contributing to attempts or thoughts on

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smoking cessation, identified by past and current smokers, were cost (75.2%), family/household (73.3%) and friends (70.5%), with health warnings on cigarette packets at 52.4%.

Fifty percent of participants who noticed graphics on cigarette packets wrote a positive remark on the graphics’ effects such as “I have stopped”, “I have decreased in how many I smoke a day” and “[it] reaffirmed my anti-smoking beliefs”. There was no significant correlation between smoking status and whether participants wrote a positive remark (χ2 = 0.468, df = 2, p = 0.791). Nonpositive remarks included “I hide the packet”, “the pictures just said what I already knew”, “no change” and non-responses.

For full references see thelsjm.co.uk.

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Discussion While other studies have compared graphical warnings to text based warnings,20---22 assessed young adults’ perception of the graphics4, 15, 18 and examined the perceived impact of graphical warnings,13---22 they did not focus on the impact of these warnings on tertiary students in Australia. 23.6% of the study participants were current smokers, which is similar to the overall figures for the national smoking rates of 18---24 and 25---34 age groups.1 The limited number of tertiary institutions sampled and the method of selecting participants are potential sources of bias.

The high number of people who stopped smoking in the six months following the graphics’ release suggests that cigarette packet graphics could have a significant effect on smoking cessation. However, this result is potentially confounded by the release of television campaigns of a similar nature.23 Although the long term effects of the graphic health warnings could not be ascertained by this study, it has been shown that previous attempts to stop smoking is a predictor for future attempts at cessation and reduced smoking intensity.24, 25 While cost is a contributing factor to smoking cessation, it has been consistently increasing since 1993.26 Therefore, its effect on smoking cessation after the introduction of cigarette packet graphics should be minimal. While participants reported family and friends as contributing to thoughts and attempts on smoking cessation, this encouragement may have been motivated by their own viewing of the graphics.

Although this study was useful in measuring the possible shortterm impact of the graphics, further research is required on the actual long-term effects. A larger sample size of past smokers may allow comparative analyses between predictors of smoking cessation to be conducted. The delay between the official release date and actual sale of cigarette packet graphics in stores was another limitation, resulting in variable initial exposure amongst study participants. Participants who had cigarette packets in view, retrieved cigarette packets or discussed the survey with friends may have also confounded the results.

Conclusion Cigarette packet graphics appeared to encourage short-term smoking cessation in the participants surveyed. This pilot study has the potential to contribute to future studies focussing on tertiary students, however, due to the low statistical power and the use of convenience sampling, the generalisation of results to all tertiary students is limited. Future study is required to determine the long-term effects of graphic health warnings and other avenues for smoking cessation in tertiary students.

Acknowledgements This study was supervised by Associate Professor Ken Jones, Miss Tsharni Zazryn and Dr Craig Hassed. Assistance for statistical analyses was provided by Miss Tsharni Zazryn. Background information was provided by Julie Taylor and Sally McDonald from Department of Health and Ageing, Canberra. The researchers would also like to acknowledge Ms Victoria Cooper, Ms Bianca Ferrante, Mr Damien Smith and Ms Christina Taitt for allowing the research to be conducted at their respective locations.

The researchers received no funding for this study.

Conflicts of Interest To the best of the researchers’ knowledge, no conflicts of interest could be identified.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

1 Australian Bureau of Statistics. National health survey: Summary of results, 2007---2008 (reissue). Cat. No. 4364.0. Canberra: Australian Bureau of Statistics; 2009.

2 Australian Bureau of Statistics. Tobacco smoking in Australia: A snapshot, 2004---05. Cat. No. 4831.0.55.001. Canberra: Australian Bureau of Statistics; 2006.

3 Hammond D. Smoking behaviour among young adults: Beyond youth prevention. Tobacco Control. 2005;14(3):181---5.

4 Koval JJ, Aubut JA, Pederson LL, O’Hegarty M, Chan SS. The potential effectiveness of warning labels on cigarette packages: The perceptions of young adult Canadians. Canadian Journal of Public Health.

2005;96(5):353---6.

5 Mucha L, Stephenson J, Morandi N, Dirani R. Meta-analysis of disease risk associated with smoking, by gender and intensity of smoking. Gender Medicine, 2006;3(4):279---91.

6 Bjartveit K, Tverdal A. Health consequences of smoking 1---4 cigarettes per day. Tobacco Control. 2005;14(5):315---20.

7 Reardon JZ. Environmental tobacco smoke: respiratory and other health effects. Clinics in Chest Medicine. 2007;28(3):559---73.

8 Wang H, Preston SH. Forecasting United States mortality using cohort smoking histories. Proceedings of the National Academy of Sciences of the United States of America. 2009;106(2):393---8. Electronic publication.

9 Critchley J, Capewell S. Smoking cessation for the secondary prevention

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ABSTRACT

What are the beliefs of adult patients on the prevention of adult obesity in primary care?

A qualitative interview-based study Muhsanath M. Choudhury, BSc Medical Student, University College London m.choudhury@ucl.ac.uk doi:10.4201/lsjm.med.012 With: Dr Richard Meakin MD MSc FHEA (Clinical Senior Lecturer in General Practice), University College Medical School, London.

Background: Obesity is an increasing problem for health care. Associated comorbidities are increasing with damaging effects on health and medical expenditure. The literature suggests the existence of weak interventions and identifies multiple barriers to obesity prevention.

PIC

Aims & Objectives: This study aimed to explore patientsâ&#x20AC;&#x2122; beliefs on adult obesity prevention in order to better understand this problem and suggest prevention methods that are tailored to these beliefs.

Methods: The study was a qualitative interview study using audio-taped semi-structured interviews. The interviews took place in an urban practice in North London where patients were recruited using posters and handouts. The subjects consisted of 14 adults, 7 male and 7 female with a wide range of characteristics (age, occupation, ethnicity and Body Mass Index). The collected data was analysed using the framework analysis technique.

dual-approach to personalised care through patient-centredness and doctor-direction leading to empowerment was preferred by patients.

Comments: Few UK qualitative studies on patient beliefs regarding obesity prevention exist. This study uncovered beliefs, which may have a potential impact on medical education, clinical practice and health policy. Suggested interventions include, community activity programmes and group education settings held by GPs and other health professionals. The GP was seen as having the pivotal role as the main coordinator. These would address patient motivation and empowerment but the training of students and professionals would need to be addressed. Further research is indicated to further explore patientsâ&#x20AC;&#x2122; beliefs and to explore the views of GPs and other members of the primary care team involved in obesity prevention.

