Oxford Medical School Gazette Issue 64(3)

BOUNDARIES

11 Is it mental or physical, Sir? 21 The Tortured Genius

24 Death and the Medical Student

A Cure for Paralysis 52

Man Ex Machina 54 Ebola: Beyond Barrier Nursing 74

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OXFORD MEDICAL SCHOOL GAZETTE COMMITTEE Editors: Nicola Kelly, Amrit Gosal Sub-editors: David Gleeson, Edward Matthews, Claudia Snudden, Emma Pencheon, David Rowland, Charles Coughlan, Giles Neal, Eva Dumann, Bing Tseu, Thomas Stewart, Selali Fiamanya, Laura Munglani News Editor: Elizabeth Whatling Book Review Editor: Reza Khorasanee Design: Evie Kitt Patron: Professor Sir John Bell, Regius Professor of Medicine Honorary Treasurer: Mr Stephen Kennedy Senior Members: Dr Tim Lancaster, Dr Peggy Frith, Dr Sue Burge and Dr Vanessa Venning OMA Liaison: Dr Peggy Frith Alumni Officer: Jayne Todd Accounts Officer: Christine Lees-Baxter Development Officer: Charlotte Pallett Oxford Medical School Gazette (OMSG) is the oldest medical school journal in the world.

OMSG is produced by the students of Oxford University Medical School for the enjoyment of students, doctors, alumni, academics and any other interested readers.

OMSG may not reflect the views of Oxford University Medical School itself. The views of our writers do not necessarily reflect the views of the Gazette staff.

The Gazette is a not-for-profit publication and relies on the generosity of advertisers and its readers to subsidise production.

If you are able to contribute in any way, all donations, either financial or in kind, are gratefully received.

SUBMITTING ARTICLES TO THE GAZETTE The Gazette welcomes submissions from students, alumni, clinicians, other health professionals and members of Oxford University academic staff. Articles do not need to have been specifically written for the Gazette. The editors reserve the right to reject, alter or amend any copy received, following discussion with the author. If you would be interested in contributing please contact the editors at editors@omsg-online.com.

SUBSCRIBING TO THE GAZETTE To subscribe directly to the Oxford Medical School Gazette please contact the editors by email at editors@omsg-online.com or by post at the address below.

ACKNOWLEDGEMENTS The editors would like to thank the members of the senior committee, Jayne Todd, Karen O’Brien and the Medical School Office Staff for their hard work and helpful input. Particular thanks to Robin Roberts-Gant from the Medical Informatics Unit who has, as ever, given tremendous support in producing this issue of the OMSG. ILLUSTRATION AND PHOTOGRAPHY Many of the images used in OMSG are produced by members of the medical school and we thank all those involved in the modelling, photography, and illustration of this issue. Images without specific acknowledgement are outside copyright and freely available.

COMMUNICATION Oxford Medical School Gazette, Medical Sciences Office, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU. PRODUCTION Medical Informatics Unit, NDCLS, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU. Telephone +44 (0)1865 222746 COPYRIGHT NOTICE Š 2015 The editors of Oxford Medical School Gazette (OMSG) and the contributors to OMSG. All rights reserved. The contents of this publication may not be reproduced in whole or in part without the express prior written permission of the editors.

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6Through Through thick thick andand thin:thin: thethe bugs bugs within within Henrietta Henrietta MillsMills wonders wonders whether whether the microthe microbiomebiome mightmight be the be key the key to controlling to controlling our our waistline waistline

CONTENTS

9“Doctor, “Doctor, where’s where’s MYMY medicine?” medicine?”

Claudia Claudia Snudden Snudden asksasks whether whether personpersonalisedalised medicine medicine will live will live up toupthe to hype the hype

50nicBionic eyes:eyes: the new the new windows windows to theto soul? the soul?

