Innovation by theLSJM Ltd

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INNOVATION

Innovation doi:10.4201/lsjm.ed.002

It would be myopic to regard ‘Innovation’ in healthcare as simply advancements in technology and pharmaceuticals. In this edition of the LSJM, students explore its wonderfully multifaceted nature -from Mitra’s discussion of robotics in surgery, through Sood’s editorial on transformations in international aid-provision, to Adlington’s ethical review on stem cell research. The core of innovation is change. Change in thoughts, change in practices and resultantly change in behaviour. Innovation has ripple effect; a single idea has incredible power to transform. For instance, vaccination has seen the eradication of entire diseases and incredible advances of sanitation and medication have increased life expectancy in the United Kingdom by over 50% in the last century. However, an over-zealous and perhaps premature lust for rapid progress has led to tragedies in drug trials and profound disability. This clearly provides a justification for regulation in healthcare. Omar’s fascinating piece on developments in drug-doping within sports medicine brings to light the ethical implications of innovation and highlights our responsibility, as the gate-keepers of health, to moderate steps towards innovation, which must be made without a heavy hand. Innovation remains, however, at the core of what we do. Much of the world remains ravaged by diseases that we understand, but cannot combat. Just as the virulence of HIV is dependent on constant mutation in its genotype so must we continue to embrace innovation in research in order to defeat it, as Dr. Mark Nelson explains to Guyett. Policy-makers are key regulators, but their influence has received mixed reactions. For instance, current EU regulations (European Directive 2001/20) attempting to streamline research and clinical trials have been met with criticism by scientists who feel the new ‘red tape’ is excessively beaurocratic.1 More locally, government rewards and financial incentives in the form of Quality and Outcomes Framework (QOF) awards points to primary care centres for using less expensive interventions2. This ‘rationing’ could impede innovation, with little impetus for creativity, as the latest advancements in service or technology are usually the more costly. Accordingly, in our bid (and duty) as healthcare professionals to provide the best possible care with limited resources, where should we draw the line? The LSJM met with the General Medical Council to discuss the recent introductions of guidelines specifically for students, shedding light on its background and reasoning. The LSJM is itself a reflection of student innovation. By creating a new vision for what a medical journal should offer, we hope to educate, entertain and inspire further innovation and thereby improve the care for our patients. We leave it to our readers to discover the pros and cons of innovation in healthcare in this edition. One of our aims is to provide a platform for balanced and honest discussion amongst students. A new step for the LSJM is the ombudsman (noun /omboodzman/ a trusted intermediary). Send us your thoughts, your critiques and feedback, and there will be a dedicated section for your views in the next edition. Talk to us at ombudsman@thelsjm.co.uk

Vishal Navani Acting Editor-in-Chief 106

Nana Seiwaa Opare Co-Editor-in-Chief

Jonathan Hyer Creative Director lsjm 30 november 2009 volume 01

30 NOVEMBER 2009 VOL 01 ISS 02

Contents Page:

Sections of the LSJM Surgery pg.114 Editors- Milan Makwana & Jonathan Cheah Submit to: Surgery@thelsjm.co.uk Psychiatry pg.130 Editors- Alexander Ross and Samuel Ponnuthurai Submit to: Psychiatry@thelsjm.co.uk Global and Community Health pg.144 Editors- Harpreet Sood and Vishal Navani Submit to: gch@thelsjm.co.uk Health Law and Ethics pg.154 Editors- Sandra Sadoo Submit to: hle@thelsjm.co.uk Medicine pg.168 Editors - Laura Vincent Submit to: medicine@thelsjm.co.uk Careers pg.182 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 Alzheimer’s: the future What is the future of medicine? Change or die?

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Reviews The effect of exercise on stroke survivors

110 142 147 184

Interviews with Martin Hart of the GMC Professor Richard Bentall on psychiatric diagnoses Dr Mark Nelson on innovations in HIV research Sunita Deshmukh and Newton Wong on publishing a text book

133 192 194

Report Mental health care in prisons A pregnant pause The physician’s assistant

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Research Does ethnicity impact on the reporting of depression in London medical students?

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Case Report Defensive medicine in obstetrics

118 124 128 157 164 166 174 186

Articles Laparoscopic surgery: are you game? The world’s first full facial transplantation – are we ready? Transforming the culture of surgical safety A cybrid cul-de-sac in stem cell research? Feature series on obesity Doctors lead the battle against drug doping in professional sports Should cage-fighting be banned? Publish or perish

122 150 152 161 186 189 190 191 193

Perspectives The European working time directive is beneficial for surgeons First do no harm: overcoming barriers to refugee health Heroin on prescription for addicts Dementia: is honesty the best policy? Obama’s healthcare reform: hope or hyperbole? Psychiatry in the Bronx The view from a bridge Breaking into the world of NGO medicine Medical notes – the newby

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Profiles Professor Steven Bown Amy Newton and Neil Howie Also in this issue News; Mystery object competition; Ask the expert; Crossword; Book reviews

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THE BRITISH LIBRARY

Find out more at www.bl.uk/bipc

In line with our theme of Innovation, the London Student Journal of Medicine is excited to inform readers about the British Library’s Business & IP Centre who recently held the Global Entrepreneurship Week. British Library Business & IP Centre The Business & IP Centre in London is designed to support small & medium sized Enterprises and entrepreneurs from that first spark of inspiration to successfully launching and developing a business. Funded by the London Development Agency, the Centre offers free access to the UK’s most comprehensive collection of business and intellectual property information, covering:

ORACLE Innovation Pass launched by Department of Health Laura Vincent Innovation Pass could allow patients with rare disease to receive new drugs which have not been appraised by the National Institute for Health and Clinical Excellence (NICE). The pilot scheme will run for three years and will allow data to be collected on the impact of these new drugs, including their cost effectiveness. This will then help contribute towards future NICE appraisals. Funding for the project will be taken from a new ringfenced £25million budget. In ‘Life Sciences Blueprint’ the Office for Life Sciences announced a series of measures to help maintain a competitive life science sector, which included the introduction of an ‘Innovation Pass’. The Innovation Pass allows earlier access to innovative drugs for patients with the greatest need, whilst allowing collection of further information to support future NICE appraisals. Doctors to Report Knife Crime Vinoth Nadesalingam Doctors in the U.K ‘must’ tell the police every time they treat a victim of gun or knife crime, under new guidelines from the GMC. Following the failure of the government “anti-knife” strategy, doctors have now been given special authorisation to breach patient confidentiality, if the patient is a victim of knife crime. Prior to this, doctors only needed to report victims of gunshots wounds to the police.

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• • • • •

General funding and business advice Research on markets, companies and products Consumer trends and national statistics Business news Patents, trademarks, registered designs and copyright

British Library information experts are on hand to guide you to the resources you need. Anyone is welcome to use the Library; you just need to gain a free Reader Pass. The Centre also offers free and highly subsidised workshops, oneto-one advice sessions and networking events run by British Library staff and its partners.

Under the new guidelines, doctors will be asked to decide whether to break patient confidentiality if they believe that a crime is about to or has been committed. It is believed that these guidelines, which will predominantly be used in A&E settings, will help provide more accurate statistics about the prevalence and locality of knife crime, in order to aid police and improve public safety.1 The guidelines also allow for a doctor to inform relatives of patients diagnosed with a genetic disease, such as certain types of cancer, about the potential risks to their health, if the patient refuses to tell them. The GMC have argued that doctors must use their discretion to judge cases, and that the duty of the doctor to protect the public occasionally outweighs the rights of the individual. However, this alteration to the confidentiality rules has opened up many contentious issues. For instance in the bond of trust between the doctor and patient, and the GMC has acknowledged that this may lead to some injured people choosing not to seek help. It may also lead to more patients not giving a truthful account about the circumstances of their wound, thus complicating their medical treatment. It has been argued that many of the victims of such attacks are “not entirely innocent themselves”, often taking part in gang culture. This new ethical grey area may also lead to more doctors being brought to court for breaching confidentiality. It also raises the issue as to where a doctor’s priority lies: with the general public’s safety or the individual in his care.2 References 1. 2.

‘Doctors must report knife crime’. BBC.co.uk Available at: http://news.bbc.co.uk/1/hi/uk/8276609.stm. Doctors ‘must report knife crime.’. Available at: http:// www.express.co.uk/posts/view/130186/Doctorsmust-report-knife-crime-. Sunday Express

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The best patient outcome depends on the collaborative work of all healthcare disciplines. Calling all nursing, physiotherapy, radiography, environmental and occupational health students Join us e-mail: charlotte.spelman@thelsjm.co.uk

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INTERVIEW

The LSJM Interviews the GMC

doi:10.4201/lsjm.ed.003

My name is Martin Hart and I am the Assistant Director of Education at the GMC. I am responsible for overseeing all aspects of the GMC’s work on medical education. This includes developing guidance and policies on issues related to undergraduate education and the first year of the Foundation Programme. I also oversee our quality assurance programmes, which ensure that medical schools are meeting the standards we set in Tomorrow’s Doctors and, jointly with PMETB, that deaneries are meeting the standards for the delivery of the Foundation Programme.

Please give us a brief summary of the GMC guidelines for students The GMC, with the Medical Schools Council, published an updated version of Medical Students: Professional Values and Fitness to Practise in March 2009. The guidance stresses that student fitness to practise is not about preventing trainee doctors relaxing or having fun. Rather it is about creating a safe environment for patients and promoting professional standards. The guidance advises medical schools on how to develop fair and consistent fitness to practise procedures for the small minority of students who cause concern. It is based on the seven headings in Good Medical Practice, the GMC’s core guidance document which students will be expected to adhere to when they register as a doctor. It’s also important to note that issues such as students’ relationships with patients and probity are also addressed in the guidance.

What was the reason for such a recent establishment the guidelines for medical schools and students? Whilst the GMC does not have formal responsibility for students while they are at medical school, we have a clear interest in ensuring that only those who are fit to practise graduate and join the medical register. The GMC and the Medical Schools Council established the joint Student Fitness to Practise Working Group in 2005. The aim of the group was to enhance the effectiveness and consistency of fitness to practise processes both within and between medical schools. It also sought to share good practice. The product of that working group was Medical Students: professional values and fitness to practise. We continue to monitor the implementation of the guidance and consider other issues related to student fitness to practise.

What are the benefits to us as students in familiarising ourselves with the guidelines? Medical students have privileges and responsibilities that are different from those of other students. The guidance sets out the standards that we, and society, expect of them. Familiarising yourselves with the guidance will help you to understand the standards and help you to maintain them. The vast majority of students do not encounter problems that call their fitness to practise into question, and an understanding of our guidance will help to ensure that this remains the case. As the guidance is based on Good Medical Practice it will provide you with an insight into the standards you will be expected to meet when you begin to practise. An understanding of the guidance will also assist students in knowing what they can expect from their school should they encounter any fitness to practise issues.

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What has been done to ensure that prospective medical students are aware of the guidelines and your expectation from them before applying to do Medicine? The guidance is available on our website and copies have been sent to all medical schools. When we receive enquiries from prospective medical students we refer them to the guidance and we have also held medical student roadshows and given presentations to students. In addition we have worked hard to raise awareness of our guidance in medical schools’ internal newsletters and magazines.

Were students involved in the establishment of these guidelines? How so? Yes, students were involved in the process throughout. There was student representation on the working group. Students were also encouraged to respond to the consultations we have run on draft versions of the guidance. We also held a workshop to which we invited students, along with medical school deans, school leads for fitness to practise and others. This provided an opportunity for students to discuss the issues with us and other stakeholders. These discussions fed into the current version of the guidance.

How does the GMC view its current relationship with students? Although we do not have formal responsibility for medical students, as tomorrow’s doctors we are keen to engage with you throughout your time at medical school. Following the merger of PMETB with the GMC in April 2010, and with the introduction of revalidation, today’s medical students will have a different relationship with the GMC than their predecessors. For example, moving from provisional

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INTERVIEW to full registration, successful completion of the Foundation programme, awarding Certificates of Completion of Training (CCT) and relicensing a doctor as fit to practise following the process of revalidation. This relationship will be characterised by us recognising and certifying good practice, marking key milestones in your career. We want to begin this positive relationship early on in your medical careers. This involves us giving you the information you need about the GMC, but also listening to and learning from medical students. Over the past 12 months we have been looking at ways we can engage more effectively with medical students and we continue to look for new ways of doing so, such as our medical student roadshows, presentations to medical schools by council members and encouraging student involvement in consultations.

Some students have regarded the guideline as a form of mistrust of students and/or their medical school. What is your perspective on this? We did not publish Medical Students: Professional Values and Fitness to Practise because we mistrust medical students. Medical students are held in high regard by the public. This guidance articulates the high standards that the vast majority of medical students meet and maintain, justifying the status that they have. We believe this guidance will promote a positive approach to professional behaviour among medical students. However, there are some students who, for a variety of reasons, encounter issues that call into question their fitness to practise. By setting out the standards we expect of both students and medical schools, these concerns can be addressed in a consistent and transparent manner. The guidance means that medical students and, more widely, the public, can have confidence that any concerns are dealt with fairly and appropriately.

Thank you, do you have any advice for students? Medical students should familiarise themselves with our fitness to practise guidance. For those who are due to graduate from 2012 onwards, read the new edition of Tomorrow’s Doctors. This sets out the outcomes you will be expected to meet by the time you graduate. The outcomes are the product of a wide ranging consultation, and represent a consensus between the public and the profession on what new doctors should be able to do. For those who are nearing the end of their course, download a copy of The New Doctor from our website. This document sets the outcomes for the first year of the Foundation Programme. You will need to demonstrate that you have met these outcomes if you want to move from provisional to full registration. If you are trying to decide which deanery to apply for, you might find it helpful to read our Quality Assurance of Foundation Programme (QAFP) reports. These can be accessed from our website. However, students should remember that that whilst our fitness to practise work gets the most attention, it is not all we do. We can provide support and guidance to students and doctors throughout their career on a range of issues such as standards and ethics, the revalidation process and advice on specific queries.

Useful links & upcoming GMC student events Students can keep up to date with what is going on at the GMC on our website: www.gmc-uk.org/students. We also have a regular e-bulletin, which you can sign up for via our website.

Whom shall I contact when...when querying a fellow student’s/ consultant’s fitness to practise? At some point in your career, whether at medical school or when you are a practising doctor, it is likely that you will encounter a situation when you are concerned about the performance or conduct of a colleague. These situations can be challenging, especially if it is a senior member of the team that you are concerned about. However there are many sources of good advice. Your colleagues are a good place to start, particularly as they may share your concerns. If you are at medical school, talk to a member of staff that you trust. The GMC can offer advice if you are unsure of what to do - hundreds of doctors contact our Standards and Ethics team for advice every year. Other organisations, such as the BMA and medical defence bodies, can help too. The most important thing to remember is that your overriding responsibility is to make sure patients are not put at risk of harm, and there are lots of people and organisations who can help you address any concerns you might have.

How can students get involved with the GMC? We are always keen to hear from medical students. The GMC regularly runs consultations on a variety of issues - recent examples are the new edition of Tomorrow’s Doctors and draft guidance for doctors on confidentiality. We read all the responses we receive to these consultations, so they represent a genuine opportunity for medical students to influence our policy. We also run other events from time to time that will be of interest to students. The best way to keep informed about what we are doing and how to get involved is to sign up for our bi-monthly e-bulletin for medical students. You can do this on our website at www.gmc-uk.org/students

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PATRONS PAGE

Patrons of the LSJM The LSJM is proud to introduce its Patrons, and formally thank them for their immense contribution to the success of the journal thus far. Dr. Deborah Bowman PhD Dr Deborah Bowman is a Senior Lecturer in Medical Ethics and Law and Associate Dean (Widening Participation) at St George’s, University of London. She has a longstanding interest in professional competence, and disputes in healthcare, with a particular emphasis on education. Deborah Bowman’s interest in ‘applied clinical ethics’ enables her to work closely with policy organisations and the NHS. She has written widely, both in the academic and popular press, and is a regular commentator in the media, most recently as a panelist on Radio 4’s series ‘Inside the Ethics Committee’. Deborah is currently doing a part-time secondment at the Department of Health.

Professor Joe Collier MA MD FRCP Joe Collier is emeritus professor of medicines policy at St George’s, University of London and former editor of the Drug and Therapeutics Bulletin. Do you have a copy of the Grey book (guidelines for the management of emergencies) at your trust? The Grey book and subsequent remakes owe their début to Prof Joe the first editor and founder of this very helpful book. For more about Prof Joe and his views visit his BMJ blog

Professor Parveen Kumar CBE, BSc,MD, FRCP (L&E), DM(hc), FCGI Professor Parveen Kumar is professor of Medicine and Education and Honorary Consultant Physician and Gastroenterologist at St Bartholomew’s and the London. She has held several offices at the Royal College of Physicians, including Director of Continuing Professional Development and recently as Academic Vice- President. She was on the academic sub-committee of Modernising Medical Careers has served on many other committees including the Northern Ireland Distinction and Meritorious Awards committee. She is a trustee of the charities, CancerBackup and the Medical College of St Bartholomew’s Hospital’s Trust. Parveen was awarded CBE for Services to Medicine in 2000 and was also the first Asian Woman of the Year (Professional) in 1999. She was appointed as President to the BMA in 2006. Parveen is also co-author of the medical student bible Kumar & Clark: Clinical Medicine.

Karen Middleton Karen Middleton was appointed as Chief Health Professions Officer for England in March 2007 and is the Government’s most senior Allied Health Professions. Prior to taking up her current post, Karen was Health Professions Advisor at the Department for Health, from 2003, with the specific lead for children and primary care. Before moving to the Department of Health, Karen worked in the Primary Care Development Team at the London Regional Office, developing primary care across the capital. Karen has also held a range of NHS management posts across the allied health professions, nursing and support services.

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EDITORIAL

Welcome to this ‘Innovation’ issue of the London Student Journal of Medicine. In this section, innovation can be found in everything from revolutionary surgical procedures to the evolution of new working practices for trainee surgeons. Kavit Amin’s article on face transplant surgery and Anuja Mitra’s discussion of laparoscopic robotic surgery both demonstrate the ethical complexity typical of medical advances. In the case of face transplantation, surgery finds itself amidst the profound challenges faced by patients who have to come to terms with a procedure whose success will most likely cause them crises of identity while leaving them significantly disabled. In contrast, the lower costs, shorter healing times and reduced likelihood of complication offered by laparoscopic robotic surgery appear to present a more straightforward set of gains for the patient and the National Health Service. Similarly promising is the work of Professor Bown at the National Medical Laser Centre in pioneering photodynamic therapy, minimising the invasivenessv common to so many other cancer treatments. But it is not only in procedures that we can find huge innovation affecting the work of surgeons. Debate of changes to working practice lead Naomi Kaplan and Jarnail Bal to show how entrenched opinion in our profession has become towards the European Working Time Directive. We welcome your contributions to this debate by writing to us: surgery@thelsjm.co.uk. Less contentious, but equally innovative, is the World Health Organisation Surgical Safety Checklist which we featured in our first issue. Building upon this, Carson-Stevens et al. show how student involvement in the initiative will build awareness and hopefully produce a generation of surgeons and healthcare professionals that adhere to a common set of high standards, wherever they practice. The London launch of the Safe Surgery Student Mentor Project was held 22 October 2009 – more information at http://www.safesurg.org/studentmentors.html. Hope can also be found in Nick McNally’s description of the way that Academic Health Science Centres are innovating the way we practice medicine (covered in the last issue) by providing a centre of excellence for research and providing a streamlined path to translational research from bench to bedside. On matters closer to home, Jonathan Cheah, Associate Editor for the Surgery Section will be stepping down in January to pursue other commitments and we welcome statements of interest from anyone who wishes to find explore the option of joining the LSJM team. For more details, please send any enquires to jonathan.cheah or milan.makwana@thelsjm.co.uk In summary then, this issue shows us surgery at its most dynamic: innovative, pioneering and revolutionary - facing head on the complexity and controversy generated by ethical and political challenges.

Illustration: Ella Beese

Milan Makwana & Jonathan Cheah Section Editors Surgery

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NEWS Robots and Medicine Exhibition A new exhibition at the Hunterian Museum at the Royal College of Surgeons of England explores the history and potential for robots in all areas of Medicine. Sci-Fi Surgery: Medical Robots runs from 8 September – 23 December 2009 and alongside robots in current use today also features robots from the world of science fiction. (For more information see www.rcseng.ac.uk)

Prostate Specific Antigen and Screening for Prostate Cancer BMJ 2009;339:b3537 Swedish researchers using a national cohort have sought to evaluate the use of prostate specific antigen (PSA) as a screening tool for prostate cancer. Patients with prostate cancer and their initial PSA levels, taken on average 7 years prior to diagnosis were compared to matched individuals who did not develop prostate cancer. The authors could not identify a cut-off value that had a high enough sensitivity and specificity to validate the use of PSA as a screening marker. However, it appeared that a PSA concentration of below 1ng/mL virtually ruled out a subsequent diagnosis of prostate cancer during the follow-up period of the trial. They concluded that the search for a suitable marker must continue before population based prostate cancer screening can be introduced.

centres, both high-mortality and low-mortality, had similar rates of overall complications (24.6% vs. 26.9%) and major complications (18.2% vs. 16.2%). The rates of mortality after major complications significantly differed. These included myocardial infarction and acute renal failure, which were 21.4% in high-mortality centres vs. 12.5% in low-mortality centres (P<0.001). These findings suggest that although reducing post-operative complications is beneficial, the appropriate management of surgical patients once they suffer complications is also crucial in reducing mortality following surgical procedures. Surgery Worries for Patients Researching on the Internet Ann R Coll Surg Engl 2009; 91: 460–463 Misleading information found on the internet regarding surgery has been found to cause worry and confusion in 26% of patients who looked for it. Of the 105 patients surveyed at the Chesterfield Royal Hospital one in four found the information they discovered on the internet worrying. Over half of the patients searched the internet using a search engine that could provide results subject to commercial prejudice and populated with inconsistent information. The Royal College of Surgeons has commented that ‘it is vital that patients have access to appropriate, understandable information before and after an operation. Too often information provided online is patchy, unregulated and inconsistent’.

Mild Gestational Diabetes – Treat or Not? N Engl J Med. 2009 Oct 1;361(14):1339-48 A recent large multi-centred trial has sought to elucidate if treating mild gestational diabetes has any effect on pregnancy outcomes. 958 women who were in their 24th-31th week of gestation with a blood glucose concentration of 7.5-11.1mmol/L after a 1 hour 50g oral glucose tolerance test, but a fasting glucose concentration of below 5.3mmol/L, were randomised to treatment or usual ante-natal care. The treatment arm consisted of nutritional counseling, glucose self-monitoring and insulin if required. No significant difference was noted in the composite endpoint, a combination of stillbirth or perinatal death and neonatal complications. However, treatment compared to control was associated with lower mean birth weights (3302g vs. 3408g), lower risk for large-for-gestational-age infants (7% vs. 14%), caesarean deliveries (27% vs. 34%), and preeclampsia or gestational hypertension (9% vs. 14%). Surgery for Carpal Tunnel Syndrome? Lancet. 2009 Sep 26;374(9695):1074-81 To determine the effectiveness of surgery for patients with carpal tunnel syndrome without denervation, American researchers randomised 116 patients to either surgical or non-surgical treatment including hand exercises and splinting. Hand function and symptoms were measured using the Carpal Tunnel Syndrome Assessment Questionnaire by blinded investigators. Patients in the non-surgical group, if still symptomatic after three months were offered a surgical opinion and as a result substantial crossover did occur. Using intention to treat analysis, 67% of patients had functional improvement of 30% or more at 1 year with surgery, compared to 46% with nonsurgical treatment. However, the authors conclude that although patients in the surgical treatment group fared better and is a useful treatment for carpal tunnel syndrome, the magnitude of the improvement over conservative techniques was of only ‘moderate clinical relevance’. Hospital Mortality and Surgery N Engl J Med. 2009 Oct 1;361(14):1368-75 Nearly 85,000 patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program were followed and hospital rates of mortality and post-operative complications studied. Rates of mortality ranged from 3.5% in low-mortality hospitals to 6.9% in high mortality centres. However,

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PROFILE

Profile of Professor Stephen Bown

Undergraduate training BA Physics, Cambridge University Masters in Physics, Harvard University Pre-Clinical Medicine, Cambridge University Clinical Medicine, University College London Postgraduate MD, MRCP (UK), FRCP (UK) What do you do? I run and co-ordinate transitional research projects in the diagnostic and therapeutic use of light and undertake three clinics a week in therapeutic endoscopy. Why did you get involved in surgery? I am not a surgeon but have always worked closely with surgeons. The attraction of endoscopes is due to the application of physics with practical procedures, interesting instruments and no cutting or stitching! Describe your typical day On a mixed day of clinical and academic work I am on the wards first thing in the morning giving tutorials to students. I will then go back to the office and have academic meetings about research projects. In the afternoon, I will go back to the hospital to do an endoscopy list. I also do a lot of travelling as I work within a small research field and meet many interesting people around the world. I have given invited lectures in 41 countries. What have been your major achievements? Bringing together scientists and clinicians and overcoming the barriers between the clinical world and science. Also, establishing photodynamic therapy as a viable treatment option in many different fields. What is Photodynamic Therapy (PDT) and what are its applications? PDT is a combination of drug and light. You activate the photosensitising drug with light of a wavelength matched to the absorption peak of the drug, thus only having a biological effect where you get drug and light. It is a non-thermal effect so kills living tissues but doesn’t kill collagen or elastin so maintaining mechanical integrity. It is currently used in the treatment of head and neck cancer, all stages of oral cancer, Barrett’s oesophagus and cancers of the skin and bile duct. Exciting new projects in early clinical trials include PDT for treatment of cancers of the pancreas and prostate and the prevention of re-stenosis after balloon angioplasty – three techniques pioneered at University College Hospital (UCH). Amongst all the available minimally-invasive ablative technologies in use, will PDT become the one dominant modality? PDT should be seen as complementary to surgery, radiotherapy and chemotherapy. For many patients, the best option is a combina-

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Picture: Professor Stephen Bown

Current Post Professor of Laser Medicine and Surgery Director of the National Medical Laser Centre, UCL Division of Surgery and Interventional Science Honorary Consultant Gastroenterologist, University College Hospital

tion of treatments. PDT is particularly attractive for small volume disease close to vital structures and where preservation of functional and mechanical integrity is essential. The side effects are usually less and the recovery time shorter with PDT as it is minimally invasive; however, the treatment must be matched to the extent of disease in each patient. Where do you see PDT in 20 years time? I see it as one of a variety of minimally invasive treatments; we will have to ask when PDT is the best treatment within the range of alternatives. How do you balance clinical and academic work and do you have any advice for future clinical academics? The key to a successful academic career is the motivation of the individual. Most doctors prefer a purely clinical working life, but for those who enjoy the challenge of research, the academic life is rich and rewarding. What are your ambitions for the future? I am involved in the ‘Killing Cancer’ charity which promotes PDT to the general public and raises funds for research. We are also working on optical diagnosis involving spectral analysis to detect normal or neoplastic tissue using large data banks to correlate optical spectra and histology. This technology won a Medical Futures Innovation Award last year. Who or what has been the greatest influence on your practice? My approach to clinical practice was guided by Professor John Lennard Jones (the consultant on my first firm as a clinical student at UCH), but the greatest influence on my medical career has been my background in physics and lasers and the opportunity to put the two together. What is the most important thing you learnt as a student? Clinical medicine is an art – you can’t expect everything to fit the textbooks. If something doesn’t fit, look around to find an explanation and sometimes accept that there isn’t one. There is a limit to how far it is worth digging to get clinical answers. And be nice to patients and your colleagues at all levels. Do you have any advice for future students? Be sure you know what you are letting yourself in for in your career choices and look at all the options, both clinical and academic. Interviewed by: Helen Pickburn Intercalating BSc Medical Student, UCL Medical School and LSJM Panellist

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ARTICLE

Laparoscopic Surgery: Are You Game? Anuja Mitra

anuja.mitra06@imperial.ac.uk Year 4 Medical Student, Imperial College London doi:10.4201/lsjm.surg.007

Source: www.intuitivesurgical.com

Figure 1: The da Vinci robotic surgical system.

Introduction Video games have been integrated successfully into modern day culture. The change in demographics of the ‘typical’ gamer has reflected the popularity of this phenomenon. Once held as the purview of school children, the average gamer is now 33 years old with a twelve year history of playing video games1. In 2006, the gaming industry welcomed the release of a highly anticipated new prototype: the Nintendo Wii™. The appeal of this model mainly resided in the fact that the gamer could manipulate objects on the screen using a wireless remote that detected movement in three dimensions. In an age where Minimally Invasive Surgery (MIS) has evolved and we are now looking towards the use of robots in surgery, there have been various anecdotal links suggesting that Video Gaming Experience (VGE) contributes to laparoscopic ability. This article explores the link between VGE and laparoscopic skill and discusses the surgical and societal implications of these findings. Professor Lord Ara Darzi informs us “The golden age of surgery is waning. The industrial age is being replaced by the information age and laparoscopic surgery provided the wake- up call for the information age”. Laparoscopic surgery is currently held as the gold standard for many surgical procedures, perhaps the most renowned being the laparoscopic cholecystectomy.

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Arguably, the most important development is the shift of the surgical field from 2-dimensional (2D) to 3-dimensional (3D) visual input. As laparoscopic surgery is entirely dependent on visual stimuli, it is essential that the visual system simulates a natural, high quality image of the surgical field. It was demonstrated that the use of 3D vision in laparoscopic surgery superseded 2D techniques of surgery when performing standard laparoscopic tasks on the da Vinci robot. The 3D vision outclassed in both the time taken to complete the procedure and the number of errors that were performed, proving particularly important for suturing2. The History Previously, the use of long, rigid laparoscopic instruments had detrimental effects of amplifying tremor and reducing the range of movement. Currently, these instruments are shorter with tremor abolition filters and motion scaling facilities to eliminate fast movements3. Robots have been increasingly used in surgery over the last twenty years. In the 1990’s the Probot was the first robot to be used in surgery for the transurethral resection of the prostate to treat benign prostatic hyperplasia4. Perhaps the most renowned and

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ARTICLE clinically relevant robot up to date is the ‘da Vinci system’ (Figure 1). This was manufactured by an American based company named ‘Intuitive Surgery’ in 2000. It is primarily used for laparoscopic radical prostatectomy and gynaecological surgery, but has been approved for thoracoscopic surgery, laparoscopic and thoracoscopically assisted cardiotomy procedures. The four key components of the da Vinci robot are summarised in Figure 2.5 Discussion Robotic surgery has its drawbacks, for example longer operative times to execute standard surgical tasks such as capping a hypodermic needle6 and steeper learning curves for basic operations7. However there are some general advantages over open surgery. These are lower morbidity rates, smaller postoperative scars yielding an improved cosmetic result and reduced risk to the patient in terms of intraoperative blood loss and infection rates8. In laparoscopic surgery, the surgeon has the task of navigating surgical instruments through small incision points on the patient’s body. Operating in a three-dimensional space represented on a viewing screen with minimal tactile feedback constitute basic parallels between laparoscopy and video games9. Surgeons recognise that laparoscopy has changed the required skill profile and training needs. It is this new set of skills that have led to anecdotal evidence suggesting VGE is a positive predictive factor for laparoscopic skill10. In particular, professionals believe that the Wii™ has the most potential of any console for trainee surgeons.

Figure 2: Key components of the da Vinci robot Component

Advantage

Master console

The surgeon is able to manipulate robotic arms by moving dials on the console whilst seated.

Robotic Arms

The laparoscopic arms pivot at 1- 2cm operating ports, eliminating the use of the patient’s body for leverage and minimising tissue damage.

Endowrist surgical instruments

The instruments enable the surgeon to rotate 360° with 7 degrees of freedom, allowing ambidexterity (2)

3D endoscope visual system

Operating images are enhanced, refined and optimized using image synchronizers, high-intensity illuminators and camera control units. The visual system enables a accurate hand- eye relationship to give natural depth perception necessary for precise manipulation of tissue layers

eliminating the ‘training’ effect15. The use of the Wii™ as a ‘warm up’ tool has been investigated11. A training device called ProMIS which simulates a patient’s body in 3D and tracks the surgeon’s movements as they operate was used in this study. The movements were fed into an algorithm which illustrated Wii™-playing surgeons scored 48% higher on tool control and performance than those without the Wii™ warm-up. It was concluded surgical residents performed better during simulated surgery after playing on the Wii™ console as a warm up to hone their skills. Figure 3: Wii™ remote

The Nintendo Wii™ is a home video gaming system which is the seventh generation console released by Nintendo. Perhaps the most distinguishing feature is the Wii™ remote (Figure 3). The remote is a wireless controller that can be used as a handheld pointing device that allows players to direct on-screen action using a wireless wand. Acceleration is detected in three dimensions11 and the user is able to manipulate and interact with objects on the screen through gesture recognition and pointing. Video games which require the user to navigate through virtual reality settings such as flying, swimming and racing can lead to the acquisition of complex skills. For instance, depth perception, spatial orientation and visual attention capacity have been shown to develop from a young age12. Accurate hand-eye coordination is a vital skill required in surgery that has been demonstrated to improve with video gaming practice13. One study explored the relationship between video games and laparoscopic performance by asking participants to perform tasks intended to measure hand–eye coordination, ambidexterity, and depth perception14. The subjects performed three timed laparoscopic tasks on a pelvic trainer. Participants then had 10 minutes of playing on a video game. Finally, subjects repeated the timed laparoscopic tasks. Paired-sample t-tests were used to measure differences between the pre- and post-tests. Results revealed a significant difference between pre and post tests on all three laparoscopic tasks (p = 0.001), (p = 0.008) and (p = 0.000) respectively. The authors concluded that playing video games improved laparoscopic skill and time taken to complete the tasks. Evidence shows that a brief warm up on a virtual reality simulator ahead of surgery, significantly improves surgical performance by

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The advent of MIS poses significantly steeper learning curves and a greater pressure on the individual to master novel skills. A study hypothesised that participants with previous VGE would acquire new surgical skills faster than those with no gaming experience thereby reducing the learning curve. A high VGE was defined as more than 3 hours per week of video game playing. Both groups trained to proficiency on two abstract tasks (Acquire Place and Traversal) on the minimally invasive virtual reality simulator (MISTVR) and the number of trials required to achieve proficiency were recorded. Results revealed the gamers reached proficiency quicker than the non-gamers (median 0 trials versus 6 trials, p = 0.01) thus it was concluded that previous VGE shortens time to proficiency on two tasks on a validated surgical simulator16.

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ARTICLE

For the full references see thelsjm.co.uk.

Implications on surgical training The success and popularity of laparoscopic surgery poses another dilemma: how shall we train the new generation of surgeons? Surgical training has seen a paradigm shift from traditional training based on apprenticeship to training using a virtual reality (VR) simulator. The MIST- VR training programme is one current curriculum which provides a validated and established approach to assess laparoscopic training on VR simulators17. A study performed with 622 participants showed VR training resulted in a greater reduction in operating time, error and unnecessary movements than standard laparoscopic training18. With VGE being identified as a positive predictive factor for laparoscopic skill, it could have an impact on the current training curriculum. Video games may be used as a practical teaching tool to help train surgeons. In a study performed by Rosser et al on 33 surgical residents, it was shown that video-gamers, past and present were faster, made fewer errors and had higher scores than non-gamers when asked to perform in the Rosser Top Gun Laparoscopic Skills and Suturing Programme10. Therefore training curricula that include video games may help thin the technical interface between surgeons and laparoscopic applications. However, another study found that although there is a link between VGE and surgical skill, it is not strong enough to warrant changes in the training programme. The relationship between baseline laparoscopic scores and nonsurgical skills were assessed and results showed students who played computer games, typed, utilized chopsticks, or played a musical instrument had better scores and fewer errors than those who did not though this did not reach statistical significance in any comparison19. Nevertheless, the appeal of video games as an enjoyable, readily available adjunct to VR training is attractive. Software from Nintendo is to be used for the purpose of aiding surgical training by simulating routine procedures11. With the added advantage of vastly cheaper software — the expected price is set to be $250, this is a highly appealing option in comparison to traditional virtual training tools. Societal implications Despite the growing body of evidence showing video gaming to be advantageous in laparoscopic surgery, there are still many unanswered questions and ethical issues which must be addressed before they can be officially incorporated into surgical culture. Video games have been shown to improve laparoscopic skill, however surgical ‘skill’ is one of many important qualities necessary for a successful surgeon. Other qualities such as patient communication, empathy and social interaction have been shown to be hindered by video games. More than 85% of video games contain violence. Research shows that playing violent entertainment games produces aggressive behaviour, affect, and cognition, physiological arousal, desensitisation to real-life violence, and a decrease in pro-social behaviour20. Additionally, the practicalities of introducing video games as an education tool have not been explored yet. What types of video games are optimal for enhancing surgical skill? How often should one play video games? Are there any differences in the types of video games that men and women should use to acquire these skills? The use of video games is an attractive idea but one that has enormous potential for distortion. It is acknowledged that “indiscriminate video game play

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is not a panacea”21 and conscientious supervision must be applied to children’s video gaming. Conclusion With laparoscopic surgery held as the gold standard for many routine procedures, surgeons must use a different profile of skills to those that were required with open surgery. The immense popularity of video games in modern culture has lead to a suggestion that there is a positive association between VGE and laparoscopic skill. Evidence has demonstrated video games to help in the development and acquisition of a similar set of cognitive skills to what is required in laparoscopic surgery, to act as a warm up prior to surgery to exclude the ‘training’ effect and to reduce the learning curve for novice surgeons. With a change in the training curriculum for laparoscopists which is based on VR simulators, the idea of video games being used as an adjunct seems rational. It is tempting to incorporate this relatively enjoyable, cheap method of training into the curriculum, however a pressing social problem arises with the use of video games. We must make every effort to avoid encouraging a culture of unlimited video gaming with the justification of promoting surgical skills in the generations to follow. The Nintendo Wii™ has gone on since its launch in 2006 to emphatically outsell its competitors in the market, it seems that time will tell if video games will ever be incorporated formally into the world of surgery. References 1.

5. 6.

10.

Entertainment Software Association. Essential facts about the computer and video game industry. 2006. http://www. theesa.com/archives/files/Essential%20Facts%202006.pdf Hubens G, Coveliers H, Balliu L, Ruppert M, Vaneerdeweg W. A performance study comparing manual and robotically assisted laparoscopic surgery using the da Vinci system. Surg Endosc. 2003 Oct;17(10):1595-9. doi:10.1007/s00464-002-9248-1 Reynolds RK, Advincula AP. Robot-assisted laparoscopic hysterectomy: technique and initial experience. Am J Surg. 2006 Apr;191(4):555-60. doi:10.1016/j.amjsurg.2006.01.011 Davies BL, Hibberd RD, Ng WS, Timoney AG, Wickham JE. The development of a surgeon robot for prostatectomies. Proc Inst Mech Eng H. 1991;205(1):358. doi:10.1243/PIME_PROC_1991_205_259_02 Intuitive Surgical, Inc. - da Vinci Surgical System.2005. http:// www.intuitivesurgical.com/ [Last accessed 17 October 2009] Garcia-Ruiz A, Gagner M, Miller JH, Steiner CP, Hahn JF. Manual vs robotically assisted laparoscopic surgery in the performance of basic manipulation and suturing tasks. Arch Surg. 1998 Sep;133(9):957-61. doi:10.1001/archsurg.133.9.957 Lenihan JP Jr, Kovanda C, Seshadri-Kreaden U. What is the learning curve for robotic assisted gynecologic surgery? J Minim Invasive Gynecol. 2008;15:589–94. doi:10.1016/j.jmig.2008.06.015 Menon M, Tewari A, Baize B, Guillonneau B, Vallancien G. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology. 2002 Nov;60(5):864-8. doi:10.1016/S0090-4295(02)01881-2 Greenfield PM. Technology and Informal Education: What Is Taught, What Is Learned. Science. 2009 Jan 2;323(5910):69-71. doi:10.1126/science.1167190 Rosser JC,Jr, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The Impact of Video Games on Training Surgeons in the 21st Century. Arch Surg. 2007 Feb;142(2):181-186. doi:10.1001/archsurg.142.2.181

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ASK THE EXPERT

What is Whitehead’s Varnish and who was Walter Whitehead? Luke Cascarini BDS MB BCh FDSRCS FRCS (OMFS) lcascarini@hotmail.com Whitehead’s varnish is an antiseptic liquid made from: iodoform 10g, benzoin 10g, prepared storax (a resinous exudate of the Sweetgum tree) 7.5g, Balsam of Tolu 5g (a resin obtained from South American balsam trees) and solvent ether mixed to 100 ml. Whitehead’s varnish has many uses including dressing of skin graft donor sites, packing after exposure of unerupted canine teeth, jaw cavities, and nasal packing. Whitehead’s varnish remains ‘clean’ and uninfected in contaminated environments like the mouth. The aromatic resins it contains are slowly broken down to produce benzoic acid, which is a potent antiseptic. This, together with its waterproofing capacity makes it more potent than other media. Walter Whitehead was born in 1840 at Halsam Hey, Bury and at the age of 16 he entered his family’s textile business. This is probably when he learned about chemicals and led him to develop his varnish. When he was 19, he was invited by a medical student to observe some operations at the local infirmary. This inspired him

to become a doctor. He initially went into general practice, but surgery was his real passion. He became a fellow of the Royal College of Surgeons of Edinburgh in 1866 and at the age of 54 became professor of surgery at the Victoria University, Manchester. Walter Whitehead was a bold and distinguished surgeon and was known to have said that “the greatest drawback under which a surgeon can suffer is knowledge of anatomy – it makes him timid”.

Luke is a Specialist Registrar in Oral and Maxillofacial Surgery at Queen Victoria Hospital East Grinstead, West Sussex and co-author of the surgical text book ‘Principles of Surgery – Everything you need to know but were frightened to ask!’