Results: Seven key themes emerged from the analysis which were: Time, Information, Awareness, Individuality, Getting Help, Understanding My Problem and Modern Living. Generally patients recognised a lack of public awareness and education as well as patient and doctor barriers affecting adherence to lifestyle change. Furthermore a

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271

ARTICLE

A discussion of drug-induced hyponatremia Tracey Liebman

Year 3 Medicine, New York University School of Medicine tracey.liebman@med.nyu.edu doi:10.4201/lsjm.med.011

Image: Wellcome Image

Diuretics Thiazides and loop diuretics have been implicated in association with hyponatremia. Thiazides have been shown to cause more cases of hyponatremia when compared to loop diuretics, though the mechanism not fully explained. Thiazides block the reabsorption of sodium and potassium at the distal convoluted tubule. Therefore, solutes are lost in the urine, and the ability to dilute the urine is diminished. Thiazides also lead to volume depletion, which is a stimulus for ADH release and can increase thirst. 2 Thiazides may also cause an idiosyncratic reaction that occurs rapidly and would therefore be more dangerous 1.

Thiazides do not inhibit the ability of the kidney to concentrate urine, though loop diuretics interfere with concentration and

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dilution abilities. Thiazides were shown in one study by Liamis et al to be the most common cause of â&#x20AC;&#x153;community-developed hyponatremiaâ&#x20AC;?.2,2a The thiazide-induced hyponatremia has been seen often in elderly individuals.2,2a Individuals with low body mass and with hypokalemia are also at risk 1. In some studies, females have been shown to have a greater risk than males, but this has been controversial.1,2 Psychiatric medications Selective serotonin reuptake inhibitors and atypical antipsychotics may lead to SIADH and can cause hyponatremia. This possible complication is not common.3However; this can occur rapidly and therefore the harmful effects of acute hyponatremia may occur.

There have been reports that all SSRIs can cause hyponatremia, but many of the studies are small and confounding factors abound. The hyponatremia soon is eliminated with removal of the drug; some studies have shown that it may be possible that patients may develop tolerance and that the hyponatremia effect could decrease. However, the overall risk of hyponatremia may be underestimated because cases may be asymptomatic In elderly patients who are taking SSRIs, the risk of hyponatremia is increased; for instance, the Swedish Adverse Drug Reactions Advisory Committee found that individuals over 70 years old had an increased risk.4 Patients should undergo fluid restriction and removal of the medication. Other classes of psychiatric drugs that may lead to hyponatremia include tricyclic antidepressants, monoamine oxidase inhibitors, nicotine, methadone, and benzodiazepines.

However, the number of possible cases is extremely low. For example, in the literature there are fewer than 10 reported cases of hyponatremia associated with atypical antipsychotics.3 Antiepileptic medications Various antiepileptic medications have been associated with hyponatremia, as well. For instance, carbamazepine, oxcarbazepine, valproic acid, and lamotrigine have been implicated. In various studies, the rate of hyponatremia in patients treated with carbamazepine has ranged in 1.8% to 40% and with oxcarbazepine the rates have ranged from 23% to 73%.5 Many of these studies, as well, have been confounded by other factors that may increase the patientâ&#x20AC;&#x2122;s risk of hyponatremia such as increased age and other medications. The mechanism by which these antiepileptic drugs cause hyponatremia is not fully elucidated, but it may occur by increased reabsorption of water in the collecting tubule of the kidney.5 Many of these cases, as well, are asymptomatic and occur early in treatment.

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Image: Wellcome Image

The cause of hyponatremia in a patient may be difficult to figure out, and the differential diagnosis can be complicated.

Hyponatraemia, which is defined as serum sodium concentration less than 135 meq/L and is the most frequent electrolyte disorder in clinical practice, has a variety of etiologies, but can be caused by or complicated by the effect of medications.1 There are many categories of drugs that are associated with hyponatremia, including diuretics, psychiatric medications, antiepileptic drugs, and others.

ARTICLE

PIC

Others Chemotherapeutic agents such as vincristine, vinblastine, cyclophosphamide, cisplatin, and melphalan can stimulate the release of ADH and lead to hyponatremia.6

References

Angiotensin converting enzyme inhibitors, such as Lisinopril, have been described in very few cases in the literature to possibly be associated with severe hyponatremia. In these cases, the hyponatremia began after the ACE-inhibitor treatment was initiated, and it improved within days after the drug was stopped.

The mechanism by which ACE-inhibitors are associated with hyponatremia is unclear, however, and some of these patients in the literature had also been taking other medications concurrently, so causality is difficult to prove.7, 8

3.

Omeprazole has been noted in case reports to be associated with SIADH and reversal of hyponatremia was noted when the drug was discontinued, but these findings are not well documented.9 Ecstacy (3,4-Methylenedioxymethamphetamine) may also lead to temporary increase in ADH along with ingestions of large quantities of water. This can bring about a symptomatic hyponatremia with symptoms such as confusion or coma and should be treated with water restriction.10 Conclusion A multitude of drugs can contribute in some way to SIADH and hyponatremia, and clinicians should not fail to consider these medications when evaluating a patient with complicated electrolyte disturbances.

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1.

2.

4.

5.

6.

7.

8.

9.

10.

Chow, K.M. et al. “Risk factors for thiazide-induced hyponatremia.” QJM. 2003 Dec; 96 (12) 911.2a. Liamis, G. “Blood pressure drug therapy and electrolyte disturbances.” Int J Clin Pract. 2008; 62(10):1572-1580.

Liamis, G et al. “A Review of Drug-induced Hyponatremia.” Am J Kidney Dis. 2008; 52: 144-153.

Kohen I et al. “Anti-Psychotic-induced hyponatremia: case report and literature review.” Am J Ther. 2008; Sep-Oct; 15(5): 492-4.

Kirby, D and D Ames. “Hyponatremia and selective serotonin re-uptake inhibitors in elderly patients.” Intl J of Geriatr Psychiatry 2001; 16: 484-493.

Castilla-Guerra L et al. “Electrolyte disturbances and Seizures.” Epilepsia.

2006; 47 (12) 1990-1998.

Raftopoulos, Harry. “Diagnosis and management of hyponatremia in cancer patients.” Support Care Cancer. 2007; 14:1341-1347.

Izzedine, Hassane et al. “Angiotensin-converting enzyme inhibitor-induced syndrome of inappropriate secretion of antidiuretic hormone: Case report and review of the literature.” Clin Pharm and Therapeutics. 2002 Jun;71(6):503-7.