Antonio Antonio Ji XuJi considers Xu considers the use the use of visual of visual prostheses prostheses to restore to restore sightsight in the in blind the blind

11IsIsit itmental mentalororphysical, physical,Sir? Sir? Daniel Daniel Murphy Murphy examines examines the problems the problems facedfaced by mental by mental healthhealth services services in today’s in today’s NHSNHS

52 A cure for paralysis Peggy Peggy FooksFooks updates updates us on us the on state the state of of spinalspinal cord cord injuryinjury research research

14Neurology Neurologyand andpsychiatry psychiatry – different – different and and yet the yet same? the same?

Clinical Clinical student student Angela Angela Sheard Sheard argues argues the the casecase for neuropsychiatry for neuropsychiatry as aas new a new specialty specialty

54 Man Ex Machina Alec Alec NoarNoar and and Freddy Thurston investigate Freddy Thurston investigate how how neural prosthetics can can interact directly neural prosthetics interact directly with with our brains... our brains...

19Neuropsychiatry Neuropsychiatryforforthe the21st 21stCentury Century Preclinical Preclinical student student Marco Marco Narajos Narajos explores explores the no-man’s the no-man’s land land between between psychiatry psychiatry and and neurology neurology

56Boundaries BoundariesofofHuman HumanCommunication Communication DavidDavid Rowland discusses how brain-comRowland discusses how brainputercomputer interfaces interfaces could change the future could changeof the human communication future of human communication

21The Thetortured torturedgenius genius Natalia Natalia Cotton Cotton sets sets out to outuncover to uncover if great if great art really art really is born is born from from greatgreat pain pain

58Magic Magic Numbers: Numbers: Social SocialCircles Circlesand and Community in the Century Community in 21st the 21st Century Charlie Coughlan surveys the the shifting Charlie Coughlan surveys shifting sandssands of our networks of social our social networks

24Death Deathand andthe themedical medicalstudent student Jonathan JonathanAttwood Attwoodrecommends recommendsfrankfrank discussion discussion aboutabout this this delicate delicate subject subject

63Whst in yoga in yoga Whenmeets East West: meets frontiers West: frontiers JulieJulie Bolitho-Lee thinksthinks aboutabout whatwhat it it Bolitho-Lee means to live a ‘yogic life’ life’ means to live a ‘yogic

27 Carer Carer vs. vs. Daughter Daughtervs. vs.Medical MedicalStudent Student Anonymous Anonymous

66Medicine Medicineononthe theEdge Edge Nicola KellyKelly opensopens our our eyeseyes to medicine Nicola to medicine in extreme environments in extreme environments

30 Oh, how lovely!

RubyRuby Carrington Carrington reflects reflects on what on what it means it means to beto an be obstetrician an obstetrician 32 Doctors under scrutiny Yoni Yoni Dennis Dennis explores explores how how the the risingrising expectations expectations of the of public the public are affecting are affecting the the patient-doctor patient-doctor relationship relationship 36 The The all-seeing all-seeingeye: eye:GMC GMC regulation regulation vs vs doctors’ doctors’ privacy privacy Michael Michael GachGach questions questions whether whether the private the private lives lives of doctors of doctors should should be regulated be regulated

68 Read This If You Don’t Have Time Jay Jay Ghanashyam Shetty explains why why we we Ghanashyam Shetty explains should all make time time to meditate should all make to meditate 70AA triple childhealth healthfromfrom triple export ofof child Oxford Oxford to Uganda to Uganda HelenHelen SimsSims Williams shares the the storystory of of Williams shares threethree Oxford graduates Oxford graduates 74Ebola: Ebola:Beyond BeyondBarrier BarrierNursing Nursing Emma Pencheon contemplates the the EbolaEbola Emma Pencheon contemplates crisiscrisis

38 In defence of la mode française Dominic Dominic Ballard Ballard advocates advocates a return a return of the of the banished banished whitewhite coat coat

78News News Elizabeth Whatling keepskeeps us inusthe Elizabeth Whatling in know the know

40 Duties of a doctor?

Rachel Rachel McGalliard McGalliard needsneeds a cup a cup of coffee! of coffee!

79Frith FrithPrize Prize We We present the the winning photos from from this this present winning photos year’s Frith Frith Photography PrizePrize year’s Photography

42High Hightime timeforforchange change––What’s What’s sto stopping us?