COMPETITION Mystery Object Competition

Thank you for your entries from the previous issue. We still haven’t received the winning answer!

Can you identify this object from the Hunterian Museum, based at the Royal College of Surgeons of England? If so, the Surgery Section has a signed copy of The Knife Man: Blood, Body-Snatching and the Birth of Modern Surgery, a biography of John Hunter, eighteenth-century surgeon by Wendy Moore, to give away. The prize has been kindly supplied by the Hunterian Museum.

lsjm 30 november 2009 volume 01

To enter, e-mail your answer to surgery@thelsjm.co.uk with ‘Mystery Object Competition’ as the subject line along with your name, course and year/place of study by 31 January 2010 . The winner will be the first randomly selected from all the correct entries.

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Perspective

The European Working Time Directive will be beneficial for Surgeons FOR

Naomi Kaplan BSc (Hons) kaplan.naomi@ googlemail.com 1st Year Clinical Student UCL Medical School

For the full references see thelsjm.co.uk.

The European Working Time Directive (EWTD) has met much resistance since coming into effect at European Union level in 19931. Though the British government questioned its legitimacy as health and safety law; it was validated by the European Court of Justice in 19962. The uproar is baffling, considering that this directive was put in place to prevent worker exploitation1, an objective towards which all European countries should be striving. The directive covers a spectrum of employment issues, not limited to: annual leave payment, additional security for night workers as well as appropriate weekly and daily rest periods.3 However the true battle ground remains the 48 hour working week, applicable to doctors in training as of August 1st 20091, that incorporates both overtime3 and on-call time.4 Various points pertaining to the EWTD remain unresolved at the level of European Parliament and Council, most notably the ability of countries to opt out of the directive, in addition to the debate as to whether on-call time can be justified as working time.4 Surgeons in training should not be fighting against an abbreviated work schedule, reduced from the 72 hour weekly timetable accepted in 1991.2 They should instead see this as a much-needed change that will protect their long-term health, safeguard their patients, and provide the necessary impetus to dramatically streamline surgical training. Importance in Surgery Surgical departments are staffed by surgical trainees according to a schedule of shifts, with surgeons’ hours in the hospital extending well beyond the typical 8 hour working day of many office-based employees. 5 Shift work, which can be divided into night shifts, rotating shifts and ad hoc work hours has the ability to upset both the circadian rhythm and societal integration of those carrying out shifts 5. The health impact of shift work, as opposed to day work, cannot be underestimated. Research has indicated that the risk of coronary heart disease may be higher in women who have undertaken six or more years of shift work.5 The frequency of obesity amongst male and female shift workers is higher than that seen in day workers.6 Metabolic syndrome may be linked to shift work due to the clustering of metabolic risk variables in males and females working shifts.6 Clearly, surgery will never be converted into a nine-to-five job, but any legislation that attempts to normalize hours and incorporate both daily and weekly rest periods must be seen as a valuable attempt at reducing the health threats of shift work. The argument that care should be delivered by the same firm of healthcare personnel throughout a patient’s entire hospital admission 7, and that this is in the best interest of the patient, has been used without much supporting evidence. Surely patients would be more than willing to be seen by a different surgeon if they knew that, when testing their surgical skills on a virtual reality laparoscopic simulator, 20% more errors were made by

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surgeons who were awake all night, compared to those who had had a full night’s sleep? 8 Seventeen hours of continuous work, with no sleep, will impair cognitive psychomotor performance to an extent equivalent to a blood alcohol concentration of 0.05%, a level of intoxication which makes driving illegal in twenty-nine countries.9 Similar results showing the detrimental effects of fatigue have been found when workers reach the seventeenth hour of wakefulness between 10:30pm and 12:30am, well before hitting the circadian trough of alertness.10 Healthcare professionals, specifically surgeons in training, are expected to work longer hours than employees in the transportation and nuclear power sectors.11 Many regard it as a badge of honour 10, a display of commitment to a praiseworthy career of saving lives. It goes to show how warped surgical attitudes have become, when in fact the research clearly indicates that fatigue cannot and should not be tolerated in the work environment. With a reduction in working hours comes the worry that surgical trainees will not be exposed to enough operative cases. This can be prevented by a strong commitment to training and by implementing an effective hospital-specific training curriculum.12 New strategies need to be embraced, for example a shift towards component-based training in the instance of intricate, multi-step procedures such as coronary artery surgery.12 A separation between care-provision and training has been advocated by some as a way to ensure that enough time is allocated for surgical trainees to gain the necessary skills 13, either via artificial tissues, animal models or computer simulation, the latter approach having been successfully employed by the aviation industry for over 40 years.14 Emphasis should be placed on instruction rather than apprentice-like case exposure 15, and early sub-specialization may be a wise approach to handling the new time constraints.14 Surgical training can be carried out on a 48-hour schedule, with a concerted effort by all parties to focus the training regime. Surgical training must fit into the latest timetable, so that as a profession with an elevated reliance on the accuracy and precision of its workers, it can be carried out safely and to the highest standard. References: 1.

Q&A: Working time directive; BBC News [online] 2006 http://news.bbc.co.uk/1/hi/world/europe/4536891. stm. [Last accessed Aug 19 2009]. Pickersgill T. The European working time directive for doctors in training. BMJ. 2001 Dec 1; 323(7324):1266. doi:10.1136/bmj.323.7324.1266 Working Time Directive; European Commission [online]. c2003 http://ec.europa.eu/social/social/main. jsp?catld=706&langId=en&intPageId-205. European [updated 2008 Dec; Last accessed Aug 19 2009]. No agreement reached on the Working Time Directive; Parliament [online] 2009 http://www.europarl.europa. eu/news/expert/infopress_page/048-54485-117-04-18908-20090427IPR54484-27-04-2009-2009-false/default_ en.htm. [updated 2009; Last accessed Aug 19 2009]. Kawachi I, Colditz GA, Stampfer MJ, Willett WC, Manson JE, Speizer FE Hennekens CH. Prospective study of shift work and risk of coronary heart disease in women. Circulation. 1995 Dec 1;92(11):3178-82. doi Karlsson B, Knutsson A and Lindahl B. Is there an association between shift work and having a metabolic syndrome? Results from a population base study of 27 485 people. Occup Environ Med. 2001; 58: 747-752.doi:10.1136/oem.58.11.747 Scott-Coombes D. Reduction in juniors’ hours abolishes concept of continuity of care. BMJ.2002; 324(7339):736. doi:10.1136/bmj.324.7339.736

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PERSPECTIVE

The European Working Time Directive will be beneficial for Surgeons

The European Working Time Directive (EWTD) was enacted into United Kingdom (UK) law in 1998, with the intention of improving patient care by reducing doctors’ working hours. From 1 August 2009, all doctors will only be allowed to work a maximum of 48 hours per week.1 This has had a massive effect on the British healthcare system and left many junior doctors and surgical trainees worried about their future careers. The implementation of the EWTD has not been well thought-out and is unrealistic. It puts patients at risk and has a detrimental effect on surgical training. The working patterns that the EWTD has introduced will not necessarily reduce tiredness and fatigue but may in fact increase it.2 Hospitals must abide by the EWTD and are thus required to design rotas, which work “on paper” but not in reality. As there is now a shortage of cover, there are gaps in rotas, which are filled by doctors who are working over their designated hours but not declaring so, as they are more concerned about their patients’ care than the regulations set by the European Union. The SiMAP and Jaeger rulings, which state that all hours spent in hospital (whether working or resting) count as work under the EWTD, has exacerbated the effects of the regulation.1 As a result, a significant number of work rotas have moved on to full shift systems, with multiple handovers disrupting continuity of care, to the detriment of both the patient and junior doctors’ training. The surgical specialities have been particularly affected in terms of their educational opportunities being diminished due to the EWTD. Surgery is a craft dependent on exposure and practise. The introduction of the EWTD may result in surgical trainees devoting their educational time to doing service jobs. Traditionally a consultant would have had around 30,000 hours of training, now the maximum number of hours a trainee could acquire is 18,000 on an 8-year surgical programme.3 Many trainees now feel they are at a disadvantage and will not be as well trained as their predecessors. With the lack of daytime availability of trainees and the fragmentation induced by disparate shift systems, it is increasingly falling to consultants to undertake tasks, which, in the past, would be performed by their trainees. Ironically, whilst consultants too are subject to the EWTD, the regulations have increased their workload to the point that they themselves may be in breach of the EWTD.

A survey by the Association of Surgeons in Training (ASiT) of surgical trainees, covering all surgical specialities, has shown that 80% of trainees would support an individual or speciality ‘opt-out’ of the EWTD to protect their training. Additionally, the same survey showed that 90% of trainees worked over their allocated time every week and 55 % of trainees were pressurised into falsely declaring their actual hours worked 3. The president of the Royal College of Surgeons (RCS), Mr John Black has been very vocal with his views against the EWTD and its devastating effects on patient care and surgical training. He has stated that surgical training should match trainees’ needs, not the hours that they have worked 6. ASiT have suggested an ‘ideal’ job plan which is fully supported by the RCS. The plan is based on a 65 hour working week and for a typical trainee would consist of; two outpatient clinics, four operating sessions, an endoscopy session and one on-call. This plan fits both patient priorities and teaching requirements. The RCS president suggests a change back to the traditional ‘firm’ with each trainee attached to a team of two consultants for both elective and emergency procedures 3, 6. The changes implemented by the EWTD significantly hinders the training of surgeons. It does not help, or take into consideration surgical trainees’ professional, educational and personal requirements and makes the process of surgical training almost impossible, ultimately affecting the quality of future service delivered to patients. Surgeons’ training is taken out of their hands and being dictated to them by an external body. Unless the government listens to the views of organisations like ASiT and the RCS and changes their current policies, the quality of surgical training in the UK will take a great blow and patient care will be compromised.

The ‘opt-out’ option is given to all doctors who may voluntarily choose to work up to a maximum of 56 hours. However, this does not necessarily mean that the extra hours will be used for training purposes and may very well be taken up doing service jobs.

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Jarnail Singh Bal BSc (Hons) jarnail.bal@student. manchester.ac.uk Final Year Medical Student The University of Manchester

Acknowledgement Dr Arnab Ghosh (Clinical Research Fellow, The National Hospital for Neurology and Neurosurgery) for his help in reviewing this article

References: 1.

In the face of difficulty in recruiting substantive and locum staff in order to fill the vacancies created by EWTD-compliant rotas, many trusts have resorted to using internal locum shifts in order to make their rotas appear compliant. This has the result of trainees working hours in excess of the EWTD through locum shifts. This is combined with a significant decline in the availability of locum staff, partially exacerbated by recent changes to immigration rules.4, 5

AGAINST

European Working Time Directive. Department of Health [online]. 2009 http://www.dh.gov.uk/en/Managingyourorganisation/ Humanresourcesandtraining/Modernisingworkforceplanninghome/ Europeanworkingtimedirective/DH_415 [Last Accessed 19 August 2009] Bamford N, Bamford D. The effect of a full shift system on doctors. Journal of health organization and management. 2008;22(3):223-37. doi:10.1108/14777260810883512 Cresswell B MC, Hawkins W, Harrison E, Fitzgerald E, Roon AV. Optimising Working Hours to Provide Quality in Training and Patient Safety: A Position Statement by The Association of Surgeons in Training. January 2009 http:// www.asit.org/assets/documents/ASiT_EWTD_Position_ Statement.pdf [Last Accessed 16 August 2009] Immigration rules - NHS Careers [online]. 2009. http:// www.nhscareers.nhs.uk/explore_oversea_immigrationrules.shtml [Last Accessed 23 September 2009] Immigration change will hurt NHS. BBC NEWS [online]. 2009. http://news.bbc.co.uk/1/hi/health/8048744. stm [Last Accessed 23rd September 2009]

For the full references see thelsjm.co.uk.

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ARTICLE

The surgical, psychological and ethical barriers to performing the world’s first full facial transplant - are we ready? Kavit Amin kavamin@yahoo.co.uk Year 5 Medicine, St. George’s, University of London doi:10.4201/lsjm.surg.005

For the full references see thelsjm.co.uk.

Introduction There are over 250,000 severely disfigured individuals in the United Kingdom (UK) alone, many of them are housebound, unable to face the outside world1. Depression, anxiety and even suicidal intent are some of the consequences of suffering from facial disfigurement. Facial disfigurement can occur as a result of severe infections, burns, and congenital birth defects2. Facial transplantation has more recently become a reconstructive option for these individuals when there have been unsatisfactory outcomes from conventional methods. In recent times, there has been much debate over facial transplantation, questioning whether it is technically feasible, ethically correct and the psychological impact on individuals receiving the transplant. As we now know it is technically possible, the long-term consequences of immunological therapy and considerable psychological and ethical dilemmas must be considered. Long term immunosuppressive medications are used to maintain graft viability but can shorten life by up to 10 years3. Facial transplantation is not a life-saving operation, rather life-enhancing. This contrasts with established organ transplantation such as that of the heart or kidney, whose principle aim is to prolong life. However, the idea that facial transplantation can improve quality of life makes it a viable prospect. In 2003, Sir Peter Morris, President of the Royal College of Surgeons of England concluded: ‘We do not feel the time is appropriate to proceed with this experimental procedure. Organ transplantation is to save lives while this is to improve the quality of life’4. The Working Party report highlighted that it would only consider granting ethical approval with further research and emphasis on controlling complications such as immunosuppression. Subsequently, after much deliberation and research by a team in Britain, on 25 October 2006 ethical approval was granted to conduct the world’s first full-facial transplantation. This review aims to explore the surgical, psychological and ethical issues posed by what is still regarded as an experimental procedure. What has been achieved so far? The world’s first full-facial replant was carried out on a young girl named Sandeep Kaur in 1994. The north-Indian born girl fell victim to a disastrous accident where a thresher caught her braids causing avulsion between the overlying facial tissue and the skull5. Using microsurgical techniques the face was replanted successfully.

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This brought plastic surgeons to further consider the prospect of transplanting facial tissue from deceased individuals. The defining moment for facial transplantation took place in November 2005 when a lady from Lyon in France was given the first partial donor transplant. Professors Dubernard and Devauchelle made history by transplanting a triangular section of nose, mouth and chin from a brain-dead individual. The recipient, 38 year old Isabelle Dinoire, suffered traumatic amputation of her ‘distal nose, upper and lower lips, chin, and adjacent parts of the cheeks’ when she was attacked by her dog6. The results since have been encouraging with some restoration of facial movement and sensation. In China, doctors have also carried out successful facial transplant operations. In April 2006, the cheek, upper lip and nose were transplanted after a man was attacked by a bear. Subsequently he died in December 2008, his death attributed to non-compliance with immunosuppressive medication, although this was never confirmed7. More recently in the United States, Maria Siemionow performed a near total facial transplant that took 22 hours. On 9 December 2008, the 45-year-old underwent what is known to be the fourth facial transplantation to date8.

The surgical challenge In plastic surgery there is a surgical reconstructive ladder. The surgeon starts simple at the bottom rung of the ladder and works up through various surgical techniques depending on the complexity of the task. At the bottom of the ladder is allowing the wound to heal itself (primary intension) or suturing the wound closed (primary closure). Then there is skin grafting. Skin grafts are thin pieces of skin with no intrinsic blood supply. The graft will only survive when blood vessels from the recipient vascular bed grow into it. Higher rungs on the ladder consist of tissue expansion and pedicled flaps, both of which are not indicated in severe facial injuries since they do not cover a sufficient area and do not produce aesthetically pleasing results. The highest, most advanced rung is called a ‘flap’. A flap is a piece of tissue disconnected from its intrinsic blood supply and re-anastomosed to another part of the body using microsurgery. Microsurgery involves operating with a powerful microscope to perform anastomoses of vessels or coaptation of nerves, which are as small as 1mm9. These flaps are known as free flaps or free tissue transfer because they can be moved freely around the body and is known as an auto-transplant10.

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ARTICLE Facial transplantation utilises a similar concept, but the flap is harvested from another individual as opposed to coming from the patient12. This is known as Composite Tissue Allo-transplantation (CTA). Allo-transplantation refers to the transplant originating from another person, whereas composite indicates it is composed of heterogeneous tissue types. Facial skin grafts and free tissue transfer are often carried out on burns patients, often with mixed results. Patients can be left with unsatisfactory cosmesis and distorted facial expression. Skin grafts can contract over time leaving a hardened, distorted appearance1. Texture and pliability of facial skin is unique, therefore facial transplantation has been proposed only for those patients where multiple skin grafts and free flaps have failed. The surgeon faces many challenges, which include mal-alignment of the facial graft, aesthetically displeasing surgical scars, but most importantly, graft viability. Graft viability is maintained by effective vascularisation of the donor face by reconnecting the terminal branches of the external carotid artery, superficial temporal artery and internal maxillary artery that will supply the upper third of the face. The facial artery supplies the lower two thirds of the face and is the most essential anastomosis since it supplies most of the graft. Venous drainage will depend upon reconnecting the internal, external and anterior jugular vein. Failure to reconnect any of these vessels or thrombosis at anastomosis sites will result in necrosis of the donor face13. It is important to note that this type of graft failure is a separate process from that of immunological failure. Skin can withstand ischaemia for up to 13 hours, whereas muscle can become ischaemic within 6 hours14. If substantial graft necrosis were to occur, removal of the remaining facial tissue may prove problematic leaving the patient worse off. For this reason, muscle will not be included in the full-facial transplantation, unlike the French partial transplant, but will include skin and subcutaneous tissue6. As well as immunological matching of donor and recipient, the surgeon must also consider the characteristics of the graft, an essential component for good aesthetic outcome. Sex, ethnicity and age are important to match the degree of similarity in skin texture and composition3. Interestingly there is little literature with regards to donor populations and their attitudes and concerns to donating their facial tissue. In one study, 120 people were questioned (one third doctors, one third nurses and one third lay) about their opinions on facial transplantation. A large proportion stated they would indeed accept a face if they were victim to severe disfigurement. However, none said they would donate their own15. Rejection, graft vs host and lifelong immunosuppression The majority of the immune system response is mediated by the Major Histocompatibility Complex (MHC), which represents immunological similarity between donor and recipient. Similarity refers to having a high degree of correspondence between MHC which are alleles of a group of genes17. If a foreign graft is introduced it will be attacked unless it is histocompatible, therefore rejection is most likely if the donor and recipient differ in their histocompatibility11. The body’s ability to detect the difference between self and non-self tissues means that transplantation of allografts activates an immune response leading to rejection, a lifethreatening complication.

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Rejection can be hyper-acute, acute or chronic. Hyper-acute rejection occurs due to B-cell antibodies present in the recipients’ blood stream. This occurs within minutes and can lead to a systemic inflammatory response. ABO blood compatible grafts are therefore required to prevent this problem occurring with cross-matching to enable antibody screening3. Cytotoxic T cells are at the forefront of rejection called the acute phase that can take up to a week. It can even take many years to develop but its effects can be reversed if treated promptly, unlike hyper-acute rejection. The T-cells cause cell lysis and produce cytokines and can be accurately diagnosed on tissue biopsy18. Chronic rejection refers to a complex chronic response that manifests gradually over a longer period of time. It is more concerning in CTA since solid homogenous organ transplants can still survive after partial rejection whilst facial CTA would become functionally impaired. Furthermore, facial CTA will be performed in younger individuals with a higher risk of chronic rejection over time19. As well as the direct problems with immunosuppression, the combination of organ transplantation and immunosuppression brings about a phenomenon termed graft versus host disease. The donor graft mounts a response against the host. Donor T-cells migrate from the donor organ into the recipients system potentially causing neutropenia. Prophylactic immunosuppressive regimens have decreased graft versus host severity and incidence3. The Royal College of Surgeons of England estimates that the likelihood of acute rejection in the first year may be as high as 10% and that the risk of developing chronic rejection is 30% to 50% between the second and fifth year20. Therefore, accurate donor matching and immunosuppressive medication are at the forefront of transplantation success. However, medications cause many side-effects including hypertension, diabetes and renal toxicity. Even more concerning is the susceptibility to infection by pathogens, which is responsible for a high proportion of posttransplant morbidity. Those with a weakened immune system can become very ill from minor illness necessitating the need for prophylactic antibiotics and antivirals21. Malignancies are another complication and are usually of the skin, colon and lungs. NonHodgkin’s lymphoma, Kaposi’s sarcoma and cervical cancer are all virally induced cancers with up to fifty-fold increases in incidence. Immunosuppressive regimens for facial transplants are relatively novel and as yet we are currently unsure about the degree of their safety17. Graft failure is a serious and relatively known consequence of non-adherence14. Evidence for this comes from Clint Hallam and his hand transplant regimen resulting in hand amputation after 29 months. He developed diabetes initially and later triggered a rejection process due to non-compliance with medication. Several options for overcoming the issue of immunosuppression are currently being explored and initial data is promising. These include biological substitutes through to tissue engineering and adult stem cells. Psychological and societal concerns The face transmits one’s thoughts, with facial disfigurement greatly hindering our ability to communicate. It is therefore regarded as paramount to human interactions22. Facial movements govern two thirds of our communication, and this in particular has importance for our relationships with others23. Disfigured persons have difficulties accepting their appearance and hide as an adaptive

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ARTICLE response. Moreover, studies have shown that the degree of disfigurement correlates with the level of psychological distress24. Coping with a new face and the psychological implications to the individual, are extremely important factors for successful facial transplantation, arguably more so than the operation itself. Psychological assessment is vital in selecting persons with realistic expectations to achieve the best outcome for the patient. Individuals that believe they are judged purely upon appearance more prone to unrealistic expectations25. Only those able to cope with intense stressors are likely to be compliant with treatment. Those with higher depressive indices are believed to be less likely to conform to immunosuppressive regimens due to an unstable and fragile psyche26. It is imperative that selected patients have stable families, a strong support network and good understanding of the risks involved. Suitable candidates must be aware of the medical risks, possibility of unsuccessful surgery and media attention15. There has been concern the transplanted face would resemble that of the donor’s raising significant emotional issues for the deceased’s family and friends. This idea may in part be propagated by the 1997 movie ‘Face/Off’, in which an undercover officer makes use of facial transplantation to take on the physical appearance of a major criminal and infiltrate his organisation27. However, computer generated imaging using laser scanning and photography reveals that despite similarities, the transplanted faces would not be identical. Cadavers have also been used to transfer free facial flaps to assess the degree of similarity between recipient and donor. Both models found the overlying soft tissue moulds to the recipient underlying bone structure resulting in a ‘hybrid’ face28. Media involvement brings a previously isolated individual to the forefront of society’s attention, a radical change the patient will be ill-prepared for. Isabelle Dinoire claims she is sent many thousands of letters from people saying how ‘well’ she has done and how she should ‘stay strong’. This is a positive facet but with the media coverage assessing graft progress and possibilities of rejection, it is clearly unwarranted and will perhaps create more psychological discomfort in the future29. In view of this, Professor Peter Butler of the Royal Free Hospital, London has stated that for each of his fullfacial transplant operations, patients will be kept anonymous and guided through the process using a biopsychosocial approach14. Ethical Debate and Society Previously, surgeons argued ‘should we do it, and how should we go about doing it?’ Ethicists argued ‘just because we are in a position to perform such procedures, does this mean we should?’ However, the debate has since moved on. We are no longer questioning the ethics of performing facial transplantation, but merely the ethics of how30. Supporters of facial transplantation will argue that individuals are hidden in society and resolution of their disfigured features will revive self-esteem and therefore improve their quality of life even though they may not live as long. Since patients are told the potential risks and benefits, patients should have autonomy to make their own decision to proceed31. Conversely, it is argued that when patients are offered a revolutionary new surgical procedure, they will opt for that surgery concentrating on the benefits more closely23. Clark states, ‘if potential patients are desperate for a procedure, the question arises whether it is feasible for them to assess if possible improvements in quality

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of life outweigh the potential morbidity and mortality caused by long-term immunosuppression’15. Others argue that consent with regards to facial transplants is counterintuitive. A person with a facial deformity will have hope at the prospect at receiving a new life. The ‘nothing to lose’ approach can be dangerous for these individuals and regulations may need to be enforced to protect these individuals. The surgeon has a role in informing the patient the risks for the entire process and not giving a biased overview of what may be involved24. A short report by a British plastic surgeon claims that teams from the United States of America, UK and China may be racing for ‘media attention’ rather than the welfare of the patient involved32. Critics argue that all other avenues on the reconstructive ladder should have been explored first for Isabelle Dinoire before attempting the partial facial transplantation33. Conclusion Partial facial transplantation has been carried out to date with some success. We have progressed from successful allograft of a nerve in 1988 to near full-face transplants in 20088. We now know it is technically possible to perform facial transplantation with current microsurgical techniques. Individuals so far have been shown to exhibit a tolerance to the level of toxicity from immunosuppressive medications34. Therefore, we cannot ignore facial transplantation as a reconstructive option. Despite the prospect of such an achievement, there are considerable reasons for concern. Longterm risks may not be apparent to patients, which include rejection, immunosuppression and inadequate post-surgical care. The British Association of Plastic, Reconstructive and Aesthetic Surgeons claims it hoped full-face transplants, long seen as the ‘Holy Grail’ of surgery, would become routine given the right safeguards. There are divided opinions on the psychological well being of these patients post-transplant. Thus the selection process for suitable candidates will be especially important. It is encouraging to see the level of discussion from scientists, ethicists and psychologists, ensuring every aspect of the procedure is considered. We must not lose sight of the fact that our ultimate ambition lies in producing the best outcome for our patients. This will by no means be an overnight process, but will require a dedicated team of individuals attempting to restore an individual’s quality of life. References 1. 2.

Hartman RG. Face value: challenges of transplant technology. Am J Law Med. 2005;31(1):7-46. Van Loey NE, Van Son MJ. Psychopathology and psychological problems in patients with burn scars: epidemiology and management. Am J Clin Dermatol. 2003;4(4):24572. doi:10.2165/00128071-200304040-00004 Hettiaratchy S, Randolph MA, Petit F, Lee WP, Butler PE. Composite tissue allotransplantation--a new era in plastic surgery? Br J Plast Surg. 2004 Jul;57(5):381-91. doi:10.1016/j.bjps.2004.02.012 Morris PJ, Bradley JA, Doyal L, Earley M, Hagan P, Milling M, et al. Facial transplantation: a working party report from the Royal College of Surgeons of England. Transplantation. 2004 Feb 15;77(3):330-8. doi:10.1097/01.TP.0000113810.54865.BE Interview: Diana Whybrew. The Guardian [online]. 4 November 2006. http://www.guardian.co.uk/science/2006/nov/04/ medicineandhealth.comment [Last accessed 18 October 2009] Devauchelle B, Badet L, Lengele B, Morelon E, Testelin S, Michallet M, et al. First human face allograft: early report. Lancet. 2006 Jul 15;368(9531):203-9. doi:10.1016/S0140-6736(06)68935-6 Chenggang Y YH, Xudong Z, Binglun L, Hui Z, Xianjie M, Li Y, et al. Some issues in facial transplantation. Am J Transplant. 2008 Oct 2008;8(10):2169-72.

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BOOK REVIEW

Surgery, An Oxford Core Text Editors: Peter Stonebridge, David Smith, Lesley Duncan and Alastair Thompson Publisher: Oxford University Press ISBN: 0192629905

and stereotypical imaging results for the major surgical conditions. Further, the text is broken up by summary boxes and ‘fast facts’ boxes which help to re-emphasise the key points of the section that has just been read. Although this book is an excellent introduction to surgery for medical students, it should by no means be seen as a comprehensive manual of everything you need to know about surgery. Firstly, this book lacks chapters on orthopaedics and ear, nose and throat surgery and the section on breast surgery is brief. I also feel that there could be more written about the common operations and basic surgical procedures that we as medical students need to know about. Additionally, this book does not really cover any of the specialist surgical examinations in anywhere near enough detail to be able to perform them, unlike texts such as Browse’s Introduction to Signs and Symptoms of Surgical Disease or even Surgical Talk.

When facing the prospect of starting clinical medicine, it is not immediately obvious which are the good surgical texts for medical students. Once you start delving into the subject area you become overwhelmed with the choices on offer. Surgery, An Oxford Core Text is a textbook written for the clinical medical student’s first surgical encounter. The lead editor, Peter Stonebridge, a consultant vascular surgeon has compiled a book which is easy to read and explains surgical concepts in a simple and understandable way that does not assume any prior clinical knowledge. The book is divided into two main sections. The first covers the main general surgical specialties, namely gastro-intestinal, hepatobiliary, vascular, breast and also includes a section on neck lumps and thyroid surgery. The second section contains chapters on peri-operative care and anaesthesia and care of the post-operative patient. Each chapter begins with a number of patient-based clinical scenarios, which are broken down into a stepwise fashion to promote understanding of the clinical presentation and initial management of these common surgical problems. This is then followed by a more detailed explanation of these conditions, including when necessary, a description of the background scientific theory underpinning the clinical knowledge. The text is supplemented with numerous, well annotated clinical photographs

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Where Surgery, An Oxford Core Text does excel is with its perioperative and post-operative chapters and these alone are enough for one to recommend this book as an essential read. The perioperative section covers areas such as the anaesthetic assessment, post-operative pain management, control of nausea and vomiting, fluid management, nutrition and blood transfusion. The postoperative section covers both common and serious post-operative complications using the universal DRABCDE method. These sections are again centered around clinical cases yet what sets them apart from similar chapters in other books is the fact that the authors explain the scientific theory underlying the rationale for every clinical decision made at each stage of the assessment of a patient. This approach leaves you with a clear understanding of the pre- and post-operative care of a surgical patient and a little less daunted by the prospect of having to deal, for instance, with a patient who has just collapsed on the wards post-operatively. In this respect, not only is this book useful for critical care OSCE stations, but would also be of great help to foundation year doctors on surgical wards. While this book never becomes overcomplicated in its descriptions, the style it is written in means that it is more suited to being read chapter by chapter than to being dipped in and out of - a point that is underpinned by the editors in the preface. I would not recommend this book as a primary revision tool for surgery as there are other surgical texts that are written specifically with revision for exams in mind. However, I do feel that this would have been the book that I would have liked to read during the weeks in September last year when I first set foot on the surgical wards. Peter Arthur-Farraj PhD peter.farraj@ucl.ac.uk Year 4 Medicine, UCL Medical School

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ARTICLE

Transforming the Culture of Surgical Safety Andrew Carson-Stevens

MB BCh/MPhil student, Cardiff University

Shabnam Hafiz

MD student, Ben Gurion University, Beer Sheva, Israel

Jordan Bohnen

MD student, University of Connecticut School of Medicine

John Rose Jr.

MD/MPH student, University of California

MD/MPH student, Harvard School of Public Health, Harvard University MD/MPH student, University of California

carson-stevens@doctors.org.uk

Lily Gutnik

Daniel Henderson Thomas Tsai

MD/MPH student, University of California, Irvine, CA, USA

Rachel Fesperman

Surgical safety is an under-recognised public health problem. Estimates show that approximately 234 million operations are performed worldwide each year and that as many as seven million people each year suffer a disabling surgical complication and one million die as a direct result of their surgery.1 In 2006, the World Health Organization (WHO) launched an effort to improve global surgical safety, to reduce surgical mortality and complication rates.2

are designed to address safety issues at three distinct time points for a surgical patient: first, when the patient ‘signs-in’ to the operating theatre, prior to induction of anaesthesia; next, a ‘time-out’ period immediately prior to incision; and finally, a postoperative ‘sign-out’ stage, before the patient leaves the operating room. Each component builds on effective teamwork, keeping all surgical team members aware of the needs of the patient and prepared for any expected complications.3,4 The Checklist has been compared to the detailed flight checks carried out by an airline pilot.

To achieve this goal, WHO leaders created an evidence-based Surgical Safety Checklist (Figure 1). Components of the Checklist

MD/MPH student, University of North Carolina

Figure 1: The World Health Organization Surgical Safety Checklist

Surgical Safety Checklist Before induction of anaesthesia

Before skin incision

Before patient leaves operating room

(with at least nurse and anaesthetist)

(with nurse, anaesthetist and surgeon)

Is the site marked? Yes Not applicable Is the anaesthesia machine and medication check complete? Yes Is the pulse oximeter on the patient and functioning? Yes Does the patient have a: Known allergy? No Yes Difficult airway or aspiration risk? No Yes, and equipment/assistance available Risk of >500ml blood loss (7ml/kg in children)? No Yes, and two IVs/central access and fluids planned

Confirm all team members have introduced themselves by name and role. Confirm the patient’s name, procedure, and where the incision will be made. Has antibiotic prophylaxis been given within the last 60 minutes? Yes Not applicable Anticipated Critical Events To Surgeon: What are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss?

To Surgeon, Anaesthetist and Nurse: What are the key concerns for recovery and management of this patient?

To Anaesthetist: Are there any patient-specific concerns? To Nursing Team: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns? Is essential imaging displayed? Yes Not applicable

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.

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Nurse Verbally Confirms: The name of the procedure Completion of instrument, sponge and needle counts Specimen labelling (read specimen labels aloud, including patient name) Whether there are any equipment problems to be addressed

Revised 1 / 2009

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Source: World Health Organization

Has the patient confirmed his/her identity, site, procedure, and consent? Yes

ARTICLE Between October 2007 and September 2008, the WHO’s Safe Surgery Saves Lives program conducted a pilot-study of the Checklist in eight hospitals in eight cities representing a variety of economic circumstances and diverse patient populations.5 The rate of death was 1.5% before the Checklist was introduced and declined to 0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the Checklist (P<0.001). A group of likeminded students are collaborating to facilitate the spread of the surgical checklist as part of the patient safety movement. These students represent multiple health professions (e.g. medicine, nursing, healthcare management and public health) from several countries. Together, we clarified a common vision and outlined a strategy for promoting student-led efforts related to the WHO’s Checklist. The vision – “students across the world helping to disseminate the WHO Surgical Safety Checklist and partnering to improve healthcare quality” – reflects our belief that health professions students can play a meaningful role in improving healthcare quality in any setting. In pursuit of this vision, the group’s strategy highlights a number of potential opportunities for student involvement. Specifically, to build awareness about the Checklist, serve as catalysts for its implementation, and collect data regarding its usage to encourage uptake. This collaboration amongst students is known as the Safe Surgery Student Mentor project. The Safe Surgery Student Mentor project exists to provide support to Student Mentors of the Checklist. Initially, to foster growth and collaboration on campuses, we developed partnerships with surgical and public health faculty, hosted chat sessions, and united with student-oriented quality improvement groups including the Institute for Healthcare Improvement’s (IHI) Open School for Health Professions and the American Medical Student Association’s (AMSA) Surgery Specialty Forum.6-8 Off campus, students are engaging in trials disseminating the Checklist in the U.S, Pakistan, Israel, Uganda, and Wales. Lessons from these efforts, and from additional case studies currently underway, will be used to inform via a guide to improve efficacy in the future. Until that time, the team challenges students worldwide to join the dissemination process by: (1) reading the original research in an article dedicated to the Checklist, (2) visiting the WHO Safe Surgery project website, (3) investigating whether or not the Checklist is currently used at your home institution or facility, and where applicable, (4) considering taking the Checklist on any clinical electives (see Figure 2). Currently, the Surgical Safety Checklist is endorsed by over 300 organizations worldwide and is actively being implemented in at least 768 sites around the world.9 The Safe Surgery Student Mentor project is currently partnering with over 140 student groups of the

IHI Open School and over 150 chapters of the AMSA and launched the global “Check a box. Save a life” campaign in October 2009 encouraging healthcare student groups to sign up and become partners of the 1st Global Sprint to Improve Healthcare. The WHO Safe Surgery Saves Lives initiative, already in its third year, will benefit greatly from this mobile force of students playing the role of ambassadors for the Surgical Checklist. Beyond the immediate effects of implementation, which have already been documented to save lives and precious healthcare resources, Student Mentors will set a precedent of patient safety for the next generation of healthcare professionals. The Student Mentor project has also served as a vehicle for students to be engaged in health service delivery and quality improvement research, bridging their clinical experiences with their passion for health reform. This is a call to arms to faculty and senior colleagues to support the enthusiasm of junior colleagues, to assist in developing their ideas for improvement, and aid them in executing this important work. There is an army of enthusiastic students eagerly awaiting new opportunities to improve healthcare quality and patient safety, both domestically and abroad. In this age of grassroots movements and social networks, the Student Mentor project has shown that medical and health professions students are an underutilised resource for translating research into change, policy into practice. The Safe Surgery Student Mentor project can be reached online via the WHO Safe Surgery campaign’s website, http://www. safesurg.org/student-mentors.html. Students are encouraged to use this forum to share their own experiences with the Checklist in preparation for a more formal launch through IHI and AMSA this autumn. References 1.

Source: Andrew Carson-Stevens

Figure 2: The Safe Surgery Student Mentor Challenge Safe Surgery Student Mentor Challenge (1) Read the article dedicated to Safe Surgery Checklist. (2) Visit the WHO Safe Surgery website and become familiar with available materials (http://www.safesurg.org/studentmentors.html) (3) Investigate your home institution or healthcare facility’s Quality Improvement protocols and see how you can get involved. (4) Spread awareness by talking to your colleagues about the Checklist.

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Weiser T, Regenbogen S, Thompson K, Haynes A, Lipsitz S, Berry W, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139-44. doi:10.1016/S0140-6736(08)60878-8 World Alliance for Patient Safety. Global Patient Safety Challenge 2007-2008: Safe Surgery Saves Lives. Geneva: World Health Organization, 2007. http://www.who.int/patientsafety/ safesurgery/en/index.html. [Last accessed 19 June 2009] Allard J, Bleakley A, Hobbs A, Vinnell T. ‘”Who’s on the team today?” The status of briefing amongst operating theatre practitioners in one UK hospital. Journal of Interprofessional Care. 2007;21:2:189–206. Lingard L, Espin S, Whyte S, Regehr G, Baker G R, Reznick R, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Journal of Quality and. Safety in Health Care. 2004;13:330-334. doi:10.1136/qshc.2003.008425 Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–499. doi:10.1056/NEJMsa0810119 IHI Open School for Health Professions. Institute for Healthcare Improvement. Cambridge: IHI, 2008. http://www.ihi.org/IHI/ Programs/IHIOpenSchool/. [Last accessed 19 June 2009]. Surgery Specialty Forum. American Medical Student Association. Reston: AMSA, 2009. http://www.amsa. org/surg/. [Last accessed 19 June 2009]. Carson-Stevens, A. The IHI Open School: Primum non nocere. The London Student Journal of Medicine {Surgery}. 2009;1(1):46-47. doi:10.4201.lsjm/surg.002 Safesurg Project. Safesurg.org: a website for information on how to reduce deaths in surgical care globally. Boston: Safesurg.org, 2009. http://www.safesurg.org./. [Last accessed 19 June 2009].

Acknowledgements The authors would like to acknowledge the WHO Safe Surgery dissemination team and the IHI Open School for their ongoing support of the Safe Surgery Student Mentor project.

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EDITORIAL

Alzheimer’s: The Future According to the 2009 World Alzheimer’s report (released 21st September)1, the number of Alzheimer’s sufferers will double every 20 years, reaching 115 million by 2050. So what are the options for the future cure, treatment, and prevention of this global health burden?

For the full references see thelsjm.co.uk.

Current opinion is that amyloid beta deposition, neurofibrillary tangles, and tau protein aggregates play a key role in the pathology of Alzheimer’s disease8. These aggregates were present in large numbers in Alzheimer’s patients, and it was assumed they were a direct cause of pathology. However, evidence is now emerging that these may serve a protective role, turning long held beliefs on their head9. Early diagnosis of Alzheimer’s preserves a greater level of patient function for longer periods of time, and reduces healthcare costs2. One approach to early diagnosis is non-invasive imaging, which may display structural changes before any symptoms begin to appear3. Biomarkers have also proved promising and may allow more accurate diagnosis of the early stages of disease4. However, the possibility of making such expensive and time consuming techniques available to the entire population is questionable, and the accuracy of the such methods is in doubt4. On a more positive note, we are now coming to the end of a five year Alzheimer’s Disease and Neuroimaging Initiative (ADNI) project, which examined patient’s using MRI, PET, and CSF10. Results are still being assessed, and should be released in the next few months but Michael Weiner, a neurologist working for the ADNI has described the results as “a phenomenal success.” Prevention is better than cure and there has been heavy focus on a potential Alzheimer’s vaccine5. Accumulation of a peptide known as ‘amyloid beta’ is thought to be responsible for the symptoms of Alzheimer’s disease, so this molecule has been focused on as a target11. Work done by Schenk et al.12 in 1999 showed promising results in mice, but when an amyloid beta vaccine was then tried in humans it was halted as some patients developed meningoencephalitic symptoms13. Two new approaches to a vaccine are in early development, firstly using amyloid beta monoclonal antibodies, and secondly using a DNA vaccination. Both of these approaches are in their infancy, with monoclonal antibodies entering clinical trials. If we are getting better at diagnosis, and there is not yet an efficient prevention, what about a cure? Currently there is no treatment for Alzheimer’s, however, there are some drugs used to limit its progression7, such as Aricept and Exelon. Development of pharmaceutical solutions to Alzheimer’s has been held up by the difficulty of crossing the blood brain barrier15, and there are no new ‘wonder drugs’ on the horizon. Heads are quite literally turning to a different approach to treatment, made famous by Terry Pratchett, who recently made a documentary about his own struggle with Alzheimer’s Disease6. His series featured what appeared to be a groundbreaking treatment that halted disease progression. This space age contraption was a helmet that uses infrared red light targeted at the brain, with an aim to increase cell growth. Although initial use of this helmet appears to have been positive, it is currently undergoing clinical trials, with eagerly anticipated results. So with a potential worldwide explosion in Alzheimer’s, the race to find a successful solution is on. The most desirable answer would surely be a cheap and safe vaccine that could be distributed globally, but how long will we have to wait?