Hussain A Shaikh, Zakir. “Syndrome of Inappropriate Antidiuretic Hormone Secretion Associated with Lisinopril.” Annals of Pharmacotherapy. 2000; 34:176-9.

Durst, Ronen Y et al. “Hyponatremia caused by omeprazole treatment.” Am J Med. 1994 Oct; 97 (4): 400-1.

Farah, Raymond and Rola Farah. “Ecstasy-Induced Inappropriate Antidiuretic Hormone Secretion.” Pediatric Emergency Care. 2008; 24(9) 614-617.

11.

Other resources Fauci AS, Braunwald E, Kasper DL, SL Hauser SL, Longo DL, Jameson JL, Loscaizo J (eds), Harrison’s Principles of Internal Medicine, 17e. New York, McGraw-Hill, 2008.

Milionis, Haralampos et al. “The hyponatremic patient: a systematic approach to laboratory diagnosis.” CMAJ 2002; 166 (8): 1056-62.

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REVIEW

Familial Hypercholesterolaemia Farwah Mehdi

Medical Student, University College London farwah.mehdi@ucl.ac.uk doi:10.4201/lsjm.med.013

ABSTRACT Background Those diagnosed with Familial Hypercholesterolaemia (FH) can improve their health by changing their behaviour. Health professionals should advise them to reduce fat intake, increase physical activity and stop smoking. A genetic test is available that can confirm the diagnosis of FH in those with high cholesterol.

A potential concern is that this may undermine the likelihood of clinicians to give this advice and/or patients to follow it.

Aims This cross-sectional interview study investigates: I. The ways in which clinicians giving genetic test results confirming a diagnosis of FH present the issue of behaviour change and II. Patientsâ&#x20AC;&#x2122; attitudes towards this advice and their motivation to make behavioural changes.

Method The study sample comprised of seven FH patients who had received test results detecting the presence of a genetic mutation.

These results were given to patients by a clinician during a specially arranged consultation. In-depth interviews were conducted with participants approximately one month after the results meeting, to achieve a better understanding of the impact of genetic testing on the thinking and behaviour of these individuals. Audio-recordings of the consultations and interviews were transcribed, anonymised and analyzed using both qualitative thematic and quantitative content analysis.

PIC

Results Clinicians discussed the genetic cause of the condition and downplayed the role of behaviour and the desirability of behavioural changes: indications were made towards such changes being ineffectual in significantly reducing cholesterol levels.

The emphasis was on medication as the most effective method in controlling cholesterol levels. Similarly, most patients were

274

very confident about being able to adhere to medication and its efficacy in reducing cholesterol levels. However, patients also reported that they had made behavioural changes prior to genetic testing and were optimistic about attempting to maintain them.

Conclusion Clinicians and patients appeared to have different models regarding behaviour change: patients recognised the value of lifestyle behaviour changes in combination with medication in managing FH, whereas clinicians emphasised the importance of medication. More research is needed to investigate ways in which clinicians could communicate with patients to encourage the adoption of lifestyle behaviour changes, as well as adhering to medication. Future research should explore the impact of genetic testing on the behaviour of those for whom genetic testing provided a new medical diagnosis, rather than, as in FH, confirming an existing one.

INTRODUCTION Genetic testing is available for an increasing number of multifactorial conditions, which consist of a genetic component and are also influenced by the individual lifestyle choices that people make (Khoury et al., 2005; Yang et al., 2005). The rapid growth of this relatively new medical technology raises a variety of psychological and social issues that need to be addressed in order to appreciate its full potential.

There are fears that the provision of personal genetic risk information will instigate a feeling of fatalism, with those tested experiencing diminished control over their condition and a reduced motivation to adopt risk reducing behaviour (Senior, Marteau and Peters, 1999; Marteau and Lerman, 2001; McClure, 2002; Haga, Khoury and Burke, 2003; Marteau and Weinman, 2006). A hypothetical study investigated the potential behavioural consequences of genetic testing for obesity risk.

Participants assigned to a genetic high-risk group perceived to

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REVIEW

have less control over their behaviour than a genetic average risk group. However, there was no difference in the intention to eat a healthy diet between those given a high risk result based on a genetic test, and those given the same result determined via a hormone test (Frosch, Mello and Lerman, 2005). Another study of three hundred and forty-one families assessed the psychological impact of genetic testing to make or confirm a clinical diagnosis of FH, and found no support for the proposal that detection of a mutation precipitates fatalistic reactions. Results suggested that participants perceived biological methods used to control cholesterol levels to be more effective than behaviour changes, such as diet, owing to the genetic basis of the condition (Marteau et al., 2004).

Some studies suggest that people are more likely to make healthier lifestyle changes subsequent to receiving personal genetic risk information (Audrain et al., 1997; McBride et al., 2002; Botkin et al., 2003; Schwartz et al., 2003). Patients from nine UK genetics centres that had undergone predictive genetic testing for breast and ovarian cancer predisposition by means of detecting mutations in the BRCA1 and BRCA2 genes, were asked to complete self-report questionnaires that considered the matter of risk management behaviour. Female gene mutation carriers were more inclined to embrace risk management strategies than non carriers in the year following the test. For example, ninety-two percent of carriers versus only thirty percent of noncarriers reported having had mammograms twelve months post-testing (Watson et al., 2004). Similarly, a recent analogue study recruited two hundred and sixty-one smokers who were randomly assigned to a scenario of having either a genetic or an oxidative test to assess heart disease risk. Results indicated that the genetic test-high risk group had a greater intent to quit smoking relative to the oxidative test-high risk group, which was partly due to a belief that smoking cessation would reduce chances of developing heart disease (Sanderson and Michie, 2007).

Genetic testing is available for those affected by Familial Hypercholesterolaemia (FH) and, using cascade DNA testing, to aid in the accurate identification of family members that may also be affected (NICE CG71, 2008). FH is a dominantly inherited condition affecting one in five hundred of the general population but with a current detection rate of only 10% (Marks et al., 2004).

Traditionally, the condition has been diagnosed clinically by the presence of elevated levels of low-density lipoprotein cholesterol (LDL-C), tendon xanthomata, premature onset of CHD and a family history of hypercholesterolaemia and premature CHD (Ward et al., 1996; Marteau et al., 2004). A number of mutations in the low-density lipoprotein receptor (LDL-R), apolipoprotein B (APOB) and PCSK 9 genes have now been robustly associated with FH (Austin et al., 2004). This knowledge has been used in the development of genetic testing as a method of confirming

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a clinical diagnosis in patients with FH (Marks et al., 2003), enabling those individuals to make behavioural changes to improve their long term prognosis (Marks et al., 2006). Where a LDLR/ APOB/PCSK 9 mutation is detected patients are advised to reduce dietary fat intake, take regular exercise, avoid smoking and adhere to prescribed lipid lowering medication (Betteridge et al., 1999).