Edward Edward Matthews Matthews argues argues for the for need the need to to re-evaluate re-evaluate our stance our stance on drugs on drugs

81Schools’ Schools’Essay EssayPrize Prize We We present the the winning essayessay from from this this present winning year’s competition year’s competition

47 The Thephilosophy philosophyof ofcognitive cognitive enhancement enhancement Elective Elective student student ChadChad BeyerBeyer wonders wonders whether whether therethere is more is more to the to the argument argument than than mental mental gains? gains?

82From Fromour ourarchives archives 84Book BookReviews Reviews 85Subscription Subscriptionform form

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A Note from Design The design of ‘Boundaries’ employs exciting and contemporary stylistic choices in a play on traditional magazine layout, so that the issue itself challenges the ‘boundaries’ of editorial design. I hope you enjoy this issue as much as I did designing it.

If you have any queries, or would like to get involved, please do not hesitate to get in touch at: design@omsg-online.com Evie Kitt, Head of Design design@omsg-online.com

Full references available at: www.omsg-online.com

Evie Kitt is a Fine Art graduate of The Queen’s College

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64(3) EDITORIAL

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We’ve chosen ‘Boundaries’ to be the theme for this, our final issue. Boundaries, limits, frontiers, barriers: with both positive and negative connotations, these have the potential to restrict or challenge human ambition.

Be sure to read David Rowland’s futuristic exposition on the boundaries of human communication. A beautiful article by Julie Bolitho-Lee then delves into the mysteries of yoga and challenges us all to be open-minded in our approach to medicine.

We start on the microscopic scale, with Henrietta Mills’ discussion of the power of the microbiome in weight management. Her informative piece may well have you reaching for a probiotic drink…

As promised in our editorial for ‘Inequality’ (64(2)), we are proud to present the winners of our two competitions. Firstly, enjoy the stunning work produced by the winning entrants to the Frith Photography Competition. Next, we are delighted to publish an essay by Madeleine Turner, winner of our Schools’ Essay Competition. Congratulations to all of the winners and runners-up – the standard of both these competitions surpassed all expectations.

This issue has a strong focus on the mind-body divide.

Whilst Daniel Murphy considers the difficulties facing mental health services in the modern NHS, Angela Sheard and Marco Narajos question the relevance of the split between neurology and psychiatry.

Moving on, we encounter Jonathan Attwood’s commentary on the oft-avoided topic of death. The subsequent article, written by an anonymous contributor, addresses an even more personal and difficult subject. As medical students, boundaries between our personal and ‘professional’ lives can serve both to protect and frustrate, and leave us questioning our own views on humanity. We hope that you will take time to reflect after reading this piece.

Yoni Dennis and Michael Gach consider the clash between public expectations and doctors’ right to privacy. In the digital age, we are constantly reminded to moderate the content of our online presence and to uphold our professional identity. Meanwhile, Dom Ballard thinks that we have much to learn from our colleagues across the Channel, a must-read before you hit the high street in search of new ward-clothes!

From body to mind, we are pleased to present a range of articles examining this nebulous interface.

After this issue, we hand over to Edward Matthews and Claudia Snudden, incoming Editors-in-Chief. We have no doubt that the Gazette will flourish under their capable leadership and await their first issue with eager anticipation. We wish them the best of luck for the coming year.

We’d like to thank all of the team: our hard-working sub-editors, News Editor Elizabeth Whatling, and Development Officer Charlotte Pallett. We must also give special thanks to Marco Narajos, our splendid Online Editor, whose sterling work has seen the website transformed. Finally, we would like to thank our magnificent Design Lead, Evie Kitt. It has been wonderful working with such a talented artist to create the print copies we are so proud of.

Thank you for reading the Gazette this year. It’s been a pleasure.

Nicola Kelly and Amrit Gosal Editors-in-Chief, OMSG 2014-15

THE OMSG EDITORS-IN-CHIEF, NICOLA KELLY AND AMRIT GOSAL

editors@omsg-online.com | www.omsg-online.com

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THROUGH THICK AND THIN: THE BUGS WITHIN A LOOK AT HOW THE MICROBIOME MIGHT BE THE KEY TO CONTROLLING OUR WAISTLINE

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etween 2012 and 2013, the number of eating disorderrelated hospital admissions in England rose by 8%1. Meanwhile, the rise in obesity is seemingly incessant, with its prevalence predicted to climb to more than 50% of the adult British population by 2050. In brief, it would appear that we are diverging towards a society of weight extremes.