Illustration: Ella Beese

Alexander Ross Section Editor Psychiatry

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131

NEWS

Innovation and News In Psychiatry Nicola Hood

Innovations take many different forms and should be judged on the value of their contribution to society, not their flash, razzmatazz or how they capture the medias or the public’s imagination. Unlike so much of our anatomy, the brain retains so many of its mysteries. This unfathomably complex organ, resulting from constant unrelenting interactions between genetics and our environments, en-

Source: Wellcome Images

It’s better to give… After surveying a range of patients with mental health illness, the Royal College of Psychiatrists were disappointed to discover over half did not receive any gifts or cards when they had been unwell. This notably differed from only a third who had not received similar offerings during a period of physical illness. Television presenter Trisha Goddard, who has been treated for both depression and breast cancer, said that this did not surprise her. Indeed the experience reported by service users resonated very much with that of her own. The college identified that one problem may have been that many of the existing cards available were not suitable, and have thus launched their own range as 4 out of 5 patients agreed a card would improve their recovery. The cards come in two designs and can be purchased here: http://tinyurl.com/yhluw92 Innovation and News In Psychiatry Chicken Tikka Masala for the brain? If Chicken Tikka Masala is your takeaway treat of choice, then your attention may be enticed by the theory Professor Doraiswarny presented at the annual meeting of the Royal College of Psychiatrists. It was proposed that curcumin, a component of the spice tumeric may significantly reduce the risk of dementia if ingested regularly. Although research is not yet completed, it appears curcumin may bind to amyloid plaques (thought to play a key role in dementia progression) and prevent their advancement. Early animal experiments have shown curcumin can dissolve existing plaques. Unfortunately for curry-lovers, dissenters maintain that levels in curry are well below those required to be statistically significant. Until the study is formally peer-reviewed, it seems unlikely curries will feature under the department of heath’s nutrition guidelines. Paid to be treated A novel new approach to improve patient attendance for treatment is being pioneered in London, where patients with bipolar disorder or schizophrenia are re-numerated £15 per anti-psychotic injection. The scheme, was introduced as yet another step in tackling the long standing problem of poor adherence, building on initial findings regarding oral medication that showed missing even one treatment in ten is correlated with an increase in hospital readmissions. Whilst a change in method of administration increased adherence, the often unfavourable side effects of antipsychotics meant overall levels remained unsatisfactory. Mind has criticized the trial; contending patients should be motivated to take their medication for the health benefits alone. The team at Queen Mary’s disagree, and insist that the ultimate benefits to the patient and their mental health justify their paternalistic approach.

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sures that developments in psychiatry are slow and faltering. It does not mean they are worthy of any less attention. With mental health escaping a finite definition (and instead remaining a continuum upon which we must all find our place) it is increasingly apparent that every new discovery, however small, is of relevance to all of us.

A Cocaine Vaccine Promising results have been observed at the Yale School of Medicine in a study targeted to reduce cocaine dependency. A cocaine vaccine was administered in a placebo controlled trial resulting in over half of trial participants having significantly reduced cocaine usage at six months (monitored by thrice weekly urine testing). The pharmacological mechanism involves mobilizing an antibody response and preventing cocaine crossing the blood brain barrier so that addicts do not experience a ‘high’ after using. Enticingly, scientists are already contemplating a similar vaccine design with other drugs of dependency. However, the charity Action on Addiction has urged caution, emphasizing that addiction has many psychosocial aspects which cannot be ignored if doctors are serious about achieving long-term large-scale impacts. Sweet Agression Cardiff School of Medicine recently published a study demonstrating a relationship between the amount of confectionery consumed in childhood and the aggressive tendencies in later life. Children who ate sweets or chocolate daily had a significantly higher rate of crime by their thirties than those who did not. However, it should be carefully questioned if a causal relationship exists, compared to a more plausible correlation between parenting styles regarding both diet and discipline.

lsjm 30 november 2009 volume 01

REPORT

Source: Wellcome Images

Changes to The Mental Health Act 1983 Angharad Woolley

Year 5 Medicine, St George’s University of London akwoolley@googlemail.com

Mental health disorders have the potential to affect anyone. The law is in place to define mental disorder, what treatment is given, and what rights are given to a person requiring treatment, given that by its very nature, such a disorder may impair the ability of an individual to make choices for themselves. In the context of our evolving healthcare system, particularly in such evocative areas as mental health, it is important that law keeps up to date with practice, and vice versa. Hence the recent modernisation of the 1983 Mental Health Act (MHA). The changes were a result of nine years of lobbying by the Mental Health Alliance. Changes have been made throughout the act and affect issues as diverse as what qualifies as a mental disorder and who may be given treatment, rules governing the power a parent has in decisions over their children’s mental health, the use of electro convulsive thereapy and increased rights of those in same sex civil partnerships in the eyes of the MHA. A new code of practice for the Mental Health Act came into force in November 2008. Although not legally obliged to abide by it, clinicians not following the code of practice should record their reasoning for doing so. Principles of the code of practice are: Purpose to treatment (improving disorder rather than just sedating) Minimising restriction of patient’s freedom Respect for individual cultural needs and values Maximal participation of patient, family and carers Efficient and effective use of resources The changes have been welcomed by those who lobbied for them although there are still more issues which continue to remain controversial. For example whether or not detention could be restricted to those who have lost mental capacity, as is already the case in Scotland.

Increased rights for young people From January 2008, young people aged 16 or 17 are able to consent to or refuse voluntary admission to hospital for treatment, without a parent being able to override their decision. Wider definition of mental disorder From November 2008, the previous categorisation of mental disorders (4 categories under the MHA 1983) will be dropped to incorporate the wider definition which will mean ‘any disorder or disability of the mind’. Although unlikely to increase the number of people able to be detained under the MHA, the change is hoped to open up treatment for those previously seen as untreatable, such as those with personality disorder.

More information on these and other changes recently made to the Mental Health Act is available on the Rethink website: http://www.rethink. org Rethink is a member of the Mental Health Alliance whose years of lobbying were crucial in bringing about these changes.

Further restriction of controversial treatments From November 2008, where a patient retains capacity to make decisions about their treatment, they may not be given ElectroConvulsive Therapy (ECT) without their consent being recorded on a certificate. Patients may make an advanced decision to refuse ECT at a time in the future where they may have lost capacity and this will only be overridden in the case of immediately necessary life-saving treatment. Supervised community treatment From November 2008 this will replace supervised discharge in the community, providing a framework to treat patients in the community. This is most likely to apply to patients who have a history of stopping medication after discharge. Facilitating patients to be aware of, and exercise their rights From April 2009, qualifying patients (including but not limited to anyone detained under the MHA for more than 72 hours) will be appointed an independent mental health advocate (IMHA) who will explain to them their rights and how to exercise them.

So what has changed? The most important changes to the act are summarised, in chronological order: Equality of Heterosexual and homosexual couples From December 2007, civil partners in same sex couples who have registered their partnership will be given equal status as a husband or wife and can therefore act as a nearest relative – a family member that is given important rights in the case of their relative being ‘sectioned’, which they may use in what they believe to be in the patient’s ‘best interests’, if they disagree with healthcare professionals.

lsjm 30 november 2009 volume 01

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REPORT

Mental health care in prisons in England and Wales: its state and changes over the last decade Ilia Kantsedikas

Year 3 Medicine, Barts and the London I.kantsedikas@gmail.com doi:10.4201/lsjm.psy.005 For the full references see thelsjm.co.uk.

Mental health is a popular topic with a great deal of literature devoted to it and several campaigns dedicated to removing its associated stigma. However, mental healthcare in prison has been largely overlooked. This piece reviews the current trends in the field with the help of relevant publications.

commitment to match the services offered by the NHS, equality still had not been achieved by 1999 prompting an attempt at a radical overhaul of the system with the responsibility for health care provision transferred from HM Prison Service to the Department of Health by 2006.5 While it is too early to comment on the results of this reform, Hayton and Boyington have been cautiously optimistic in their early review of the changes it brought about.4

Background A report by John Howard (the prison reformer) published in 1784 is fascinating proof of how old the problem is. A more up-todate information source is the full survey of the mental health of prisoners in England and Wales undertaken by the Office for National Statistics.2

Insofar as mental health is concerned, it has been an area lagging particularly far behind the other areas of the prison health care. While it is now widely acknowledged that not all prisoners with a

The survey unequivocally shows an increased prevalence of mental illness among prisoners (Figure 1). For example 7% of sentenced men, 10% of men on remand and 14% of all female prisoners showed evidence of psychosis in the year prior to being interviewed â&#x20AC;&#x201C; a figure far outweighing the rate of 0.5% observed in the general population.3 In the light of this it is pertinent to explore how mental health care is currently delivered in prisons. The prisons in the UK have the oldest civilian medical service, established as a result of John Howardâ&#x20AC;&#x2122;s work. Presumably for this reason, prisons were left outside of the National Health Service (NHS) remit when it was established in 1948. However as time progressed it became more evident that the needs of the prisoners were not being met by the existing system, largely due to shortfalls in staffing, training and equipment.4 Despite the explicit

Figure 1: Comparative prevalence of probable psychotic disorder in the UK, % (based on 2,3)

134

lsjm 30 november 2009 volume 01

â&#x20AC;Š

REPORT mental health problem require a bed at a NHS forensic psychiatric unit, some of the practices deemed to be necessary regardless of the setting only very recently started to appear in the prison service. Another issue is the presence of the seriously ill inmates who do require treatment in a NHS unit, but whose transfer cannot be arranged within reasonable time. As psychiatric morbidity is known to increase in absence of treatment6 such a situation leaves inmates with an increased risk of a major illness. The research so far has identified two major areas underpinning this weakness – material problems and a lack of policy on mental healthcare in prison.7,8 These are often interlinked, as policy affects staffing and material provisions and input from those working in the system is bound to affect policy. This essay will attempt to highlight the key issues in these areas and explore what has been done to tackle them. Discussion Material problems, such as staffing issues and availability of resources are often the first to be cited when healthcare in prison comes under scrutiny. Although prison healthcare centres are commonly referred to as hospitals, they are often more akin to sick bays with primary health cover than an NHS hospital. Some of them do not even have beds of their own, although every prison has access to hospital beds by transferring inmates to a different prison. Another issue stemming from financial limitations is the lack of meaningful activities to occupy the patients during the day. A policy is in place stating that patients whose clinical state permits it are to spend 12 hours a day unlocked and out of their rooms with at least 6 hours a day devoted to therapeutic activity, such as education and developing interpersonal skills, however while this is the case in the NHS setting, none of the prisons inspected by Reed and Lyne met the standard.8 The shift in responsibility for prison health care to the Department of Health has led to an improvement in the availability of resources and funding;4 but discrepancies still remain in regional funding that cannot be explained by differences in salaries and costs alone (fig. 2).9 Staffing issues stem from both funding difficulties and policy decisions. For example health care officers with limited nurse training making up a quarter of the nursing workforce and receive little training on policy or practice in caring for prisoners with mental illnesses, which is likely to be due to financial constraints.7,8 On the other hand, while staff availability (and thus finances) plays a role in reduced levels of night staffing at the health care centres, its interaction with the security requirements (meaning that the duty nurse often cannot carry keys to the prisoners’ rooms and will need keys and the necessary extra security staff brought over from the main prison) and the lack of standard for night staffing are primarily responsible for limitation of rapid access to the patient. The multidisciplinary team approach which is commonplace in the NHS was also sadly lacking at the time of inspection, which relates back to the insufficient amount of time the patients were allowed to remain unlocked and lack of meaningful therapeutic activity – the staff necessary to deliver it were simply not in place.8 Community care within prison Apart from the practical problems of delivering quality mental health care in prison described above, a number of issues surrounding precisely what mental health care in prison should entail and how it ought to be delivered exist. An area where some progress has been seen lately is that of how prisoners can access mental health care. Previously it was a widely held belief that nearly

lsjm 30 november 2009 volume 01

Figure 2: Prison health care spending per inmate by region9 all prisoners with mental illness must be placed at the prison health centre. This notion has since been abandoned as it was recognised that the majority of mentally ill prisoners would have been treated in the community if they were free, meaning that they can remain in their general location provided the standard of care delivered is equivalent to the NHS.9 The recent prison health care reforms have attempted to enable this by establishing mental health in-reach teams, whose function is broadly equivalent to that of community mental health nurses.4 Initially these teams were geared towards the severely ill patients who have to remain in prison (for example while they are waiting for a bed in a forensic mental health facility); however their remit has been rapidly expanding to include less ill prisoners. It appears that implementing the other models of care that are found in the community such as assertive outreach will also fall on the in-reach teams.9 While this is a commendable effort to close the gap between the services available in the NHS and in prison, this expansion of the in-reach teams remit also raises the question of whether they will receive the appropriate support to avoid being overstreched. In light of this it is interesting that at least one publication suggests transferring all prisoners requiring specialist mental health care to the NHS either under the provisions of the Mental Health Act 1983 (MHA 1983) or on temporary license, thus avoiding the duplication of resources.8 Consent in this population Another area policy change that has recently come under the spotlight is the enforcement of treatment orders in non-consenting patients. At the moment treatment without consent can only be provided in emergencies or where common law can be used to justify necessity, since no part of a prison can be considered a hospital under MHA 1983. Evidence suggests this has been taken very literally in many prisons, resulting in patients lacking capacity due to their illness refusing treatment that can relieve their suffering until a place at an NHS facility (where they can be treated without consent according to MHA 1983) can be found for them. As previously mentioned the wait for beds at these facilities is often long, meaning that patients may remain untreated for prolonged periods of time potentially leading to increased morbidity. Earthrowl et al10 have explored the issue and proposed a policy that can be used to provide more extensive treatment to patients in the

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REPORT situation described above. While enforcing treatment may appear to be in breach of a patient’s human rights, it can be argued that it is in fact a balance between a patient’s right to autonomy and one’s right to receive treatment to relieve them of their illness. Earthrowl argues that the latter outweighs the former, a view which appears to be shared by the others in the profession.11 It is noteworthy that the proposed policy is not intended to replace treatment in a setting more suitable for a severely ill person, but rather as an interim measure to resolve the ethical dilemma of leaving a patient to suffer due to legal ambiguity.

entirely to the NHS as advocated by Reed. The relative merits of the two models and reasons for choosing one over another warrant further exploration. Given the progress made so far, turning our attention away from the issue of mental health care in prison will condemn the inmates to unjustified suffering. It is therefore paramount that this area of mental health care continues to receive funding and that further research is carried out into both policy and practical aspects of care to provide the best possible service. References

Conclusion Reviewing the literature devoted to mental health care in prison it is immediately obvious that there is a striking difference between the care available in the NHS and in prison. The reasons underlying this difference are inadequate financing and lack of coherent policy. The latter has been subject to attention recently with the focus in policy development shifting from HM Prison Service to the Department of Health, resulting in a number of positive changes. These changes have also brought some much-needed resources into prison health care, leading to introduction of methods that have been commonplace in the NHS. It can be argued that prison health services are becoming an extension of the NHS services, however more co-operation between the two services is required and a great deal of stigma must be overcome for this vision to reach its full potential. There is also evidence that financing still remains inadequate and the financial difficulties faced by the NHS may threaten the progress of this reform. A further interesting point was the difference in approach to mental health care for prisoners, either keeping it primarily in prison (which appears to be at the heart of government policy) or entrusting it

2. 3.

6. 7. 8.

10.

Howard J. The state of the prisons in England and Wales, with preliminary observations and accounts of some foreign prisons. Warrington; 1777 Singleton N, Meltzer H, Gatward R. Psychiatric morbidity among prisoners in England and Wales. London: Stationery Office; 1998 Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H. Psychiatric morbidity among adults living in private households, 2000: summary report. London: Stationery Office; 2001 Hayton P, Boyington J. Prisons and health reforms in England and Wales. Am J Public Health 2006; 10: 1730-1733 doi:10.2105/AJPH.2004.056127 Joint Prison Service and National Health Service Executive Working Group. The future organisation of prison health care [online]. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ DH_4006944 (accessed 16/4/2009); 1999 Michael-Titus A, Revest P, Shortland P. The nervous system. Edinburgh: Churchill Livingstone Elsevier; 2007 Reed J. Mental health care in prisons. Br J Psychiatry 2003; 182:287-288 doi:10.1192/bjp.182.4.287 Reed JL, Lyne M. Inpatient care of mentally ill people in prison: results of a year’s programme of semi-structured inspections. Br Med J 2000; 320:1031-1034 doi:10.1136/bmj.320.7241.1031 Brooker C, Duggan S, Fox C, Mills A, Parsonage M. Shortchanged: spending on prison mental health care [online]. Available: www.scmh.org.uk/pdfs/short-changed.pdf (accessed 16/4/2009); London: Sainsbury Centre for Mental Health; 2008 Earthrowl M, O’Grady J, Birmingham L. Providing treatment to prisoners with mental disorders: development of a policy. Br J Psychiatry 2003; 182:299-302 doi:10.1192/bjp.182.4.299

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lsjm 30 november 2009 volume 01

RESEARCH

Does ethnicity impact upon reporting of depression in London medical students? Rachel Baigel*, Deborah Ragol Levy, Robert Freudenthal, Daniel McNaughton, Sara Taha (all Year 4 Medicine, University College London) rachel.burns@ucl.ac.uk doi:10.4201/lsjm.psy.003

Abstract Background Mental illness, particularly depression, is responsible for a significant proportion of the world’s health burden. Psychiatric disorders, particularly depression with suicidal ideation, have long been known to be more prevalent amongst healthrelated occupations. Depression can present in a wide variety of ways. This study seeks to ascertain how ethnic differences impact on the presentation of depression in London medical students and what factors prevent students from seeking professional help. Methods An online questionnaire was distributed to pre-clinical medical students at University College London, Kings College London and Bart’s and the London School of Medicine. Students were asked to respond to four case vignettes describing different levels of depressive symptoms in a student. These were constructed based on the ICD-10 criteria for mild, moderate and severe depression with a control vignette that represented subclinical symptoms of depression. Students were asked how likely they would be to seek help from different services and the reasons that would prevent them from going to these services. Analysis of variance (ANOVA) tests were used to conduct statistical analysis. Findings Overall, the most common health-seeking behaviour was from friends, with the exception of Black African-Caribbean students, who were more likely to get help from their family. Seeking help from general practitioners, counsellors and university tutors was unpopular, even in severe depression. There were statistically significant differences between ethnic groups in attitudes towards seeking help from: a friend in both subclinical (p=0.032) and mild (p=0.043) depression; a relative in subclinical depression (p=0.047); a counsellor in mild depression (p=0.025), and from a university tutor in subclinical depression (p=0.04). When students were asked about the factors deterring them from seeking help for depression, 31% said they definitely wouldn’t seek help as they believed their grades would suffer as a result, 35% said they wouldn’t want the label of depression, and 33% said they believed that seeking help for depression could affect their medical career. Interpretation Our findings indicate that despite an abundance of services available, greater efforts should be made to increase student awareness of these services at induction and throughout medical school. Students should be familiar with the multiple presenting symptoms of depression and understand the ramifications of not seeking help. Greater efforts can be focused on students of Black African-Caribbean origin, who have been shown in this study to be less likely to seek help from professionals.

Introduction Mental illness, particularly depression, is responsible for a significant proportion of the world’s health burden. The World Development Report 1993 states that depression is the fifth most common cause of morbidity amongst women and seventh amongst men. The World Health Organization has predicted that by 2020, depression will be the second most common cause of disability worldwide after ischaemic heart disease1. Depression is commonly under-diagnosed with an estimated 56% of people worldwide exhibiting clear-cut features of clinical depression but receiving no treatment. An estimated 74% of Europeans are affected by mental illness but remain untreated2.

lsjm 30 november 2009 volume 01

Prevalence of depression varies across different socioeconomic and occupational groups. There is evidence that young people have the highest population prevalence for mental health problems and substance abuse, however, their use of primary care and specialist services tends to be lower compared to other population age groups3. This remains true amongst university students, where the high prevalence of anxiety and depression is thought to be related to social and academic factors. One study of Oxford University students reported higher rates of suicide than in the general population, with half of these students suffering from clinical depression4. University students are notoriously reticent in presenting depressive symptoms to healthcare services. One study involving six French universities highlighted that only 30.5% of students with psychiatric symptoms sought professional help in the previous twelve months5. Psychiatric disorders, particularly depression with suicidal ideation, have long been known to be more prevalent amongst healthrelated occupations, due to pressurised working environments and easy access to suicidal agents6. However, few studies have investigated the prevalence of psychiatric disorders amongst medical students compared to the rest of the student population.

ERRATUM Due to an administrative error, an early version of this article was included in Vol1 Issue 1. The final version has been included in this publication and is also available is available online at www. thelsjm.co.uk/psychiatry. The LSJM apologises for any inconvenience caused. *Conflicts of interest - Rachel Baigel is a panellist for LSJM Psychiatry

University students, particularly in London, are a heterogeneous group with a large proportion from ethnic minority backgrounds. It has been shown that presentations of depression are culturally dependent with somatic complaints dominating over psychological symptoms amongst non-Western cultures7. Within the UK it is unclear if the prevalence of depression is higher amongst ethnic minorities, with one study showing that whilst London Punjabi populations have a lower rate of diagnosis, they experience more depressive thoughts than their white counterparts8. Previous studies have explored the different factors that prevent presentation to healthcare services and suggest that many people hold stigmatising attitudes towards depression. The diagnosis of depression is commonly viewed as a sign of weakness9 and those diagnosed are often seen as being unpredictable and threatening. If the likelihood of self-presentation to healthcare services for depressive symptoms does vary between ethnicities, then de-stigmatising interventions that attempt to minimise these preventative factors can be targeted to the appropriate groups. It is likely that the burden of depressive illness amongst London medical students is high, however the interaction between ethnicity and presentation of clinical depression within this student group is complex and as yet unexplored. Therefore, this study aims to ascertain how this interaction impacts on the likelihood of selfpresentation to healthcare services when experiencing features of clinical depression.

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RESEARCH

Figure 2. For each vignette students were presented with the following statement: If you were experiencing these problems how likely would you be to see help from: please fill in 1-4 where 1 = wouldn’t go, 2 = might go, 3= would probably go, 4=would definitely go) Internet/books A friend A relative GP University counsellor Other counsellor University tutor Someone else not on this list, please specify ________

Figure 3. At the end of the questionnaire the participants were asked:

Methods To study the impact of ethnicity on help seeking behaviour for depressive symptoms, four vignettes were prepared which presented a fictional case study about a student (appendix). One vignette described a person with no symptoms of depression and the other three represented scenarios of mild, moderate and severe degrees of depression according to the ICD-10 classification of depression (figure 1). Whilst it would have been preferential to maintain the same triggers in each vignette, it was decided to vary the triggers in order to engage the respondents’ interest and increase the completion rate.

whether there were significant differences between the attitudes of medical students from different ethnic groups in seeking help for sub-clinical, mild, moderate and severe depression from internet/ books, friends, relatives, their GP, university counsellors, other counsellors or university tutors. ANOVA was used as this method allows the comparison of the means of multiple groups. ANOVA tests were also carried out to identify statistical differences between ethnicities regarding factors that would affect students seeking help for depression. In total 36 ANOVA tests were performed. Statistical significance of the results was defined to be at the 5% level of significance.

In relation to each vignette, participants were asked to score the likelihood of them seeking help from a range of services (figure 2). Participants were also asked to score the different factors that would affect their decision to attend these services (figure 3).

Where the ANOVA tests were significant, the results were divided into binary variables, with 0 representing ‘wouldn’t go’ and ‘might go’, and 1 representing ‘would probably go’ and ‘would definitely go’. Logistic regression analyses were then carried out to determine the situations in which ethnic categories had significantly different odds of seeking help compared to White British students (odds ratio - OR). This group was selected for comparison as it contained the greatest number of respondents.

This questionnaire was distributed to pre-clinical medical students (including undergraduate and graduate entry level students) at University College London Medical School, King’s College Medical School and Bart’s and the London School of Medicine. The latter two universities sent an email directly to the students’ account with a link to the questionnaire, whilst the first university requested that students participate through a weekly medical student newsletter. Distribution of the survey in undergraduate lecture theatres was considered, but it was felt that this might introduce a selection bias towards those that attended lectures. Nevertheless, some selection bias remained as students with an interest in depression may have been more likely to complete the questionnaire. Therefore, students were asked to state whether they had a personal and/or family history of depression. Some confounding factors remain; where students were educated, which respondents were overseas students, and if any had personal experience of working in the mental health sector. However, this data was not collected. The questionnaire was hosted online at www.surverymonkey.com and was accessible for a period of three weeks, from Monday 20th October to Monday 10th November. An incentive of £20 was made available to encourage responses, as evidence indicates that responses double when a monetary incentive is used10.

How likely would it be that the following factors prevented you from seeking help from the list above? 1-3 where: 1 = wouldn’t prevent me at all, 2 = might prevent me 3 = would definitely prevent me They would think less of me. I wouldn’t want other people interfering with my business. Wouldn’t want to waste their time. This could affect my career as a doctor. This could affect my grades or go on my university record. Wouldn’t want to have a label of “depression”. The opening hours wouldn’t suit me/I wouldn’t have time. The service is too far away. Another reason ___________

On entering the online domain, participants were presented with contact details of the counselling services of their respective institutions and were given the chance to opt out of the study at any point. Ethical approval, data protection and research governance was granted by the relevant departments at University College London. Statistical analysis was carried out using Stata Version 10. Ethnicities were grouped together under seven categories and analysis of variance (ANOVA) tests were performed to ascertain

Figure 1: The vignettes were constructed from the ICD-10 classification of depression. The vignette titles correlate with the ICD-10 criteria for mild, moderate and severe depression.

Symptoms

Mild

Moderate

Severe

depression

Depression

Depressed mood

Loss of interest and enjoyment

Reduced energy with increased fatigability Reduced concentration and attention

Reduced self esteem and self confidence Ideas of guilt and unworthiness

Bleak and pessimistic views of the future Ideas or acts of self harm or suicide

138

Disturbed sleep

Results This questionnaire was sent to 1760 students. 360 (21% of the study population) started filling out the questionnaire and 311 (86%) of these people responded to all the questions. 56% of respondents were second year students and 44% were first year students. 10% of the students had previously suffered from clinical depression and of these 33% suffered from mild, 27% from moderate and 9% from severe depression. (See figure 4 for more demographics.) Of the students who completed the questionnaire, 58% were female and 42% were male. All participants were aged 18-30, with 64% aged 19-20. The response rate of 18% fell only slightly below the expected response rate of an email survey of 20.7%.11 Data concerning the ethnic make-up of pre-clinical students in these medical schools was unavailable so it was not possible to ascertain how representative this sample was. The representation of ethnicities in the study was: White British 51%, Indian-Asian 16%, White Other 12%, Chinese 8%, Mixed Race 6%, Asian Other 5%, Black African-Caribbean 2% These ethnic categories were used in line with UK National Census 2001 categories12, however due to the small sample size in some of the minority populations it was necessary to group together Black African and Black Caribbean students. Overall, the Indian and Asian Other populations suffered the highest morbidity, with 50% of the subjects claiming to have experienced severe depression and the other 50% reporting moderate depression. The only other cases of severe depression occurred in the White British and White Other populations. In the

Figure 4: Demographic data of 311 respondants

Ethnicity

Percentage of each ethnicity who had been depressed

Percentage of total depressed

Severity of depression within each ethnic group Unknown

Mild

Moderate

Severe

Asian Other Black AfricanCaribbean Chinese

0.0%

12.5%

3.0%

100%

14.8%

12.1%

75%

25%

Indian-Asian

3.5%

6.1%

50%

Mixed

18.2%

12.1%

75%

25%

White British

7.7%

42.4%

29%

36%

29%

White Other

17.8%

24.2%

38%

13%

38%

13%

50%

lsjm 30 november 2009 volume 01

RESEARCH Black African-Caribbean and mixed populations, all participants classified their depression as either mild or unknown. None of the students in the Asian Other population reported suffering from depression (see figure 4). There were 4 situations in which the ANOVA tests were significant and where Bartlettâ&#x20AC;&#x2122;s test indicated that the variances were not unequal, implying that the ANOVA test was appropriate to use (figure 5). In 3 of these situations, even though the ANOVA test was significant, no ethnicities were found to have significantly different odds ratios from the White British group (not shown). This implies that there is a significant difference between at least two of the groups excluding the White British group. The situations where both the ANOVA and the odds ratio were significant are shown in figure 7, where four bars are displayed for each ethnic group, representing the percentage of that group who selected each response. Figure 5: Significant findings with ANOVA test. For these vignettes there were statistical differences between the willingness of different ethnic groups in seeking help from the services indicated. Vignette Seeking help from: severe depression friend moderate depression friend mild depression friend unaffected

relative

P value P=0.048 P=0.015 P=0.015 P=0.04

One of the assumptions that ANOVA requires is that the different ethnic groups have equal variances. This can be tested using Bartlettâ&#x20AC;&#x2122;s test. When this test reaches significance it means that the variances are unequal, implying that the distributions for each of the categories are not identical. ANOVA can be thought of as a test of equality of distributions, so when the test for equality of variance fails, this is a good indication that the distributions are not the same, implying that there are differences between the categories. Unequal variance was found in 7 of the tests (figure 6). Figure 6: Situations where ANOVA failed due to unequal variance. As the variance of the data from the ethnic groups are non-identical, it is reasonable to suggest that there were differences in the willingness of the ethnic groups to seek help from the services stated for the mentioned vignettes. Vignette

Seeking help from:

severe depression moderate depression moderate depression mild depression

internet/books internet/books non-university counsellor internet/books

mild depression

non-university counsellor

unaffected unaffected

internet/books university counselor

Of the situations where there was unequal variance, 3 had significant odds ratios. These are illustrated in figures 8-10, with two bars for each ethnicity due to the binary nature of the data which is required to calculate the odds ratios. In cases where there was unequal variance with a non significant odds ratio, it can be concluded there were significant differences between at least two of the groups, excluding the White British group. ANOVA tests were also carried out to investigate whether the reasons for not seeking help differed between the ethnicities. None of these were found to be significant, implying that the reasons did not differ between ethnicities. However, the student population was unwilling to seek help due to stigma and concern about future careers and exam grades, regardless of ethnicity (see figure 11).

lsjm 30 november 2009 volume 01

Discussion & Conclusion The reasons that students present to welfare or healthcare services for depression are complex. This study attempted to ascertain what factors lead to some students presenting earlier than others, and to identify any correlations between the ethnicity of the students and their presentation. The results showed similar trends between the ethnic groups in reporting behaviours for depression. The Black African- Caribbean group deviated more from this trend than any other ethnic group. This was particularly notable in subclinical and mild depression, where help was commonly sought from friends. In subclinical depression, seeking help from a friend was the most popular choice among all the ethnic groups, with the exception of the Black African-Caribbean group, who were just as likely to seek help from their relatives. This shows that for subclinical depression most students felt that there was no need to approach a professional, whether a health professional or a university tutor, and felt that they could deal with their symptoms through a social context using friends and family for support. Students may feel that they do not need professional support or may feel more comfortable talking to friends and family who understand their cultural and religious background. This is supported by our findings that students were reluctant to seek help for depression due to accompanying stigma and concern about confidentiality (see below). In keeping with the trend for subclinical depression, all the ethnic groups were most likely to seek help from friends for mild depression, with the exception of the Black African-Caribbean group who sought most help from relatives. This could be attributed to the strong family values in these communities. Overall, there seems to be a reluctance to approach professionals, which is further evidence to support research looking into health seeking behaviours for psychiatric disorders in students13. In this study, the Black African-Caribbean students seemed more reluctant to seek help from any source. However, our study population of this ethnic group was small and therefore may not be truly representative of the Black African-Caribbean population we were surveying. In order to confirm our findings, these students could be compared to students of other ethnic groups on a larger scale. If it was confirmed that Black African-Caribbean students were less likely to seek help for depression, steps should be taken to introduce campaigns to increase awareness of these services and their confidential nature to these students to increase help seeking in this ethnic group. With regard to moderate depression, it was interesting to note that once again friends were the most popular choice for help amongst all ethnic groups. Therefore, even though the severity of the condition had increased, the health seeking behaviours remained the same. Students may be more inclined to seek help from friends due to the fact that they are commonly in their late teens, away from home and spend lots of time with their friends. As many students live with fellow university students it seems natural that they would share their problems with those who are closest to them. The only group who were likely to go to their General Practitioner (GP) were the Black African-Caribbean students for mild depression, where the GP was the most popular option after talking to a relative. However, this became the least popular choice in moderate depression, with a slight increase in popularity in severe depression. In other ethnic groups, although the GP was an unpopular choice overall, students were collectively more likely to go to the GP as the severity of their depression increased.

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Figure 7: This graph shows that for mild depression there were significant differences between the wouldn't go ethnic might gogroups. The responses of the White Other would probably go population towards not seeking help from would definitely tended go a friend in mild depression, whilst the White British population were more inclined to seek help from a friend OR 0.36 (CI 0.18,0.74). From the graph, every ethnic category were more likely to seek help from a friend than the White Other group.

Mild depression - Seeking help from a friend (P=0.015) 50 40 30 20 10

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Figure 8: Here there was unequal variance, but the odds ratios clearly show that the White British population would tend towards seeking help from the internet or books in severe depression, but wouldn't/might go would probably/definitely go that the Asian Other OR 0.03 (CI 0.00 - 0.26), Black African-Caribbean OR 0.08 (CI 0.01 - 0.70) and Chinese OR 0.13 (CI 0.05,0.37) populations would all tend not to use this form of help. From the graph, the Indian Asian, Mixed and White Other populations all appear to be inclined towards seeking help from the internet and books in severe depression.

would probably/definitely go

Unaffected - Seeking help from a university counsellor 100 80 60 40 20

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Percentage response of each Ethnic Category (%)

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Figure 9: For this example there was unequal variance and all the ethnic categories tend towards not seeking help from the internet/books in mild depression. However, the Asian Other OR 0.11 (CI 0.01 - 0.86) and Chinese OR wouldn't/might go would probably/definitely go 0.14 (CI 0.03 - 0.60) groups were much less likely to use this modality for help than the White British population, and from the graph the Indian Asian group also mirrors the sentiments of the White British group. The Mixed and Indian Asian groups were more divided concerning this issue, but of the Black African-Caribbean population, none would consider seeking help from the internet/books for severe depression.

wouldn’t/might go

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a. My exam grades would suffer as a result of seeking help

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Figure 11 (a-c): Reasons for not seeking help for depression a) 63% of students were concerned that their exam grades would be affected b) Many were concerned that it would affect their medical career. This corroborates with data from figure 10 which shows how unlikely students were to approach a university tutor c) many feared stigmatisation.

c. I would not the label of depression Would definitely prevent me going Might prevent me from going Would not prevent me from going

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With the lack of presentation to health services, it seems that depression remains undiagnosed amongst students. When comparing students to the population, the same trend can be seen; people who are suffering from depression do not report it14. Consulting university tutors and counsellors for depression was universally unpopular. However, students of Chinese origin were more inclined to consult a university tutor for mild symptoms of depression than any other ethnic group. A medical degree requires frequent use of internet and library services, so it was interesting to see what role this played within medical students’ health seeking behaviours. Indian-Asian, White British and White Other groups consistently used this method more than other ethnic groups. The severity of the symptoms did not impact on the decision to use this resource in any ethnic group. It could be that being brought up in a Western society, with the internet as a popular source of information, would lead certain groups to use it more frequently. However, other factors need to be considered, as medical students may be more sceptical about the reliability of the internet as a source of information than the rest of the population. With many students being away from home for the first time, it is unsurprising that they may feel alone and experience depressive symptoms. It has been shown that overseas students experience more stress as they are away from family and often find it difficult to adjust to a new routine and interact with members of the host culture, and that this stress can sometimes trigger depression.15 As such, the overseas student population is a population that is particularly vulnerable to depression and should perhaps have been analysed separately. In this study we did not require students to state whether they were an overseas or a home student, and this could be helpful for further research. Overall, the study found that despite the diversity of the respondents to the questionnaire there were some unifying factors across all groups that prevented presentation of depressive symptoms. Seeking help from friends and family was always more popular than seeking help from tutors or counsellors. This was elucidated by the fact that 63% of respondents had concerns that seeking help for depressive symptoms would affect their medical career, whilst 69% of students were concerned that seeking help would result in an unwanted label of ‘depression’. These statistics are concerning as they highlight the stigma that exists within the medical world. Previous research into students’ attitudes to depression has demonstrated a lack of knowledge about the illness and the implications that a diagnosis and its subsequent treatment may, or may not, have16. Our study provides further evidence for misconceptions about depression amongst students. The fact that the majority of respondents fear that contact with welfare or health services will have negative implications for their future career has clear implications for the presentation of students with depression. This carries a significant risk of under-diagnosis and subsequent poor management of depression within this group. There are some confounding factors which mean that these results cannot be extrapolated to the remainder of the London student population. The vast majority of students studying medicine will have fully engaged, participated in and succeeded in the British education system and therefore may have adopted similar views and responses to depressive symptoms. In using medical students as a study population, we surveyed a highly educated, medically interested subsection of society, who have all been trained in the importance of confidentiality in a professional setting. We would expect this group to have greater

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RESEARCH immunity to society’s stigmatisation of depression than other social groups and understand that a medical professional is bound to keep patient’s details confidential. It is worrying that a large proportion of students in this study would not seek help due to stigma and concern about exam grades and future careers. We suggest that action should be taken in medical schools to promote a better understanding of the issues on confidentiality, as this would impact both on the care of future patients and the unwillingness of medical students to seek help in the knowledge that their disclosure would remain completely confidential. Such action would also help to improve the cost effectiveness of university counselling services. This study asked theoretical questions about the likelihood of students seeking help for depression. The majority of the students assessed claimed to have had no history of depression and therefore the study largely surveyed the attitudes of healthy students as to whom they would go to for help. To accurately address the question of how likely students are to present for help with depression, it would be important to interview and identify students who were depressed, classify their depression according to ICD-10 criteria, and then ask them how likely they would be to present to each service. These results would be far more accurate than the results obtained in this study, but would require a larger study population and greater amounts of time as each student would need to be interviewed to assess their mental state. Further research needs to be done to investigate why these attitudes persist in order to execute suitable interventions to tackle these potentially damaging attitudes amongst the London medical student population. This study surveyed a population where the majority of respondents had no history or diagnosis of depression. Focused research should be done amongst patients with diagnoses of depression to ascertain whether these attitudes also persist in that population group. Having achieved these results, it is important to address the negative attitudes of medical students to seeking help for depression. Universities should establish focus groups to gain some insight into how to improve their services, and should encourage medical students to present to mental health services when needed. The reluctance to present to mental health services may be ingrained prior to arrival at University. Therefore, it is important to assess the attitudes of children and teenagers towards seeking help for depression and to provide education at primary and secondary school level to combat this. A further study could provide students with information about confidentiality, particularly in relation to university counselling services, to assess if this information would improve the attitudes of students to seeking help. Perhaps, an audit on the use of university counselling and its success rates in preventing depressive sequelae would increase the students’ confidence in the service. Appendix 1 – Case Vignettes Vignette 1 – Severe depression Since your grandma passed away three months ago, you have noticed some changes in your daily routine. You wake at 5am despite feeling tired all the time. You have little energy and rarely cook for yourself. You are feeling down and have little interest in your university course. You remember an incident from the beginning of the summer when you left a shop with an apple and forgot to pay for it. You feel very guilty about this and feel that you have brought shame on your family. Sometime you hear voices talking about you and to you saying that you are worthless and you should turn yourself into the police for stealing the apple.

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Vignette 2 – Mild depression Since starting university over three weeks ago you have been feeling quite low. You are struggling to make it in for your 9am lecture, despite getting a reasonable night of sleep and you find that you are eating less and rarely make your own food. You find that you are going out a bit less in the evenings, but are finding it harder than usual to concentrate in lectures, and you no longer enjoy some of the things that used to. Vignette 3 – Unaffected by clinical Depression You have noticed that a few things have changed in the last couple of weeks running up to your first big set of exams. You wake earlier in the morning in order to make it to lectures, but oversleep a couple of days a week. Your eating habits have changed – you haven’t had much time to cook for yourself and find yourself skipping breakfast due to the morning rush and consequently nosh more during the day. Sometimes, especially towards the end of the day, you find it hard to concentrate in lectures. One evening in the last week you felt a bit down, and so you decided to go to the cinema and watch an upbeat film. Vignette 4 – Moderate depression Since your boyfriend/girlfriend broke up with you over a month ago, you’ve started to notice some changes. Your appetite has gone and you notice that your clothes are starting to look increasingly baggy. You feel tired a lot of the time, but still wake most mornings at about 5am. Things take you a lot longer than they used to, so often you just stay in your room. You begin to feel guilty about this and think that you don’t deserve anything better anyway. Your friends have been out partying and normally you would have loved to join them, but just don’t seem to enjoy the things you used to anymore. Acknowledgements Many thanks to Rebecca Landy for help with the Statistical analysis Thank you to Dr. Mary Howman for reviewing and editing the questionnaire. Thank you to Dr. Angela Hassiotis for her assistance with obtaining ethical approval. References 1.

2. 3.

7. 8. 9.

10.

Bhugra et al. Globalisation and mental disorders. Overview with relation to depression. The British journal of psychiatry : the journal of mental science (2004) vol. 184 pp. 10-20 Thornicroft. Most people with mental illness are not treated. Lancet (2007) vol. 370 (9590) pp. 807-8 National Mental Health Report 1996, Fourth Annual Report. Changes in Australia’s Mental Health Services Under the National Health Strategy 1995–96. 1998 Canberra : Dept. of Health and Family Services, 1998. Hawton et al. Suicide in Oxford University students, 1976-1990. The British journal of psychiatry : the journal of mental science (1995) vol. 166 (1) pp. 44-50 Verger et al. Psychiatric disorders in students in six French universities: 12-month prevalence, comorbidity, impairment and helpseeking. Social psychiatry and psychiatric epidemiology (2009) pp. Meltzer et al. Patterns of suicide by occupation in England and Wales: 2001-2005. The British journal of psychiatry : the journal of mental science (2008) vol. 193 (1) pp. 73-6 Minhas FA, Nizami AT. Somatoform disorders: Perspectives from Pakistan. Feb 2006; International Review of Psychiatry. 18(1) (55-60) Ibid Bhugra et al. 2004 Barney et al. Exploring the nature of stigmatising beliefs about depression and help-seeking: implications for reducing stigma. BMC public health (2009) vol. 9 pp. 61 Edwards et al. Increasing response rates to postal questionnaires: systematic review. BMJ (2002) vol. 324 (7347) pp. 1183

For the full list of references see thelsjm.co.uk.