The aim of this project was to explore the impact of genetic testing on the health behaviour of FH patients and their relatives who have undergone genetic testing. A cross sectional interview study was conducted with patients recruited from a lipid clinic who had received a positive genetic test result, indicating the presence of a LDLR/APOB mutation. As part of the genetic service offered, participants attended a consultation in which a clinician communicated the test results. Specific research questions were: 1. How do clinicians present the issue of behaviour change?

2. What are the attitudes of participants towards behaviour change?

3. Does detection of an FH-causing mutation have an effect on motivation to make behavioural changes?

The design of this study builds on prior studies since it investigated the way in which people talked about health behaviour, rather than using questionnaires with predetermined responses (Michie et al., 2003; Marteau et al., 2004). Much research has addressed similar questions in the context of other multifactorial conditions using an experimental analogue design and hypothetical scenarios (Frosch et al., 2005; Wright et al., 2008). This project was a real clinical situation with patients that had actually undergone DNA testing for FH, for which little qualitative work has previously been undertaken.

To the authorâ&#x20AC;&#x2122;s knowledge, there has been no previous work looking at the way clinicians communicate information regarding lifestyle behaviour changes, in the context of FH. However, this issue has been researched in primary care settings with family practitioners counselling patients to make lifestyle changes for both genetic and non-hereditary conditions (Arborelius, 1996; Arborelius and Bremberg, 1994). There is tentative evidence to suggest that clinicians may be less likely to use motivational strategies on patients with conditions believed to have a genetic cause (Thompson, Schwankovsky and Pitts, 1993).

As well as adding to our understanding of patientsâ&#x20AC;&#x2122; reactions to a relatively new medical technology, the results of this project will be useful to health professionals in terms of communicating genetic information in a way that increases motivation to reduce risk. There may also be implications for the training of genetic

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REVIEW counsellors to increase their understanding of the psychological impact of the information they provide on their patients’ behaviour in relation to health.

METHOD Design This is a cross-sectional interview study.

Sample The recruitment of FH patients for DNA testing was ongoing as part of a three year DH-funded research arm of the UK FH Cascade Audit Project at the Royal Free Hospital. There were a total number of seven participants, who were FH patients that had received a positive DNA test result, (identification of a genetic mutation), to confirm the clinical diagnosis of the condition. The criteria for FH diagnosis are predefined (Betteridge et al., 1999), as are the methods for mutation detection (Heath et al., 2001).

Participants are referred to by a number (e.g. III) to preserve anonymity.

Procedure Approval from the NHS ethics committee was granted for this research project. Informed consent was obtained for samples to be taken from patients and sent to the DNA diagnostic laboratory at Great Ormond Street Hospital for analysis. A target of three months was set for returning the final test results of participants, on receipt of which, patients were invited to the Royal Free Clinic to be given their results by a clinician and arrange follow-up for family members. Consent was also obtained for the results consultation to be tape-recorded. During this meeting, patients were given a verbal introduction to the study by the Genetics Nurse, a further information sheet to read and an informed consent sheet to sign and return if they wished to participate.

Those that agreed to take part in the study were contacted to arrange an interview approximately one month after receiving the test result, which were completed either in the patient’s home or in a special clinic visit, as preferred by participants. Qualitative, indepth interviews were conducted by the researcher of this project to gain an understanding of two general issues: communication of genetic information within a family and the impact of this information on the thinking and behaviour of individuals. The interviews were semi-structured and started with a schedule but important topics were probed as they arose. Both the interview and consultation for each of the seven participants were tape recorded, transcribed and anonymised, generating fourteen transcripts for analysis.

Analysis The interview and consultation transcripts for each of the seven FH patients were read and re-read individually by the author to identify and extract quotations relating to: 1.

2.

3.

The way clinicians presented the issue of behaviour change.

The attitudes expressed by patients towards behaviour change.

Responses given by patients regarding their motivation to make behaviour changes.

This process entailed considering both lifestyle behaviour changes (e.g. diet, physical activity, smoking and cholesterol checks) and

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medication use but as two separate categories.

A word search was then carried out for each transcript using the Microsoft Word package to ensure that all relevant quotations had been gathered. Words that were used included: pills, tablets, medicine, medication, statins, drugs, prescription, treatment, diet, fat, oil, sugar, alcohol, food, weight, healthy, habit, intake, drink, eat, physical, activity, exercise, gym, sport, walk, fit, active, smoke, cigarettes, check, test, level, precautions and cautious.

One consultation and one interview transcript containing a high frequency of quotations, as deemed by the author, were emailed to the researcher involved in the project to read, and similarly extract relevant passages of the transcripts. A comparison was then made to check whether the researcher and author had identified the same quotations.

Qualitative thematic analysis (Joffe and Yardley, 2004) was carried out for each participant individually, using the quotations separated from both consultation and interview transcripts.

Emergent themes for each patient, together with the illustrative quotations, were emailed to the principal investigator of the project to be checked and refined. These themes were then compared across all participants and used to devise a coding frame to identify and categorize the parts of the transcripts that addressed the specific research questions of this study.

The frequencies of illustrative quotations for each theme were recorded, with totals, averages and ranges subsequently being calculated to give a quantitative content analysis. In addition, the number of lines of interview and consultation transcripts and, therefore, percentage of total transcript that referred to behaviour was worked out for both patients and clinicians. All figures were calculated to one decimal place.

By convention, all elisions in the text will be indicated by three dots, with square brackets used for insertions or clarifications made by the author. (Green and Thorogood, 2004, pg. 101).

All quotations are labelled as follows: (VII, C/I, pg 3, 115-117).

This information translates to the participant number, source of the quotation; where ‘C’ represents the consultation transcript and ‘I’ the interview transcript, page number and line numbers.

‘C’, ‘P’ and ‘I’ are the abbreviations used to indicate whether the quotations belong to the clinician, participant or interviewer respectively.