Unsurprisingly, there is more pressure than ever before to resolve these issues, with attention shifting to focus on previously neglected factors influencing appetite and metabolism.

Into this mix we must add the remarkable ascension of the gut microbiota, long regarded as a mere bystander but now touted by many as a key player in health and disease.

Indeed, we are bombarded with advertising pertaining to the ability of “friendly bacteria” to influence everything from our mood to the development of cancer. So, could it be that the microbiota is more than a passive passenger with respect to our weight – or do the naysayers have it right, is it all “pseudoscience” cooked up to convince us to reach for that little bottle of probiotic drink?

THICK There have been musings that gut bacteria could be involved in the aetiology of obesity for some years.

This thinking was lent credibility when comparison of gut bacteria from mice and humans revealed significant differences between obese and lean individuals, culminating in the description of an “obesity associated gut microbiome” 2. Here, the relative contribution of the two

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THERE HAVE BEEN MUSINGS THAT GUT BACTERIA COULD BE INVOLVED IN THE AETIOLOGY OF OBESITY FOR SOME YEARS

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main gut-colonising phyla, namely Bacteroidetes and Firmicutes, to the microbiota of obese and lean individuals was assessed. In the obese, there was a relative abundance of Firmicutes, whilst the opposite was true of their lean counterparts.

Crucially, transplanting the Firmicutesrich microbiota of an obese mouse into a germ-free mouse led to more weight gain than an equivalent transplantation from a lean mouse, despite no significant difference in food consumption.

The idea of transmissibility of obesity via gut bacteria was developed when it was shown that transplanting the microbiota from human twins discordant for obesity into germ-free mice transmitted the phenotype of the donor twin (obese or not) to the recipient mouse3. Whilst no exact mechanisms were elucidated to explain a link between differing bacteria and host metabolism, some important observations were made. The investigators found that the obese mice had significantly higher serum levels of branched chain amino acids (BCAAs) than the lean. BCAAs have been related to obesity and diabetes in their own right4 and here, the BCAA level was found to correlate positively with one particular Firmicute, Clostridium hathewayi. Although this is far from concrete evidence, it does suggestive some connection between the “obese microbiome”, BCAAs, and metabolic malfunction.

THIN Thus far, the microbiota has been presented as something of a “fait accompli”; one set of bacteria for the obese and another for the lean. In reality, the composition of the microbiota is incredibly dynamic. Whilst it is postulated that gut bacteria have the capacity to affect metabolism and, by extension, weight, they are themselves affected by host factors such as diet. Indeed, dieting shifts

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DIETING SHIFTS THE BALANCE OF BACTERIA AWAY FROM THE “OBESE MICROBIOME”

microbiota is known to change within a week of a gastric bypass, but the question of whether this could be actively involved in the metabolic sequelae of the surgery has not been adequately addressed. Last year, a group in Boston began to unravel the Beyond dieting, one particularly involvement of the microbiota using extreme situation to consider is a murine model of gastric bypass gastric bypass surgery. Although surgery6. the success of this procedure (as quantified by weight loss) relies Firstly, the changes in bacterial in part on the physical barrier to composition paralleled that seen in excessive food intake together with a humans following this operation; such reduction of nutrient absorption, this as increases in mucin-degrading is not the whole picture. Following bacteria and concomitant decreases the procedure, alterations in param- in Firmicutes. Secondly, transfer of eters including gut hormone secretion the microbiota from the operated and glucose homeostasis have been mice to unoperated germ-free mice reported even before appreciable led to decreased weight relative weight loss. The composition of the to the germ-free recipients of the the balance of bacteria away from the aforementioned “obese microbiome” towards a microbiota characterized by abundant mucin-degrading bacteria, as this ability confers an advantage in a nutrient deficient environment5.