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INTERVIEW

What’s in a name?

In an interview, Richard Bentall challenges psychiatric diagnosis Andy Gray Year 4 Medicine, Cardiff atgray@gmail.com Introduction Professor Richard Bentall is a clinical psychologist who wants to revolutionize psychiatry. Author Sebastian Faulks recently named Madness Explained by Richard, written in 2004, as one of his favourite books. He calls himself an ‘anti-psychiatrist’ and argues that because psychiatric diagnoses are largely defunct, we should get rid of them. His basis for this argument is that the diagnoses psychiatrists use are actually very poor markers of outcome, including treatment response. This controversial argument has been made before, but largely by people without sufficient rigour or discipline to be taken completely seriously by the scientific community. Richard, however, is “committed to the scientific world view” and comes across as very well researched. What he really wants is to see psychiatry move forward like the rest of medicine has over the last fifty years. This busy man, found time to see me on a Friday afternoon in his office. He arrives a little late from his previous meeting, but is clearly pleased for this opportunity to get “the future psychiatrists” thinking about his work. The History “Emil Kraeplin was an austere, frightening German patriot who wrote awful, nationalistic poetry” begins Richard in a shortened and slightly alternative history lesson. He continues by saying that Kraeplin was also a “genius for his time”, who decided that in order for psychiatry to succeed, a classification system was needed. Perhaps interestingly, his brother was a botanist who classified plant species. Kraeplin went on to identify individuals that had the same symptom clusters and similar outcomes. He reasoned that they should also have the same brain pathology and aetiology, although these were probably beyond the scope of his research at the time. He was famous for first describing dementia praecox (schizophrenia), manic-depressive psychosis (bi-polar disorder) and paranoia (delusional disorder). Later, the ‘Neo-kraeplinians’ would develop the DSM (Diagnostic and Statistical Manual of Mental Disorders) based on Kraeplin’s concept. The DSM was to be purely descriptive and neutral, making it easy to use and less objective. Other than Post-Traumatic Stress Disorder (PTSD), which is classed by its aetiology, this is in theory true. But Richard argues that in practise this is not true; explaining that the problem is that users of the manual have assumed (along with Kraeplin) that the severe psychoses are genetically determined, biological issues.

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The Issue Like most self-respecting scientists Richard stumbled upon his field of interest slightly by accident. He told me how a distinguished psychiatrist was interviewing him for a job and asked, “What is the scientific validity for the schizophrenia concept?” Not quite yet the learned man in front of me, he replied badly and failed. Various clichés could describe the importance of this moment and the following process that led him to his current position: that the schizophrenia concept (amongst others) is rubbish. He tells me a joke, ‘Why does a psychiatrist diagnose schizophrenia?’ ‘So they can prescribe anti-psychotics of course!’ ‘Why does a psychiatrist diagnose delusional disorder?’ ‘So they can prescribe anti-psychotics of course!’ ‘Why does a psychiatrist diagnose bi-polar disorder?’ ‘Well… so they can prescribe Lithium! But, they tend to use antipsychotics…’ OK, so it wasn’t a funny joke. But he got his point across – diagnoses are not always useful. He tells me the literature is clear, diagnoses do not predict treatment response (in this field). Then Richard whips out his famous catchphrase: “the DSM is about as scientific as star signs!” The purpose of star signs is to tell you something about your future, like diagnoses. Problem is they don’t. Richard has been discussing this issue with psychiatrists for twenty years and apparently a “sense of crisis is emerging slowly”. “The idea that the DSM is seriously wrong is no longer regarded as a wacky, left-wing delusion” at least not by the academics. However, the DSM is often regarded as the bastion of modern psychiatry and certainly won’t disappear over night, even if there was a perfect alternative. The ‘Solution’ The idea that, for example, schizophrenia is more complicated than whether you have it or not isn’t new. However, the DSM still works on this principle. Currently debated is the dimensional classification system that will divide disorders into ‘dimensions’ allowing more meaningful diagnoses, with better predictions for treatment response. Richard thinks this is a step in the right direction, but his solution is far more radical. “Schizophrenia doesn’t exist!” he exclaims, querying the usefulness of diagnoses at all. He vies for a ‘complaintorientated approach’: don’t worry about a diagnosis; just write a list of the patient’s problems (“similar to the list that’ll be written

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Source: Richard Bentall

INTERVIEW under the diagnosis anyway!”) Amongst other benefits, “this will help healthcare professionals look after the patient’s problems, not their symptoms”. Richard sometimes tends to paint a bleak picture of today’s psychiatrists blindly prescribing and missing the issues that are actually causing the patient angst. He recently went to a ‘voice hearer’s conference’ in Europe and tells me that a lot of people hear voices, including lots of normal people (even doctors!) These people do not need their symptoms “aggressively stamped out by drugs with side effects”. Richard argues that it is much more important to deal with each of the patients’ own concerns, as “once the complaints are broken down and dealt with, there won’t be any schizophrenia left to treat!” I wondered whether with this approach problems might arise with deciding which complaints to treat. Fundamental to Richard’s work is the idea that psychiatric complaints are exaggerations of normal experiences. However, the issues dealt with here are a little more complex than, say, essential hypertension and the use of a diuretic or ACE inhibitor. Richard, with the slightly knowing gleam in his eye of a man who’s been asked this before, replies “but this is the crystal issue of psychiatry! Experiencing symptoms is not the problem, but rather the inability to function properly”. Homosexuality used to be part of the DSM, and PTSD was only recently added. Boundaries between normal and abnormal change; so don’t attach so much importance to them. Classical psychiatric symptomology can miss the real issues. A complaint is anything that is an issue for the patient (housing, relationships etc.) Richard tells me that the list of potential complaints is relatively small when dealing with severe psychoses (although this number will never stay the same for long). These include: hallucinations, delusions, thought disorder, negative symptoms, depression and anxiety. We’re often told being a doctor is about pattern recognition; medicine isn’t exactly chaos theory. I asked Richard whether patterns could re-emerge after being broken down. “Yes, it’s possible… I’m not against the principal of diagnoses… but the DSM just doesn’t work”. He tells me he would bump his head against the wall and cry, “why didn’t I think of that!” if someone came up with the perfect solution. In the mean time however, “we can make more progress by targeting complaints”. I also wondered whether removing the diagnostic labels would make it difficult for people to fit into the sick role. Apparently this is a rare problem, and in actual fact “most patients hate being told they have schizophrenia”. Therapy OK. So, we’ve binned diagnoses and now have lists of ‘complaints’. Frequently accused of disregarding the usefulness of antipsychotics, I wonder what Richard has in mind in terms of treatment possibilities. He sounds frustrated, “I am not against psychiatric drugs, I am just for the cautious use!” A self-proclaimed pragmatist he wants treatment that isn’t just built on the “current biobiobio model”. His argument is simple – drugs are overused, psychological interventions are underused; so change. To develop this point Richard tells me how the current use of anti-psychotics can be viewed as unethical. Although the effect of anti-psychotics in an acute crisis is remarkable, this only occurs in 70% of patients. However, 98% of psychotic patients are on these drugs, despite the high number of horrendous side effects. Moreover, “effects of long-term use may even increase the risk of relapse” and yet lifetime use is the most common treatment method. At this point Richard reminds me of his practical approach and states the obvious: “treatments

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should be given to those who benefit from them”. This goes on to include psychological interventions, which are legion. The relatively small amount of research done in this area makes it difficult to make accurate comparisons. However, the consensus is increasingly that such interventions are helpful, and at least as efficacious as drug treatment in mild to moderate disorders. Cognitive behavioural therapy is Richard’s speciality, and he gives me a quick run-through on how you might approach a paranoid patient. Firstly, of course, the problem list. The key then is to introduce them to skills that enable them to work out whether they are looking at things that frighten them in the best way possible. This does not include saying “I’m the expert and know what’s going on. You’re wrong, and I’m going to prove it to you”, but rather “You’re having some puzzling experiences and they seem strange to me. Let’s try and figure out whether there is another way of looking at them”. I ask Richard who he thinks will be performing these treatments in the future. He tells me that nearly forty years ago Hans Eysenck predicted a divorce between psychiatry and psychology. He thought psychiatrists would retain expertise in severe mental illness, and psychologists would become the experts on milder conditions (anxiety, depression). But, amongst other problems, the psychological needs of the psychotic patient were not best seen to in this manner. Richard believes “the future is clearly greater integration between psychiatry and clinical psychology. If we were starting from scratch, we’d probably design a hybrid profession”. He suggested that psychiatrists might develop more interest in psychological therapies, and likewise psychologists adopt roles traditionally restricted to psychiatrists (case management and even prescribing). “In the NHS of the future, professions will only hold skill monopolies by default. People should play roles that depend on their competencies, rather than according to which professional tribe they happen to come from”. Exciting vision or unobtainable idealism? Final Thoughts Richard gave a talk recently to a “rather pleasant and receptive group of psychiatrists”. Unfortunately, after the talk they turned round and said ‘Well… we can’t do anything to change… we must focus on drug therapy, otherwise the other doctors won’t take us seriously’. Richard replies, “Why this anxiety about surgeons looking down on you? Psychiatrists should celebrate the fact they are different”. In thirty years time will we look back and laugh at how scattered our approach to psychoses was? Hopefully we will have a better understanding of how mental illness works, and therefore how we can treat the problems it causes. But this is a complex issue probably in need of philosophers as much as psychiatrists or psychologists. Many critics say that Richard is correct to point out the validity issues of psychiatric diagnoses. However, they would claim that getting rid of them is not the answer, but rather more research to refine them. We shouldn’t forget, however, that Richard’s favourite ice cream is ‘hokey-pokey’ – vanilla mixed with broken up Crunchie.

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EDITORIAL

The issue of giving aid to the developing world constantly sparks up fierce debate. In the developed world we are undoubtedly in a privileged position where it is our duty, in some ways, to give aid. However, the question arises - should aid be given as an altruistic measure or can it be given in a way that encourages innovation rather than reducing it? As an example, over the last 50 years, Africa has received more than $1 trillion in aid, with a rapid increase between 1970 and 1995. However, during the same period, GDP per capita growth in Africa has decreased. The unfortunate fact is that most African countries are poorer now than they were at the time of their independence from their respective colonial powers. Aid, it seems, may have lowered rather than increased their economic growth. Aid given for more specific causes such as malaria and HIV for example, is equally vast and whether it is really making a difference remains to be seen. The $300million annual funding for HIV in 1996 currently stands at $10billion. However the number of individuals with the virus stands at an all time high. In this edition, Elvena Guyett interviews Dr Mark Nelson, a leading HIV specialist, who brings this into perspective and discusses whether innovation and the way funding is used can play a role in eradicating this deadly virus. Whilst the West needs to revamp its strategy of giving aid and find innovative solutions to solve global problems, developing countries need to implement tighter and increased amount of regulation for the funding it receives. Additionally, more risks need to be taken by individuals and organisations - fear of failure should not be a hindrance but an opportunity to learn from one’s mistakes. This is classically demonstrated by the Bill and Melinda Gates Foundation through its Grand Challenge Explorations Scheme. Encouraging risk taking behaviour is part of the Challenge’s remit and vast sums of money are given for innovative solutions with further funding for projects that make progress. Challenges like these are extremely welcome as they contrast with industry-funded projects where we often have results which end up being very expensive and fails to be of benefit those who need it most. Secondly simply giving away large sums of money to poor governments is not the solution to the problem of poverty. This approach keeps people and their governments’ dependant on donors. Developing countries need to become more independent, self reliant and self sufficient. The developed world, as well as the low-income countries can do this by encouraging entrepreneurship and teaching skills which will eventually empower individuals. Aid is only effective and works best when governments put in population-centred economic policies, effective strategies for poverty reduction and measures for tackling corruption. The idea of innovation in health does not however only lie with giving aid or solving global problems. It is also very relevant for how healthcare systems are being run and whether we can save costs by being more efficient and productive. The US is currently in the middle of a historic healthcare reform where it will hope to provide healthcare to a much wider share of the population. Elishba Chacko discusses a similar theme and argues that perhaps healthcare infrastructures do need to be overhauled so that refugees and immigrants are not excluded. Carrying on with the idea of innovation, Elena Atkinson looks at the theme from a different lens. She considers the policies in healthcare and whether prescribing heroin for addicts is an innovative or an outdated idea. The good work at the LSJM continues and hopefully we have brought our readers a fascinating selection of articles. I would like to take this opportunity to thank all our authors, panelists and reviewers. The world, now advancing through the 21st century, needs its policies and ideas kept up to date. Let us encourage more risk-taking and let us help the less developed countries develop human and social capital for themselves. The impact of the credit crisis is weakening economic growth, reinforcing poverty, and eroding health and education systems. The future of developing countries should not depend on financial aid, but on its people and its governments.

Illustration: Ella Beese

Harpreet S Sood Section Editor Global & Community Health References 1. http://www.avert.org/worldstats.htm 2. http://news.bbc.co.uk/1/hi/sci/tech/4209956.stm 3. http://www.grandchallenges.org/Pages/default.aspx 4. UNAIDS (2008) ‘Report on the global AIDS epidemic’.

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NEWS Malaria Vaccine in Final Stages of Development Angela Fanshawe

Foundation, UNICEF and WHO, among others, would provide ongoing funds.

Manufacturers of a vaccine against malaria announced this week the start of the final stages of its clinical trial. The trial, which will take place across 7 sub-Saharan African countries, will involve more than 16,000 children under the age of 18 months.

The vaccine – which has been in development since 1987 – contains two genetically engineered proteins of the Plasmodium parasite, the causative agent of malaria, coupled with an agent to potently induce the immune system to react against these proteins.

Researchers are hoping that the vaccine – ‘Mosquirix’ – will reduce the number of malarial infections by 80% by 2025 and be effective for more than 4 years. Realistically, however, it has been suggested that the vaccine will not reduce infection numbers by more than 50% by this date. “Some may say, ‘50%, that’s not great,” says Dr. Dave Jones, US Army Colonel and director of a clinic in Kombewa, Kenya, “But at the same time, when you consider we lose 1 million kids a year, if you could cut that in half it would be a great step forward.”

The manufacturers aim to introduce the product onto the market by 2012, with infants receiving the vaccination as part of their standard vaccination program before their first birthday.

GlaxoSmithKline has developed the vaccine with financial backing from the PATH Malaria Vaccine Initiative, funded by the Bill & Melinda Gates Foundation. Dr. Joe Cohen, co-inventor of the vaccine and vice-president of research and development at GlaxoSmithKline, states that GlaxoSmithKline “is committed to making sure pricing will never be a barrier to access for this vaccine.” The Gates

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Sources: 1. The LA Times: http://www.latimes.com/news/nationworld/ nation/la-sci-malaria7-2009nov07,0,1735189.story 2. Associated Press: http://news.yahoo.com/s/ap/20091103/ ap_on_he_me/af_africa_malaria_vaccine_4 3. ABC News International: http://www.abcnews. go.com/International/extending-malariavaccine-reaches-africa/story?id=9004991

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INTERVIEW

Innovations in HIV research: An Interview with Dr. Mark Nelson Elvena Guyett, BSc (Hons) elvena.guyett@kcl.ac.uk Year 4 Medicine, King’s College London doi:10.4201/lsjm.gch.005

Source: Boehringer Ingelheim

Dr. Mark Nelson is a Consultant Physician for HIV inpatients at the Chelsea and Westminster Hospital. He is also deputy director of research, director of the HIV clinical trials unit, author of over four hundred publications, and also the principal author for the British HIV Association (BHIVA) guidelines for treatment of Hepatitis C co-infection. He has worked closely with several pharmaceutical companies as a Consultant and runs HIV programmes in twenty African and Asian countries, for which he was recently awarded the medal of honour of Vietnam. Elvena Guyett went to the Chelsea and Westminster Hospital to meet and speak to him about innovations in HIV research, treatment, and funding, and what the future holds in this field. The theme this issue of the LSMJ is innovation. HIV has featured again in the news this week with results of the vaccine trial in Thailand. What are your opinions on this and your thoughts on the fact that it was published in the press before a peer-reviewed journal? That is always going to be a problem. The press will always exaggerate findings, it is what the press do. They like things when they go wrong and when they go right and so you have to be careful of the results of studies like that. First of all, we have not seen the study and so we do not know the ins and outs, we have just got the numbers. It reminds me of the results by a man called Stanley Plotkin (one of the people who discovered the MMR vaccine). In my youth I went for an interview with him and he said the problem with the vaccine study is what to do with a result that is 30% effective which is exactly what happened there. Again, it is about numbers and significance – it is 30% protective, or more protective, but is that significant? Quite small numbers got HIV, which is a good thing, but then one of the issues with vaccines is do we want people to display risky behaviour? This highlights one of the other issues with vaccines - we also need to educate people concurrently. Say that we have a vaccine, what do you do with it, do you stop there? Do you give everyone that vaccine, with only 30% protection? What happens to people’s behaviour, once they know they have been vaccinated? Do you actually do more harm than good? So first of all we need to look at the results carefully and see what they show.

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Image: Electron microscopy of HIV particles budding from the surface of a CD4 cell. Another study on a microbioside showed exactly the same – 30% protection – but that was not significant – we interpret that how we want. So the problem with medicine is when something is just not significant. It perhaps gives us some ideas and a bit of hope, but it does not work perfectly, by any means. Of course, a lot of money has gone into vaccines, and is still going into vaccines, without any results. All those investors want to continue getting something. So you have to be careful spending when there is only a certain amount of money in the pot. Has there been a shift in funding? Early on, research into treating HIV was encouraged. Now with the success of available antiretrovirals, are we seeing more of a change towards research into prophylaxis? It depends on where you are, and where the epidemic is found. We do a lot of work in Africa and we can say the situation is still bad. People are being given drugs that we would not use in this country. Again, that is a question of where do you best spend your money? On more expensive drugs and treat fewer people, or do you treat more people with less expensive drugs. That is more about reducing toxicity rather than improving efficacy. I think there was a shift in the developed world into more research into prevention, but it varies. When you get negative results on microbiosides, vaccines and suchlike, it is difficult to say where the money’s going to go.

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INTERVIEW prevention. So rather than someone having to use a microbioside, or a man not happy with circumcision (which has been shown to work), you could get an injection of some relatively cheap, longacting anti-viral as a preventative measure. So I think really the true innovation actually comes from the researchers applying for grants. The pharmaceuticals are very good at doing research, but we have to accept that the majority of the time this will be based around their own products. With regards to effective measures such as circumcision, through seeing the patients here on a day-to-day basis, as well as your work abroad, do you find there’s more of a trend towards risk-taking behaviour? A lot of work has been done in the developing world on the risk of transmission. The latest research shows that your transmission risk is related to your viral load. There is also some data that if a patient’s plasma is negative i.e. fully suppressed with drugs, the virus also is suppressed in vaginal and seminal fluid. That does not mean definite suppression, but in some people’s sexual fluid there will be virus and that there will probably be a risk of transmission, but this will be less than 1 in 100,000. So a lot of work has been going into transmission of the virus which has led to people having more unsafe sex. In the academic circle, we see the gay community is having an increase in the transmission of Lymphogranuloma Venereum (LGV), Syphilis, Hepatitis C and more Hepatitis B which would suggest that there is more risk-taking behaviour. The question is whether this is between two HIV positive partners or just an increase in risk-taking behaviour generally. In the developing world, there is the ‘ABC programme’ promoting “Abstinence, Be faithful, Condomise”. But really the epidemic is so vast it ought to be concentrating on testing.

You have been involved with pharmaceutical companies and publishing guidelines. With funding coming from institutions such as these as well as charities such as the Bill and Melinda Gates Foundation, to name but one, does this tend to concentrate money on already-established research, or does it still leave room for innovation? If you look at pharmaceutical companies and spending you have to be honest: the company wants you to spend more and use more drugs, not necessarily the research into the population as a whole. I think they look for niches rather than innovation - a lot of the research will be about expanding where you would use that drug rather than being truly innovative. If you look at other non-pharmaceutical bodies it tends to be much more innovative, perhaps based more on basic science. There are two examples of that going on in this institution – a grant from the Medical Research Council for a therapeutic HIV vaccine to allow people to come off antiretrovirals, not as a prophylaxis. We have another grant in the pipeline to look at a novel preventative strategy giving an antiretroviral which has long-lasting sustained release which could be given by injection every few weeks as

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We have actually done a project where we have gone out to several African countries to see how best to test African populations in this country - knowledge of your diagnosis and HIV status in a population where you can get drugs really is a big thing. Certainly where there are roll-out programmes in Africa this has driven a lot of the testing programmes. However, they are being tested where nothing can be done. We are doing some really interesting things - in Malawi we were looking at how we can target the Malawian population and they said it is all about the chiefs. There will be a chief for some villages, and if the chiefs say everyone needs to be tested, everyone gets tested. And so there are lots of things we can learn from Africa that can innovate changes in this country which can promote testing, which is probably the most important thing. The first integrase inhibitor, Raltegravir, was developed about 2 years ago. Are you seeing a shift in the treatments available now, has there been an improvement with that? There was a big change two or three years ago because there were a lot of people who were failing terribly, who had been treated very badly. Now we know you have to give several drugs or the virus becomes resistant. Many people were treated with single agents with other agents added-on and developed multi-resistant viruses through necessity and a lack of our knowledge at the time. It was not just about the integrase inhibitor, a lot of other drugs came out about the same time. There were the CCR-5 inhibitors which

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INTERVIEW prevent viral entry. Drugs in classes which we already had, such as proteases and non-nucleotides, but had activity against resistant viruses. Everyone in our clinic, or the majority, has had successful treatment of their virus and is actually very, very well. There are a few people that fail, still, that we do need new drugs for, but that was the really big breakthrough two or three years ago. Now we are looking at using these drugs more in naïve patients who have not taken any therapy at all. The problem with these drugs is that they are really expensive. Two drugs that are very similar, where one is slightly more toxic or one is under patent can affect things. And certainly because of the pressure of cost it is becoming more and more difficult for doctors to try things out - say if Raltegravir were the best drug for that patient it would be very difficult to give it to that patient if they had not taken anything else, because of the issue of cost. Where do you see the future of HIV research and treatment going? Will there ever be a place for something like gene therapy, for example? People are looking at gene therapy, ribozymes and nanotechnology to deliver drugs. I think it will change, but the question is in this country is, as the amount of money available falls and the cost of the therapies becomes more and more expensive, are we going to change from a developed, resource-rich world to a resource-poor health service? And this is the worrying thing, we can look at all these studies on interesting things but can we afford to actually give them to the patients? You have been heavily involved in research into co-infection with Hepatitis. Is that something that is causing a big problem now, or do you anticipate it being a bigger problem in the future?

Hepatitis C co-infection. The Phase 3 studies are almost finished and none of the companies will do studies in HIV positive people until they have been licensed, and so basically people are dying of it. What we are trying to do now is to get a big European group together to do studies with the aim of pressurising more research and funding. Hepatitis C will be an amazingly interesting field over the next ten years with similar issues to HIV - oral drugs being made available, how to give them, in what combination, what happens when they go wrong, resistance, and that is going to be the field to get into, it is going to be really fascinating. Carrying on from that theme, in the event of a new virus emerging, which potentially could happen in the future, do you think we have learnt a lot through our studies on HIV and the development of therapy, to better prepare us? In some ways, but I think actually we are all a bit slow and do not use common sense. When HIV first came out we used to give one drug and add in extra drugs on top of this. I can remember going to a meeting and someone said ‘I’m very sorry but I think you’re all mad’. We said ‘That’s the way to treat people!’ and he said ‘We’ve learnt if you do that even in TB, you get resistance’, but everyone proclaimed that this is HIV, not TB. Of course, he was absolutely right. Looking again at Hepatitis B, you have single drugs for it and there is a bit of a move towards using combination therapy here as well, but people don’t learn from the results of another disease they always think it is going to be different. So I think we need to take a long hard look at ourselves as physicians and think about what we can learn from other specialities and experiences. The frightening thing is, I bet if there is another infection like HIV we will be making the same mistakes again.

We have got epidemics of acute hepatitis C in this country, first described at this hospital in fact, and no-one believed us and in fact thought we were making it up - it was almost impossible to get it published. Then we saw it in another hospital in London, so it was a ‘London thing’ and then we saw it in Brighton so it was a ‘British thing’, then in Germany, Holland and France so it was a ‘European thing’ and then it was seen in Australia and America, so yes, it is on the increase.

Hepatitis C is really a bit of a disgrace - we have two drugs to treat it and there are 87 products in development in Phase 1 studies. We are looking at gene therapy, anti-viral compounds and immunomodulators, and not one of them has been given in a trial to an HIV-positive patient. Despite the furore in the early 80’s and 90’s by doctors and patients over the lack of HIV drugs, everyone’s looking a bit lethargic about Hepatitis C, and yet it kills people. The last two people that have died on this ward died from untreated

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Source: Boehringer Ingelheim

Hepatitis B is a ridiculous disease, really. When you do see Hepatitis B it is in the immigrant population, mostly, but it is a completely preventative disease. It is one of those things when talking about innovation and all these exciting breakthroughs, you have also got to look at the basics. It frightens me, sometimes, to look at the number of people who have not been immunized against Hepatitis B or have not finished their course of vaccination. We get a lot of co-infection in the HIV population - around 7-8% are infected with Hepatitis B in this country, around 20% with Hepatitis C. Hepatitis B is relatively easy to treat, with the same drugs used to treat HIV.

Image: Structure of a HIV virus

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First do no harm: overcoming barriers to refugee health

Elishba Chacko, MA BEd emailelishba@doctors.org.uk Year 3 Medicine, University of Sheffield

Source: Flickr

doi:10.4201/lsjm.gch.006

Introduction Refugee:

So I have a new name—refugee Strange that a name should take away from me My past, my personality and hope Strange refuge this is So many seem to share this name —refugee Yet we share so many differences I find no comfort in my new name I long to share my past, restore my pride, To show, I too, in time will offer more Than I have borrowed For now the comfort that I seek Resides in the old yet new name I would choose—friend Ruvimbo Bungwe (9), from Zimbabwe, 20021

“

The issue of asylum is an emotive one. This article seeks to dispel some of the moral panics surrounding refugees, to shed light on their rich contribution to our society, and to highlight the crises they face in their struggle to survive.

The former home secretary David Blunkett raised fears in the British public when he claimed that Britain was being swamped by asylum seekers2. A poll indicated that people believed that the UK took 25% of the world’s refugees2. The UK, despite being one of the world’s richest countries, harbours just 2% of the world’s refugee population. In contrast, it is the world’s poorest countries that take in the vast majority3.

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Refugees have made many positive contributions to British society. Prominent people given refuge in the UK include Karl Marx, Sigmund Freud, Victor Hugo and Michael Marks (of Marks and Spencer). We even owe one of our national dishes—fish and chips—to 17th Century Jewish refugees.4 Many more have made positive contributions without rising to fame. Elizabeth Josephs, an asylum seeker who fled from Rwanda to the UK, is keen to integrate and make the country her new home if given the chance. She was a former teacher and businesswoman in Rwanda. She says, “I’m not a criminal, I’m an ordinary person— use us, some of us are professionals, I’m not contagious—think!”5 The United Kingdom has relied on migrants to build up its trade and industry, including the NHS and continues to do so6.

We even owe one of our national dishes—fish and chips—to 17th Century Jewish refugees. Categories of Immigrants The term refugee includes people at all the various stages of the asylum process. However progress through each stage bestows a different label on the individual6. Asylum seeker—someone who has fled to another country to escape persecution and has made an application for asylum. Refugee—an individual who has had their asylum application approved and therefore has a right to live and work in the UK. Failed asylum seeker—an individual whose application for asylum has been rejected, but who has not yet been repatriated. Illegal immigrant—a person who enters the country without the necessary governmental approval or extends their stay long after the designated period stated on their visa.

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”

PERSPECTIVE The asylum process is complicated and with the spectre of forced repatriation looming large over the applicant. In order to be granted asylum under the Geneva Convention, the seeker must meet specific criteria, demonstrating threat to personal safety - a difficult thing to prove6.

GPs who promote refugee health, the provision of interpreters in health centres, conversation clubs for refugees, national telephone interpreting services, maintenance of patient records and the development of health information packs with proof of entitlement to free treatment.

Common Health Problems Every face tells a story, some refugees have escaped horrific situations in their home country - violence, rape and torture. Many escapees suffer from post-traumatic stress, anxiety, depression, and somatisation as a result of the ordeals they have undergone7. Refugees may have other health problems such as hepatitis, TB, HIV/AIDS, malnutrition and other musculoskeletal problems as a result of neglect, sleeping rough, emotional distress, and trauma8. Only a minority of refugees arrive with these health problems, but treatment and conditions in the UK increase their prevalence in the refugee communities8. Though some form of screening exists for new arrivals, this is limited to communicable diseases and is more likely to be provided with an aim to protect the indigenous population from the influx of disease.

Educating primary healthcare workers with cross-cultural medical education will go a long way towards improving current practices and attitudes to refugees. The NHS is already recognising and highlighting this need. The author contributed to the NHS 2009 National Conference for Nurses and Health Visitors Working with Asylum Seekers, which focused on the specific health care needs of these marginalised groups. There is a concerted effort to provide resources for health workers to co-operate that allows them to support one another (such as the national refugee integration website at http://nrif.org.uk). Healthcare practitioners who work closely with refugees are hungry for more information and skills that can enable them to provide complete and effective care. Outlook The future healthcare infrastructure will determine the quality of care afforded to refugees. Refugees form a valuable part of our society and restoration of their dignity will take considerable political will, courage and co-operation.

Source: Flickr

Proper access to health care is therefore essential. Sadly, asylum seekers in the UK, including children in removal centres, continue to receive sub-standard medical care and are often subject to abuse that is “widespread and systemic”.9

References Failed asylum seekers receive support that is limited to £35 a week of food vouchers. To quote research findings “the effect…can be devastating as the lack of cash support increases…isolation and exclusion and removes any opportunity to fill time with activities”. The enforced poor nutrition has serious consequences on their health. The supermarkets are likely to be some distance away: “three miles is okay if you are young and fit…if pregnant, asthmatic, diabetic or recovering from surgery…more than a mile can be difficult”.10 The Refugee Council has stated that this current support system also known as Section 4 support is inhumane and should be dispensed with and replaced with permission to work.

Barriers to Health Refugees, asylum seekers (and after a 2008 high court ruling failed asylum seekers) are entitled to free healthcare under the NHS11. Despite this, many of the above categories of immigrants have difficulty accessing health care. Health care workers face a lack of time, cross-cultural education and the necessary expertise to provide suitable care to the refugee11.

General practices too can differ in their attitudes to refugees, creating areas of unequal health distribution. Many practices are unaware of rights afforded to various categories of immigrant. There is a major language barrier during consultation; even working with an interpreter can be stressful and difficult8. Women are likely to be excluded from screening and other health programmes including sexual health, family planning clinics, and maternity care. This may be due to religious and cultural constraints and to poor compliance. What Can Be Done? Increasing spending on refugee primary care may never be implemented as it would mean prioritising refugees’ health needs over that of the native population. There are however positive steps that can be taken12,13: due recognition and additional funding for

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10.

11.

12.

13.

Teichmann I. Credit to the nation: Refugee contributions to the UK. London: The Refugee Council; 2002. Are UK asylum laws working?; 28 July 2003. Available from: http://news.bbc.co.uk/1/hi/talking_ point/3080129.stm. Accessed 23 October 2009. UNHCR — 2007 global trends: Refugees, asylum seekers, returnees, internally displaced and stateless persons; June 2008. Available from: http://www.unhcr.org/statistics/ STATISTICS/4852366f2.pdf. Accessed 17 August 2009. UNHCR in the UK — briefings and resources; Available from: http://www.unhcr.org.uk/info/briefings/asylum_ issues/myths.html. Accessed 17 August 2009. Josephs E. Video nation; 11 July 2003. Available from: http://www.bbc.co.uk/videonation/articles/l/leicester_ ordinarypeople.shtml. Accessed 23 October 2009. Burnett A, Peel M. What brings asylum seekers to the united kingdom? BMJ 2001, Feb;322:485-8. Available from: doi:10.1136/ bmj.322.7284.485. [Accessed on 7 December 2008] Jaranson JM, Butcher J, Halcon L, Johnson DR, Robertson C, Savik K, et al. Somali and oromo refugees: Correlates of torture and trauma history. American Journal of Public Health 2004, Apr;94(4):591-8. Available from: doi:10.2105/ AJPH.94.4.591. [Accessed on 7 December 2008] Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ 2001, Mar;322:544-7. Available from: doi:10.1136/ bmj.322.7285.544. [Accessed on 30 December 2008] Cohen D. Asylum seekers in detention centres receive poor medical care, MP says. BMJ 2008, Dec;337:a3022. Available from: doi:10.1136/bmj.a3022. [Accessed on 31 December 2008] Doyle L. Refugee council research report—more token gestures: A report into the use of vouchers for asylum seekers claiming section 4 support; October 2008. Available from: http:// stillhumanstillhere.files.wordpress.com/2009/01/rc_more_ token_gestures_oct_2008.pdf. Accessed 23 October 2009. Ford R. Ruling gives failed asylum-seekers free healthcare. The times 12 April 2008. Available from: http://www.timesonline.co.uk/tol/ news/politics/article3732002.ece [Accessed on 17 August 2009.] Jones D, Gill PS. Refugees and primary care: Tackling the inequalities. BMJ 1998, Nov 21;317(7170):1444-6. Available from: PMC1114300. [Accessed on 7 December 2008] General practitioners’ knowledge of issues relating to asylum seekers is poor. BMJ 2000, Oct;321:893. Available from: doi:10.1136/bmj.321.7265.893. [Accessed on 30 December 2008]

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Heroin on prescription for addicts: an innovative or old idea? Elena Atkinson, BSc Year 5 Medicine, Imperial College London elena.atkinson05@imperial.ac.uk doi:10.4201/lsjm.gch.007

Drug addiction, especially to opiates, has been around for centuries and many different treatment methods have been tried over that time with little success. Recently it seems the attention has shifted from treating the addiction to treating the social problems such as theft, prostitution and drug dealing that many addicts rely on to fund their habit. A Canadian study has found that 50% of those addicts involved in crime claim they would give up their illegal income if they didnâ&#x20AC;&#x2122;t need to fund their drug addiction1. This claim has been tested recently with a study in the South of England known as the Randomised Injecting Opiod Treatment Trial (RIOTT) which made national headlines for providing heroin addicts with diamorphine (medical heroin) at special clinics2. The addicts had to attend the clinic twice daily to receive a dose of the drug under controlled, supervised conditions and at no time were they allowed to take any diamorphine away with them. The RIOTT study, though in its early stages, appears to be mirroring the results of similar studies around the world, with the number of addicts involved in crime dropping by half and those addicts who continue to engage in illegal activities doing so less frequently (from a maximum of 30 times a month before the scheme to 13 times after six months of treatment)3. As well as the proposed benefits to the community there are obvious advantages to such a scheme for addicts, with users no longer running the risk of HIV or hepatitis C infection from needle sharing, less risk from unknown drug contaminants and a lower risk of overdose due to supervision. The fact that the aim of the scheme is not to cure is unique, but the estimated cost of ÂŁ15000 per patient per year raises controversy. While those behind the scheme claim it will be only for the minority of addicts, who have failed on previous rehabilitation attempts, it is still hard to find justification for funding this from healthcare money, especially given the perilous state of NHS finances4. One way of avoiding the inevitable

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PERSPECTIVE debate, whether the NHS fund a self inflicted condition, could be to subsidise the scheme with money from the police force and local councils as both these bodies stand to benefit financially from the reduction in crime and anti social behaviour. Prescribing heroin is not a new phenomenon; the current trials in the UK follow those conducted in Switzerland in the mid 1990’s where they were deemed to be such a success at tackling the drug induced social problems that a recent referendum has led to 68% of voters calling for it to be part of the government’s drug policy5. Also when the reduction in crime and addiction associated healthcare costs were considered against the scheme implementation and maintenance costs, the programme was actually estimated to save Switzerland’s economy US$26 per addict per day6. The front-runner in prescribing heroin to addicts though is Britain. In this country it has been legal since the 1920’s, and many drug clinics around the country still retain this right7. If this is the case why are we not leading the way with heroin prescription for this purpose? The truth is many of the doctor’s legally able to prescribe diamorphine simply choose not to. This is not to say these professionals find it detrimental to the addicts or an outdated method of treatment. On the contrary the findings of a questionnaire based study in 2002 showed that many of those doctors eligible to prescribe believe it to be beneficial but there was little consensus on what dose should be used and which patients should be considered for it8. While much of this confusion may be cleared up by the renewed interest in studying this method of treatment, an overriding reason for low levels of prescribing is resource availability. Both the Swiss and British study into heroin clinics involved substantial social and psychological support for the addicts which led to an impressive reduction in street heroin use for not only the cohort receiving heroin but also in those receiving methadone when heroin prescription had previously failed. This suggests manpower and increased support may have a more important role than it has previously been credited with and methadone, the treatment mainstay, may not be finished with just yet. The lack of people trained in such close supervision of addicts and the funding issues described above mean that, for the short term at least, these clinics are not going to be rolled out on a national scale in Britain. However they are a feasible way of minimising the damage from drug use by the difficult to treat minority. Other methods which have been shown to reduce crime, overdose rates and other drug related sequelae, are; making it almost impossible for addicts to get hold of heroin or legalising it. This is illustrated by a case in three Australian states in 2001 where street heroin was in short supply for three months leading to a drop in fatal overdoses by 40% and by Portugal, where decriminalisation of drug possession has caused HIV infection rates to fall by 17% in addicts9,10. Practically, it is almost impossible to fully stop the illegal trade of heroin and it is unlikely given the furore surrounding cannabis reclassification that heroin possession will be decriminalised here in the near future nor am I suggesting it should be. With other options largely dismissed, heroin drug clinics may provide part of the answer to minimise drug related problems in this country. More of a fresh perspective on an old idea than something completely new, it creates new ethical issues of doctors providing a service whose main aim has changed from curing the addict to reducing the social harms of addictions. A discussion of such issues

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is warranted, though outside the remit of this article. There are funding issues, implementation difficulties and likely media uproar that mean this innovative idea is still in its infancy. However I feel that if these problems can be overcome and the data from trials continues to be encouraging, this could be a way in which heroin addiction treatment is managed in communities in Britain in future.

References 1. DeBeck K, Shannon K, Wood E, Li K, Montaner J, Kerr T. Income generating activities of people who inject drugs. Drug and alcohol dependence 2007 Nov 2;91(1): pp. 50-56. 2. Lintzeris N, Strang J, Metrebian N, Byford S, Hallam C, Lee S, et al. Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): evaluating injectable methadone and injectable heroin treatment versus optimised oral methadone treatment in the UK. Harm reduction journal 2006 Sep 27;3: pp. 28. 3. Siva N. Heroin clinics reduce street drug use and crime, shows study. BMJ (Clinical research ed.) 2009 Sep 18;339: pp. b3845. 4. Batty D. Q&A: Herceptin. The Guardian. [Online] . Available from: http://www.guardian.co.uk/ society/2007/jan/05/cancercare.health. 5. Swiss approve prescription heroin. [Online] Available from: http://news.bbc.co.uk/1/hi/world/europe/7757050.stm. 6. Brehmer C, Iten PX. Medical prescription of heroin to chronic heroin addicts in Switzerland - a review. Forensic science international 2001 Sep 15;121(1-2): pp. 23-26. 7. Carnwath T. Prescribing heroin. The American Journal on Addictions / American Academy of Psychiatrists in Alcoholism and Addictions 2005 Jul-Sep;14(4): pp. 311-318. 8. Metrebian N, Carnwath T, Stimson GV, Storz T. Survey of doctors prescribing diamorphine (heroin) to opiatedependent drug users in the United Kingdom. Addiction (Abingdon, England) 2002 Sep;97(9): pp. 1155-1161. 9. Degenhardt L, Day C, Dietze P, Pointer S, Conroy E, Collins L, et al. Effects of a sustained heroin shortage in three Australian States. Addiction (Abingdon, England) 2005 Jul;100(7): pp. 908-920. 10. Greenwald G. Drug decriminalization in Portugal, Lessons for creating fair and successful drug policies. USA: Cato Institute; 2009.