Results References to four different behaviours were made across interviews conducted with the seven participants: diet, physical activity, monitoring cholesterol levels via regular tests or appointments and medication. Additionally, participants I and III mentioned that they had given up smoking during consultations with the clinician but not when interviewed: And then I stopped smoking (III, C, pg 2, 70) In the past I was, I have been, I have, I smoked for, and I have given it up from 18 years. In 1989, I think, as far as I remember, I gave it up. I was smoking earlier. (I, C, pg 8, 339-241) The range of references made to behaviour over individuals was ten, and for across all four behaviours was sixteen. Table 2 indicates that references were made to medication and diet by

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REVIEW Table 1: Demographic characteristics of participants recruited in study Participant Number I II III IV V VI VII

Gender

Age (Years)

Male Female Female Female Female Female Male

Nationality

77 64 Unknown 75 75 29 46

Ethnic Group

Iraqi British British British British Kosovan Turkish

Non-White White White White White Non-White Non-White

Table 2: Frequency of references made to behaviour by participants during interviews Participant Number I II III IV V VI VII

Diet 3 3 4 2 1 4 3 20 2.9

Total Average number of references per participant Range of references made between each behaviour

Physical activity 0 0 3 0 1 2 1 7 1.0

3

3

Cholesterol tests and appointments 1 3 1 2 0 3 2 12 1.7

3

Medication 1 4 6 5 1 2 4 23 3.3

Total 5 10 14 9 4 11 10 62 8.9

5

Table 3: Percentage of total interview transcript that referred to behaviour (diet, physical activity, cholesterol tests/appointments and medication) for participants Participant Number

I II III IV V VI VII Average From table 3 and 4 it is evident that the issue of health behaviour comprised of less than 10% of the interview and consultation transcripts. However, the percentage of total interview transcript that referred to health behaviour was almost double that of the consultation transcript.

How do clinicians present the issue of behaviour change?

Three categories were derived from the ways in which the clinician related the matter of lifestyle behaviour changes to participants

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Number of lines of transcript referring to behaviour 28 82 46 62 13 58 46

Percentage of interview transcript referring to behaviour (%) 3.0 7.1 5.6 6.7 1.8 7.2 3.7 5.0

across all seven consultations, as illustrated in table 5. The clinician commenced five of the consultations in a similar manner by mentioning that a link existed between different lifestyle choices made by individuals and cholesterol levels: *Um, so thereâ&#x20AC;&#x2122;re lots of reasons why people can have raised cholesterol other than genetic reasons, just from diet, eating the sort of fat in the diet, and not taking enough exercise. (III, C, pg 1, 17-19)

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REVIEW Table 4: Percentage of total consultation transcript that referred to behaviour (diet, physical activity, cholesterol tests/appointments, smoking and medication) for clinicians Participant number

Number of lines of transcript referring to behaviour

I II III IV V VI VII

36 11 83 20 9 9 3

Average

Percentage of consultation transcript referring to behaviour (%) 3.1 1.3 6.5 2.0 1.4 2.2 1.5 2.6

Table 5: Categorization of the ways clinicians presented lifestyle behaviour changes to participants Participant number

I II III IV V VI VII Total

Instances that clinician downplayed lifestyle behaviour change in context of genetic cause and/or medication 2 1 1 1 1 0 1 7

Instances that a link between behaviour change and cholesterol was mentioned

Total

3 0 4 0 0 0 0 7

1 1 1 0 1 1 0 5

7 2 6 1 2 1 1 19

Clinicians downplayed lifestyle behaviour changes in six out of seven consultations by placing less emphasis on the potential efficacy of such changes in reducing cholesterol levels. Only in the cases of participants I and III did the clinician advise on the utility of some lifestyle behaviour changes, however others were simultaneously downplayed, thus providing these two patients with conflicting advice regarding the overall benefit of lifestyle behaviour changes. For example, during the consultation with participant III, physical activity was encouraged whilst diet was downplayed in the context of the genetic cause of FH by the clinician:

that doesn’t have that much effect on the problem. (III, C, pg 2, 61-68)

P: I do take a lot of exercise… I just walk everywhere… so I do do a lot of walking actually…I love it, even in the winter, it doesn’t matter - you know what I mean?

C: ... it’s helping your cholesterol as well (III, C, pg 1, 21-50)

a)

b)

P: I do eat very healthily…I don’t eat chips and I don’t eat takeaways, and I cook everything myself, and I do eat fruits, but you know, so I’m doing my best and there’s nothing more, really, I can do about it.

C: Yeah, that sounds perfect, so for someone who doesn’t have a genetic cause, then doing all that can help, but if you’ve got FH all

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Instances that clinician positively promoted lifestyle behaviour change

The effectiveness of medication was always reinforced by the clinician when broached in five of the consultations, as discerned from table 6. Likewise, all seven participants showed evidence of adhering to the prescribed statins and no predicaments were reported in implementing this behaviour change.

The attitudes identified from analysis of the transcripts were broadly divided into those in which patients: Felt positive about carrying out behaviour changes and/or expressed a belief that these were effective in controlling cholesterol levels.

Felt pessimistic about the potential value of behaviour changes and/or held the view that these were not effective in reducing cholesterol levels.

As observed from table 7 and 8, the total frequency of statements made by patients that reflected a feeling of control with respect to behaviour change was higher than those that alluded towards a perceived lack of control. A greater number of attitudes expressing confidence in medication as opposed to lifestyle

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REVIEW behaviour changes were also recorded. Participants II, III, IV and VI all believed that medication effectively reduced their cholesterol levels. In the instances that participants I and III exhibited a degree of pessimism and loss of confidence in medication and diet, it was noted that this was not accompanied by a reduced motivation to adhere to those particular changes.

Motivation to make behaviour changes Two of the participants revealed that genetic testing had impacted on their motivation to make behavioural changes, as shown in table 9. Participant VII exhibited a greater inclination to increase his physical activity levels, whilst participant VI indicated that her diet had become less rigid as a result of testing positive for a genetic mutation. In the case of the latter, this was owing to an attribution of the condition to genes and a belief that diet no longer had a causal influence on cholesterol levels. Referring back to table 5, it can be seen that the clinician only mentioned the presence of a link between cholesterol and behaviour change during the consultation with participant VI, and in fact downplayed behaviour change in the meeting with participant VII. Participants I, II, III and IV demonstrated efforts to try and persevere with lifestyle behavioural changes made prior to testing, and showed an awareness of the different approaches used in managing cholesterol levels.

value of any previous encouragement given. Medication use was positively promoted when mentioned during consultations and emphasis placed on this biological based way being more effective than any behavioural changes made to lifestyle.