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microbiota from sham-operated animals. This finding strongly supports the idea that the altered microbial composition of the gut following gastric bypass surgery is directly involved in the ensuing weight loss.

VERY THIN Inevitably, given the changes in microbial composition accompanying excessive weight gain, changes associated with the excessive weight loss in eating disorders have also come under scrutiny, albeit to a lesser extent. In a recent study, the established rodent model for anorexia nervosa, activity based anorexia, was used to investigate changes in the microbiota of anorexic animals compared to their healthyweight counterparts4. The authors also measured serum levels of the appetite-related hormones, leptin and ghrelin. Levels of ghrelin positively correlated with these anorexic-associated bacteria, whilst the opposite was true of leptin, which was in keeping with their respective rise and fall in anorexia. The position held by ghrelin and leptin in the pathophysiology of anorexia remains controversial but one intriguing idea is that the microbiota may influence the production of auto-antibodies against appetite-related hormones7.

LIMITATIONS AND BEYOND Comprising over 100 trillion bacteria and 100 times the number of genes in the human genome, it is little wonder the microbiota has been dubbed “the forgotten organ”. Whilst an emerging body of evidence points to a role for the microbiota in helping to shape the nation’s waistline, the situation is far from clear cut8. One thing is apparent, the “propaganda” surrounding gut bacteria devalues important science; it won’t be a one-size-fits-all with Yakult as a miracle cure, but unraveling the contribution of the trillions of bacteria in our gut to metabolism and beyond could direct new strategies for tackling the ever-topical issues of obesity and eating disorders. I

Full references available at: www.omsg-online.com

Henrietta Mills is a fifth year medical student at Jesus College.

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“DOCTOR, WHERE’S MY MEDICINE?” PERSONALISED MEDICINE - A FUTURISTIC REVOLUTION IN PATIENT CARE, OR MERELY AN OVERHYPED CONCEPT WITH LIMITED POTENTIAL?

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ndeniably one of the ‘buzzwords’ in science and medicine at the moment, the notion of personalised medicine offers exactly what it says on the packet: a treatment package tailored to the individual. Based on the idea of individualising treatment choices according to the molecular traits of a patient’s genome, together with the microbial profile of any organism involved, personalised medicine is built on the concept that each of us will have slightly different disease susceptibilities and predispositions.

Historically, you could argue that the lack of standardisation in treatment resulted in customised healthcare for the patient. However, with the more recent adoption of evidencebased medicine, backed by scientific experimentation and clinical trials, standardised application of therapies is the new norm.

Responses and side effects to treatments will nevertheless continue to vary among patients though; the difficulty we now face is how to individualise medicine with an evidence-based approach.

For personalised medicine to really take off, a huge number of changes and developments must take place.

We need to expand our repertoire of disease biomarkers, integrating these into new lab tests to identify and accurately subgroup patients. In order to target treatment based on genotype, we need to develop a whole host of new and specific drugs. We also need to consider how the large amounts of patient genetic data, hospital laboratory results, medical records and treatment information can be integrated electronically into a coherent, manageable system that can then be used to deliver patient-centred healthcare.

Despite all the benefits personalised medicine can bring, it faces a multitude of challenges1. New drugs require clinical trials; as drugs become more targeted and specific, recruitment of eligible, genotype-matched volunteers for testing will become increasingly difficult.

In a similar fashion, there is the risk that genetic minorities could become ‘therapeutic orphans’ if the pharmaceutical industry decides it is not profitable to develop drugs targeted at these smaller markets.

With the inevitable increase in genetic testing, action must be taken towards preventing the potential discrimination that could result from knowing your predisposition to different diseases.

In the ethical and legal debate, a number of issues arise: should it be mandatory to ask for informed consent before all forms of diagnostic testing? How would patients’ privacy be protected? Who should be given access to patient’s genetic data, and how much data will be made visible?

Sequencing of large segments of the genome as part of the testing process could inevitably unveil more personal information than requested through the original test; the question of how to deal with this problem is, as yet, unresolved.