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EDITORIAL

You are warmly welcomed to the Health Law & Ethics section of The LSJM’s second edition. We address a crucial component of medical disciplines across the board, tackling the ethics and policies behind controversial issues that affect all healthcare professionals and the public that we serve. In a society where the delivery of healthcare is inseparable from the complex world of politics, it is essential for us to question medical practice, from the point of our personal morality through to national legislation. We may find our traditional philosophies and the relevance of the Hippocratic Oath challenged in the growing face of medical innovation and technology. The issue of medical confidentiality is one that has received prominent attention and confrontation in recent times, but which has a longstanding and variable course through history that has largely not been looked at. An apparent progression has been seen from the paternalistic, physician-centred doctor’s oath, to a focus on the autonomy and rights of the individual. Nevertheless, the importance of respecting patient confidentiality was established at the very birth of modern medicine, with Hippocrates’ pledge “whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets”. 1 While he championed acting in the patient’s best interests, “never with a view to injury and wrongdoing”, there were no clear boundaries as to what would legally constitute a violation of the oath. It was a decision almost solely attributed to the individual physician, and concerns about negative gossip affecting patient confidence were part of the consideration. Similar versions of the oath were published throughout Europe in following centuries. In the 1700’s, John Gregory, a professor at Edinburgh University, published a paper, stating his concerns of the power that doctors had over their patients, the lack of professionalism and regularity in the profession, and that the protection and rights of patients were not of primary importance. He took a sympathetic view of the plights of patients, advocating women in particular and was to become influential in the reform of medical ethics at the time.2 In 1803, Thomas Percival was to become another influential figure in modern medical ethics, with a publication designed to guide the conduct of new physicians who had signed up at a Manchester Hospital during a taxing outbreak of typhus fever. He endorsed consulting with patients “in a tone of voice which cannot be overheard”, strictly observing “secrecy”, and using the knowledge gained in such consultations “with discretion... and the most scrupulous regard to fidelity and honour”. A similar policy was then incorporated into the first American Medical Association’s ethical code in 1846.2 Furthermore, a century later in 1948, the World Medical Association’s Declaration of Geneva published that “A doctor owes to his patient absolute secrecy on all which has been confided to him or which he knows because of the confidence entrusted to him”. 3 Here we start to see the disparity between recent changes to confidentiality laws, where the duty of the physician to a wider population has shifted to largely eclipse the absolute duty of physician to patient. A landmark case in 1971 saw a British physician, Dr. Robert Browne, appear before a disciplinary hearing of the General Medical Council for charges of serious professional misconduct, due to breaching patient confidentiality by informing a 16 year old girl’s parents that their daughter was taking the oral contraceptive pill.1 His defence centred on his belief that his decision had considered the possible adverse emotional impacts on the patient, the hazards of the drug, his belief that her parents -with whom he was familiar - would be most able to counsel her in this situation, and that in the spirit of Hippocrates’ Oath, his only interest was in what he believed was best for her. He was contentiously ruled as not guilty, due to a recognition that cases must be judged individually, and that it must considered that in some situations the disclosing of confidence may benefit the patient. In light of the case, the British Medical Association’s 1959 Code of Ethics was amended from, “It is a practitioner’s obligation to observe the rule of professional secrecy by refraining from describing voluntarily without the consent of the patient (save with statutory sanction) to any third party, information which he has learnt in his professional relationship with the patient”, to include that, “If in the opinion of the doctor, disclosure of information to a third party seems to be in the best medical interest of the patient, it is the doctor’s duty to make every effort to allow the information to be given to the third party, but where the patient refuses, that refusal must be respected”.1 The complexity of 21st century medical systems, which require and involve communication between physicians and multiple health disciplines, the availability to appropriate staff of medical records, issues of valid consent, and the need to address social issues, has realised the obsoleteness of some of the traditional views. Flexibility has particularly been required with at-risk or vulnerable groups, involving situations of abuse, sexual health and communicable diseases. A recent change in the GMC guidelines has sanctioned the release of certain information to the police regarding knife crime (see HLE News), and not solely gun crime as was previously the case, anticipating that increased statistics of the when and where’s of violent crime will aid police work and be in the interests of the safety of the public at large.4 What’s at stake here is a compromising of the fundamental bond of trust between doctor and patient. It will be a matter of treading that fine line between the physician’s duty to warn and duty to protect. Sandra Sadoo Section Editor Health Law & Ethics References

Illustration: Ella Beese

1. 2. 3. 4.

The Genuine Works of Hippocrates. Trans. Francis Adams (1886). Vol. 2, 344-5 Rachel McAdams and Mark Skippen. The Eleventh Wellcome Trust Regional Forum for the History of Medicine in Scotland. Available from: http://www.gla.ac.uk/departments/historymedicine/conferencesandpublications/eleventhwellcometrustregionalforum Declaration of Geneva (1948). Adopted by the General Assembly of World Medical Association at Geneva Switzerland, September 1948. Available from: http://www.cirp.org/library/ethics/geneva Doctors must report knife crime’. (2009) BBC News. Available from: http://news.bbc.co.uk/1/hi/uk/8276609.stm

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NEWS Late Abortions: A confidential or public matter? Maria Knoebel Year 3 Biomedical Sciences, Imperial College London Maria.knoebel06@imperial.ac.uk

MPs move to ban public display of cigarettes Jenifer Salmons Year 5 Medicine, Imperial College London Jenifer.salmons04@imperial.ac.uk

Statistics on late abortions (performed after 24 weeks gestation) held by the Department of Health (DoH) may soon be made public, as ruled by the Information Commissioner. The legal and ethical battle was sparked again as the Pro Life Alliance requested the data under the Freedom of Information Act and was originally turned down.

MPs have approved an amendment to the Health Bill, meaning that England, Wales and Northern Ireland are all one step closer to sanctioning the removal of cigarettes from public display, including the outlawing of cigarette vending machines. Scotland is considering a similar ban. The amendment will now go before the House of Lords, before being initiated between 2011 and 2013 if passed.1, 2

Since the Jepson case six years ago over the abortion of a child with a cleft lip and palate, the DoH have ceased publishing full statistical information on late stage abortions due to foetal abnormality, as this case led to the doctor being identified and pursued. Under the 1967 Abortion Act, abortions after 24 weeks may be terminated up until birth, if there is evidence of a serious mental or physical risk to the mother or foetus. However, anti-abortion groups have argued that a cleft-lip, club foot, and other such malformations do not constitute “serious” abnormalities. The DoH lawyers are concerned about releasing such information deeming it “sensitive, personal, and private”. Julie Bentley, CEO of the Family Planning Association released a joint statement with Brook stating that they were “dismayed” by the decision of the Information Commissioner, adding that the potential for individual women and doctors who carry out the procedure to be identified is worrying and unethical.

The move has been defended by supporters who say that the banning of vending machines will cut off a major route by which underage children gain access to cigarettes, stopping younger generations from taking up and becoming addicted to smoking in the first place.3, 4 Some fear that this is yet more proof of the nanny state culture gone too far, further criminalising smoking and diminishing the individual’s right to choice and responsibility. In addition, the removal of tobacco products from public display will have the biggest impact on newsagents, for whom the sale of cigarettes contributes a large proportion of their income.5 Will the banning of such products from public places really reduce the number of people buying cigarettes? Won’t determined children find a way around such a ban? Only time will tell. References 1.

Although the Information tribunal has said that it is very unlikely for patients and doctors to be identified from the statistics alone, an internal review conducted by the DoH showed that the numbers were very small, and since such abortions are rare, the information should not be released to protect identities. Pro Life Alliance barrister Paul Diamond maintains that statistics do not constitute personal data, and that transparency is necessary to satisfy public interest in this controversial medical practice. There are fears that the availability of such information will move Britain towards the US-style targeting of doctors who carry out abortions, and give anti-abortion campaigners ammunition to put pressure on individual women and doctors. The DoH will consider the implications of this judgment and may lodge an appeal with the High Court. Whether or not the release of such information will prevent future “unlawful killings”, or violate the privacy individual doctors and families, remains to be seen, as the issue of late abortion continues to tread a fine legal and ethical line.

BBC News. MPs approve cigarette vending ban. 2009 [cited 2009 Oct 13]. Available from: http://news. bbc.co.uk/1/hi/uk_politics/8303975.stm Griffiths P. Cigarette vending machines may be banned. 2009 [cited 2009 Oct 13]. Available from: http://uk.reuters.com/article/idUKT RE59C14320091013?pageNumber=2&virtualBrandChannel=11564 Mccartney I. McCartney wins support for cigarette vending ban. 2009 [cited 2009 Oct 25]. Available from: http://www.ianmccartney. com/mccartney-wins-support-for-cigarette-vending-ban British Heart Foundation. Sending vending machines to the scrapheap will save lives. 2009 [cited 2009 Oct 13]. Available from: http://www.bhf.org.uk/news-and-campaigning/pressoffice/latest-news--views/cigarette-vending-machines.aspx BBC News. Newsagents warn Labour over ban. 2009 [cited 2009 Oct 11]. Available from: http://news.bbc.co.uk/1/hi/uk/8301195.stm

References

2. 3.

156

The UK Statute Law Database. Abortion Act 1967 (c. 87). Westminster: Office of Public Sector Information. [cited 2009 Oct 24]. Available from: http://www.statutelaw. gov.uk/content.aspx?activeTextDocId=1181037 Dreaper, J. Late abortions data to be public. (2009) BBC News. Available from: http://news.bbc.co.uk/1/hi/health/8309432.stm Boseley, S. Confidentiality fear over late abortion data. (2009) The Guardian. Available from: http://www.guardian.co.uk/ society/2009/oct/16/pro-life-alliance-abortion-jepson-case

Source: Wellcome Images

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ARTICLE

A Cybrid Cul-De-Sac in Stem Cell Research? Katherine Adlington

Source: Wellcome Images

Year 3 (GEP) Medicine, King’s College London katherine.adlington@kcl.ac.uk doi:10.4201/lsjm.hle.005

Image: A stained 13 day old embryonic chick Introduction “Scientists to create ‘frankenbunny’ in big research leap” 1 was just one of the many sensational headlines to greet attempts by two research groups in 2006 to gain licences for the creation of the first cytoplasmic hybrid (‘cybrid’) embryos in the UK. In contrast, charities supporting diseases identified as potential targets for such research, rushed forward to defend and promote the methods proposed by the two teams. These responses typified the extreme and varied emotional reactions of the British population to the prospective creation of these novel interspecies embryos. What are the ethical issues underlying these public objections to cybrid research? In light of recent advances in non-embryonic stem cell technology, are the possible advantages of cybrid research sufficient for these objections to be ignored? And do these ethical issues have any relevance to medical students? For many years, stem cell technology has promised huge hopes in the field of medical research. Adult stem cells have been successfully used for transplantation in a number of diseases2, and human Embryonic Stem (hES) cells - with their ability to be isolated and genetically manipulated in pluripotent stem cell lines - seem to offer even greater hopes for studying genetic disease and

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exploring pharmacological therapeutic interventions3. Despite this promise, new evidence has shown that in order to create a single successful cloned hES cell line thousands of oocytes are required4. Unwanted gametes from IVF patients are currently the main source of oocytes for hES cell research but these cannot satisfy the required volume. The use of animal oocytes has been suggested as a practical solution to this shortage; cloning technology would then be used to transplant a human nucleus into the enucleated animal oocyte. Traditionally, a significant ethical hurdle associated with oocyte-harvesting for research has been the associated risk of physical and emotional harm to female donors. The procedure is complicated and painful and often financial incentives are offered in exchange for eggs, leaving women vulnerable to the risk of exploitation, especially in resource poor settings. Using animal oocytes and a human nucleus (that could come from any somatic cell in a male or female donor of any age) would remove the need and resultant ethical issues of using human eggs in stem cell research. However this makes it straight forward to access cellular material for experiments. Some would argue it is too easy since it would be possible to get a cell sample for cloning purposes without even the donor’s knowledge.

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ARTICLE The resulting part-human, part-animal embryo is termed a humananimal cytoplasmic hybrid embryo. This ‘cybrid’ would be over 99% genetically identical to the human donor of the nucleus, with just 0.1% of the embryo’s genetic material derived from the animal oocyte’s mitochondrial DNA5. Animal-animal cybrid embryos have previously been created and have even resulted in live offspring, when involving closely related animals6. This technology was used by conservation biologists to successfully clone a wild endangered sheep species using oocytes collected from a closely related, domesticated species, with the hope of preserving these endangered mammals. There are currently no rules to prevent the creation and full gestation of animal-animal cybrid embryos. The first successful example of a human-animal cybrid was reported in 2003, when Chinese scientists obtained well-characterised hES cell lines using a rabbit oocyte donor7. In this experiment, the Chinese research team classified the cybrids as human embryos and thus it was performed in accordance with international guidelines on human stem cell research (The Human Fertilisation and Embryology Act 1990 in the UK), such that human embryos should not be kept beyond 14 days and should not be introduced into the uterus of any species. Day 14 cut-off is used for two reasons; first, it appears to be the limit after which twinning does not occur so before this it is hard to consider an embryo as a distinct individual; and second, it signals the development of the primitive streak, which eventually develops into the embryonic neural system. Thus, it is considered that the early embryo before 14 days of development is not the equivalent of a foetus or person. These regulations remove the potentiality of such embryos to develop into living individuals, therefore, the classification of cybrid embryos as human can immediately quash any ‘frankenbunny’ fears.

Source: Wellcome Images

In November 2006, two research teams in the UK applied to the Human Fertilisation and Embryology Authority (HFEA) for licences to create cybrid embryos with the aim of conducting research into the genetic reprogramming of cells and the genetic basis of neurodegenerative disorders8, 9. The Human Fertilisation

Image: Colour-enhanced electron microscope image of a human embryo at the blastocyst stage opened to reveal the inner cell mass. These cells go on to form the embryo and can be harvested and cultured to give rise to embryonic stem cells.

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and Embryology Act 1990 had prohibited the mixing of human and animal gametes but had made no specific mention to the creation or classification of cybrid embryos and thus there existed no formal guidance in the UK as to whether the Chinese research team were justified in treating their cybrid embryos as human10. Whereas, the mixing of human and animal gametes would create a true hybrid embryo with equal genetic contribution from both gamete donors, a cybrid embryo is almost entirely genetically identical to the nucleus donor, with a minimal genetic contribution from the oocyte donor. A huge question hangs over the relative importance of the genetic and environmental contribution of the ooctye to the resulting embryo. A number of government consultations occurring since 1990 had reached conflicting conclusions as to how to classify cybrid embryos – human or otherwise – and whether such research was acceptable, resulting in no regulatory consensus or framework11, 12. This uncertainty was not reserved to regulatory groups. These research applications also generated a firestorm of controversy in the media and a very sudden, emotive reaction from the public, which prompted the UK Government to propose that the creation of hybrid and chimeric embryos in vitro should be banned once and for all13. Instead, the HFEA embarked upon a public consultation to explore the emotive and extreme reactions surrounding this issue and try to reach a consensus about how to classify and regulate cybrid research. Ethical objections or knee-jerk reactions? The highly emotive response from the media and a proportion of the public that greeted the emergence of details of cybrid research appeared to stem from an instinctive, visceral reaction against it. Such reactions are often referred to as the ‘yuck factor’ and involve an insistence that the thing they are reacting to is inherently wrong without being able to suggest a logical explanation14. This notion of intuitive awareness forms part of the wider philosophical theory of ethical intuitionism, which states that instinctive moral reactions are the expression of an underlying and universal moral code15. Anthropologists such as Mary Douglas claim that this ‘yuck factor’ is a response to the violation of cultural taboos, which have evolved in all societies as a result of the innate human need to categorise the world around them16. Such reactions, however, are dangerous since projective emotions of disgust have been used in the past to wrongly justify group subordination in many societies, for example to drive racism or sexism7. John Harris highlighted the fact that there is no necessary connection between things that disgust us and cases where there are good reasons for judging as unethical18. Yet knee-jerk reactions are often unavoidable and perhaps, one could argue, even a necessary emotional starting point, without which we would be left with indifference. Interestingly, in a series of public workshops about issues surrounding stem cell research, organised by the Medical Research Council in 2008, initial negative views of cybrids were largely overcome in response to education about the precise nature of the research19. Instinctive moral reactions are not always permanent nor can be relied upon exclusively because they may arise from ignorance of facts. Such ignorance is often fuelled rather than enlightened by the media. Reports frequently incorrectly refer to cybrid embryos as ‘chimeras’ or simply as ‘hybrids’: neither of these are biologically accurate definitions for cybrids20. These misnomers could have significant repercussions, for example, causing the public to associate cybrid technology with pre-existing images of mythological monsters, such as Homer’s fire-breathing chimera or the aforementioned ‘frankenbunny’.

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ARTICLE Unnatural? A significant objection to the creation of cybrid embryos, especially amongst religious opponents, is the belief that it causes a violation of natural species boundaries. Yet there does not seem to exist one universal biological definition of species - in total there are between nine and twenty-two definitions in biological literature and none have received unanimous support 21. Similarly, the great hope that modern genomic technology would provide us with a unique blue print of the human genome to categorically define Homo sapiens has been ruined by the revelation that much of ‘our’ DNA is shared with a large number of apparently distantly related animals, such as yeast and worms, and we differ genomically from chimpanzees by as little as 1.2%22. Aspects of human cognitive capacity have also been used to distinguish Homo sapiens from other animals, such as language, intelligence or emotional complexity. However, any attempt to define features of human beings will either include non-human animals within their scope (dolphins are intelligent, sentient, emotionally-complex animals too) or exclude many patently human individuals (for example, those who are comatose, infants or even illiterate). Hence, it seems that no accepted identifiable species boundaries exist that cybrid research could be said to violate, nor is there any clear species definition that can be used to categorise a cybrid embryo. Although there appears to be no consensus for biologically demarcating human beings, the public consultation showed that people felt reassured by the revelation that cybrid embryos would be almost entirely genetically-related to their human nuclear donor19. DNA continues to be recognised by the public at least as a significant part of what makes us human. However, this is not an exact science, we may ask at what genetic percentage would this embryo no longer be classified as human? It is important to consider not only the amount of genetic contribution of the animal donor to the resulting cybrid embryo but also the precise effect this genetic material has on its development. Although initially many of the cellular proteins and RNA in the embryo are animal-derived, by day 14 when the embryo is currently destroyed, the only genetic contribution from the animal would come from the oocyte’s mitochondrial DNA(mtDNA)23. Evidence from animal-animal cybrid embryos that have survived (invariably animals that are closely related) suggests that this mtDNA does have an impact on the resulting embryo’s energy production ability. It would be extremely reductionist to state that a molecular change in the cellular control of ATP production changes the overall identity and classification of an individual. However, it is a change that is pervasive, occurring in every cell of the resulting embryo, and one for which we cannot predict the potential developmental impact. Xenotransplantation (such as the frequent use of pig heart valves in human cardiac surgery) is another form of interspecies manipulation. We can see that it is far easier to biologically classify a transplant recipient as human because there is an observable and measurable change to a discrete region of an already developed human body. On the other hand, cybrid embryos threaten our biological notion of humanness at the most basic level of all cells - at the very beginning of life. Moral status? Membership in the human community has always depended on far more than DNA and an individual’s moral status exists apart from biological classifications. Immanuel Kant believed a universal

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moral boundary exists separating humans from all other nonhuman animals based on the unique human quality of rationality 24. Membership in the human community is dependent on the innate possession of dignity by rational beings, which therefore bestows on humans alone an innate right to respect and ethical treatment. Cybrid research presents a dilemma for the concept of human dignity. On the one hand, it is the respect for the dignity of human beings that supports medical research to prevent human suffering38. On the other hand, the admixing of human and animal material in the creation of cybrids crosses the moral barrier between dignified human beings and undignified animals, violating human dignity in the process. According to this theory, not only would the dignity of the essentially human embryo be denigrated but also the dignity of the nucleus donor (as it is their DNA material that is being affected) and the future recipient of any resulting stem cell transplant. However, using rationality as a prerequisite for moral consideration presents the same problems as those previously encountered when trying to define human nature – it causes the exclusion of many marginal members of the human race. Even if we expand this definition to include the potential to become rational, we face further problems since; a) under current regulations, the cybrid embryo has no potentiality beyond 14 days, and b) even if it did, this is a novel being and we can only make predictions as to its future capacities for rationality. Many people object to the human dignity theory because it denies the possession of dignity or moral status to any non-human animal. Whilst few claim that all living organisms should have equal moral status to humans25, there have been many attempts to define certain animals as worthy of moral consideration26. According to Peter Singer, these arguments are just as unacceptable as the human dignity theory: they all justify discrimination on the grounds of species or group membership27. Singer condemned such discrimination as ‘species-ism’ and branded it as indefensible as racism or sexism. However, whether ethically justifiable or not, humans have historically behaved as if they have a right to own animals and be in charge of their fate. This means there is a possibility for conflict and confusion in our moral obligations to cybrid embryos as part-animal, part-human beings. Slippery slope? Overall, one of the main fears for the public is science would lead to the generation of live interspecies individuals from interspecies embryos. The stigma and moral confusion over our obligation to such individuals, as well as the uncertainty surrounding their successful biological development, would be great. The threat of such individual psychological harm is almost sufficient to motivate a complete ban on cybrid embryos, at least until such a time that social attitudes change and the moral status of animals has been addressed. Conclusion Ethical objections to cybrid research could largely be silenced by careful regulation that ensures embryos are classified as human and therefore not kept beyond 14 days’ development. Development beyond this time would not be in the best interests of the potential individual or society due to the confusion that would surround classification and obligations of society to the cybrid person. This confusion partly explains the instinctive public reaction against this research. However, the high cost, risk for disease and lack of real promise all make cybrid research seem like an expensive, practically

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Image: Undifferentiated embryonic stem cells

unjustifiable cul-de-sac in the field of stem cell research. With the recent development of Induced Pluripotent Stem (iPS) cell technology, it would seem wrong to pursue such an ethically controversial and divisive research when an alternative is available. This is reflected by the fact that although the cybrid research was licensed by the HFEA and the HFE Act was amended to allow cybrid research in 200833, both research teams have failed to make progress, citing a lack of funding as a major reason34. It is important for medical students to be aware of the different types of ongoing stem cell research since it is possible that some of these technologies and treatments will become vital clinical interventions in their future medical careers. However, it is important to distinguish the controversial media hype surrounding the experiments from the real clinical hope. Practitioners will not only be expected to understand the intricacies of the technology behind their treatments but also the complex ethical objections they might face from their patients, particularly those that have been negatively influenced by poorly informed media reports. Similarly, it is important to consider the use of animal materials for interventions in different areas of medicine and how each procedure has its own unique ethical nuances. Whilst the future of stem cell research in this country seems to lie in iPS cell technology, it is interesting to note that huge funds are being directed into all areas of stem cell research in China, where the government believe the solution to a rapidly ageing population is investment in regenerative medicine. The first cybrid embryo was created in Beijing and scientists there are not only benefiting from the increase in funding but also a cultural environment where there seem to be fewer moral objections to the use of embryonic stem cells, perhaps partly due to a different religious and political tradition35. This limitless financial, public and governmental support offers an ideal environment for the advancement of cybrid embryo research, but it leaves us with the question, are the same ethical objections being debated in the UK universally relevant? And should regulations be universally binding?

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Image: Heart muscle differentiated from embryonic stem cells

References 1. Daily Mail. Scientists to create â&#x20AC;&#x2DC;frankenbunnyâ&#x20AC;&#x2122; in big research leap [Online] October 5 2006. Available from: http://www.dailymail.co.uk/news/article-408692/ Scientists-create-frankenbunny-big-research-leap. html [Accessed 30th September 2006) 2. Mimeault, M., Hauke, R. and Batra, S.K. Stem Cells: A Revolution in Therapeutics â&#x20AC;&#x201C; Recent Advances in Stem Cell Biology and Their Therapeutic Applications in Regenerative Medicine and Cancer Therapies. Clinical Pharmacology & Therapeutics 2007; 82: pp. 252-264. 3. Braude, P., Minger, S. and Warwick, R. Stem cell therapy: hope or hype? BMJ 2005; 330: pp. 1159-1160. 4. Hall, V.J., Compton, D., Stojkovic, P., Nesbitt, M., Herbert, M., Murdoch, A. and Stojkovic, M. Developmental competence of human in vitro aged oocytes as host cells for nuclear transfer. Hum. Reprod 2007; 22(1): pp. 52-62. 5. Human Fertilisation and Embryology Authority (ed.). Hybrids and Chimeras: A Consultation on the ethical and social implications of creating human/ animal embryos in research. London: HFEA; 2007 6. Loi, P., Ptak, G., Barboni, B., Cappai, P. & M. Clinton. Genetic rescue of an endangered mammal by crossspecies nuclear transfer using post-mortem somatic cells. Nature Biotechnology 2001;19(10): 962-964 7. Chen, Y., He, Z.X., Liu, A. et al. (2003) Embryonic stem cells generated by nuclear transfer of human somatic nuclei into rabbit oocytes. Cell Res.2003; 13: pp. 251-263 8. Tilgner, K., Atkinson, S.P., Golebiewska, A., Stojkovi, M., Lako, M. and Armstrong, L. Isolation of Primordial Germ Cells from Differentiating Human Embryonic Stem Cells. Stem Cells 2008; 26(12): pp. 3075-3085 9. Minger, S. Interspecies SCNT-dervied human embryos- a new way forward for regenerative medicine. Regenerative Medicine 2007; 2(2): pp. 103-106 10. Department of Health. Human Fertilisation and Embryology Act 1990. London: DoH: 1990

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PERSPECTIVE

Dementia: Is honesty the best policy? Source: Wellcome Images

Elizabeth Precious

Year 4, Imperial College London elizabeth.precious09@imperial.ac.uk doi:10.4201/lsjm.hle.008 Dementia is an umbrella term for a number of clinical symptoms common to a wide range of pathological processes1. The ‘normal’ natural decline in cognitive performance with increasing age may hinder its diagnosis. Indeed, the prevalence of dementia increases with age. In today’s society the major demographic shift concerning the expansion of the over fifties population is a recognised phenomenon; with the greatest rate of increase evident in the higher-risk age cohorts. Consequently health professionals are increasingly coming into contact with the clinical symptoms. The primary carers of those with dementia are usually family members. Dementia care raises moral issues and challenges for all participants due to the nature and distress associated with the condition. In clinical decision-making it is important to address the four principles: autonomy, beneficence, non-maleficence and justice as defined by Beauchamp and Childress. These are principles, not ordered rules. Today, physicians are commonly torn between respecting autonomy, doing good and avoiding paternalism. Ethical dilemmas occur in dementing disorders, as patients are unable to practise the decisional and/or executional elements of autonomy. In cases where the patient is not competent some physicians believe it is morally just to act paternalistically4. Competence is the clinical term for the legal concept of capacity. At present clinicians lack an accepted definition of what constitutes deceptive practice regarding dementia care2, 3. Deception encompasses a number of strategies from being ‘economical with the truth’ to outright lying; all involve intentionally making others believe what we do not. Decision-making concerning dementia needs to be addressed in order to alleviate the ethical unease currently experienced. This review will explore the tensions that exist due to the obligations to avoid harm and respect autonomy. The current situation Interest and knowledge with regards to dementia has escalated in recent times, perhaps shifting public opinions and clinicians’ practices. Research has shown that family members are reluctant to have patients learn the truth, but would want to know if they developed the condition. Controversially, recent studies of those undergoing assessment for memory impairment, show that their desire to be informed is relatively high5-7. Currently, less than half of dementia patients are told their diagnosis; physicians find it easier to convey the diagnosis to relatives. The range of opinions revealed by studies shows the huge potential for disagreement.

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DISCUSSION In favour of disclosure Physicians are required to employ the professional standards set out by the GMC; these guidelines are considered to be ethically correct and have weight in court. ( Table 1)

Table 1: The Duties of a Doctor: relevant statements. • Respect patients’ dignity and privacy • Respect the right of patients to be fully involved in decisions about their care • Be honest and trustworthy • Make sure that your personal beliefs do not prejudice your patients’ care • Avoid abusing your position as a doctor • Work with colleagues in the ways that best serve your patients’ interests

Virtue ethics incorporates the importance of these duties: a virtuous person is one who exercises principles of moral conduct. Choosing to withhold the diagnosis undermines the trust in the doctor-patient relationship, which could sway the patient’s compliance. The National Service Framework for Older People 2001 and the Canadian Alzheimer’s Society Guidelines concur that explaining the diagnosis to patients and carers is always a part of dementia care. The truth is always important to know despite how painful it may be4. Withholding information is a form of disrespect; it is patronising to permit them to live in a false reality. Article 3 of the Human Rights Act 1998 (HRA), which came into force in October 2000, states that no one will be subjected to degrading treatment. If a physician does not act on the test results, the diagnostic procedure is arbitrary and may be seen as abuse. Not telling the patient could be perceived as using their disability to manipulate them: both constitute exploiting the position of a doctor2. For some patients the news will trigger immediate sadness and fear, but this is usually neither significant nor irreversible6. As the disease progresses depression is less likely, because patients become less aware of their deficits. Depression is less likely to develop in patients with a well established care support network. Duty-based ethics considers the nature of the action, independent of the anticipated outcomes. In dementia care, lies are often used with the best intentions8; however, there is a strong moral presumption against all forms of deceit. Deceitful practices may tarnish the reputation of the health services. It is important for physicians to take heed of their responsibility to the community.

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PERSPECTIVE The majority of family members act paternalistically to protect the patient from the harsh reality. Studies show that relatives are reluctant to deal with the patient’s grief and deceptive practice is often for the carer’s benefit2. Physicians’ decisions should not depend upon the opinions of the family, but their views should be taken into consideration. A study reported that only 58% of people would trust their spouses to make decisions on their behalf if they became incompetent9. British Law does not give patients’ families authority to make decisions on behalf of those aged 18 years and above. The Mental Capacity Act 2005, which commenced in October 2007 states that an adult may appoint a Lasting Power of Attorney who is entitled to make decisions regarding their health and welfare as well as financial affairs. Clinicians should presume all adults to be competent in decision-making; capacity is decision and time specific. If the patient is incompetent at the time of diagnosis physicians should attempt to facilitate the patient’s abilities to enable them to participate as fully as possible in the proceedings. This is as much a part of respecting the patient’s autonomy, as allowing them to make their own decision. Physicians may be liable for negligence if they do not provide appropriate information. Gaining consent is a process, not a one-off event. Valid consent requires that the patient be: informed, competent and not coerced. Inflicting unwanted treatment on someone undermines their personhood and could lead to cases of perceived battery. Alternatives include acting in the patient’s best interests, referring to any advance directives, making substituted judgements or proxy decision-making. Article 5 of the HRA states that everyone has the right to liberty and security. Without a diagnosis the patient is unable to exercise this right. This is also true of articles 9 and 10: the right of freedom of thought, conscience and religion, and freedom of expression, respectively. In the early stages of the disease, patients are capable of undertaking decisions and should not be treated differently from others7. The deterioration, typically seen, can be slowed in those who remain mentally and socially active. Facilities can be implemented to allow the individual an extended period of independence. If a patient’s dignity is respected, their well-being can be enhanced. People with a mental illness deserve the same respect and equality as others; the stigma of the diagnosis is not a Table 2: Reasons supporting disclosure. Reasons to inform • Reduce distress and improve psychological adjustment • Patients have a right to information about their condition • Patient is aware that they are ill – diagnosis explains the symptoms • Patients more likely to accept help and support • Patient is then responsible for informing necessary services e.g. DVLA • Can provide a sense of relief e.g. that the cause of abnormal cognitive performance is not malignant • Patient can consider treatment options and participate in research if willing • Patient can attain information on and be referred to community-based services • Patients can make plans and sort financial affairs • Promotes trust in doctor-patient relationship • Enables family to anticipate care needs, plan for the future and prepare for change • Family members can assess their own risk for dementia

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reason to withhold the information. Discrimination is widespread. However, this is against article 14 of the HRA. Table 2 summarises the support for disclosure. It is interesting to note the evolution of disclosure of cancer diagnosis: between 1961 and 1977 the number of doctors in favour of informing the patient increased from 10% to 97%10. The explanations against disclosing were similar to those currently given for dementia. In support for more deceptive strategies As dementia patients withdraw into their own world, they lose their capacity to distinguish between true and false. Truth is a privilege available to those who can understand it and cope with its’ burden: theoretically it becomes impossible to lie. Treatment options are limited, and there is no cure for dementia. People receiving this diagnosis require resources. Currently time constraints are problematic11. An abnormal level of cognitive performance is hard to assess and determine. Revealing a false diagnosis of dementia is unethical and uncertainty deters physicians from disclosing the diagnosis. The GMC states that clinicians need to recognise their professional limits. Therefore, in cases of significant doubt it is better to withhold the information. However, health professionals should always work with their colleagues in a way that best serves the patient and should seek the medical opinions of their colleagues. The vast majority of physicians have never received dementia training. In the absence of a specialist clinical framework there is nationwide variation in dementia care. Instruction and supervision need to be accessible in order to improve the quality of care. Utilitarianism is often used to describe the best outcomes as those which maximise happiness. The response to the disclosure is an individual process; some patients lose their self-esteem and withdraw from social activities. If the revelation of the diagnosis is likely to cause such suffering, the physician stands at risk of not practising non-maleficence. In this instance, where well-being is considered to be synonymous with happiness, the physician is giving hope, sparing pain and preserving self-respect by not disclosing the information, and therefore promoting the well-being of the patient. A physician should not let their personal beliefs affect the assessment of the situation; if deceptive practice will benefit the patient, a physician morally against dishonesty should still consider the strategy4. Article 3, the only absolute right in the HRA forbids torture; this may support keeping the diagnosis from those patients who are susceptible to suicide and other depressive behaviours. Although the risk of suicide is relatively small, it is something that physicians need to be aware of. A study undertaken in 2002 asked family members of dementia patients about the disclosure of the diagnosis: half thought the informed patient reacted poorly to the diagnosis, and two-thirds felt that the disclosure was unhelpful to the patient12. Family members commonly disagree with the decision to disclose the diagnosis13. It is important to differentiate between a psychological reaction and a psychopathological complication; the latter gives deceiving a moral justification. Depression is likely to occur especially in the early stages, and may hasten the patient’s decline. Distinguishing between the negative consequences of disclosure and the natural

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PERSPECTIVE course of the disease is difficult. If the physician believes the patient does not have the ability to cope with the information the virtuous action is to withhold such a diagnosis.

What level of information needs to be provided? The question is no longer if we should disclose the diagnosis, but when and how.

The ethical duty to be honest is not absolute3; physicians need to be aware of the difference between the world of pure practical reason and that in which we live. Deceptive strategies are potentially beneficial for both carer and patient. The Data Protection Act 1998 states that although a patient has a right to their medical records, if a health professional believes that the knowledge is likely to cause serious harm to the physical or mental health of the patient or any other person they are justified to withhold the information. The GMC, however, highlights that upsetting the patient is not synonymous with ‘serious harm’.

References

If the assessment of the patient occurs in the latter stages of the disease process, the decline in the individual’s competence would render the disclosure procedure futile. The severity of dementia and the physician’s perception of the patient’s comprehension are key factors when deciding whether to disclose. Doctors must always be prepared to justify their actions. Table 3 highlights the factors that defend withholding the diagnosis. In conclusion Good decisions consider all the relevant ethical principles, laws and current practice, and address truth-telling, confidentiality and dignity. The deontological approach recognises the importance of an individual’s rights and thus supports disclosure. Deciding which right predominates is not simple: any act that is not wrong is a possible right act. The consequentialist perspective offers a more person-centred approach, considering the impact on the patient. In light of the evidence I believe this theory supports the disclosure of the diagnosis. There are many rational reasons for non-disclosure, but there is a lack of evidence supporting that it is more beneficial. The difficulty in diagnosing dementia must be differentiated from the difficulty in telling people an unwanted diagnosis. The negative outcomes anticipated by physicians and carers alike are worse than the reality. Literature supporting the disclosure of diagnosis is building. If possible disclosure should occur in the early stages of the disease process. Physicians need to be flexible: patients require an individual approach. The rights of those who do not wish to know should be respected. Basic principles demand physicians to be truthful, so that patients can implement their moral and legal rights to decide whilst still competent. Nevertheless, blunt honesty is inappropriate; the truth should be eased across with compassion, to avoid hurting the patient. The final decision involves a complex balance between the clinical findings, the patients’ preferences, and their social context. I believe deceptive practice should not be completely disregarded; it may be appropriate if the patient is emotionally, psychologically or intellectually unable to cope with the diagnosis. Further empirical research is needed to establish best practice. Paired interviews are needed to gain the physicians and family members’ views on the same experience. Future questions might include: Should patients and carers be informed simultaneously?

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2. 3. 4. 5.

7. 8.

9. 10.

Jagger C, Lindesay J. The epidemiology of senile dementia. In: Alistair Burns. Ageing and Dementia: A methodological approach. London: Edward Arnold, 1993:41-57. Wood-Mitchell A. Can a lie ever be therapeutic? The debate continues. The Journal of Dementia Care 2007; 15(2):24-28. Sokol DK. Can deceiving patients be morally acceptable? BMJ 2007; 334:984-986. Schermer M. Nothing but the truth? On truth and deception in dementia care. Bioethics 2007; 21(1):13-22. Turnbull Q, Wolf A, Holroyd S. Attitudes of Elderly Subjects toward “Truth Telling” for the Diagnosis of Alzheimer’s Disease. Journal of geriatric psychiatry and neurology 2003; 16:90-93. Pinner G, Bouman WP. Attitudes of patients with mild dementia and their carers towards disclosure of the diagnosis. International psychogeriatrics 2003; 15(3):279-88. Elson P. The diagnosis of dementia: who wants to know? The Journal of Dementia Care 2006; 14(5):36-38. Wood-Mitchell A, Waterworth A, Stephenson M, James I. Lying to people with dementia: sparking the debate. The Journal of dementia Care 2006; 14(6):30-31. Jones RG. Ethical and legal issues in the care of those with dementia. Reviews in Clinical Gerontology 2001; 11:245–268. Maguire CP, Kirby M, Coen R, Coakley D, Lawlor BA, O’Neill D. Family members’ attitudes toward telling the patient with Alzheimer’s disease their diagnosis. BMJ 1996; 313(7056):529.

Acknowledgements I would like to thank Dr. Ian Davidson for his encouragement and guidance with this work

Table 3: . Reasons against disclosing the diagnosis of dementia Reasons not to inform • Patient may become upset e.g. because their family role is altered • Patient may suffer psychological distress e.g. depression, suicide • The prognosis may frighten them and they may feel burdened by the inevitable future • Patient has a dread of developing dementia • Patient not cognitively/emotionally equipped to understand/retain the information • No benefit in knowing as no curative treatment available • Patient does not wish to be aware of any illness • To maintain/give hope • Stigma associated with dementia • Family may not be able to cope with patient’s reaction

Info box Diagnosing Dementia The Abbreviated Mental Test (AMT) and the Mini Mental State Examination (MMSE) are used extensively to screen older people for cognitive impairment. The AMT consists of 10 questions, with a score of 6 or less suggesting impaired cognition. The MMSE is the gold standard; it covers orientation, calculation, language, registration and recall. The examination involves 19 items; a score of less than 25 out of a possible maximum of 30 is suggestive of dementia. Tester variability makes the MMSE unreliable, and so the key is a thorough history. It is considered good practice to ask relatives and friends about progressive decline in function and memory. This exercise requires care, as relatives may be in denial about changes in their loved ones behaviour. Ascertaining a diagnosis of dementia is not easy; not only is the list of differentials inexhaustible, but the range of cognitive processes affected, and the severity of their presentation can vary both within and between dementing disorders. This article makes no distinction between the classifications of dementia, which may be of importance as new treatments are unveiled.

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Feature Series on Obesity Sheena Sabherwal

Year 5 Medicine, Imperial College London Sheena.sabherwal05@imperial.ac.uk doi:10.4201/lsjm.hle.006

Childhood Obesity as a Form of Parental Neglect It is estimated that 4% of children are obese and 15.4% of children are overweight1. Worryingly, these children already have important risk factors for developing coronary heart disease, which are unlikely to resolve as they are at an increased risk of remaining obese as adults1. In 2007, Dr. Matthew Capehorn proposed to the BMA that extreme cases of childhood obesity should be regarded as cases of parental neglect. Although this motion was not accepted, Dr. Capehorn makes a valid argument for the case; “If you are faced with a child who is severely under-nourished, alarm bells would be ringing, and social services, doctors and other authorities would be involved. But the same approach is not taken when faced by a child who is obese.” If a doctor fears that a child is being neglected, it is their legal duty to inform social services despite patient confidentiality. The issue to consider here is whether or not severe childhood obesity is a form of neglect, and if referral to social services is in the best interests of the child. From the perspective of the Royal College of Paediatrics and Child Health, “Obesity is a public health problem, not a child protection issue. There may be a few families who give cause for concern where there are other matters of neglect or emotional harm, and this is where a paediatrician might have discussions with social services”. This is an important argument, as according to reported cases, obesity has only formed part of child protection cases rather than being the sole cause of them. If parents are suspected of neglect due to the over-feeding of their child, it is important for them to first of all understand what the correct sized portions are for a child, through education by dieticians. However, a child who is morbidly obese with a number

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of co-morbidities that affect their quality life may find that adhering to dietary guidance as well as exercise advice does not lead to successful attempts at losing weight. It is therefore an ethical grey area to solely and confidently attribute blame to the parents.2 Children with co-morbidities are less likely to be physically fit or have the motivation to exercise, thus despite the parent’s best attempts to encourage them, the child may be unable to lose weight. In particular, older children have increased autonomy and so parental control is less likely to be effective.3 However, it has to be considered that the removal of a child from their family and their home due to neglect, could cause significant emotional distress to them and other parties. Such situations need to be considered carefully to ensure that all that is done is in the child’s best interests, taking into account both emotional and physical factors as they may consider their home to be a happy and loving environment, It is of course difficult to assess what the child’s best interests are; social factors needed to be considered as well as the attitude of the parents and the child, in deciding if severe obesity in a child is a case of medical neglect. More thorough guidelines to doctors and other health professionals on when to refer a child to social services for medical neglect would be beneficial in such cases. References 1.