There was no evidence of feelings of fatalism as a result of receiving a positive genetic test result, with most participants conveying optimism and confidence in maintaining risk-reducing behaviour. The patients who did express a degree of pessimism did not completely withdraw from engaging in those particular behaviours but showed attempts to comply with the approaches used in treating FH. These results can be considered in the context of Leventhalâ&#x20AC;&#x2122;s common sense model of self-regulation of health and illness, which describes the way health risk information evokes cognitive representations of the threat in people based on five dimensions: identity, cause, timeline, consequences and control (Cameron and Leventhal, 2003). This is used as guidance in determining which strategies should be drawn upon in order to control the threat. The outcomes are then appraised and used to feed back to their appraisals of threat and coping. Patients in this study were previously aware and being treated for their clinical diagnosis of FH, and so had experience of methods effective in controlling cholesterol levels, by undergoing continual evaluations to ascertain which behaviours to pursue and maintain. Therefore, the threat posed by FH was perceived as being a controllable one by most participants. (Marteau and Weinman, 2006).

Three models emerged with respect to the utility of lifestyle behaviour changes, as illustrated by the quotations in tables 10 a), b) and c):

Confirmation of a clinical diagnosis of FH via genetic testing did not appear to alter the overall motivation of patients to make behavioural changes in relation to health. Most participants 1.

Due to genetic cause of FH and/or because the patient continued to apply the same management techniques to control

is taking medication, lifestyle behaviour changes do not cholesterol levels that were being used prior to testing positive

make much difference. for a mutation; namely a combination of adhering to prescribed 2.

Lifestyle behaviour changes are important. medication and attempting to be more cautious with their diets.

3.

Lifestyle behaviour changes work in combination with This is consistent with a previous randomized controlled trial in

medication. which there was no difference in the total fat intake, frequency of vigorous exercise, self reported rates of smokers and number of Clinicians and patients did not share the same models, since in participants taking statins amongst those with a genetic diagnosis most cases clinicians demonstrated a belief that lifestyle behaviour of FH and those with just a clinical diagnosis for the condition changes made no difference to cholesterol levels due to the (Marteau et al., 2004). Similarly, there was no significant genetic basis of FH and/or in the context of medication. However, difference in the levels of attendance for mammography in females most of the participants recognized the importance of making before and after receiving genetic test results that revealed an behavioural changes in addition to medication use. increased predisposition to inheriting breast cancer (Lerman et al., 2000). A further study, of analogue design, found that genetic DISCUSSION risk information did not encourage adults to engage in riskIn this study, clinicians predominantly downplayed lifestyle reducing behaviour to a greater extent than receiving family-history behaviour changes by indicating that such changes were ineffective based risk information (Hicken and Tucker, 2002). A speculative in reducing cholesterol levels due to the genetic cause of FH. explanation in the context of this project is that people strive to Comparisons were also made to the beneficial impact lifestyle perceive their world as being stable, predictable and controllable behaviour changes had in those individuals with high cholesterol by contriving causal explanations for events (Heider, 1958). Hence, levels that were not under the influence of a genetic component. holding the view that FH is influenced by both genes and lifestyle This provides support for the suggestion that physicians are enables an increased perception of control (Senior et al., 2002). less likely to use motivational strategies in case presentations The one participant that did reveal a reduced adherence to diet of hereditary conditions (Thompson, Schwankovsky and Pitts, after receiving the genetic test results attributed her condition 1993). Patients were not advised to make lifestyle behavioural solely to genes and rejected the idea of diet having an effect on her changes in any of the consultations. However, when patients cholesterol levels. This may have reduced the patientâ&#x20AC;&#x2122;s perception initiated discussion regarding the utilisation of different techniques of control over FH and so weakened her will to maintain a to manage FH, clinicians praised and advocated their efforts in restrictive diet. Although variation was observed across participants attempting to lower cholesterol levels. In these instances, other regarding their views on the relative effectiveness of different lifestyle behavioural changes were simultaneously downplayed risk-reducing behaviours, no-one reported FH treatment to be by the clinician, which may have reduced the overall benefit and completely ineffectual (Senior, Marteau and Weinman, 2005).

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REVIEW

All participants exhibited adherence to prescribed statins and this was generally regarded as an effective means of controlling cholesterol levels, with no concerns reported in implementing this behaviour. The study by Marteau and colleagues (2004), also investigating the psychological impact of genetic testing for FH, suggested that on receiving results testing positive for a mutation, patients altered their perceptions of the way in which control of cholesterol levels was best elicited. Learning of the genetic basis of the condition reinforced biological methods of control (e.g. medication) versus behavioural changes, principally dietary interventions. This is also supported by an analogue experimental study that explored smoking cessation in smokers who were given the hypothetical situation of testing positive for a genetic predisposition to nicotine dependence. Participants were more likely to opt for pharmacological methods to aid in quitting smoking and less likely to use willpower. Overall perceptions of control were not significantly different between gene positive and gene negative individuals (Wright, Weinman and Marteau, 2003). The current study cannot provide further support for this hypothesis, since although FH patients did show confidence in the value of statins, lifestyle behavioural changes were not simultaneously downplayed by all participants.

For full references see thelsjm.co.uk.

Overall, clinicians and patients did not hold the same models with respect to behaviour changes. Whereas clinicians reinforced cholesterol-lowering medication as the best way to treat FH, patients adopted a multifactorial approach: taking medication in combination with attempting to adhere to lifestyle behaviour changes. Following genetic counselling, patients use beliefs about inheritance, personal and family experience to regenerate their risk perceptions (Emery, Kumar and Smith, 1998; Peters and Biesecker, 1997). A study demonstrated that only 9% of relatives of Cystic Fibrosis patients obtained knowledge of the disease from a genetic counsellor, with the rest being accessed from family members and family doctors (Denayer et al., 1992). It was found that people perform correctly on knowledge tests about the condition but convey beliefs and understandings that differ from this knowledge (Weil, 1991; Shiloh, 2006). This may explain the findings in relation to participant VI, who had an increased motivation to increase physical activity levels despite the clinician downplaying this behaviour change during her results meeting.

The ethnic group of the patient may have had a bearing on health behaviour and the attitudes expressed towards FH. There is evidence to suggest that cultural, ethnic and religious factors are accounted for when individuals interpret genetic information (Richards, 1996; Wilson et al., 2004). These factors may incite discordance between professional and lay theories, resulting in reluctance on the patient’s part to endorse the advice given by clinicians (Browner et al., 2003; Shiloh, 2006).

Caution should be taken in making generalizations from this study since it comprised of a small sample, was drawn from one lipid clinic and patients were tested for one condition. The fact that the patients already had a clinical diagnosis of FH, were taking medication, regularly attending the lipid clinic, and agreed to take part in the study means that the genetic test results probably had less of an impact on behaviour than on those individuals previously unaware of a diagnosis of FH. In addition, most patients were over sixty years of age and so had previous experience of dealing with the condition. An earlier study also found that older patients are

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more likely to report total adherence to behaviours in treating FH (Senior et al., 2002). The cognitive representations formed by individuals in response to health risk information are dynamic and change over time, thus the attitudes and beliefs captured during the interview, which was held one month after receiving the test results may be subject to change (Hallowell and Richards, 1997) The main implication of this project concerns effective communication with patients about the benefits of lifestyle behaviour changes, even when a condition is attributed to a genetic cause. A patient-centred approach should be used to gauge an appreciation of the patient’s own unique beliefs, understanding and social environment to facilitate in empowering individuals to make behaviour changes (Lynch and Lynch, 1996).

Studies researching the effect of ethnic group on health behaviour are required to ensure genetic services facilitate informed decision-making in the cosmopolitan environment of the UK. Future research should explore whether the same results are obtained in a population previously unaware of the possible diagnosis, such as relatives who have tested positive for a genetic mutation. Further work is also needed to investigate ways of communicating with these patients in order to encourage their engagement with healthy lifestyle behaviour changes, in addition to adhering to their medication regime.

Acknowledgements I am very grateful to Susan Michie for all her support, guidance, helpful comments and suggestions and to Caroline Dancyger for the all the data collection of this project.

References 1.

2.

3.

4.

5.

6.

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Arborelius E and Bremberg S. (1994). Prevention in practice. How do general practitioners discuss life-style issues with their patients?

Patient Education and Counseling. 23, 23-31 Arborelius E. (1996). Using doctor-patient communication to affect patients’ lifestyles. theoretical and practical implications.

Psychology and Health. 11 (6), 845-855.

Audrain J, Boyd NR, Roth J, Main D, Caporaso NF and Lerman C. (1997). Genetic susceptibility testing in smoking- cessation treatment: one-year outcomes of a randomized control trial.

Addictive behaviors. 22(6), 741-751 Austin MA, Hutter CM, Zimmern RL and Humphries SE. (2004).

Genetic causes of monogenic heterozygous Familial Hypercholesterolaemia: a HuGE prevalence review. American Journal of Epidemiology. 160(5), 407-420.

Betteridge DJ, Broome K, Durrington PN, Hawkins MM, Humphries SE, Mann JI, Milller JP, Neil HAW, Thompson GR and Thorogood M. (1999). Scientific steering committee on behalf of the Simon Broome Regisetr Group. Mortality in treated heterozygous familial hypercholesterolaemia: implications for clinical management.

Atherosclerosis. 142, 105-112.

Botkin JR, Smith KR, Croyle RT, Baty BJ, Wylie JE, Dutson D, Chan A, Hamann HA, Lerman C, McDonald J, Venne V, Ward JH and Lyon E. (2003). Genetic testing for BRCA1 mutation: Prophylactic surgery and screening behaviour in women 2 years post testing. American Journal of Medical Genetics. 118, 201-209.

Browner CH, Preloran HM, Casado MC, Bass HN and Walker AP. (2003). Genetic counseling gone awry: miscommunication between prenatal genetic service providers and Mexican-origin clients. Social Science and Medicine. 56 (9), 1933–1946.

Cameron LD, Leventhal H. (Eds.) (2003). The Self-Regulation of Health and Illness Behaviour . London : Routledge.

lsjm 30 april 2010 volume 01

ABSTRACT

The media and medical response to the introduction of prescription charging in the National Health Service Louis John Koizia

Keywords: • NHS • Prescription • BMA

Image: Wellcome Image

Year 5 Medicine, Imperial College London louis.koizia05@imperial.ac.uk

Abstract: In April 2009 the National Health Service (NHS) prescription charge rose to £7.20 in England, whereas in Wales prescriptions have been free since 2007. This major difference has led to much controversy amongst the public, media and medical profession.

When established on July 5th 1948 the NHS provided free healthcare including prescriptions to the entire population of Britain. However, concerns arose shortly after establishment, when in 1949 the expenditure of the NHS was far in excess of the initial estimate; By June 1952 the Conservative government introduced a one shilling prescription charge. Previous literature has focused on the political debate which surrounded this charge. The purpose of this paper is to historically assess the response from the media and the medical profession. Information gathered from the newspapers, despite their differing readerships and political affiliations, revealed that the media generally accepted the charge with little opposition. In contrast, large debate and divisions arose amongst the medical profession, with huge volumes of literature being published in medical journals throughout 1952 on the issue. The London based British Medical Association opposed the charge as they felt doctors were not government tax collectors; whereas rural doctors became concerned that the charge would affect the doctor-patient relationship. This paper identifies that the introduction of the prescription charge, not only aroused debate in parliament, but caused a spectrum of views amongst lay and medical circles.

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THE LSJM...

The London Student Journal of Medicine accepted its first cohort of staff in January 2009. The journal is a peer-reviewed journal that functions through the support of students from around the world and benefits from the invaluable support of our experts.

The peer-review process at the journal is a three-tiered process. Journal stuff under the auspices of section panels form the entry tier of this process and select articles for peer-review. We at thelsjm are grateful for the contribution of these individuals. For the period of January 2009January 2010, the journal hoped to produce 4 issues but has managed 3 through the hard work of the following panel members: Harpreet SoodFarhana AkterHina KhanKatherine SharrocksSean PereraSophie RobertsVishal NavaniDhupal PatelEddie Guzdar Jennifer DaviesMaria Eleni SmyrniotiNicola HoodRani SubassandranRebekah LawSian WhiteTiffany Munroe-GrayCatherine Rees Ronit DasDaniel FurnedgeKaren GunanayagamDaniel HammersleySonia DamleRob McGuireBen AmiesCharlotte Spelman Rachel Owusu-AnkomahDeepak KumarOluwadamilola HaastrupNicola HoodSharmin BadieiRachel Baigel Alexander Ross Samuel Ponnuthurai Amin GolmohamadGeraldine Dutta-GuptaJocelin HallKush PatelLaura VincentLisa YangMaham Khan Samirah ToureThisbe Louise ArcherBen CollardCassisa LimHelen M PickburnJonathan CheahKalpesh VaghelaKartik Logishetty Manaf KhatibMilan Makwana The second tier of the journal consists of student-review. The journal hopes that by including students in the review process their individual critical appraisal and written work would improve with the added benefit of giving them an insight into the publication process. We would like to thank the following individuals for giving up their time to assist the journal with this: Helen Pickburn Manaf Khatib Ben Collard Cassia Lim Kartik Logishetty Jonathan Evans Jennifer Clough Kalpesh Vaghela Anuja Mitra Ammar Natalwala Tim Wang Adil Todiwala Joseph Ward Laurence Glancz

CROSSWORD.....ETC.