Susan A Jebb, Kirsten L Rennie and Tim J Cole. Prevalence of overweight and obesity among young people in Great Britain. Public Health Nutrition, 2004 7: 461-465 Collier D, Perkin R, Zanga J. Obesity as Medical Neglect: Should Doctors Report? American Medical Association Journal of Ethics 2003 Volume 5, Issue 2 Varness, Todd, Allen, David B., Carrel, Aaron L., Fost, Norman. Childhood Obesity and Medical Neglect Pediatrics 2009 123: 399-406

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Illustration: Jonathan Hyer

Fat Tax: More harm than good? Obesity is a health burden, which is showing no signs of regressing and in fact is rapidly progressing. It is estimated that by 2050, 90% of the adult population will be obese1. Within the UK, obesity-associated morbidity mounts enormous pressure on NHS resources, costing £4.2 billion every year1. Obesity and poor diet are associated with the development of serious morbidities, including ischaemic heart disease, type 2 diabetes and cancer, and accounts for 10% of all disability-adjusted life years lost2. These can result in doctors and health professionals dedicating more time to deal with these preventable problems, drawing away resources and time from other important health issues. A ‘Fat Tax’ is one proposed way of preventing the progression of obesity and encouraging healthier eating. In basic terms, it means that high calorie, high sugar and high fat foods or drinks will have a considerable tax added onto their selling price, in an attempt to deter their purchase. It is a system which has been implemented in a number of North American states and is a proposal which has previously been discussed by the UK government. However, how ethical is the Fat Tax proposal, and how will its implementation affect the associated burdens of disease? An important ethical issue to consider is the effect of the inflation of food prices on the poor. Those with lower incomes will naturally spend a greater proportion of their household expenditure on food than the wealthy. Fat Tax may be effective in deterring the purchase of unhealthy foods in those with lower incomes, but such foods tend to be more calorific and cheaper than healthier foods, and so overall, food expenditure for the poor will increase3. This will unfairly reduce the money available for this group of the population to spend on other necessities such as rent, with possible subsequent economic problems. Alternatively, it may decrease expenditure on food, potentially leading to malnourishment. A method of overcoming this problem could be to subsidise healthier foods with the increased revenue from the Fat Tax. One study has shown that such an initiative will overcome differences in the effect of Fat Tax on the different income groups, and also anticipates that such a situation would be associated with a reduction of 6400 deaths due to cardiovascular and cancer-related causes.4

consumption in terms of risk factors for associated morbidity. Bearing all of this in mind, it seems that deciding which foods to be taxed is a complex and contentious process, as one needs to take into account that all foods, even those classically seen as unhealthy, cannot be ruled solely as good or bad. For instance a food may be high in saturated fats but also high in calories, providing an important calorie intake to meet a person’s recommended daily allowance. It could be argued that a Fat Tax would eliminate our autonomy and instead enhance paternalism whereby the government would have increasing control resulting in a population with reduced individual freedom. On the other hand, Fat Tax may simply reverse the powerful and negative implications of mass advertising by large multinational companies in promoting their unhealthy foods. It may also encourage manufacturers to make their food healthier by reducing saturated fat content and offering a wider range of healthy foods and snacks. A similar concept was adopted in the UK to reduce smoking by increasing tax on cigarettes; this has been shown overall to have had a successful outcome5. Therefore, a Fat Tax could simply be seen as an extension of this policy to promote good health within the community. Upon reviewing the evidence, Fat Tax will inevitably have important consequences for the health of the population, particularly for lower income groups. This group is also known to have a greater prevalence of cardiovascular disease, so with careful implementation of the system, the obesity crisis as well as risk factors for morbidity should decline. This would reduce the burden on the NHS and the increased revenues from the Fat Tax could be used to fund campaigns promoting healthy eating and health education. As health professionals, it would be our responsibility to make sure that patients are aware of how to change their diets appropriately for optimal health in response to the effects of the Fat Tax. References 1.

A problem with implementing Fat Tax is deciding which foods the policy should affect. Many studies have suggested that those high in saturated fats should be taxed. In theory, this is a worthy idea as high saturated fat consumption increases cholesterol levels, thereby increasing cardiovascular risk. However, it is suggested that this will also decrease the consumption of monounsaturated and polyunsaturated fats, as well as increase salt intake2. All of these dietary changes would be associated with a decrease in the consumption of unsaturated fats and an increase in blood pressure, outweighing the benefits of the decrease in saturated fat

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Department of health. Obesity [document available on the internet] Department of health [Acessed: 21st October 2009]. Available from: http://www.dh.gov.uk/en/ publichealth/healthimprovement/obesity/index.htm Mytton, Oliver, Gray, Alastair, Rayner, Mike, Rutter, Harry. Could targeted food taxes improve health? J Epidemiol Community Health 2007 61: 689-694 Marshall T. Exploring a fiscal food policy: the case of diet and ischaemic heart disease. British Medical Journal 2000; 320(7230): 301–5. Kelechi E Nnoaham , Gary Sacks , Mike Rayner , Oliver Mytton , and Alastair Gray. Modelling income group differences in the health and economic impacts of targeted food taxes and subsidies.Int. J. Epidemiol. 2009 38: 1324-1333. Joy Townsend, Price and consumption of tobacco Br Med Bull 52: 132-142.

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ARTICLE

Doctors Lead the Battle against Drug Doping in Professional Sports Jamal Omar, MEng

Year 1 GEP Medicine, Barts and the London jamoma1@gmail.com doi:10.4201/lsjm.hle.007 “Nature cannot be tricked or cheated. She will give up to you the object of your struggles only after you have paid her price.” (Napoleon Hill, 1883-1970) London 2012 is dawning. One need not look far to find athletes and instructors who assert a win-at-all-costs paradigm. They say that history has a funny way of repeating itself; if so, then the legacy of the next Olympics will doubtlessly be tainted by exclusions and withdrawal of honours, for the use of banned chemicals and procedures. Newsflash: athletes cheat. For over 100 years, the modern Games have inspired a journey for supremacy, displaying awesome talent and proud nationalism, giving the world an ephemeral shared focus in the celebration of eternal champions. But triumph is no longer merely the product of hard work and natural ability. Scientifically motivated developments in exercise regimens have had such a monumental influence on athletic performance that world records are now being broken more often than plates in a Greek restaurant. Yet, science is the academic backbone of doping and for methods aimed at dodging its discovery. So why should healthcare professionals be aware of these issues? If elite athletes are allowed to cheat the rules of fair competition then the mainstream acceptance of these substances in the wider community - where the behaviour of victors is imitated - would have dire repercussions. Men, women, boys and girls the world over are submitting to the relentless onslaught of Adonis-like bodies staring out from magazines and movie screens, and are now demanding their piece of the ‘hormone cake’. Indeed, clandestine exploitation of performance-enhancing drugs amongst the general public is escalating10. Athletes dope for several reasons: the perception that all their competitors are doing it, public expectation, financial reward, fame, desire to be the best, or to win private sponsorship. The fear of exposure and ignominy is a more potent disincentive than the possibility of self-injury. One study found that 50% of athletes interviewed would take a drug that guaranteed success, even if it resulted in death some years after the event1. Thus, the role of the

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doctor, both in the research and clinical arenas, must be to develop methods for detection of prohibited drugs and to counsel those patients partaking in their abuse. Which hormones are drugs of abuse, and which are fountains of youth? Anabolic steroids (AS), derivatives of testosterone, are manipulated by athletes for their alleged anabolic benefits. Google ‘anabolic steroids’ and a plethora of flashing advertisements appear, selling dubious elixirs that promise ‘ripped abs’ and ‘a cut physique’, all endorsed by golden, perfectly-sculpted mortal engines. Modes of action of anabolic steroids include binding of androgen receptors which results in positive nitrogen balance in muscle, and favours anabolism. However, in ‘normal’ men, endogenous testosterone predominantly saturates the androgen receptors, so this result has limited significance6. Thus it follows that steroids must antagonise catabolism of muscle tissue. At saturation point, exogenous steroids competitively impede the binding of catabolic glucocorticoids to androgen receptors, thereby conserving lean muscle mass. Finally, steroids may bestow increased psychotropic stimulation resulting in greater motivation and reduced exhaustion4. Scientists and physicians have often doubted athletes’ contentions that steroids actually work. But scientists have been one step behind, as the literature indicates that suprapharmacological quantities of steroids may be anabolic in eugonadal men; however, the mechanistic pathways underlying these effects are unclear5. In any case, steroids have both anabolic and androgenic properties, which explain the side effects involved. These include risk of developing coronary heart disease, liver cancer, severe acne and gynaecomastia. Is it really worth it? Evidently, steroids are not the panacea. So, where do athletes turn to next? Growth hormone (GH) also appears in the catalogue of sports pharmacopoeia forbidden by WADA (World Anti-Doping Agency). GH is particularly difficult to identify in the laboratory, so prevalence data is often anecdotal. Nonetheless, nobody disputes that GH is widely abused. Its effects, mediated by IGF-I, comprise amplified total body protein turnover and skeletal muscle synthesis in athletes and GH-deficient adults1. GH may also boost fatty acid availability and moderate oxidative protein loss in athletes to reduce fat deposits7. Furthermore, this response is affected by age, gender, individual fitness and by

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ARTICLE exercise routines8. It seems unlikely that this will better athletic performance, but athletes are desperate to maintain an edge. Current technology is accelerating, and genetic engineering of the GH/IGF axis has arrived. In vivo upregulation of anabolic molecules can be achieved via transfer of an athletically superior genotype to the host, inducing specificity that is virtually undetectable in the lab6 – illustrating the level of daring sophistication that doctors and scientists must face. The risks involved in taking GH are many. Cadaver-derived pituitary GH harbours the threat of infection with CJD. Even using recombinant human GH, adverse effects include various forms of cancer, because IGF-I biochemical cascades play a role in carcinogenesis4. This author believes that researchers and doctors have a duty to publicise these risks. They must learn from athletes and bodybuilders, victims of the slippery slope, who inject substantial doses of an unknown cocktail of drugs in a trial-and-error fashion, and end up with terminal illness. Let us not forget the acute dangers involved: people can be become so obsessed that they unintentionally overdose and kill themselves. Healthcare professionals must adhere to the principle of ‘patients come first’, which is enshrined in all ethical and legal codes of medical practice. Introducing – the final member of the doping repertoire – Erythropoietin. Time to shift gears again. Picture this: is there anything more physically and mentally devastating than being overtaken by an opponent in a race? Your legs are screaming, your chest is on fire; you rasp and wheeze for precious air to stay abreast of the leader. You know that if you let him leave the pack, your will to continue shall ebb away. You quash the blazing panic rising in your stomach, and say a silent prayer as you bend over the handlebars and push for all you are worth. But it is all in vain.

Illustrations: Yasmin Jaffer

By the top of the hill, he is a tiny blip in the distance. What could you have done, aside from choose better parents? Do you accept genetic limitations, or suspect foul play? Erythropoietin (EPO) burst onto the professional cycling scene in the early 1990s, and has infiltrated elite sport across the board, with organised doping strategies now commonplace in international teams3. Availability of EPO boomed with the advent of recombinant DNA technology. EPO stimulates the bone marrow to secrete more red blood cells into the circulation. Sportsmen abuse it to increase the oxygen carrying capacity of blood to improve stamina, but the subsequent increase in blood viscosity increases the risk of stroke and MI. Too many athletes have paid the ultimate price. This all begs the question…what are researchers and doctors doing about it? We will take the example of GH. The numerous difficulties for lab-based GH quantification include the identical amino acid sequences of endogenous GH and rhGH, their short systemic half-life, pulsatile discharge behaviour and post-exercise elevation. Urine testing is not viable for rhGH detection because neither GH nor its biomarkers are excreted in adequate concentrations10. Scientists have devised a two-pronged method to expose GH abuse. A combination of these approaches satisfies WADA’s stipulation for two separate assays to charge an athlete. This formed the thrust of the international collaborative research project ‘GH-2000’. The consortium was led by the clinical endocrinologist Prof. Sönksen at St. George’s Hospital, London. Briefly, GH actions result in

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production of various proteins, whose plasma levels may be utilised to identify exogenous GH. Numerous skeletal and soft tissue indicators also fluctuate due to GH dispensation (e.g. P-III-P, PICP and ICTP). It was concluded that IGF-I and P-III-P impart the optimum sensitivity and specificity1. Separate from GH-2000, researchers led by Dr. Strasburger in Munich have developed a direct test for rhGH. Pituitary GH exists as a 22 kDa isoform (constituting 75% of total), and others labelled non–22 kDa (20- and 17 kDa isoforms). rhGH possesses only the 22-kDa isoform, and external rhGH leads to a striking reduction in the natural pituitary-derived non–22- kDa isoforms by negative feedback. Hence, a high ratio of 22- to non-22 kDa isoforms is being trialled as a means of discovering GH abuse3. However, the ‘window of opportunity’ is fleeting – 36 hours maximum. The GH-2000 project was hugely successful, bringing together scientists and physicians across Europe to get one step ahead of rogue athletes, and adding flesh to the bones of this emerging medical specialty. These endeavours are critical not just to uphold respect for international sport, but also to prevent the wrong message from sifting through to the impressionable young. Conservative estimates of adolescent hormone abuse range from 3% to 7%, with users starting as young as nine10. This author echoes the mindset of many others out there, who argue that blanket prohibition is a flawed strategy in a climate of reward3. Those who stand to gain from deception will inevitably be more imaginative than those implementing the regulatory policies, until the deceivers are progressively pushed into a corner and dare to take more desperate and perilous actions. Alternatives to this zero-tolerance approach must be sought, and users should be referred by their doctor to harm minimisation groups for supervision of injections in order to prevent needle sharing and overdose. In this way, the concept of doping will lose its underground appeal, and we can leave behind those who call themselves elite athletes, but are merely entertainers. References 1.

3. 4.

McHugh C.M., Park R.T., Sӧnksen P.H., Holt R.I.G. Challenges in Detecting the Abuse of Growth Hormone in Sport. Clin. Chem., 51(9): 1587-1593 (2005) doi:10.1373/clinchem.2005.047845 Nelson, C. J. Howe, T. V. Nguyen, K.C. Leung, G. J. Trout, M. J. Seibel, R. C. Baxter, D. J. Handelsman, R. Kazlauskas, and K. K. Ho, A. E. Influence of Demographic Factors and Sport Type on Growth Hormone-Responsive Markers in Elite Athletes. J. Clin. Endocrin. Metab., 91(11): 4424-4432 (2006) doi:10.1210/jc.2006-0612 R T Dawson. Hormones and Sport (Drugs in sport – the role of the physician). J. Endocrin., 170: 55–61(2001) doi:10.1677/joe.0.1700055 Drugs and Therapeutics Bulletin (dtb). Medical Aspects of Drug Use in the Gym. Independent review from the Consumer’s Association, 42(1) (2004) Bhasin S., Storer T.W., Berman N., Callegari C., Clevenger B., Phillips J., Bunnell T.J., Tricker R., Shirazi A., Casaburi R. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. NEJM, 335: 1-7 (1996) doi:10.1056/NEJM199607043350101 Tokish J.M., Kocher M.S., Hawkins R.J. Ergogenic Aids: A review of basic science, performance, side effects and status in sports. Am. J. Sports Med., 32(6): 15431556 (2004) doi:10.1177/0363546504268041 Gibney J., Healy M.L., Sӧnksen P.H. The growth hormone/ Insulin-like growth hormone axis in exercise and sport. Endocrine Rev., 28(6): 603-624 (2007) doi:10.1210/er.2006-0052 Saugy M., Robinson N., Saudan C., Baume N., Avois L., Mangin P. Human growth hormone doping in sport. Br. J. Sports Med., 40(suppl 1): i35-i39 (2006) doi:10.1136/bjsm.2006.027573 Sönksen P.H. Hormones and Sport (Insulin, Growth Hormone and Sport). J. Endocrin., 170: 13-25 (2001) doi:10.1677/joe.0.1700013

For the full list of references see thelsjm.co.uk.

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EDITORIAL

What is the future of medicine? Research and developments in medicine over the past twenty years have lead to the UK population living healthier and longer lives. But this all comes at a cost. With predictions of shortages of healthcare professionals in the UK and ever increasing healthcare costs, there is likely to be a heavy strain on resources in the future. The government have identified various health challenges which heavily contribute to this growing strain, and have therefore implemented taskforces and programmes with the aim of alleviating the problems. Lessons learnt from Smoke Free England and the Forecast Report showed that commitment from a variety of stakeholders is required to achieve a successful outcome in these key areas1. One of the main health challenges putting a strain on NHS resources at all levels is obesity. Over the past thirty years, obesity has steadily increased, and it will therefore not be resolved overnight. We all know that preventing obesity is more complex than just simply eating less and doing more. In a letter from the Chief Medical Officer at the launch of Change4Life, it was acknowledged that if nothing is done about the obesity problem in the UK, 90% of today’s children would be classified as overweight or obese by 20502. Launched this year, the Change4Life initiative has brought together a variety of cross-functional stakeholders, with the aim of improving children’s diets and levels of activities, which ultimately would reduce the burden of obesity and its associated conditions on the future NHS. As healthcare students and newly qualified professionals we have an important role in the health of our nation, and we need to take a role in this resource-strained environment, whilst continuing to maintain standards and deliver results. New specialities in medicine, such as Sports and Exercise Medicine (SEM), will be key to tackling these issues, and as healthcare professions we have a responsibility to be aware of what this speciality involves. In our lead article Lebur Rohman, Haroon Rauf and Wisam Alwan assess the awareness, interest, need and exposure of medical students to the new speciality of SEM. The Foresight Report predicted that obesity currently costs the NHS £4.2 billion a year, and physical inactivity accounts for a further £1.89 billion a year1. So the questions raised is, should SEM have an increased presence in our undergraduate training, so we can be armed with the knowledge to contribute to the health issues raised? In the ‘exercise’ aspect of SEM, healthcare students understand the importance of physical activity in recovery and maintaining health. In a review of the effects of exercise on stroke patients, Rauri Hadlington examines the data supporting post-stroke management as outlined in clinical guidelines. With the 2012 Olympics steadily approaching, the UK has an increasing drive to get people involved in sports. Every year there are 29 million sports injuries in the UK. Sports such as rugby union and horse riding are well known as ‘high-risk’ activities. For example the BBC reported that at any given time in rugby union’s Guinness Premiership approximately 25% of players are injured. Another sport associated with a high level of injuries is Cage Fighting. In this issue Stuart Potter explores the BMA’s call to have Cage Fighting banned. The question is if cage fighting is banned; will this lead to changes in regulations for other sports? In our final article Hannah Newham explores through a case-study, the ‘MRI now, talk later’ approach to medical practice that is steadily moving across the pond from the United States to the UK. In future medical practice will we be more concerned about potential litigation, rather than prompt and accurate diagnosis and treatment and patient care? The medicine section of the LSJM is dedicated in helping you develop ideas for publication. We welcome your input into the section and value your feedback and suggestions. If you would like to get involved with writing for us please get in touch with the medicine team at medicine@thelsjm.co.uk. Laura Vincent Section Editor Medicine References Illustration: Ella Beese

1. 2.

Butland B, Jebb S, Kopelman P, McPherson P, Thomas S, Mardell J, et al. 2007. Tackling Obesities: Future Choices. Foresight. London: Government Office for Science. Department of Health. 2008. Chief Medical Officer’s Letter. [Online]. Available from: http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_092026.pdf [Accessed 28th October 2009].

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NEWS Diabetes UK warn of ‘ticking time bomb’ Diabetes UK has warned that seven million people across the UK are thought to have prediabetes, putting them at a 15-fold greater risk of developing the disease. Prediabetes (impaired glucose regulation) is characterised by a higher than normal blood glucose level, slightly below levels observed in Type II diabetic patients. Research has shown that prediabetes can cause long-term cardiovascular damage. Unlike Type II diabetes, prediabetes is normally reversible, and progression can be reduced by 60% through lifestyle modifications, e.g. diet, exercise and weight reduction. Type II diabetes is one of the UK’s healthcare challenges, due to its association with other diseases. The burden on the NHS is approximately £1 million an hour. Prime Minister Gordon Brown was recently asked to explain what the government was going doing to promote healthy lifestyles, better identify prediabetes and curb the incidence of Type II diabetes in the UK. He explained the drive to tackle obesity through campaigns like Change4Life, and also the Risk Assessment Programme for all 40-70 year olds, which was an initiative proposed by Diabetes UK. Diabetes UK has launched its ‘Get Serious’ campaign, in order to raise awareness of the danger of diabetes. The campaign is calling on healthcare professionals to highlight the implications of prediabetes to their patients and give them lifestyle advice. Douglas Smallwood, Diabetes UK chief executive stated “Identifying and educating people with prediabetes is vital, as it’s not too late for many to make healthy lifestyle changes, reverse the condition completely and reduce their risk of developing Type II diabetes”. The charity published figures last week, which showed that more than 145,000 new cases of mainly Type 2 diabetes were diagnosed in the UK during the past year. “It’s time for all of us to get serious about our health if we want to have any chance of defusing the ticking time bomb of Type II diabetes”. Move for Change - European campaign to tackle ignorance of Parkinson’s Recent Italian research into Parkinson’s disease patients has highlighted failings in the early diagnosis, access to specialist care and knowledge of the disease amongst the medical profession1. These findings may not be confined to Italy, and further research is underway to establish the extent of the problem across Europe. The European Parkinson’s Disease Association (EPDA), is concerned with the health and welfare of people living with Parkinson’s’ disease, their families and carers. They have now launched a new action campaign, Move for Change, which will target national parliaments, neurological specialists and the general public across Europe. Professor Fabrizio Stocchi, Director of the Parkinson’s Disease and Movement Disorders Research Centre, commented “The medical profession could do more for people with Parkinson’s. Current gaps in understanding about management and treatment are leading to failures in both diagnosis and care. Even when there is a correct diagnosis in place the tendency is often to delay treatment

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for as long as possible. This practice is not only negatively impacting patients’ lives but also wasting taxpayers’ money. Early Parkinson’s intervention may slow disease progression, improve the quality of patients’ lives and is also associated with significant direct and indirect cost savings”. The Netherlands are leading the way with action for Parkinson’s disease, and they have seen a significant improvement in care. They have set up ParkinsonNet, a regional programme that has allowed patients to receive earlier diagnosis, improved multidisciplinary care and faster access to treatments that slow symptom progression. Both the human and economic costs have been reduced, with the government reporting an estimated €42 million reduction in the cost of care due to the programme. Move for Change will include further research into Parkinson’s management and treatment across Europe, a European Parkinson’s Action Day and carefully coordinated activities aimed at raising awareness across the continent. Mary Baker, the EPDA patron, said “We want to unite Europe in the fight against Parkinson’s. Ignorance is costing everyone, not just those affected by the disease. The EPDA hopes Move for Change will instigate change at the highest levels to ensure that people with Parkinson’s receive proper diagnosis and the right treatment, at the right time”. 1. 2.

For more information go to: http://www.epda.eu.com/ projects/moveForChange/2009/default.asp Research conducted by GfK Eurisko. (September-October 2008

Increasing Figures for Obesity Admissions in England The number of people being treated for obesity has risen dramatically, partly due to bariatric surgery now being more widely available on the NHS, according to a BBC news report. The latest report from the NHS Information Centre for England shows an annual rise of 60% in conditions linked to obesity and a 360% increase since 20041. It reported there were 8085 obesity related admissions in England; over half of these were for surgery, the rest were for treatment for type II diabetes, respiratory disease, organ failure or cardiovascular disease. In 1993, 13% of men and 16% of women were classed as obese; in 2009 these figures are expected to rise to 25% of the population for both genders. Tim Straughan, head of the NHS Information Centre said “The large increase in admissions for obesity reflects the growing impact that obesity has on the health of our nation as well as the demands it is placing on limited NHS resources”. He went on to say “It also reflects the fact that overweight people are resorting to treatments such as bariatric surgery to tackle their health problems”. Bariatric surgery was approved by NICE in 2007 as a treatment for patients with a BMI above 40 (or 35 if there were other underlying health problems), who had not succeed with anti-obesity drugs such as orlistat. Tam Fry, from the National Obesity Forum said “We no longer try to use diet and exercise as a way of treating this problem. The increasing demand for bariatric surgery is going to put a lot of pressure on the NHS”.

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NEWS Change4Life, the government campaign to promote healthy living, is aimed at addressing these issues. The public health minister, Gillian Merron, said “We are taking action to address it and to prevent people becoming obese in the first place, backed up by major investment.” Obesity remains one of the major health challenges, only time will tell if the investment will reduce the waistline of admission figures. 1.

NHS. (2009). Hospital Episode Statistics HES (admitted patient care) England 2008/09. [Online]. Available from: http://www.ic.nhs.uk/statistics-and-data-collections/ hospital-care/hospital-activity-hospital-episode-statistics-hes/hospital-episode-statistics-hes-admitted-patientcare-england-2008-09 [Accessed 31st October 2009].

Team work, communication and patient medications The NHS may be at risk of failing to prevent harm to patients from medicines unless it improves sharing of vital information when people move between services. A Care Quality Commission (CQC) survey published in October has identified that information shared between GPs and hospitals when a patient moves between services is often “patchy, incomplete and not shared quickly enough”1. The survey of 280 GP practices found that 24% are not systematically providing hospitals with previous drug reactions, as well as co-morbidities (14%) and allergies (11%). The picture from hospitals is similar; 81% of the GP practices questions stated that hospital discharge summaries contained incomplete or inaccurate information about prescribed medication,

“all or most of the time”. The CQC urged hospitals and GP practices to ensure they are sharing “timely, complete” information on changes to patient medication, to prevent the risk of medication related patient safety incidents. Cynthia Bowers, CQC Chief Executive, said “We know that incidents related to medication can cause people significant problems and sometimes unnecessary harm and distress. Not all adverse drug reactions are preventable, but the potential risks are clear”. “People have a right to expect clinicians to know details about each stage of their care, and in this day and age they are right to do so. It’s not possible for a clinician to make good decisions about care unless they have key information about a patient. She went on to say that the NHS needs a “change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care.” From April 2010, effective medicines management will become a requirement of registration, which will be a legal requirement. The CQC has urged all GP practices and trusts to use the survey findings to identify areas that need improving. 1.

Care Quality Commission. (2009). Managing patients’ medications after discharge. [Online]. Available from: http://www.cqc.org.uk/guidanceforprofessionals/ healthcare/nhsstaff/specialreviews/2008/09/ managingmedicines.cfm [Accessed 29th October 2009].

BACKGROUND

What is Sports and Exercise Medicine?

Lebur Rohman, Haroon Rauf and Wisam Alwan Sport and Exercise Medicine (SEM) was formally acknowledged as a medical specialty in 2005. There had been significant political pressure to the creation of the new specialty due to the rising levels of physical inactivity and obesity and the subsequent burden this has on the National Health Service (NHS) via related injuries1. The bid for the 2012 Olympic Games in London was influential in driving the formal recognition of SEM. Sports and Exercise Medicine is the area of medicine that deals with the effect of sport and exercise on the body. It has roles in both sports injury management and also the promotion of physical activity, disease prevention and disease management in other specialities such as:

• • • •

Rheumatology and Rehabilitation Medicine Cardiology and Respiratory Medicine Metabolic Medicine and Endocrinology Care of the Elderly

• • • • • •

Paediatrics and Child Health Primary Care Occupational Medicine Public Health A&E Orthopaedics2

Topic editor: Laura Vincent For references see thelsjm.co.uk.

Sports and Exercise Medicine is to work in association with “Game Plan”, a governmental strategy to increase physical activity, combating physical inactivity, and enhancing international performance in sport, particularly in popular sports to the public domain, to increase the “feel good factor” affiliated with winning1. The specialty will be required to help manage the expected rise in physical and sport related injuries associated with increased activity. Currently physical inactivity costs the government £1.89billion each year, whilst the NHS spends £590m treating less than 10% of the annual 29 million sports and exercise related injuries3,4. SEM can provide specialist care, ease NHS waiting lists and provide a costeffective service.

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RESEARCH

Medical Students’ Awareness, Interest and Exposure to Sports and Exercise Medicine Lebur Rohman, Haroon Rauf and Wisam Alwan

Graduates 2009 Medicine, St George’s University of London leburrohman@doctors.org.uk doi:10.4201/lsjm.med.008 Table 1: Response rate for each questionnaire and overall result Questionnaire SEM Paediatrics

Number of Questionnaires distributed 194 136

Total

330

Number of Response Rate questionnaires returned (%) 151 121

77.8 89.0%

272

82.4

Table 2: Identification of the definitions of SEM and Paediatrics (Correct definitions in green) Number of responses, % (n) Pre-clinical

Clinical

Which of the definitions below best describes SEM? A)

The area of Medicine that deals with the effect of sport and exercise on the body including the role of physical activity in health promotion, disease prevention and in disease management.

72.4 (42)

83.7 (77)

Sports and Exercise Medicine is concerned with the management of injury, illness and disease associated with elite athletes.

22.4 (13)

14.1 (13)

Sport and Exercise medicine is concerned primarily with research into the effect of sport on the human body.

5.2 (3)

2.2 (2)

Which of the definitions below best describes Paediatrics?

A) B)

The management of diseases that affect children from birth.

The medical care of patients up to the age of puberty

The branch of medicine that deals with the medical care of infants, children, and adolescents

8.3 (3)

9.5 (8)

86.1 (31)

79.8 (67)

5.6(2)

10.7 (9)

Table 3a: Responses for the role and scope of work of SEM specialist

Pre-Clinical

SEM involves jobs in primary care (True)

SEM involves management of chronic injuries/ disease (True)

SEM involves roles within child healthcare (True)

TRUE

FALSE

% Correct

53.4

69.0

44.8

Clinical

TRUE

FALSE

% Correct

53.8

75.3

45.7

Table 3b: Responses for the role and scope of work of SEM specialist

Pre-Clinical

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SEM involves promotion of prescription of exercise in disease prevention and management (True)

SEM involves promotion of the health benefits of sport and exercise (True)

SEM involves treatment that is currently only available under private healthcare (False)

TRUE

FALSE

% Correct

87.7

93.1

58.6

Clinical

TRUE

FALSE

% Correct

84.9

88.0

57.6

BACKGROUND The prolific use of the term ‘Sports Physicians’ has led to confusion regarding what Sports and Exercise Medicine (SEM) entails1. The definition of this emerging field of medicine also varies between health professionals and in different countries. The shroud of confusion surrounding SEM is bound to affect the perception and interest of newly qualified doctors, and future development of this new speciality2. Reviews on undergraduate training in SEM is limited, and with current views from medical students unknown, this raises the question; Are current medical students adequately exposed to SEM during undergraduate training to facilitate an appreciation of the speciality? This study aims to determine the awareness, interest and understanding of SEM in medical students, as well as examining the exposure of the speciality during undergraduate training. METHOD Sampling frame The sampling frame consisted of pre-clinical and clinical medical students from St George’s University of London. Data was collected through questionnaires, and a similarly worded questionnaire relating to paediatrics was used as a control. The questionnaires were distributed randomly during lectures. Questionnaire design For this study the authors adapted questionnaires used instudies with GPs and A&E specialists, and these were subsequently revised by an orthopaedic surgeon with an interest in sports medicine3,4. This was then piloted in 10 students, who were asked to feedback on various aspects of the questionnaire. Responders were asked to select from a list of options e.g. yes, no, unsure, or true, false, or use a 5-point Likert scale e.g. strongly disagree to strongly agree. Statistical analysis Data was collated on the SPSS programme for statistical review. A Pearsons Chi-squared (x2) test was used to assess the statistical significance differences between responses to SEM and paediatrics. A Fisher’s exact test was used when the percentage of cells with an expected count less than 5 was greater than 20%. For questions were a Likert scale response was used, the data was collapsed with scores of 1 and 2 regarded as disagree, while scores of 3, 4 and 5 were regarded as agree. This was based on a pilot on 10 students, where 8 students classified 3 as ‘agree’. Table 1 illustrates the response rates for this study.

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RESEARCH RESULTS SUMMARY Q1. Awareness of Sport and Exercise Medicine Only 29% of pre-clinical (n=17) and 40% clinical students (n=37) were aware of SEM speciality, whereas over 95% of pre-clinical and clinical students were aware of paediatrics as a speciality.

In addition, there was considerable agreement amongst students that receiving further formal teaching in SEM and paediatrics would benefit their future clinical practice (87.2%, n=129; 90.7%, n= 98 respectively, p=0.428). Although not statistically significant this suggests that further teaching in both specialties may be beneficial for future clinical practice.

Q2. Definition of SEM See table 2.

DISCUSSION This study has identified that medical students have limited awareness of SEM, despite demonstrating an interest in the speciality. The respondents were aware of the importance of SEM in the health of the nation, and 74% of responders felt that they did not receive adequate exposure of the speciality in their training. Many students were interested in the speciality, with over one third considering it as a future career path. Many responders had a limited understanding of SEM, believing it involved working with elite athletes with high numeration. If students were aware of the public health aspect of SEM, would the numbers interested in the specialty decrease? Current public health initiatives are focusing on increasing physical activity in the UK to address the obesity epidemic5,6. Currently 5% of Accident & Emergency workload is due to sports injuries, and with more people taking up sports and exercise, there will be an additional burden on the NHS with related injuries7-10. In a study of GPs, over one third of responders felt their undergraduate SEM training was inadequate3. Therefore knowledge of managing sports injuries is essential for healthcare professionals, especially in foundation doctors working within A&E departments11.

Q3. What is the role of a SEM specialist? Over 50% of all students correctly identified the role and scope of a SEM specialist (table 3). The differences in the correct number of answers for SEM compared to paediatrics, is shown in table 4. There were no significant differences between pre-clinical and clinical students in the answers to the SEM questions. There was significant difference in the percentage of students identifying the correct answers for the two specialities, and therefore it was concluded that responders are less aware of the SEM specialists’ role. Q4. Training pathway Only 26.0% of students were aware of the SEM training pathway, in contrast 52.1% were aware of the paediatrics training pathway (p<0.0001). Q5. Interest in/need for Sport & Exercise Medicine Only 34.7% of students express an interest in SEM compared to 80.2% of students expressing an interest in paediatrics. There was no evidence that responders involved in sports or physical activity (89.3%) had a greater interest in SEM, or awareness of the training pathway. 63.3% of responders held the opinion that SEM should be a recognised specialty and 83.9% agreed that the burden of sports and exercise related injuries were enough to justify SEM as a recognised independent speciality. Q6. Exposure/experience in Sport & Exercise Medicine Only 38 responders (25.5%) felt that they had received adequate exposure to SEM in medical school, compared to 45.2% of responders who believed that there was adequate exposure to paediatrics (p=0.001). 67.3% of responders would like to see SEM added to the core curriculum. More students were confident they knew when to refer a patient to a paediatrician (76.9%), compared to a SEM specialist (57.1%) (p= 0.001). In addition medical students were more likely to have gained experience in paediatrics than SEM (p=0.0001).

A study of UK medical schools in 2000, showed that only 13 out of 28 institutions offered some type of SEM teaching, and a further 5 institutions had plans in place to offer this by 200512. This demonstrates a need for a national SEM curriculum in undergraduate training. CONCLUSION The results from this study were obtained from one medical school and therefore future multicentre studies are required to obtain a true representation for UK medical students. Furthermore, every UK institution’s provision of optional special study components in SEM, should be formally quantified and evaluated to establish the availability of self-directed study, outside of the core curriculum. Increasing exposure to SEM in undergraduate training would increase future medics’ ability to identify and manage sports injuries, provide training in the public health aspect of exercise for disease prevention, and finally provide clear understand and guidance for those students wishing to pursue specialist training in SEM. SEM will have a crucial role and impact on public health, and will treat all types of patients, from elite athletes through to school children. For the speciality to develop further, it is essential that early exposure is established in undergraduate medical training, thus starting at the ‘grassroots’ of the medical profession. Therefore the authors of this study conclude that the inclusion of formal training in SEM at the undergraduate level “deserves special consideration”4.

Table 4 : The figures denotes the percentage of each group identifying the correct answer, followed by the number of respondents

Specialty

Paediatrics/SEM is associated with jobs in primary care (p= 1)

Paediatrics/SEM involves management of chronic diseases (p=0.4534)

Paediatrics/SEM is associated with treatment that is currently available only under private healthcare (p=1)

Pre-Clinical

Clinical

Pre-Clinical

Clinical

Pre-Clinical

Clinical

SEM

53.4 (n=31)

53.8 (n=49)

69.0 (n=40)

75.3 (n=70)

58.6 (n=34)

57.6 (n=53)

Paediatrics

83.3 (n=30)

79.5 (n=66)

94.4 (n=34)

97.6 (n=81)

94.3 (n=33)

90.4 (n=75)

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For references see thelsjm.co.uk.

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PERSPECTIVE

Should cage fighting be banned? Stuart Potter

Year 2 Medicine, St.George’s University of London m0700759@sgul.ac.uk doi:10.4201/lsjm.med.010 Introduction

With its engaging combination of subtle technique and intensely focussed physicality, combat sports have fascinated audiences throughout history. From Pankration in Ancient Greece, to Vale Tudo in Brazil in the 1920s mixed martial arts combatants have used a variety of striking and grappling techniques to subdue their opponents1. The popularity of the modern mixed martial arts (MMA), evocatively dubbed ‘cage-fighting’, has flourished under the banner of the ‘Ultimate Fighting Championship’ (UFC). This is a competition that embraces the concept of combatants, fluent in a myriad of martial art styles, testing the effectiveness of their skills. This novel form of mixed martial arts has evoked vociferous opposition from various groups. The British Medical Association’s opposition to MMA is due mainly to concerns about the combatants’ physical health. Other critics sensationally describe MMA as “savage” and “human cockfighting”2,3. Proponents of MMA passionately object to this characterisation, referring to the sport as “human chess” and cite its safety record in defence4. On both sides of the debate, advocates present compelling arguments in defence of, and opposition to, the statement “Cage-Fighting should be banned as called for by the British Medical Association (BMA)”. Arguments For

Many groups have called to ban cage-fighting; politicians, clergy, physicians and- surprisingly- boxing officials have variously described the sport as “grotesque”, “brutal” and “savage.””3,5,6. To opponents of cage-fighting, the sport appears to revel in the glorification of violence, an attitude ‘civilised’ society cannot condone7. Utilising strikes, chokes and grappling techniques to defeat their opponents, injuries are not uncommon amongst cagefighters; deaths have also been reported8. The BMA regards this risk to a participant’s health as sufficient grounds for a ban of the sport9. The results of the report “The Boxing Debate” supported the BMA’s call for a ban of boxing, and other combat sports; describing the trauma caused to the brain, resulting from Illustration by Nana Hene Koduah, Ghana. Email: nanahehek@hotmail.com

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PERSPECTIVE the impact of strikes to the head10. The BMA redefined their opposition to combat sports in 2008 to include mixed martial arts (cage-fighting), as it felt that- although there was a dearth of research on the subject- the risks associated with boxing were applicable to this increasingly popular sport9. It has been estimated that a punch can generate a force on impact of over half a ton, equivalent to being struck with a 6kg mallet at 20mph11. An impact of this magnitude is liable to cause significant trauma as, due to the lack of protection covering the head, the force of the blow is transmitted to the brain parencyhma10. Protected by three membranous meningeal layers and surrounded by cerebrospinal fluid, the brain is relatively free to move within the skull. Trauma impairs normal brain functioning and can cause an abrupt loss of consciousness and both acute and chronic dysfunction can arise from such injury12. Blunt trauma subjects the skull to acceleration and the inertia is transferred to the brain; consequently, the brain collides with skull and ‘shearing stresses’ tear veins and nerves, resulting in subdural haematomas and in severe cases, death13. That participants in combat sports sustain neurological damage is widely supported14,15,16; the long-term effects of neurological impairment can result in the development of Dementia Pugilistica- chronic encephalopathy, or ‘punchdrunk syndrome’, a disorder characterized by a decline in cognitive function and weakness and tremors in the limbs14. These effects are cumulative; the brain becomes more susceptible to injury after initial trauma, increasing the risk of developing neurodegenerative disorders, such as Alzheimer’s disease, in later life17. The BMA believes the damage inflicted in cage-fighting is comparable to boxing, a sport in which approximately 20% of pro-fighters suffer chronic traumatic brain injury18. A 10 year review of Mixed Martial Arts competition revealed that approximately 28% of matches were stopped due to blunt trauma to the head19; the potentially debilitating, or even fatal repercussions of such trauma is unacceptable to the BMA.

Contrary to the BMA’s claims, a 5-year review of MMA competition found the risk of critical injury appeared to be low26. Additionally, the BMA is not calling for a ban on what it considers ‘proper’ martial art sports, such as karate and taekwondo, despite these sports having demonstrably high injury rates9,27,28,29. Compared to other combat sports, MMA has a low knockout rate due to the variety of match winning methods available and possibly a disinclination to strike a hard head with fragile fists, as the regulation 4-6 ounce gloves offer scant protection. In light of this information and the BMA’s admission of higher injury rates in other sports, fans are concerned the BMA is basing their opposition to MMA on ideological grounds, and not on empirical evidence4,9. In an attempt to repair the sports sullied image, supporters of MMA make reference to research that indicates that martial arts training has a beneficial impact in aiding discipline and reducing aggression31,32; this is demonstrated effectively by numerous police schemes, that aim to improve the behaviour of antisocial youths by employing combat training33,34,35. Conclusion

Participants in all combat sports expose themselves to the risk of injury, with the potential to suffer debilitating health impairment. However, the BMA fails to support their assertion that the health risks engendered by MMA is equivalent to that of boxing, and the distinction between MMA and ‘proper’ martial arts appears arbitrary; as research suggests that cage-fighting does not present a health risk greater than other combat sports. In fact, mixed martial artists may face a reduced risk of critical injury due to the unique format of their sport. Further research is required to ascertain the specific risks associated with mixed martial arts, as based on current evidence, the BMA has failed to justify its call for a ban. References 1.

Arguments Against

Advocates of Mixed Martial Arts passionately defend their chosen sport against claims it is “brutal” and “glorified violence”5, contending it is a highly technical showcase of skills. The hypocrisy of some critics is apparent, when it is revealed they ardently support boxing2,21. Officials in the sport recognise that they are partially responsible for the sports tarnished reputation, due to actively marketing early competitions as bloody, brutal events22.

3. 4.

It takes considerable technical expertise to emerge victorious in a mixed martial arts match due to the variety of skills that must be mastered.23 ; This is far from the spectacle of thugs in a street brawl portrayed by opponents of the sport24. However, the stigma remains and proponents of MMA argue that critics have failed to appreciate that the sport has evolved since its inception, instituting new rules and regulations to ensure safety25.

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10.

Walter, D.F. Mixed Martial Arts: Ultimate Sport, or Ultimately Illegal? [Online]. Available from: http://www.grapplearts. com/Mixed-Martial-Arts-3.htm [Accessed 1st April 2009]. Petty, M. Sulaiman slams ‘savage’ sport [Online]. Available from: http://www.skysports.com/story/0,19528,12183_4365313,00. html [Accessed 1st April 2009]. Plotz, D. Fight Clubbed. Slate 1999. Martin, D. Fighters & Promoters Speak Out Against BMA. [Online]. Available from: http://www. mmaweekly.com/absolutenm/templates/dailynews. asp?articleid=4667&zoneid=13 [Accessed 31st March 2009]. Smith, S. True Sport or Glorified Violence? [Online]. Available from: http://news.bbc.co.uk/1/hi/ uk/6906889.stm [Accessed 1st April 2009]. Lessware, J. Cage fighting event is condemned. [Online]. Available from: http://news.bbc.co.uk/1/hi/scotland/glasgow_ and_west/6289042.stm [Accessed 31st March 2009]. BBC News. Call to ban ‘no-holds’ fighting. [Online]. Available from: http://news.bbc.co.uk/1/hi/ health/6978438.stm [Accessed 21st March 2009]. Meltzer, D. MMA fighter Vasquez dies weeks after fight. [Online]. Available from: http://sports.yahoo.com/mma/news?slug=dm-fight erdeath120207&prov=yahoo&type=lgns [Accessed 1st April 2009]. British Medical Association. Boxing. [Online]. Available from: http://www.bma.org.uk/health_promotion_ethics/ sports_exercise/boxing.jsp [Accessed 31st March 2009]. British Medical Association. The Boxing Debate (1993).

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What is Mixed Martial Arts? Mixed Martial Arts (MMA) is a developing combat sport, where competitors use different forms of fighting in a supervised environment. These forms include jiu-jitsu, kickboxing, karate, wrestling and boxing. Competitors score points by striking and grappling their opponent. In 1993 the Ultimate Fighting Championship (UFC) brand offered a series of events, that would be shown on air across the USA. Now top fighters can command up to £500,000 per fight and TV ratings are burgeoning.. Notable cage fighters in the UK include Alex Reid, ex-Hollyoaks actor and Katie Price’s partner and Lee ‘Lighting’ Murray, the accused ringleader of the £53million heist on the Kent Securitas depot. What is Cage Fighting? Cage fighting is an extreme form of MMA, where two contestants enter combat in a cage fenced arena. Some might say it is an exhilarating combination of wrestling and kick-boxing, whilst others would label it as a dangerous and brutal sport that also encourages violence outside of the ring amongst spectators. The Rules of Cage Fighting •

Anything goes, except eye-gouging, biting, hair-pulling, head butting, groin attacks, joint manipulation, fish-hooking and inserting fingers into orifices.

•

No spitting, no abusive language, no attacking during time-out or after the bell has sounded

•

For safety reasons, no striking to the spine or back of the head, no striking downwards using the point of the elbow, and no throat strikes including grabbing the trachea.

•

Timidity, and the corner throwing in the towel during a match is forbidden

The medical society, especially here in the UK where we have relatively free health care, often brands as a health issue practices that result in an increase burden on the service. Is it time that we examined the health consequences of the “sports” we encourage and participate in as a society.

Introduction Although UK doctors joke about the “MRI now, talk later” attitude of US physicians, with malpractice litigation on the rise in the UK, defensive practices are on the rise. Modern Obstetrics in particular lends itself to high-profile legal suits. In an era of extremely low maternal mortality and morbidity, women who have a baby do not expect to be injured in the process and are quick to search for a liable party. In this climate, obstetricians may be tempted to order a large battery of tests to protect themselves from allegations of negligence. Although quick and easy to perform, screening tests often have high sensitivity and low specificity and can yield a high rate of false positives. A false positive result may lead to investigations and treatments that could adversely affect mother and baby. Routine antenatal screening varies significantly across European countries. Current UK protocol does not advocate routine screening for maternal thyroid disease. This case study illustrates how a positive result led to a chain of events that put both mother and baby at risk, and how this risk may have been avoided. For my mini-elective special study module I undertook a 5 week Obstetrics and Gynaecology placement in Rouen, France at the Charles-Nicolle Hospital. Aside from the vast differences in the structure of healthcare services in France when compared to the NHS in the UK, I noticed in France a leaning towards rigorous screening, early intervention and invasive techniques. The Case 23 year-old Mrs J.V, gravida 1 para 0, presented at 14 weeks gestation for routine screening blood tests, including thyroid function testing. She was found to have low TSH (0.01mIU/L), high free T3 (4.32ng/dl) and normal free T4 (1.08ng/dl). She reported no symptoms of hyperthyroidism; no palpitations, nausea, vomiting, weight change or insomnia. On examination, however, she was

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Defensive Medicine in Obstetrics: A Case of Maternal Graves’ Disease Hannah Newham BSc (Hons) Year 5 Medicine, St George’s University of London m0500529@sgul.ac.uk doi:10.4201/lsjm.med.006

found to be slightly tachycardic (HR 95bpm), with brisk reflexes and a fine tremor. Mrs J.V was admitted for further tests, serum testing for anti-TSH antibodies, were raised, and a thyroid ultrasound scan, which showed a regular, homogenous, hypervascular thyroid gland, with no focal lesions. A diagnosis of pregnancy-induced Graves’ disease was made, propylthiouracil treatment was commenced and Mrs J.V was discharged home. A routine antenatal ultrasound at 32 weeks, however, detected enlargement of the foetal thyroid gland. Mrs J.V was admitted and a high resolution foetal thyroid ultrasound was performed. This showed a diffuse foetal goitre, with no constriction of the trachea or oesophagus, and no polyhydramnios. To determine the thyroid status of the foetus foetal blood sampling was performed and showed foetal hypothyroidism: Free triiodothyronine (fT3) = 2.5pmol/L (normal= 1.15-3.5) Free thyroxine (fT4) = 9.2pmol/L (normal= 10.4-16.6) Thyroxine-Stimulating Hormone (TSH) = 31.9mU/L (normal= 2.6-11.8)

The obstetricians withdrew propylthiouracil therapy due to the risk of difficulties during delivery. Surveillance foetal ultrasound showed gradual regression of the foetal goitre. The baby was born by spontaneous vaginal delivery at 39+3 weeks, with no intrapartum or postpartum complications. Discussion - Did the management of this patient place her and her baby at unnecessary risk? Detection and treatment of subclinical hyperthyroidism Maternal hyperthyroidism has an incidence of 1 in 500 pregnancies. Up to 95% of these cases are secondary to Graves’ disease1. In Graves’ disease, autoantibodies (known as thyroid-stimulating immunoglobulins) activate the TSH receptor stimulating excess

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thyroxine production2. Graves’ may present for the first time during the first trimester of pregnancy, but in the majority of cases it occurs in a woman who is already known to have the disorder1,2. In cases where there is a past history, or clinical suspicion of thyroid disease, thyroid function tests should be performed. Hyperthyroidism is confirmed by high levels of fT4 and fT3, with reduced levels of TSH1. The levels of these hormones changes during pregnancy, It is therefore vital that levels are compared to trimesterspecific normal values. Normal TSH levels during pregnancy are: 0.03-2.3mIU/L in the first trimester, 0.03-3.1mIU/L in the second trimester, and 0.13-3.5mIU/L in the third trimester. Normal maternal fT4 levels are 0.7-1.8ng/dL3.

Supervisor: Miss Catherine Wykes, Consultant in Obstetrics & Gynaecology, East Surrey Hospital

Overt maternal hyperthyroidism increases the risk of premature labour, pre-eclampsia, and perinatal mortality due to foetal tachycardia, foetal growth restriction, premature delivery and stillbirth1,2,3,4. Medical treatment with propylthiouracil (PTU) is recommended in these patients1,2,5. PTU works by inhibiting the thyroperoxidase enzyme thus preventing the conversion of iodide to iodine, which is necessary for T3 and T4 production and has a similar efficacy and side effect profile in pregnancy. However, evidence shows that subclinical maternal hyperthyroidism, defined by suppressed TSH but normal free T4, as in the case of Mrs J.V, is not associated with increased adverse maternal or foetal outcomes. Casey et al conclude that detection of subclinical hyperthyroidism during pregnancy, and subsequent treatment is therefore unwarranted3. Foetal hypothyroidism secondary to anti-thyroid treatment Anti-thyroid medications are able to cross the placenta; hence there is a risk of foetal hypothyroidism and goitre1,2. This risk is minimised by using the lowest dose of PTU or carbimazole, maintaining maternal FT4 and FT3 at high-normal levels and monitoring maternal thyroid function at monthly intervals1,2.

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Foetal hypothyroidism may lead to some degree of irreversible mental retardation in the newborn, and is also associated with miscarriage, late foetal loss and low birth weight1,5. Foetal goitre can cause polyhydramnios due to oesophageal obstruction, respiratory problems at birth due to tracheal obstruction and mechanical difficulties during delivery due to hyperextension of the foetal head6. A study by Mitsuda et al. of 230 mothers with Graves’ disease found only 7 cases of foetal hypothyroidism secondary to anti-thyroid treatment5. The benefits of treatment are generally considered to outweigh the risks2. Foetal thyroid status can be monitored non-invasively by ultrasound monitoring of foetal size, heart rate and goitre4,6. Cohen et al show that serial ultrasound monitoring of foetal thyroid size may detect foetal hypothyroidism as early as 14 weeks of gestation, before goitre develops and hypothyroidism causes impaired foetal development6. They recommend that ultrasound should be used to monitor all mothers with Graves’ disease receiving anti-thyroid treatment. This is supported by Luton et al, who show that foetal ultrasound monitoring of thyroid size has a sensitivity of 92% and specificity of 100% in detecting foetal hypothyroidism7. Investigation and management of foetal goitre In maternal Graves’ disease, foetal goitre may be indicative of foetal thyrotoxicosis secondary to foetal thyroid stimulation by thyroid-stimulating autoantibodies, or hypothyroidism secondary to suppression by maternal anti-thyroid treatment1,2. Foetal thyroid function is difficult to assess in-utero. Amniotic thyroid hormone and TSH levels do not accurately reflect foetal thyroid function, and foetal blood sampling, although very accurate, carries a 1-2% risk of foetal loss4,6. Luton et al show that Doppler ultrasound may be useful in the differentiation of hyperand hypothyroid goitres7. However, is confirmation of foetal thyroid status necessary in cases of foetal goitre? Cohen et al show that reduction of maternal antithyroid treatment leads to regression of foetal goitre in hypothyroid foetuses6. Ochoa-Maya et al also report a resolution of goitre over 10 weeks after discontinuation of PTU8. Both authors advocate non-invasive management and ultrasound monitoring in cases of PTU-induced foetal goitre. In hyperthyroid foetuses, no reduction in foetal thyroid size is seen on cessation of PTU. Cohen et al recommend that foetal blood sampling is reserved for these cases6. Kilpatrick and colleagues similarly conclude that umbilical blood sampling should be considered only when there are signs of foetal hyperthyroidism: intrauterine growth restriction, goitre, cardiomegaly or tachycardia9. Cessation of PTU in the case of Mrs J.V. led to complete resolution of foetal goitre. PTU cessation and ultrasound monitoring may therefore have been more appropriate in the first instance, avoiding the risks associated with foetal blood sampling. Conclusion Modern health care professionals learn that the benefits of every procedure must be balanced against its risks. In accordance with this, the National Institute �� of Clinical Excellence (NICE) rebukes the routine medicalisation of pregnancy, emphasising that, “pregnancy is a normal physiological process and that, as such, any interventions offered should have proven benefits and be acceptable to pregnant women.”10.

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Many argue that there is no evidence to support the use of routine screening for thyroid disease, as it does not improve maternal or foetal outcome3. Although this case had a satisfactory outcome, one wonders whether this may have been observed if screening had not been performed and anti-thyroid treatment had not been given. Certainly the foetus was placed at increased risk of developmental delay, intrapartum complications secondary to maternal anti-thyroid treatment and increased risk of miscarriage due to foetal blood sampling. Evidence suggests that a more cautious approach should be taken in the management of maternal Graves’ disease: Mild or subclinical maternal hyperthyroidism should be monitored by repeat thyroid function tests and assessment of maternal and foetal wellbeing. It may not require anti-thyroid treatment2. Those on anti-thyroid medication should undergo regular assessment of foetal heart rate, foetal growth and high-resolution ultrasound monitoring of foetal thyroid size, to detect early signs of foetal hypothyroidism6. If foetal goitre develops, treatment should be withdrawn and resolution of foetal goitre monitored using ultrasound8. Foetal blood sampling should be reserved for cases when foetal goitre does not resolve following cessation of treatment6,9.

References 1. 2.

10.

Baker P.N. (ed) (2006) Obstetrics by Ten Teachers. 18th ed. London: Hodder Arnold. ATA (American Thyroid Association) (2005) Thyroid Disease and Pregnancy. [Online]. Available at: http:// thyroid.org/patients/brouchers/thyroid_dis_ pregnancy_broch.pdf [Accessed 10th April 2009]. DeGroot L. (2006) Subclinical thyroid disease and pregnancy: Evidence-based recommendations for the new guidelines. In: American Thyroid Association 77th Annual Meeting, 13 October 2006, Phoenix Arixona. [Online]. Available at: http://live.blueskybroadcast.com/bsb/client/ CL_DEFAULT.asp?Client=60&PCAT=343&CAT=346 [Accessed 28th October 2009]. Fisher D.A. (1997) ‘Fetal thyroid function: diagnosis and management of fetal thyroid disorders’, Clinical Obstetrics & Gynecology, 40(1), pp.16-31. AACE; American Association of Clinical Endocrinologists (2002) American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism & hypothyroidism. [Online]. Available at: http://www.aace.com/pub/pdf/guidelines/ hypo_hyper.pdf [Accessed 28th October 2009]. Cohen O. et al. (2003) ‘Serial in-utero ultrasonographic measurements of the fetal thyroid: a new complimentary tool in the management of maternal hyperthyroidism in pregnancy’, Prenatal Diagnosis 23, pp.740-742. Luton D. et al. (2005) ‘Management of Graves’ disease during pregnancy: the key role of fetal thyroid gland monitoring’, The Journal of Clinical Endocrinology & Metabolism, 90(11), pp.6093-6098. Ochoa-Maya M.R. et al. (1999) ‘Resolution of fetal goiter after discontinuation of propylthiouracil in a pregnant woman with Graves’ hyperthyroidism’, Thyroid, 9, pp.1111-1114. Kilpatrick S. (2003) ‘Umbilical blood sampling in women with thyroid disease in pregnancy: is it necessary?’ American Journal of Obstetrics & Gynecology, 189:1-2. NICE. National Collaborating Centre for Women’s and Children’s Health. (2008) Routine care for the healthy pregnant women. [Online]. Available at: www.nice.org.uk/ nicemedia/pdf/CG62FullGuidelineCorrectedJune2008. pdf [Accessed 28th October 2009].

lsjm 30 november 2009 volume 01

REVIEW

The Effect of Exercise on Stroke Survivors Rauri Hadlington BSc (Hons) MCSP Graduate 2009, Physiotherapy, Kings rauri.hadlington@kcl.ac.uk doi:4201/lsjm.med.007

Introduction Yearly, an estimated 150000 people in the UK have a stroke; it’s the third most common cause of death and the leading cause of severe disability1. Patients who have suffered a stroke remain at an increased risk of a further stroke of between 30% and 43% within five years2. It was therefore stated in the National Clinical Guidelines for Stroke that all patients should be given appropriate advice on regular exercise3. This review aims to investigate the effect of exercise on stroke survivors. Exercise and Chronic Stroke Physiological Outcomes of Aerobic Exercise in Hemiparetic Stroke Patients is a seminal paper in the area of stroke survivors’ response to exercise4. Despite its age and small sample size, its findings that hemiparetic stroke patients, at least six months post onset may improve their aerobic capacity and submaximal exercise systolic blood pressure response with training, still ring true today. Macko et al5 stated that stroke survivor’s capacity to perform activities of daily living (ADLs) was based on both the severity of the residual neurological deficit, resultant gait defects, individuals exercise capacity and the relative energy demands of the task. One significant finding in post stroke exercise research is that subject’s exercise capacity improved by more than expected for the percentage improvement in maximal oxygen consumption (VO2max)4,5,6. This suggests improved efficiency of movement as well as cardiovascular function. This equates to an increase in an individual’s exercise capacity due to improved cardiovascular fitness, and a decrease in relative energy demands of tasks due to improved efficiency of movement. However, sample sizes in these studies have been small and exercise programmes were intense-three weekly sessions, between thirty and forty minutes, for ten weeks to six months. Such extensive programmes are perhaps unrealistic for everyday practice. This is exemplified by high drop-out rates of 22% which sparks question as to the ability of community dwelling stroke patients to attend or maintain a long term aerobic training6. Furthermore 25% of subjects screened for a treadmill based exercise programme were unable to participate due to co-morbidity or inability to use equipment5, therefore more suitable training methods are needed. Also fitness testers were not blinded as to patient group and there

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is limited potential for subject blinding across all studies as patients are always going to be aware of whether or not they are exercising6. An important finding is that improvements have been found in subjects a mean three years post stroke, outside the accepted therapeutic window, after conventional physiotherapy rehabilitation6. This challenges our current practice in the arena. Currently outpatient stroke rehabilitation consists of approximately nine physiotherapy sessions and concludes between 28 and 140 days post stroke6. However, it has been shown nearly 40% of stroke survivors’ mobility declines in the first year post inpatient treatment and post discharge treatment has been identified as key in functional improvement at one year follow up7. Investigation into specific subsets of stroke survivors has given similar results. In a small study of African-American stroke patients, Rimmer et al saw that three, one hour aerobic training sessions a week for twelve weeks improved fitness 8. However the small sample size (35) reduced the statistical power of this study. Furthermore participants chose from a range of exercise machines and moved between them throughout the programme. The authors failed to provide information as to what equipment was used or the format of the exercises and thus it is impossible to determine the varying effect of machines on outcomes. Finally, the “lag-control group” design, whereby the control group simply performed the same intervention at a later date to the treatment group, is flawed. The control group were tested once before intervention (pre-test), once at 12 weeks, after the experimental group had performed the programme (post-test 1), and then again at 24 weeks after they had partaken in the programme (post-test 2). This means by the time their final outcome measures were assessed they had performed the test 3 times, once more than the treatment group and no mention is made of a potential learning affect on final outcomes. Finally, it is not clear if control group outcome scores are post-test 1 or post-test 2. Post-test 1 scores could in fact be considered pre-test scores for this group as they were taken prior to intervention. This omission makes it impossible to determine training affect, or lack thereof. Given all of the above the only viable result

For the full list of references see thelsjm.co.uk.

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is the significant group x time interactions in the treatment group, however even these may well be disputed given the lack of such significant improvements being reported at the post-test 2 stage in the control group. There is also no mention of blinding in the paper so the effect of bias and placebo cannot be ruled out.

health benefits of exercise for chronic stroke survivors and that functional ability may be further enhanced through motor relearning. This warrants further research however solid conclusions cannot be drawn on the basis of the current review due to small sample sizes and poor study design amongst trials.

Chu et al split a very small sample of 13 subjects between a waterbased aerobic exercise (n=7) group and a land-based upper limb functional exercise group (n=6)9. They reported a 22% improvement in VO2max in the experimental group, a greater improvement than the 8-14% seen in land based studies4,5,8. This was thought to be as a result of the increased resistance provided by the water. However Chu et al did not see the marked improvement in work load (9%9) previously noted (28%-44%4,5,8). This was put down to the fact that a water based programme did not have the same capacity for task-specific motor learning as land based programmes that used the same tasks to assess and treat. To this end one may conclude that training methods that replicate ADLs and improve cardiovascular fitness may be of most benefit to stroke survivors. This also reinforces the hypothesis that the greater than expected improvement in workload for a given improvement in VO2max might be down to increased efficiency of movement in subjects4,5,6. Chu et al experienced a 92% adherence despite the programme consisting of three one hour long sessions a week for eight weeks which may suggest that water-based training is preferable to patients than land-based. The very small study size diminishes the reliability of the findings. The sample are also all said to have been able to exercise at 70%-80% of their baseline age predicted maximum heart rate, a high level, given the well documented low fitness levels in chronic stage stroke survivors. Unfortunately the only blinding mentioned is that the subjects were not aware cardiovascular fitness was the main outcome measure. The authors failed to provide information as to blinding therapists across the control and intervention groups, or those responsible for testing outcomes is mentioned.

Exercise and Sub Acute Stroke The ideal window in which exercise should be prescribed to stroke survivors is another area that has spawned research. Duncan et al randomised twenty mild to moderate stroke patients, 30-90 days post stroke into an exercise and a control group13. The experimental group performed an eight week, three times a week exercise programme designed to improve strength balance and endurance. The results of the paper found little improvement with the only real significant differences being improved gait speed and lower limb function in experimental subjects. This did not translate to significant functional improvements for ADLs. The poor quality of the study and the lack of significant outcomes mean only limited conclusions can be drawn from this body of work. Firstly the authors stated that 17 of the 20 participants would have been unable to participate had transport not been provided to and from sessions so raising questions over the feasibility of centre based programmes in this area. The study also suggests that it is possible to exercise sooner after stroke than previously thought; many of the subjects were in what is thought to be in a fragile early stage shortly poststroke and yet no adverse events were reported.

As well as cardiovascular fitness benefits Pang et al investigated the effect of a fitness and mobility exercise (FAME) programme on bone mineral density (BMD)10. Again it was an intense, long programme with three one hour long sessions weekly for 19 weeks, with attendance rates were just over 80%. The study was well blinded; patients were simply made told which exercise group they were in; upper limb or lower limb. Personnel who performed outcome measures were blinded as to patient group. The sample size was 32 in the intervention group and 31 in the control group at baseline and no significant differences were found in descriptive data, 30 subjects completing final outcome measures in both groups. A power calculation showed that 21 participants were needed per group to provide a power of 0.80 and P<.05 based on an average VO2max + standard deviation of 17.3 + 3.0 mL/kg per minute and a desired 15% change, to this end the sample size would appear sufficient, but for VO2max analysis only. The results of the study showed that those enrolled in the FAME programme had significantly better outcomes in cardiovascular fitness, mobility and paretic limb muscle strength and the intervention group maintained hip BMD, unlike controls. Results are generalised with caution due to the mediocre sample size and the specific nature of the subjects. Further research is warranted into the effect of exercise on BMD in stroke patients given the high occurrence of falls and resultant hip fractures in this population11,12. Evidence does appear to show that there are many physiological

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More recently Marylin et al and Katz-Leurer et al investigated exercise capacity and response to training respectively in early (within one month) post stroke patients14,15. Peak oxygen consumption (VO2peak) at one month post stroke was 60% that of age matched sedentary individuals indicative of a decrease in aerobic capacity in this population14. Caution must be used when interpreting this as non-standardised testing protocols were used across subjects and the sample size of twenty-nine is too small to make general judgements. However a group of patients an average of just 15.4 days post stroke showed significant improvements in work time and work load following an eight week aerobic leg cycle ergometer training programme15 and similarly to data in chronic stroke4,5,6 these improvements were greater than expected for the improvements in cardiovascular function. Again there were no drop outs and no adverse events reported in the exercise group, strengthening the notion that exercise is not detrimental to this population. Good blinding procedures, a relatively large sample of ninety-two patients and the use of validated outcome measures strengthens findings, but it is important not to extrapolate them beyond the sub-acute stroke population. In a study of 100 sub acute stroke patients 3 subjects in the control group suffered second strokes, however this was not deemed sufficient to stop intervention and as none of these events occurred during exercise sessions, they were not deemed to be as a direct result of exercise16. The study concluded that physiological exercise is effective in improving the sub acute post mild to moderate stroke phase in subjects with low levels of baseline endurance and numerous co-morbidities. Significant improvements were seen in VO2peak, exercise duration, balance, six minute walk distance and gait velocity. The authors did however identify that the study was very resource intensive, experimental subjects received 54 hours of one-on-one therapy which may not be viable in many trusts. Also they could not ascertain the effective â&#x20AC;&#x153;doseâ&#x20AC;? of exercise and

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thus admitted a more efficient group intervention model could be effective and stated further research is needed to improve the efficiency and targeting of the model. Assessors were blinded as to patient intervention group, however patients were aware of their treatment group and thus bias may have been evident in self reporting outcomes despite the fact subjects were unaware of the study hypothesis. These findings are of higher significance given the control group received usual care from the trusts involved. The fact that significant improvements are on top of spontaneous recovery and usual care increases potential impact on service provisions. Long-Term Follow-Up Any gain in quality of life through exercise in the sub acute stroke population had dissipated by 6 months.17,18 One possible explanation is that despite improved aerobic capacity, the intervention group did not tend to exercise more than controls after training had ceased and thus the training effect was lost18. This notion is supported by the interaction effect of aerobic capacity on functional outcome measure scores demonstrated in the results of the study18. Again it is of note that despite a sample size of 92, 125 subjects screened for one study were deemed inappropriate for participation, raising questions as to its general applicability to a real life stroke population18. It was concluded then that advanced aerobic abilities could only have a real affect on functional outcomes in the presence of high motivation.

survivors. Sample sizes are generally low and training programmes are often unrealistic for service providers. However outcomes are positive and could have great benefits for the population. References 1. 2.

The Stroke Association. [Online]. Available at: http://www.stroke. org.uk/information/index.html [Accessed 1st November 2009]. Mant J, Simpson S (2004) Health care needs assessment: the epidemiologically based needs assessment reviews. Second edition. Oxford: Radcliffe Medical Press. The Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke – 2nd Edition. (2004). Available at: http://www.rcplondon.ac.uk/pubs/books/stroke/stroke_ guidelines_2ed.pdf [Accessed 1st November 2009]. Potempa K, Lopez M., Braun LT, Szidon JP, Fogg L, Tincknell T. 1995 Physiological outcomes of aerobic exercise training in hemiparetic stroke patients. Stroke. 1995;26:101–105. Macko R, Smith G, Dobrovolny C, Sorkin J, Goldberg A, Silver K. 2001. Treadmill Training Improves Fitness Reserve in Chronic Stroke Patients. Arch Phys Med Rehabil. Vol 82, July 2001 879-884. Macko R, Ivey F, Forrester L, Hanley D, Sorkin J, Katzel L, Silver K, Goldberg A. 2005. Treadmill Exercise Rehabilitation Improves Ambulatory Function and Cardiovascular Fitness in Patients with Chronic Stroke. Stroke. 2005;36;2206-2211. Paolucci S, Grazia Grasso M, Antonucci G, Bragoni M, Troisi E, Morelli D, Coiro P, De Angelis D and Rizzi F. 2001. Mobility status after inpatient stroke rehabilitation: 1-Year follow-up and prognostic factors. Arch Phys Med Rehabil .Vol 82, January 2001

This was further enhanced by two first year follow up studies of the effects of exercise on stroke19,20. In these studies an intensive exercise group was compared to a regular exercise control, however unexpectedly the controls maintained the same level of activity as the intensive group. This was despite not being provided with treatment as part of the study and simply being advised to remain as active as possible. This regular exercise group then sought their own treatment and as a result displayed similar functional ability to the intervention group at three, six and twelve month follow up. In analysis of health related quality of life (HRQoL) those who sought their own treatment fared better than those on a prescribed exercise programme20. It was hypothesised that exercise with high levels of patient motivation has the best outcomes for HRQoL. Calculations showed a power of 80% for both studies, yet the sample size of 75 limits the extrapolation of results to a wider population. Both were double blinded and well randomized and given the unexpected nature of the results, they warrant further research. Conclusion Exercise has been shown to improve cardiovascular fitness in stroke survivors and although long standing functional benefits have not been demonstrated there is a well established link between cardiovascular fitness, functional ability and stroke occurrence. Given that cardiovascular disease is the leading prospective cause of death in people with stroke it is fair to assume that improvements in this area are beneficial22,23,24. Further to this, improved efficiency of movement and subsequent decreased load on the cardiovascular system could further reduce the cardiovascular risk. Future studies should investigate the optimal intensity and method of exercise as well as the financial implications of long, intense exercise programmes. Education programmes as to the benefits of regular exercise could also be researched given the profound benefits of high motivation.19,20,21 Much research exists into the effects of exercise on stroke

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Advice. Support. Defence. Throughout your career. Discounts on medical text books Educational support through the MDU website 24-hour advisory helpline for medico-legal and ethical issues Support planning your elective with The Electives Network website Free discretionary indemnity for your elective The MDU Revision Courses Sponsorship of student events For more details on how we can support you visit our website or contact your MDU student support coordinator. Lozanne Stephenson 07989 609418 stephensonl@the-mdu.com

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CAREERS

Illustration: Ella Beese

Change or Die? The cult of innovation is nothing new. “Change or die”, declared Roman poet Claudian, writing more than 1500 years ago. Yet, this truism still feels startlingly modern, almost made for today's healthcare professionals. The last twenty years have seen a visible shift in the selection of medical students, in the way that they are taught and in the recruitment of doctors at foundation level. A greater flexibility in the entrance criteria have seen students from a broader social background entering the profession, and graduate courses have tempted those from different professional milieu to reconsider a career that they may have eschewed at eighteen. Once at medical school, the focus and method of education is changing too, with a move from the traditional division of pre-clinical and clinical training to a more integrated course with patient contact throughout. Peer-assisted learning is increasingly in vogue, with students teaching students, and this method of delivery has proved useful not just at medical school, but for the training of other health care professionals too. We look at how a scheme managed, as well as assisted, by a group of students is revolutionising the way that training is delivered to Manchester medics. Also in medical and allied health education, the Government is looking to revamp the NHS Bursary scheme, a vital source of funding to many students on healthcare courses. The consultation is underway, so read on to find out more about the proposed changes and how to make your voice heard. There's no doubt that the decisions made today will influence the doctors, nurses and allied health professionals of the future. And with the application process for the UK Foundation Programme under review again, it looks like the educational merry-goround may be spinning once more. Of course, today's junior doctors and doctors-to-be are used to hitting moving targets as they progress through their careers. In a new strand of personal profiles, we ask a fledgling F1 doctor how to survive the transition from student to professional. Earlier this year, Barack Obama, the first Black President of the United States, both embodied and extolled virtues of change: “Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek.” We look at his attempts to shake up the American healthcare system - we look at the debate raging, and hear how one student's experience of the US system of caregiving in a psychiatric unit in the heart of the Bronx has altered her perception of the mental health sector. Whilst US healthcare is changing, the UK is looking to its larger cousin when it comes to workforce planning. Could the introduction of Physician Assistants, a job already established in America, alleviate the pressure on already overstretched NHS resources? Or will this latest addition to the multi-disciplinary team deprive those training for more traditional roles of valuable hand-on opportunities? With the MTV generation now all grown-up and attention spans shorter than ever, health campaigners and charities are having to find increasingly innovative ways of securing their share of our collective capacity for concentration. One CEO has taken inspiration from social networking sites, and harnessed the power of the flashmob, to raise awareness of the devastating consequences of drinking whilst pregnant. We are on the cusp of an election year, and as those on the campaign trail vie for our affections, there is no doubt that health will be high on the political agenda, with the electorate looking to see how the parties at Westminster propose to improve the delivery of caregiving. Next issue we'll take a look at the main parties' policies on healthcare, and how these might affect healthcare professionals of the future. As ever we welcome your views on these topics, and your opinions will help us shape these pages. Contact us on careers@thelsjm.com Sonia Damle Section Editor Careers

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INTERVIEW

Publishing a Textbook: De-mystifying the Process Sunita Deshmukh and Newton Wong Year 5 medicine, University of Nottingham Medical School sunitadeshmukh@f2s.com, newronw31@yahooo.ca doi:10.4201/lsjm.car.004

‘The Renal System Explained: An Illustrated Core Text’ ISBN 9781904761846

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Writing books is a full time occupation for some, so when a couple of medical students set their minds to writing a brand new text book, the path to publication was far from easy. Sunita Deshmukh and Newton Wong share their experiences of medical publishing. What prompted you to write a book for medical students? NW: We were actually in the medical school library studying together when the idea of writing a book was mentioned in passing purely as a joke, but we both wanted a bit more clinical relevance and an easier-to-learn format from our textbooks, so we started to develop the suggestion and things blossomed from there. SD: I was immediately drawn to the idea because I love writing and drawing. Co-authoring and illustrating a textbook offered an ideal creative opportunity. I enjoy teaching and team-working, so was keen to work with colleagues in developing an educational resource. What did the process of securing a publishing deal involve? NW: Obtaining a contract with a publisher was new to us and challenging. Firstly, we had to draft a list of potential publishing companies. Next, we visited their websites to familiarise ourselves with the whole publishing process and what is expected in terms of a proposal. The proposal had to be concise and reflect our commitment to writing a renal textbook. Once the proposal was submitted, we waited for responses and answered questions from publishers. We had a few telephone conversations and face-to-face meetings with representatives of publishing companies. The whole process had its ups and downs, but perseverance was key to us finding an appropriate publishing contract. From your experience, what are some of the pros and cons of undertaking a substantial project like this during your full-time studies? NW: Having a side project of writing a book in the midst of fulltime university studies was a good opportunity to fine tune our time management and organisational skills! Authoring a book of this nature and at our stage of medical training forced us to do additional research into certain aspects of the renal system which may have been beyond core medical curriculum. In retrospect, whilst researching and writing, we were actually revising and learning about the renal system. Finding the time to work on the book was a constant challenge as we had our school and personal commitments. This was probably the most difficult part of the whole experience. Having a healthy balance was what got us through!

SD: That is the diplomatic answer to this question… truth be told, I will never forget December 2008 and the self-motivation we needed - it really was a case of sink or swim. The end of the year brought with it numerous deadlines and really demanding time-pressures. With ongoing fourth year coursework and competency assessments, clinical exams imminent, Student Union representative work, personal commitments, plus the impending contractual deadline for the final manuscript, this all amounted to work-intensive days and nights, hectic weekends and a Christmas holiday that passed by in a blurry mess of insomnia and worry. The health and balance to which Newton refers were only maintained with family support. The night before leaving for the airport, instead of packing my usual holiday suitcase with a fun book for the journey and painting my nails, I found myself packing six USB memory sticks, reference textbooks and my laptop, which accompanied me 12000 miles to India and back. Much of my work on the final draft was completed under a fan in a flat in Mumbai. It’s lovely to reflect positively on this project for the characterbuilding experience that it was. Gratitude and a sense of accomplishment are certainly the overwhelming feelings that remain when you hold a printed copy of your book, flick through chapters you’ve written, and glance over your own diagrams (blissfully ignorant to self-criticism for at least a couple of days). However I think it is worth noting the degree of responsibility and associated stress when you take on a publication of this magnitude. It was an invaluable experience – the lessons learned will stay with me forever and hold us in good stead for similar ventures in the future. What is the single most important learning point from this experience? NW: I actually learned two very important things with this book project: if you have a dream, pursue it, there’s always a way, and I discovered I have a passion for medical education. I hope to take what I’ve learned from this experience into the future. SD: A medical author we met described writers who prepare manuscripts which remain unpublished because they never feel their work is ready for submission. He advised us that there comes a point when you have to ‘let go’. I learned a lot about myself, and that I owe every happiness and success in my life to my family. What are your hopes or aspirations for the future? NW: My future academic aspirations are simple - graduate from medical school, be fortunate enough to find a branch of medicine which I will enjoy and be good at, and perhaps get involved in medical education. I’d also like to have a decent car and a golden retriever.

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NEWS SD: I'm working towards passing finals and qualifying. I've accepted an Academic Foundation Programme post which offers a first step to applying for a clinical lectureship in the future. This career pathway will hopefully enable me to contribute to evidence-based medicine in the long-term, whilst developing my clinical skills and working with colleagues on research and education publications. Ultimately I aspire to finding a happy balance between an exciting career and fulfilling family life. Do you have any suggestions for fellow readers who may be interested in a similar project? NW: Always have a plan and sense of direction - this will either make or break you! Be confident and persevere. Seek out individuals who are willing to help you along the way, they are good assets. SD: I agree. It took us real persistence, determination and a lot of hard graft to establish and to successfully complete this project. Minor setbacks in either of these aspects of writing a book may be disheartening, but you can overcome mistakes and failures, learn from them and use the experience to your advantage. Actively seek and take on board advice and feedback from academic contributors and other students. Our faculty advisors were enthusiastic and helpful. Publishers are an excellent source of information and guidance. Take the time to negotiate a suitable contract – as an author you are choosing your publisher as much as they are choosing you. We had a brilliant working relationship with our publisher, characterised by open and consistent communication with friendly and approachable team members, including the production manager and business development manager. Sincerity, dedication and reliability are essential qualities in good co-authors. Trust, compromise and the ability to recognise and complement each other’s talents and limitations also help. No matter how difficult the challenges we faced, it never felt as though our friendship was being tested. I think that signifies both professionalism and the strength of the partnership. Any regrets? SD: It’s encouraging that inspection copies of the book have received positive responses from the universities in the UK and internationally. In the grand scheme of things it’s just one book contributing to a massive medical education market, but I feel very lucky. So I try not to have regrets. I like to believe (and hope for my own peace of mind) that things happen for a reason. We tend to attribute ‘the way things turn out’ to the outcome of our most agonising decisions and painstaking efforts. But actually sheer luck and chance probably play a much bigger role in determining this than we like to think. On that philosophical note, I hope the tradition of students teaching students continues and wish any budding authors the very best of luck. NW: There is always a nagging feeling of self-doubt but as Sunita mentions, you have to conclude a project eventually. I hope ‘The Renal System Explained’ becomes a helpful tool and inspirational resource for fellow students and authors-to-be.

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U.S. Ends HIV-Immigration Ban On 30 October 2009, President Obama announced the end of the ban on HIV-positive people entering the US. The ban, which had been in place for 22 years, prevented both HIV-positive people from immigrating to the US and HIV-positive tourists from visiting the country. Speaking on the policy change, Mr. Obama said: “If we want to be a global leader in combating HIV/AIDS, we need to act like it.” He added: “Now, we talk about reducing the stigma of this disease, yet we’ve treated a visitor living with it as a threat.” UN Secretary-General Ban Ki-moon welcomed the change, stating: “I urge all other countries with such restrictions to take steps to remove them at the earliest.” Some 11 other countries still impose bans, including Saudi Arabia and Libya. Under the US ban, all potential immigrants had to undergo testing for HIV. Whilst waivers were available for those in a heterosexual marriage, they were not available for gay men. In addition, although waivers were available for tourists, many felt the process was too arduous as to be worth it. Gay-rights campaigners say the ban has separated families and discouraged HIV testing and treatment in the US. Now, for the first time since 1990, the US – which has a strong record in the attempts to control the AIDS epidemic in Africa – will be able to hold a conference on HIV/AIDS on home soil. Up until now, conferences have not been held in the country so that HIVpositive activists and researchers are able to attend. The new ruling was will take effect from January 2010. Sources: 1. The New York Times – http://travel.nytimes. com/2009/10/31/us/politics/31travel.html?s cp=2&sq=October+31+2009&st=nyt 2. The Guardian – 3. http://www.guardian.co.uk/commentisfree/2009/ nov/03/america-hiv-aids-needles 4. The Philippine Star – 5. http://www.philstar.com/Article.aspx?articleId =519465&publicationSubCategoryId=200

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Publish or Perish Emily Pull

Year 6 Medicine, University College London e.pull@ucl.ac.uk doi:10.4201/lsjm.car.005 It seems to be unavoidable now, that pressure to be able to type your name into the Pubmed search and find some publications. It counts on Foundation Application Form, looks great on your CV and is bound to make you sound so much more intelligent in front of your consultants - that’s right, medical students need to publish, publish, publish. For the former PhD students and graduates embarking on medicine, this may be a less worrying pressure, but for us run of the mill medical students who have quite enough to keep us occupied with just the medical degree, how can one go about getting into a lab and our names on a paper? And is it as vital as we’re led to believe? Professor Jane Dacre, Vice Dean Director of Medical Education at UCL is clear about the merits of academic publishing as a medical student: “medical school offers an education, not just training for a job, so we encourage a more in depth approach to the subject, and academic publications are a way of demonstrating students have engaged in that”. However, a publication is no mean feat and it can be difficult to get practical advice on where best to start. The first place that you may encounter as prime publishing ground is an intercalated BSc or BA. For many students this is the first experience of getting into a lab and with time devoted to research, this is a great opportunity to mingle with researchers, see what they’re doing and what’s more, offer to help out. It may not even be your project that ends up getting published but if you’re in the lab and willing to contribute, you could well find yourself as one of the authors of a published work. One thing is sure, a good supervisor is of great benefit and Dr Robert Dudas writing on the Royal College of Psychiatrists website gives some good advice, suggesting that bigger is not necessarily better. He advocates choosing someone who is not necessarily high profile, but who can spend time actually supervising you. One of the important things to remember with all research is that it is not a quick process,it can take months or more from finishing the lab work to the final publication. Writing up your BSc dissertation Top tips from Trish Groves (Deputy Editor, British Medical Journal): • Simple questions, answered with simple methods, can make great studies if they add usefully to what’s known and/or raise further important questions • Before you start the study decide who will do which aspects of the work and who will be an author on any papers • Always seek patients’ signed consent for publication if your paper could allow them to be identified • Always cite all your sources - plagiarism is a tempting shortcut, but never worthwhile or right

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may be done in a haze of parties and late nights but a manuscript fit for publication can take many attempts with feedback from peer reviewers and the journal editors. Dr Dudas states that, for the most part, producing publishable data is not the tricky part. The difficulty often lies elsewhere, for example in devising the initial research and study design. Trish Groves, Deputy Editor at the British Medical Journal has some good advice for first time researchers: “Think of a good research question first and ask a librarian to help you search previous studies so you can narrow it to something original enough. Plan, conduct, and write up your study around the question - don’t collect some data and then try to analyse them hoping that a research question will emerge”. Most journals will be looking for an original research question that, importantly, their readers will be interested in. Picking the most appropriate journal for your work can greatly increase the chance of publication. “Choose a journal because it will reach the right audience and publishes similar work, not because it’s big and famous” says Groves. Dr Dudas presents a realistic view of the world of publishing for a student, suggesting that talent is not the only ingredient needed to achieve publication. Rather, he emphasises luck as a key player in the process, coupled with a dogged determination not to give up. So don’t be downhearted if getting into a lab and published is more difficult than you expect. Talk to students in later years to find out how they got published, and try to work out which research teams are working on projects likely to get published. The most important skill it seems when it comes to publishing is to have a thick skin. The most eminent scientists and researchers will have had papers rejected by journals and rejection doesn’t necessarily mean a paper is bad. It could be something as simple as the fact that a journal never publishes a particular type of study or that the work is good but the important messages are not clear enough for the readers of the journal. The key thing to remember is don’t give up - according to Dr Dudas most journals only publish a fraction of the manuscripts they receive.. So when that rejection letter comes through the door, see if you can improve your work and resubmit to someone else. Although the perceived pressure to get published can be daunting, Professor Dacre is clear about why it can be useful: “we should not stress students unnecessarily, however, as the practise of medicine requires high standards and academic rigour, it is helpful to start practising that approach before you qualify”.