Finally, to ensure that most works outside commissioned opinion pieces are academically sound, the journal enjoys the peer-review of expert health and biomedical professionals. These individuals make the expert-review of our articles possible. The journal would like to recognise the following professionals for their invaluable contribution to putting together our first volume: Dr David Winterbourne (Division of Basic Medical Sciences, St. George’s University of London) Dr. Seema Biswas Dr. J.Chang (Consultant Neonatologist, Mayday University Hospital London) Dr. Naomi Saville Dr Peter JM Openshaw (Director, Centre for Respiratory Infection, National Heart & Lung Institute,Imperial College London) Dr. Paresh Mistry (Consultant Accident and Emergency medicine, Imperial College London) Quamar Bismil Dr Alison McGregor (Reader in Biodynamics, Imperial College London) Dr David McCormack (ST-2 Cardiothoracic Surgery) Dr Samih Hassan (Neurosurgery SpR, El Ribat university hospital Sudan) Muhammad Ali MISS Philippa Tostevin (Consultant ENT surgeon, St Georges hospital London) Kamil Asaad Dr Peter Hughes (Consultant Psychiatry Springfield) Dr Vish Gel (Clinical Teaching fellow St Georges University of London) Thelsjm recognizes the importance of new social networks in disseminating information; we would like to announce our facebook, twitter, Issuu pages. We are also part of a broader academic network known as crossref. Articles hosted in theLSJM can be cited via the doi numbers assigned to them.

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cite us via our facebook.com lsjm @thelsjm doi:10.4201/lsjm thelsjm

TheLSJM will also be announcing our new regional prices designed to encourage health trainees from different parts of the globe to join the academic forum with their research and views. Keep up with us at our pages in the above.

A new editorial team will be heading our next issue, Volume 2 issue 1. Visit out webstie thelsjm.co.uk for more information on how to join our team.

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ABOUT US Objectives About theLSJM The London Student Journal of Medicine (LSJM), founded in 2008 and first published on 15 June 2009, is an international peer-reviewed quarterly journal published by tomorrow’s health professionals.

The London Student Journal Medicine (LSJM) is a student initiative started by students from St. George’s University of London, Kings College London, University College London and Imperial College London with the oversight of senior academics and clinicians at these institutions.

The journal publishes articles on topics relevant to undergraduate medical education and interdisciplinary interest. The LSJM is widely circulated both in a print and digital format around the world; the online version is freely available. The LSJM is a registered member of Publishers International Linking Asociation (PILA). Our acceptance rate is approximately 50% of the nearly 500 solicited and unsolicited manuscripts it receives annually; the average time from submission to publication is 95 days.

Kevin Owusu-Agyemang (BSc, Yr5 MBBS St Georges University of London) and Nana Seiwaa Opare (BSc, Yr5 MBBS St Georges University of London) are the current co Editors-in-Chiefs of the LSJM The name “London Student Journal of Medicine” was chosen to unite healthcare training in London, and through this serve as a shining example to students around the world.

We believe that Medicine is a science and an art can only be realised through an interdisciplinary healthcare collaboration. The journal was created to encourage this attitude amongst students from the onset. The LSJM aims to host articles that discuss topics from the collaborative vantage points of the different allied health professionals.

ISSN: 1759-1236 (online) ISSN: 1759-1228 (print) DOI:10.4201/lsjm

Kevin Owusu-Agyemang

Sonia Damle

284

Jonathan Cheah

Milan Makwana

Laura Vincent

Harpreet Sood

Key Objective To promote the science and art of medicine among tomorrow’s healthcare professionals through journalism.

Critical Objectives 1.

To establish and maintain dignity and autonomy in medical journalism, free of partisanship

2. To provide a platform for balanced discussion of insightful research and the practical interpretation of topical and upcoming news written from the perspective of the healthcare student/practitioner.

3. To publish original, important, well-documented, peerreviewed articles on a diverse range of topics affecting medicine.

4. To provide tomorrows health professionals with the tools for developing continuing education in basic and clinical science integral to the practice of tomorrows medicine.

5. To enable healthcare students to remain informed in multiple areas of medicine, including developments in fields other than their own 6. To inspire students globally to contribute to the evolution of health and healthcare by hosting their contribution to medical research.

7.

To keep readers updated all aspects of health outside the ‘ward’ including but not limited to global and community health, law and ethical debates

8. To attain the greatest possible level of medical journalism created by students that is balanced, of high academic and intellectual quality, united by all healthcare professionals, and enjoyable to read

Alexander Ross

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Vishal Navani

Nana Seiwaa Opare

lsjm 30 april 2010 volume 01

MEET THE TEAM Our Sections The content of the journal is currently hosted under the following sections.

However, our scope is not limited to them

Medicine@thelsjm Editor Laura Vincent Panel Samirah Toure (Administrator) Humaira Kamil Thisbe Archer Jocelin Hall Tanya Mitra Kush Patel Lisa Yang Andrew Swampillai

Surgery@thelsjm Editors Milan Makwana and Jonathan Cheah Panel Helen Pickburn (Administrator) Jonathan Evans Kalpesh Vaghela Kartik Logishetty Manaf Khatib Jennifer Clough

Careers@thelsjm Editor: Sonia Damle Panel Catherine Rees Ronit Das Charlotte Spelman Karen Gunanayagam Daniel Hammersley

Psychiatry@thelsjm Editors Samuel Ponnuthurai and Alexander Ross

HLE@thelsjm Editor Sandra Saadoo Panel Rebekah Robson (Administrator) Jennifer Davies Marilena Smyrnioti Dhupal Patel

Helen Pickburn

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GCH@thelsjm Editors Vishal Navani and Harpreet Sood Panel Katherine Sharrocks (Administrator) Hina Khan Sophie Roberts Angela Fanshawe Sneha Varkey Elena Atkinson Nida Rashid

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Panel Nicola Hood Deepak Kumar Rachel Baigel Amin Golmohamad Saarah Ebrahim

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