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Obama’s Healthcare Reform: Hope or Hyperbole? Katherine Adlington BA(Oxon) Year 4 Medicine, King’s College London katherine.adlington@kcl.ac.uk President Obama arrived in the White House on the back of a promise to bring hope to the American people. Now, nine months after his inauguration, he has chosen to deliver this promise through ambitious healthcare reform that has kept politicians and the public embroiled in heated debate over the past few months. Unlike the National Health Service in the United Kingdom, there is no universal public healthcare coverage in the United States. Instead, the majority of healthcare facilities in America are owned and operated by the private sector. In most states, individuals are responsible for arranging their own health insurance, and this individual policy is then used to fund medical treatment as required. Insurance coverage is usually offered by employers. Those not so fortunate have to sign up independently for private insurance schemes. The Emergency Medical Treatment and Active Labor Act (EMTALA), enacted by the federal government in 1986, required that hospital emergency departments provide a medical screening exam and stabilise all patients on presentation to hospital regardless of their ability to pay. However, there was no concurrent increase in funding for hospitals to cover the cost of this emergency care, and hospitals largely still bill their emergency patients directly after discharge under a fee-for-service model. If a patient needs healthcare from any other part of the system, they need to have adequate insurance to cover their costs. If they are found to have no insurance, or their insurance won't cover their costs, and treatment has already started, they will personally have to foot the bill themselves - and if they can't, the treatment may be stopped or the hospital may pursue legal proceedings. The American government does not completely abandon their public when it comes to healthcare. As well as the essential medical care offered by Emergency Departments, there are two healthcare schemes that provide health coverage for specific social groups: Medicare - this scheme is a social insurance programme providing coverage to people who are aged 65 and over. It is partially funded by federal payroll taxes. Medicaid - scheme caters for low-income parents, children, pregnant women, and people with certain disabilities. This is a means-tested program that is jointly funded by the state and federal government. Children and military veterans are also covered by other public schemes. Yet, even with coverage for the young, infant mortality

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is comparable to sub-saharan African in some southern and mid-western communities1 . Shocking facts such as these, go some way to explaining why Obama has made healthcare reform such a priority. So, what are the problems with the system in the US? Despite the fact that more money per person is spent on healthcare in the US than in any other nation in the world, it still lags behind other wealthy nations in measures such as infant morality and life expectancy2. In 2000, the World Health Organisation (WHO) ranked the US health care system as the highest in cost, 1st in responsiveness, 37th in overall performance, and 72nd by overall level of health (191 member nations were included in the study)3. However, this overpriced system fails spectacularly if the per capita spending is correlated to health outcomes. Premiums for employer-provided healthcare schemes have risen four times faster than wages over the same period, doubling in just nine years4. This, coupled with the dramatic rise in individual healthcare costs means that a burgeoning number of individuals and employers are unable to afford health insurance. In 2008, the US census bureau estimated that 46.3 million Americans do not have insurance - this from a population of 300 million. Millions more are deemed 'underinsured’ – with inadequate coverage for their specific needs5 . The consequences of this can be catastrophic financially, phsycially and emotionally. Medical debt is the commonest cause of personal bankruptcy in the US, accounting for at least half of all cases6. Many people do not seek healthcare for serious conditions and consequently suffer because they simply cannot afford the interventions. Many Americans feel let down or neglected by the system, raising questions about their basic human rights to healthcare. President Obama wanted to leave the fine detail of the reforms for Congress to decide. After this broad-brush approach led to criticism, Obama's address to Congress at the beginning of September was an important one. Offering more detail, the President highlighted the three main aims of his reforms: to provide increased security and stability to health-insured Americans,to achieve universal health insurance coverage and to slow the growth of healthcare costs. Tougher regulation of the insurance industry is proposed, prohibiting the currently common practices of refusing insurance to those with pre-existing conditions and discontinuing insurance if people get ill. The reforms will also look at alternatives for employees who are not provided with health insurance at work. Emphasising the importance of rights as well as responsibilities, the address also stressed the need for individuals to take personal responsibility if the system was to succeed. This is reinforced with the threat of financial penalties for those who fail to arrange healthcare insurance. Obama stated that his reforms will cut the number of uninsured Americans by 30 million, while costing no more than $900 billion and not raising the federal deficit by “one dime”7. On 16th September this year, Max Baucus, the head of the Senate's powerful Finance Committee, unveiled a bill, carved out through intense bipartisan negotiations, that seemed

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PERSPECTIVE to offer hope of fulfilling both Obama's aims and meeting his financial specifications. To increase insurance coverage, the bill suggests the creation of internet-based insurance marketplaces that would simplify and standardise insurance offerings, whilst making refundable tax credits available to low-income families to help them buy health insurance. Mr. Baucus' plan also proposes expanding Medicaid to cover a greater percentage of the poorest American citizens. This plan also seems like the most economically viable option, with some agencies suggesting it might even result in a reduction in the federal deficit. Opponents said the bill is too good to be true, and claimed that savings would only be made through dramatic cuts to doctors’ pay and a significant, unacceptable reduction in the funding of Medicare. Many medical industries are already gearing up to contest or escape the substantial levies that Baucus hopes could partly fund this bill. As NHS in the UK shows, it is possible that a public healthcare system might offer basic healthcare coverage for all citizens. However, such a system can also curtail doctors’ wages and funding for medical research. Of course, once access to healthcare becomes a fundamental right, the distribution of inevitably limited resources and becomes the focus for controversy. The President has staked his political reputation on this - his first bold domestic manoeuvre. Recognising the need for support from medical professionals in order to popularise and push forward the reforms, President Obama invited 150 doctors from across America to a high profile summit at the White House early this month. The US reform bill is currently awaiting approval from various committees. Inevitably, different versions of the bill will continue to be proposed before agreement is reached between all parties. There is clearly a long way to go before the debating is over, and many people have yet to decide whether Obama's reforms offer hope or hyperbole. References 1.

5. 6.

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MacDorman, M.F., Mathews, T.J.. Recent Trends in Infant Mortality in the United States. National Center for Health Statistics, Centers for Disease Control. October 2008. http://www.cdc. gov/nchs/data/databriefs/db09.pdf. Retrieved 6-10-2009. UN. World Population Prospects: The 2006 Revision (Table A.17. Life expectancy at birth (years) 2005-2010.) United Nations. 2007. http://www.un.org/esa/population/publications/ wpp2006/WPP2006_Highlights_rev.pdf . Retrieved 6-10-2009 WHO. World Health Statistics 2009. World Health Organization. May 2009. http://www.who.int/whosis/ whostat/2009/en/index.html. Retrieved 7-10-2009. BBC. Q&A: US Healthcare Reform. British Broadcasting Corporation. September 2009. http://news.bbc.co.uk/1/ hi/world/americas/8160058.stm. Accessed 7-10-2009 US Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Census Bureau. Issued August 2008. Himmelstein, D, E., et al. Medical Bankruptcy in the United States, 2007: Results of a National Study. American Journal of Medicine. 2009.122;8: 741-746. The Economist. Half a loaf, or half-baked?: The latest American health-care reform plan is unveiled in the United States. The Economist. 2009, September 17th. http://www.economist.com/ world/unitedstates/displaystory.cfm?story_id=14460017 Accessed 7-10-2009

Psychiatry in the Bronx Katherine Adlington

Psychiatry has always struck me as one of the more interesting areas of medicine. An exciting and unique discipline that often had unclear pathophysiology. However, a brief six week canter through psychiatry in the first year of clinical medicine seemed limited in its scope and only gave the opportunity of a brief dip into the ocean of mental health services available. So with graduation looming a short two years away, it seemed a good idea to explore this interest in psychiatry further over the long summer break. Four weeks working at the Schizophrenic Research Unit in the Bronx Psychiatric Hospital (BPH), New York was a far cry from the glitz and glamour usually associated with the Big Apple. The BPH is a state run facility and is well recognised as the birthplace of the Positive And Negative Symptom Scale (PANSS). This is a rating scale that was originally developed by Stanley Kay, Lewis Opler and Abraham Fiszbein in 1987 and is now an internationally recognised method of identifying classic symptoms of schizophrenia1. As a general volunteer on a female-only ward for 24 patients with chronic, refractory schizophrenia, my responsibilities were both clinical and research based. From collecting data for studies; trying to establish a link between risk of schizophrenia and immigration status, vitamin D levels or ethnic grouping; to interviewing patients, the work was interesting and varied. It was a steep learning curve given the extreme psychopathology on the ward and not without risk. I found myself in threatening situations on more than one occasion: On day one a patient told me in no uncertain terms that she intended to assault me. Learning to deal with aggressive and confronting behaviour, whilst terrifying, was a challenge that ultimately gave me confidence on the ward It also gave me more insight into the frustrations that many of these women felt at having their liberty so severely restricted. One patient on my ward had been institutionalised for nearly 50 years.

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Illustration: Jonathan Hyer

As with mental health services in the UK, psychiatric hospitals in America regularly come into contact with the legal system, in order to facilitate formal admissions and medication-over-objection orders. The Bronx Psychiatric Hospital is a large facility with a makeshift courtroom on the premises, which a Supreme Court judge attends weekly to hear any pending cases and I was fortunate to be able to observe the hearing of one of the patients that I had been following. There is a much more powerful patient lobby in the in America compared to theUK, as well as a powerful legal service. This is perhaps as a consequence of the many high profile cases of abuse of institutionalised psychiatric patients in the 1960s, such as the infamous class action suit brought against the Bridgewater State Hospital for the Criminally Insane, which showed that the institution was acting in clear breach of its patients’ civil rights2 . In my experience, this seemed to lead to a highly charged hearing between the patient's treatment team and the patient's legal representatives. Often, the former held the view that it was in the patient's best medical interests to remain in the hospital, whilst the latter were trying to secure the patient's liberty as early as possible. At these hearings, patients have the right to self-representation in court. Given that they could be floridly psychotic at the time, this throws up an interesting ethical dilema and whether this affords them the best opportunity for fair legal representation, is a matter for debate. The provision of American healthcare in general and the role of health insurance was the topic of lively discussion at the hospital, and this reflected the national mood, following the first sparks of the debate over President Obama's proposed healthcare reforms. Many of my colleagues were baffled by how free healthcare could be provided for all at the point of entry in the UK.

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BPH is a state psychiatric facility funded largely by Medicaid - a state and federal-funded health program that provides healthcare cover for low income adults, pregnant women, children and people with certain disabilities. The patients at BPH were representative of the general population of the Bronx, and almost entirely of low socioeconomic status. Many were first or second generation immigrants; many had minimal work history. Often their families were unable - or unwilling - to be financially supportive, and thus they relied on Medicaid for health coverage. BPH currently receives significantly more funding from New York state than the national cross-state average, but this did not seem evident in the standard of facilities and levels of staffing. While Obama’s proposed health care reforms will mean increased funding for this state hospital, it could also result in a greater pressure on services as more of the currently uninsured patients begin to be covered by the widening healthcare safety net. This is particularly relevant for mental health services given that low socio-economic status and immigration status have been suggested as risk factors for schizophrenia3. Overall, this work experience was incredibly informative and really helped focus some of my previously vague career ideas. I would definitely be more likely to consider psychiatry as a career option now that I have had an in depth clinical and cultural experience. References 1.

2. 3. 4.

1. Kay, S.R., Fiszbein, A., Opler, L.A.. The Positive and Negative Syndrome Scale (PANSS) for Schizophrenia. Schizophrenia Bulletin. 1987. 13;2: 261-276 2. Gilligan J., The Last Mental Hospital, Psychiatric Quarterly, Vol. 72, No. 1, 2001 (Springer Netherlands) http://www.springerlink.com/content/ wm33461q2805mm07/fulltext.pdf 2. Cooper, B., Immigration and schizophrenia: the social causation hypothesis revisited. British Journal of Psychiatry (2005) 186: 361-363

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Donna Tooth

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Year 4 Medicine, King’s College London donna.tooth@kcl.ac.uk Donna is an active the British Medical Association Donna Tooth is an activeTooth member of themember British ofMedical Association (BMA), (BMA), sitting on the board of a number of student committees. sitting on the board of a number of student committees. She ensures the views She ensures the views of her GKT colleagues are heard at a national of her GKT colleagues are heard at a national level, a represents the views of level, a represents the views of fellow students to the UK Foundation fellow students to the UK Foundation Programme Office Medical Student Programme Office Medical Student Board. andfinds time to be a Board. andfindsmum-of-one. time to be aWe mum-of-one. We she asked what shefor feltthethecoming asked her what felt her the priorities priorities for the year coming year were at a national level. were at a national level. The year ahead is a time of change with the government looking to review the funding of medical education, and talk of the Foundation Programme Application process evolving too. The BMA student committee is working hard to represent student views, and it’s going to be a busy year! Here’s a flavour of what’s on the agenda over the next 12 months, and how you can get involved. 1. Shaping new funding proposals for NHS students If you are one of the many healthcare students relying on the NHS Bursary to support yourself through your undergraduate years, you should know that this funding may be about to change. This year, the government published a document setting out proposals to change the NHS Bursary Scheme1. The BMA is asking for student views on the options presented in this paper, and we will be running focus groups at each medical school this winter, to find out how you feel about the current funding scheme, and what you think about the new proposals put forward by the Department of Health. Contact your BMA student rep to find out when and where your local meeting will be taking place, and come along and have your say. Your views will then form part of our response to the government consultation, and help to shape the future of the bursary scheme. 2. UK Foundation Programme Office (UKFPO) Much debate has surrounded this, the current system being used to allocate medical graduates to their first ‘foundation’ jobs. Earlier this year the BMA conducted focus groups in medical schools as part of a consultation on the future of the foundation programme application system. Through the input of medical students the MSC were able to feed into the consultations process and effect change.

process, as well as information provided by the applicant’s medical school. In addition, a ‘Situational Judgement Test’, similar to the one faced by prospective trainees for the GP scheme is going to be piloted as part of the new Foundation Programme application process. We anticipate that the earliest a system like this would be implemented is for the application round of 2012-13, but small scale pilots are likely to happen from as early as next year. A larger pilot is planned for applicants in the 2011-12 cohort. On an individual level, I’ve also been helping current GKT finalists to make their applications, and now that the forms are in, I’ll continue to offer advice throughout the process.2 If you need some additional help with this process, contact your local school representative or visit the UKFPO website. 3. Medical Students’ Conference This year’s conference will be at the University of York on the 9th and 10th April. Here BMA members will set the agenda for the 2010-2011, looking to build on the work currently being done by the Medical Students’ Committee. You can get more information on this from the BMA website, which will be updated throughout the year.3 We need your ideas for issues that need debating at the conference, and your local representative will be in touch before Christmas. Through the work of the BMA, and on behalf of those I represent, I hope that I can usefully contribute to ongoing debate around medical education - issues of funding, access, and hours and fair selection will always be on the agenda, and hearing the views of as many medical students as possible is really important to ensuring we are an inclusive body, who can put forward a truly-representative point of view to this country’s health-makers, movers and shakers. It’s more important than ever that you get involved with this work, so have a look at the website, come along to one of our events or get in touch with your local BMA representative to find out what’s going on. References & Useful Links 1.

At a recent board meeting, tentative plans were laid out for the future of our Foundation Programme application system. Following a rigorous cost-benefit analysis, two options came out on top. Although at this early stage we don’t yet know the details of which proposals will be taken forward, we expect educational performance to remain a key determining factor in the selection

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Supporting our future NHS workforce: a consultation on the NHS Bursary Scheme http://www.dh.gov.uk/en/ Consultations/Liveconsultations/DH_105110 UKFPO: http://www.foundationprogramme.nhs.uk/pages/home Careers Advice podcasts: http://www.foundationprogramme. nhs.uk/news/story/careers-advice-podcast-now-live BMA Medical Students Conference http://www.bma.org.uk/whats_ on/branch_practice_conferences/mscconference2010.jsp?page=1 MSC Local Representatives: http://www.bma.org.uk/representation/ local_representation/medical_student_reps/index.jsp

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Breaking into the world of NGO medicine Laura James

Year 4 Medicine, King’s College London laura.2.james@kcl.ac.uk

Volunteer to work in a developing country and you can find yourself working with some of the most underprivileged societies in the world. You’ll have the opportunity to gain experience outside the realms of high-tech, well-equipped western medicine and to learn about major issues in global health. It also offers the chance to travel whilst studying, opening your eyes to different lifestyles and cultures. But just how easy is it for a medical student to go about organising such an experience? Many well-known humanitarian organisations, such as Medecins Sans Frontieres (MSF), Voluntary Service Overseas (VSO) and Merlin are reluctant to take medical students abroad with them. Nell Gray, who recruits doctors for MSF, explained why: “It’s an autonomy issue,” she said. “In order to provide stability for our projects, we aim to train people who are local to the area so that they are better skilled when MSF leave. At most, one in ten of our overseas staff are international. We also want our volunteers to be able to work for at least nine months in the area and to have at least one year of training post Foundation Year 2.” VSO take much the same attitude, stressing the focus on building capacity within the country they are helping, rather than parachuting in aid and assistance. They only take on skilled doctors who can pass on their expertise to local professionals. “We do not have the capacity to train people to go overseas,” said Petra Michalas, who works for Merlin, an organisation which sends medical teams into disaster zones. “So the type of people we need must already have experience.” Which presents something of a catch 22 situation. With the NGOs crying “no go”, can you be taken seriously enough to be considered for working overseas, without any actual experience overseas? Making the most of your elective part of your undergraduate training can be a good way to get started, as can having an interest in sub-specialisms which may be helpful to developing countries. “Those who have knowledge and interest in infectious and tropical diseases and HIV are useful areas of expertise for any future involvement.” says Nell Gray at MSF.

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Louise Hill who works for VSO said: “We obviously would encourage medical students to volunteer abroad, although not with VSO. Organisations such as Medsin have a Global Health Education Project which, among other things, is looking at how to make sure medical student electives are ethical and sustainable.” Medsin, is a UK based student network, which promotes health and educates members about disparities in standards and access to healthcare, both locally and globally. Global health issues are taught via special study modules, intercalated BScs, e-learning and Medsin projects and campaigns and these are all good ways of getting a taste of what working in the developing world may entail. Like Medsin, Friends of MSF is a student based organisation that aims to promote interest in global health issues. Its president, Tom Conway, a student at King’s College London, says the group aim to promote interest in global health issues and the work that MSF does. “The society attracts a lot of people who want to work with MSF in the future and we do have strong links with the organisation. We give opportunities to help out at MSF conferences and provide lectures from professional volunteers.” Holidays can turn into valuable opportunities to gain experience - it might be worth introducing yourself to the local hospital, if only to visit for the day. Alternatively, many companies exist to set up overseas placements, though these opportunities come at a cost. However, paying to be placed may make ethical sense as well as being an investment in a future career abroad. The fees you pay may go towards setting up local projects and health infrastructure, as well as offering students a safe way to get real experience of working within a different healthcare setting. Despite the NGOs’ reluctance to directly facilitate the student experience, many opportunities exist for those with an interest in working in developing countries. Forward planning, persistence and a little initiative are essential to planning a safe, interesting and worthwhile placement.

Sorce: Wellcome Images

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REPORT Useful Links: Medsin: www.medsin.org/ projects/globalhealth Friends of MSF: www.msf.org. uk/friends Na’an Ku Se: www.frontier. ac.uk/gap_year_projects/ Namibia/Namibia_Medical_Internship

Sangoh Lee a 5th year medical student at Imperial College, London, paid over £1,500 to spend a month volunteering in Namibia over the Summer break between his 3rd and 4th year. What made you decide to volunteer abroad? “I wanted to go to Africa and America for my elective and couldn’t decide on which. So I decided to use my Summer between third and fourth year as an opportunity to experience volunteering in Africa. After some searching I found a website for people wanting to go on gap years called 'Frontier'. Through them I found an organisation, which offered medical volunteering internships in Namibia and Malaysia. £1600 included transport within the country, food, accommodation and support. This was reasonable compared to other schemes I had found.” What did you do? “In Namibia’s capital, Windhoek I worked in a general hospital. I was given quite a lot of responsibility and had my own room to clerk and examine patients. I ordered and took blood, interpreted X-rays and carried out procedures like suturing.” “I then went to a town called Epukiro. The clinic was small and gave free health care to Bushmen, the poorest people in the community who are often discriminated against. Here it was quite frustrating as often there was not a lot that could be done. I bandaged a lot of burns, as sadly a lot of the children got burnt from fires that were made to keep them warm as it is winter in Namibia when it’s our summer.”

09/09/09 Pregnant Pause: Flash Mob

“I gained a lot of practical experience, I learnt how to take focused histories, work in a team, live in a different environment and see how other health care systems operated. It was generally a safe place and Namibia is a beautiful country. I would love to go back to do more.”

Useful links National Organisation on Foetal Alcohol Syndrome UK: www. nofas-uk.org Foetal Alcohol Syndrome Aware UK: www.fasaware.co.uk

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Susan Fleisher , Founder, National Organisation on Foetal Alcohol Syndrome UK

A Pregnant pause. . Imran Ahmed Year 4 medicine, King’s College London imran.u.ahmed@kcl.ac.uk It’s 9:09am in London on the 9th day of the 9th month of 2009. The concourse at Victoria Rail Station, is as busy as ever, when suddenly - stop! Without warning, hundreds of people are frozen in time, suspended mid-action. They remain stuck for a full minute, a flashmob, united momentarily, and then, as suddenly as it began, it is over and the participants just walk away. Though flashmobs are not a new phenomenon, this was one with a difference. Keen-eyed onlookers were left scratching their heads and asking - why did they all have balloons up their jumpers? From its origins in viral communications to a major marketing tool for the movie moguls, the humble flash mob has come a long way. It started as a social experiment at the beginning of this decade, with just a hundred people gathering for a giant pillow fight. The flash mob has now become a powerful customer-gaining tool for industry giants. The latest manifestation sees a strange lifeimitating-art, with street dancers bursting into action to promote the new film Fame. Elsewhere, charities are using the craze to their advantage, courting audiences not for box office returns, but to highlighting important causes. The Pregnant Pause, an event organised by the charity the National Organisation on Foetal Alcohol Syndrome UK (NOFAS-UK), was a flash mob which saw people putting not pillows but balloons up their jumpers and stopping for a minute in rush hour, in the hope that pregnant drinkers would take the time to stop and think for a minute too. It is thought that as many as 1% of children born in the UK have Foetal Alcohol Spectrum Disorder (FASD) as a direct result of women drinking alcohol during their pregnancy. NOFAS-UK was set up by Susan Fleisher, after she discovered that her daughter had this devastating syndrome. “I adopted my daughter Addie when she was three years old. At the time I wasn’t aware she had the condition and I wasn’t aware that her birth mother’s drinking would have such a severe impact on the rest of her life. The full extent of FAS became clear only when she was growing up. She had problems at school, trouble with learning, trouble with making friends. She was diagnosed with the condition at Great Ormond Street Hospital and that’s when I first heard about it. I looked for any support for individuals suffering with FAS but there was hardly anything. That’s when I decided to give up everything else and start the charity.” Now Executive Director, Fleisher has dedicated her life to helping those with Foetal Alcohol Syndrome and their families. “We have a helpline service Monday to Friday to give advice and support. We have support group meetings for parents and carers as well as playgroups for children affected by FASD. Also we hold regular conferences where we discuss FASD and provide training

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.................

sessions to educate the public about the condition... We also hold events such as our annual family picnic, and of course events like The Pregnant Pause.” “There are loads of major effects of alcohol consumption during pregnancy,” said Fleisher. “Physical effects include kidney damage, heart defects, limb damage, eye problems, hearing problems and damage to important parts of the brain. “They suffer attention deficits, memory deficits, hyperactivity, and poor impulse control. Also they have poor judgement, and have difficulty with abstract concepts so they can’t do simple maths. Most significantly they have difficulty learning from the consequences of their actions.

“The big travesty with all of this is all of these effects are 100% preventable if a woman just stops drinking during pregnancy,” she continues with some force. “Women only need to stop drinking alcohol for nine months to have healthier children and to avoid these devastating effects. People froze at nine past nine on 9th September 2009 to highlight this.” “Don’t drink during pregnancy. The safest amount of alcohol is no amount of alcohol at all.”

Those with Foetal Alcohol Spectrum Disorder are also more likely to be the victims of crime, as highlighted by the case of Mathew Verity, the first child in Britain to be diagnosed with the condition. “Mathew had never been in a proper relationship and he hardly had any friends.” explained Fleisher. “He met a younger man over the internet. Recognizing Mathew’s vulnerabilities the man pressurized Mathew for £5,000. Mathew’s naivety meant that he kept the relationship confidential. Then when the money didn’t show up, the young man waited outside Mathew’s flat, tied him up and assaulted him. Cases like this are very common with FAS sufferers.”

What is Foetal Alcohol Spectrum Disorder? A set of mental, physical and neurobiological birth defects that occur directly as a result of alcohol consumption during pregnancy. How common is it? UK prevalence is 1 in 100 births What are the specific damage areas to the brain? Alcohol deprives the brain of oxygen and thus permanently damages brain cells which can’t regenerate. This causes a reduced brain size, and regional loss, particularly of the frontal lobe. The loss of the frontal lobe means FAS sufferers have difficulties with critical thinking, reasoning and judgement.

PERSPECTIVE

Medical Notes - The Newby Name: Dr. X Age: Mid 20s Gender: Female Occupation: Foundation Year 1 Doctor

Management Plan: Advise and reassure: Get a little notebook to jot down the millions of codes & numbers because the bit of paper stuck to the wall is guaranteed to disappear/implode/self-destruct just at the moment you need it.

Presenting Complaint: Fatigue, stress and nausea caused by excessive hospital politics

ALWAYS carry a drink. Kidney stones are not much fun.

History of Presenting Complaint: Symptoms began 1/12 ago

When the fax machine AND computer AND telephone AND your bleep all break at once - STOP! Resist the urge to fling all said technology out of the window - and breathe.....

Previous Medical History: Nothing of note. Previously fit and well Drug & Alcohol History: Gin and Tonic - self administered as required. Chocolate - unable to quantify weekly units. Non-smoker (no, really!) Allergies : No Known Drug Allergies. Health and Safety lectures proving to be an irritant factor. Family History: Patient’s mother has ensured all cousins, second cousins and 7th cousins twice removed are aware that her daughter is (finally) a doctor. Social History: lsjm 30 november 2009 volume 01 Pt has experienced a marked decline in hardcore partying since qualifying.

Mistakes are bound to happen and there will no doubt be many times when your colleagues will royally p**s you off. So make sure you socialise with them – it’s much easier to forgive a friend a total stranger. And they’ll be much happier forgiving you when it all goes wrong! Never be afraid to stand up for yourself. Previously frightening colleagues will become much nicer and respect you more. Become a professional pest. Pester seniors for advice, even if they become annoyed - you are a junior and they are meant to help! You (and they) will thank me when you aren’t hauled up in front of the 193 GMC.

REPORT

The Physician Assistant

Illustration: Jonathan Hyer

Gurpreet Kharay Year 5 Medicine, King’s College London gurpreet.kharay@kcl.ac.uk

“Physician assistant” - the words conjure up the image of a hapless junior doctor struggling to keep up with his consultant on a busy ward round, juggling a mountain of files, trying to write notes as he valiantly tries to keep pace. In fact a physician assistant (PA) is not just an overworked doctor’s dream but a reality that has been in existence for nearly 50 years. Appearing in America in the 1960s1, the first physician assistants were paramedics, trained to fulfill this adapted role. These semi-autonomous practitioners are now an established part of the healthcare fabric across the pond. The role of a physician assistant involves far more than being a medic's minion. Rather, their job description seems to run in parallel with their doctor colleagues - history-taking and examination, ordering investigations, conducting referrals are all within their remit - as well as teaching medical students. They even have the power to prescribe.1 The idea, which has its roots in 17th century Europe, was originally adopted by the United States in a bid to mitigate the shortage of primary care doctors1, with some success. Now, with general practices hiring US-trained PAs to work for them, a training scheme is being piloted in the UK.Home-grown courses lead to qualification as a PA and are offered at several institutions including Birmingham University, and St. George’s Hospital Medical School2. Krista DeWys is a physician assistant at the Saint Francis Memorial Hospital in San Francisco, USA. She feels that the role offers a better work-life balance than a career as a doctor: “I wanted to be in the medical field as a professional and considered being a doctor but I also wanted to raise a family someday.”

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DeWys is one of a growing number of physician assistants working as part of the multi-disciplinary team in hospitals today. “I work in the Emergency Room and can diagnose and treat under the supervision of my attending doctor, and according to my comfort level and experience. We can order investigations, diagnose, treat and prescribe but we are more limited than doctors. Legally, we can not work unless under a supervising physician.” Although pleased with the more flexible nature of her role, she says the job is not without its drawbacks, mainly in the attitudes from colleagues who know little about the position, but may have preconceived notions about the usefulness of a PA. “There sometimes is a lack of support from attending physicians,” she says, “and the pay is also much lower than that of a doctor, even though we sometimes we do just as much as a doctor or more.” After graduating from University, DeWys trained as a physician assistant, and then sub-specialised in Emergency medicine. Nonetheless she acknowledged that the limitations of her role can sometimes be frustrating. “It can be frustrating when you feel your lack of experience may limit your ability to treat. I think more training and stricter requirements for pre-PA school would help address this. But I also think that educating doctors about our role would help our skills to be better used within the team.” References 1. 2.

www.paworld.net/whatpadoes.htm www.wlv.ac.uk/default.aspx?page=14123

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PROFILE

Profile: PA Amy Green and Neil Howie both chose the physician assistant route into a hospital career, and are student representatives from the UK Association of Physician Assistants. What made you decide to be a PA? AG: I was drawn to the profession for several reasons. It is a two year postgraduate course and, even though it is incredibly intense training, it is perfect for graduates looking for a profession based on the medical model that is not medicine itself. The physician assistant role is still largely unknown in the UK which can come with disadvanatges as formal registration is still being developed, but there is the opportunity to qualify in two years if you pass the university exams and the national exam. There is a regular revalidation exam which aims to keep the standard high for all physician assistants over their careers. Whilst this is not medicine and we are not doctors, there is a great deal of demand for physician assistants in all healthcare environments as we are trained to deal with all medical conditions and perform many medical procedures. What are the application requirements? NH: There are four universities in the UK which offer the physician assistant diploma. The University of Birmingham, University of Wolverhampton, St. George's University of London and University of Hertfordshire. For Wolverhampton, applicants need either at least a lower second class degree in a biological science, nursing, an allied health profession, or chemistry; or a diploma in nursing or paramedic science plus two years or more profesional experience. AG: At Birmingham, it's a minimum upper second class degree in a life science or allied health profession, as well as chemistry A-level at C grade or more, plus at least B grades in Maths and English GCSE. And for St. George's, University of London, applicants need a second class honours degree in life sciences or a health-related subject, and it must have been achieved within the last five years. What are the main ways a PA's job differs from the more established medical professions, such as nurses or doctors? AG: A physician assistant is part of the medical team and is trained to perform duties under the supervision of a doctor. There should be no confusion between the roles of a physician assistant and a doctor as we do not have the depth of knowledge or the same qualifications. We are physician 'extenders' rather than replacements. There are many different qualifications nurses can take to develop their skills and their careers, such prescription rights, and so nurses have the opportunity to work at very high levels with supervision.

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All these professions are striving to achieve the best possible care for patients and there may be crossover in certain duties but it is down the individual and the supervising doctor as to the specific role of the physician assistant in that firm and the duties they can perform competently. A physician assistant is trained to act as a generalist and this means being able to do a wide variety of procedures and manage many medical conditions but no medical professional should ever act beyond their competence. How much responsibility do PAs have for patients? AG: Physician assistants are trained to take histories, order tests, plan treatments and prescribe medications. However, a PA must act under the supervision of a doctor and therefore the full responsibility lies with that doctor. Is there scope to progress in the career of a PA? NH: PAs do not progress along a career path like, for example, a doctor might. However involvement in PA education is one route open. In America, PAs have gone on to hold positions such as directors of clinical research institutes in the same way a doctor would. PAs can specialise to a certain extent, but must retain generalist status by resiting the national exam. What are the positives of being a PA? NH: It's great being able to be hands on with patients and knowing this won't change throughout your career as a PA, as is not having to worry about advancing along the medical career path with all the new requirments, title changes and worry about getting a training post. The role doesn't tie you down to one area of the country. It's exciting to be part of something so new. And what are the negatives? NH: The uncertainty over registration and the limitations this brings in terms of prescriptive powers and ordering x-rays is sometimes frustrating, as is the lack of public and professional understanding about the role. Many doctors and medical students have some strong views about PAs but when pressed will admit to not actually knowing what PAs do, how they are trained or the history of the role. It is a knee-jerk reaction that is based on fear that the Government is trying to replace doctors on the cheap.

Amy Green

How do you think this misconception can be changed? NH: As people increasingly come into contact with physician assistants when they come to hospital, or see them portrayed on shows such as Casualty and Holby City, they'll get to see what we really do. Doctors should be taught about the part that PAs can play in the healthcare team while at medical school. Or perhaps their professional bodies such as the GMC or the Royal Colleges can educate them about the PAs' remit. Ultimately, it will be through working with talented PAs that our medical colleagues will see that PAs are neither a threat, nor a danger. Rather they can do a good job and help with the smooth running of the healthcare team.

Neil Howie

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CROSSWORD

Wellbeing of Women in association with the RCOG is delighted to announce grants available in 2010 for research in gynaecological cancer, pregnancy and birth or quality of life issues: 1. Research Training Fellowships

The purpose of these awards is to encourage medical graduates to pursue a career in academic medicine. Applications may be in any aspect of basic science, clinical or translational research including feasibility studies. Fellowships are awarded for up to three years and cover the cost of a full time salary per annum for Specialty Registrar grade (or equivalent). Registration fees for a higher degree and reasonable research expenses may be allowed. The upper limit of this award is £175,000.

Across 2 Kidnap; moving a limb or other body part away from the midline (6) 4 Terminal organ of the lower limb; 12 inches (4) 10 High potassium (13) 11 Lobe of the brain behind the frontal; contains sensory cortex and association areas (8) 14 Whitish crescent shaped area at the nail base (6) 15 Group of mammals considered by some as vermin; ulcer associated with basal cell carcinoma (6) 17 Itching (8) 18 What you aim for; red blood cells with central staining, a ring of pallor, an outer rim of staining e.g. in liver disease, thalassaemia and sickle cell disease (6) 21 Coldplay classic; this fever is an infectious disease of tropical Africa and Southern America transmitted by Aedes mosquito (6) 22 Rod shaped bacterium (8) 24 Name associated with the plantar reflex (8) 25 Flat circumscribed area of skin or an area of altered skin colour (6) Down 1 Name associated with paradoxical rise in JVP with inspiration (8) 3 Purified cardiac glycoside extracted from foxglove (7) 5 Fourth cranial nerve (9) 6 Proton pump inhibitor; 'Losec' (10) 7 Paediatrician's name associated with testing a drop of blood to exclude phenylketonuria (7) 8 FK506, immunosupressant discovered by the Japanese (10) 9 His syndrome is rheumatoid arthritis with pneumoconiosis; treated with steroids (6) 12 Inflammation of the wall of a vein (9) 13 This ligament forms the floor of the inguinal canal (8) 16 Cell type of carcinoma of the bronchus with darkly staining nuclei and scanty indistinct cytoplasm; in porridge (3) 19 Satellite of Saturn; first cervical vertebra; collection of maps (5) 20 A rare and relatively benign form of muscular dystrophy of pelvis-girdle type with better prognosis than Duchenne's dystrophy; Wimbledon's youngest men's singles winner (6) 23 Disease associated with spirochaete Borrelia burghdorferi; sounds like a citrus fruit (4)

Wellbeing of Women is delighted that our partnership with the Wellcome Trust will continue. Suitable candidates may be considered by the Trust for the award of a Wellbeing of Women/Wellcome Trust Research Training Fellowship.

2. Entry Level Scholarships

Entry-Level Research Scholarships are to provide ‘pump-priming’ funds to enable trainees to be exposed to a research environment, or to obtain pilot data for bids for definitive funding. Applicants will normally be within the first few years of graduation, and would not previously have been involved in substantial research projects. Scholarships may be held in basic science, clinical or translational research and are a single payment up to a maximum of £20,000 to go towards salary and/or laboratory costs. All awards must be undertaken in the UK.

The closing date for both awards is 2nd March 2010. Application forms are available from the Wellbeing of Women website www. wellbeingofwomen.org.uk

For more information please contact Ann Haysom, Research Grants Manager, Wellbeing of Women, 27 Sussex Place, Regent’s Park, London NW1 4SP (email: ahaysom.wellbeingofwomen@rcog.org.uk; tel: 0207 772 6458).

WEIGHING UP THE COSTS

Wellbeing of Women 196

Charity Registration No: 239281

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LSJM NEWS

The LSJM ... Attends the Scalpel Conference in Manchester Represented by Surgery panellist Kartik Logishetty, the LSJM attended the Scalpel Undergraduate Surgical Conference 2009, held on 7 November 2009. It was an opportunity for UK medical students to present original research, audits or interesting case studies at a national conference before both their peers and senior surgeons. As part of the LSJM Surgery’s partnership with Scalpel, the winning poster and essay will be published in the next edition of the journal in 2010. Welcomes a new Patron The LSJM has been honoured to receive a new Patron - Karen Middleton. Middleton is Chief Health Professions Officer for England and is the Government’s most senior Allied Health Professions advisor. She is excited to support the LSJM in its endeavours to bring all students of the various health sciences together under a common umbrella of academic journalism and healthcare education. Attends the Allied Health Professionals Conference The LSJM attended the Faculty Graduates 5th Annual Research Conference held at Kingston University, London on 11 November 2009. The theme was ‘Practice development in action: making a difference.’ Head of the LSJM Allied Health Division, member of the LSJM Founding Committee and physiotherapy student Charlotte Spelman, gave a presentation of the Journal at the interprofessional debate lecture. Spelman called for greater allied health involvement in the LSJM from students and staff, be it as authors, editorial staff or reviewers. Chief Health Professions Officer for England and LSJM Patron Karen Middleton was a guest of honour at the conference.

Receives the Student Experience Award The London Student Journal of Medicine received £1500 from the Student Experience Awards (SEA) in August 2009. The SEA is an annual competition, funded by alumni of St George’s University of London, supporting endeavours that aid a cross-section of the student population and rewarding learning initiatives. The LSJM, originating at St George’s was eligible for the award. Funding will go towards improving the journal’s website and future LSJM events. Has Staff Vacancies for 2010 The LSJM is now recruiting staff for the next volume of the LSJM starting in Feburary 2010. Though based in London, the LSJM primarily works through a virtual office therefore all vacancies (except editors-in-chief) are open to students in healthcare across the UK. Face-to-face staff meetings are kept to a minimum in consideration of healthcare students’ busy timetables and placements. Working with the LSJM gives invaluable experience in medical journalism. It is an excellent opportunity to meet and work with students from various universities. Join us by submitting a cover statement and CV to co-ordinator@thelsjm.co.uk and to the section of your choice: surgery; psychiatry; medicine; gch; hle; or careers@thelsjm.co.uk.

Vacancies: Editors-in-Chief; Section Editors; Section Panellists; Allied Health Representative; peer reviewer; University Rep; Layout and Design Deadline 31 January 2010 Illustration by Elaine Parker: Inspired by LSJM’s feature series on obesity Pg. 164

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ABOUT US About theLSJM

Objectives

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.

Key Objective To promote the science and art of medicine among tomorrow’s healthcare professionals through journalism. Critical Objectives

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) Vishal Navani (BA(Oxon) Year 5 MBBS Imperial College) 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 DOI: 10.4201/LSJM

Kevin Owusu-Agyemang

Sonia Damle

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Jonathan Cheah

Milan Makwana

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

Laura Vincent

Harpreet Sood

Alexander Ross

Sandra Sadoo

Samuel Ponnuthurai

Vishal Navani

Nana Seiwaa Opare

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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) Ben Collard 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

Charlotte Spelman

Nida Rashid

Catherine Rees

Tanya Mitra

Kalpesh Vaghela

Sneha Varkey

Jennifer Clough

GCH@thelsjm Editors Vishal Navani and Harpreet Sood Panel Katherine Sharrocks (Administrator) Hina Khan Sophie Roberts Angela Fanshawe Sneha Varkey Elena Atkinson

Proof Readers@thelsjm Michelle Attz Mukhtart Bizrah Sarah Gentry Mohamed Hussein Charlotte Spelman

Design@thelsjm Designers Jonathan Hyer (Creative Director) Robert de Niet Illustrators Ella Beese Nathalie Epperlein Yasmin Jaffar Nana Hene Koduah Elaine Parker

Panel Nicola Hood Deepak Kumar Rachel Baigel Amin Golmohamad Saarah Ebrahim

Humaira Kamil

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Rebekah Robson

Amin Golmohamad

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