Given all these factors and the huge effort and cost required, realistically we are a very long way off seamlessly integrating personalised medicine into our daily management of patients.

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PERSONALISED MEDICINE IS BUILT ON THE CONCEPT THAT EACH OF US HAS SLIGHTLY DIFFERENT DISEASE SUSCEPTIBILITIES AND PREDISPOSITIONS 9

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Nonetheless, there are certain areas of medicine in which a personalised approach to disease is already being applied; classically these include genetic conditions and chronic management of certain diseases (for example some leukaemias).

Yet the biggest potential for personalised medicine within the next decade, in my opinion, lies in its application to infectious disease. If we were able to incorporate the use of novel molecular microbiology techniques into the diagnostic cycle, allowing the rapid identification of microbes and their antibiotic resistance profiles, tailored treatment plans could be formed within the first critical hours of care.

At the moment, a diagnostic cycle is commenced following a patient admission to hospital with a suspected infection.

This process, as depicted in the flowchart, is cumbersome and inefficient; reliant upon culture-based microbiology that has a 24-hour-plus turnaround time. By the time the causative microbe has been correctly identified, empiric treatment has usually already been started. Our use of broad-spectrum antibiotics in these situations is one of the biggest contributors to growing antibiotic resistance and the resulting emergence of superbugs.

What if we could reduce the diagnostic cycle to a couple of hours? In the era of personalised medicine, patient samples (e.g. blood) would, theoretically, be processed instantly at the bedside by hand-held devices incorporating molecular technologies2, 3.

Targeted treatment, specific to the patient, the microbe, and its resistance profile, could then be commenced, maximising the efficacy and speed of our disease management.

Before point-of-care testing can be brought to the bedside, further work is needed to develop cost-effective, molecular-based tools that can be handled by clinicians. This is not unrealistic given current advances in molecular microbiology; indeed there is already significant work being done in these areas and certain rapid diagnostic kits are already on the market (e.g. for detection of Streptococcus in throat swabs4). Reducing the diagnostic cycle length is also dependent on shortening both the distance and time taken for sample processing. Consequently, a more achievable goal for the short-term, I believe, is to develop multiple small-scale point-of-care labs distributed around hospitals where molecular sample management can take place5.

Though there are many challenges we must overcome before personalised medicine truly revolutionises patient management, its potential use in microbiological diagnostics may not be that far off. Not only would this allow more effective, specific, and rapid disease management, but looking at the bigger picture there would be more efficient use of resources, reduced hospital acquired infection (from inappropriate antibiotic use), and less morbidity and mortality. Let’s hope this isn’t just hype then.I

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PATIENT ADMITTED WITH FEVER & POSSIBLE INFECTION SEEN BY DOCTOR

BLOOD CULTURE/TEST REQUESTS

CLINICAL SAMPLING/BLOOD IS TAKEN

TRANSPORT TO HOSPITAL LAB

MICROBIOLOGY TESTING

LAB REPORT/RESULTS TRANSMISSION

INTERPRETATION BY DOCTOR

ALL OF THIS TAKES OVER 24 HOURS Full references available at: www.omsg-online.com

Claudia Snudden is a fourth year medical student at Green Templeton College.

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IS IT MENTAL OR PHYSICAL, SIR? DANIEL MURPHY EXAMINES THE PROBLEMS FACED BY MENTAL HEALTHCARE IN TODAY’S NHS...

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ince the rise of Cartesian Dualism in the 17th century, mind and body have been treated as materially discrete. The shortcomings of this anachronistic distinction are highlighted by modern neuroscience, as it becomes ever clearer that diseases of mind and body often share physical aetiologies. Both, therefore, warrant physical treatment and discussion of the same calibre, yet our NHS places them on uneven pedestals. Societal perceptions of mental illness, coupled with poor structure and funding of NHS mental healthcare, present real barriers to effective care.

Social stigma surrounding mental illness is discussed abstractly, often without recognising its full extent. Labelling someone as ‘mentally ill’ can be intrinsically damaging, with stereotypes abounding of reclusive or ‘crazy’ patients with whom no one would want to associate. When this is combined with commonly held misconceptions about mental illness, it is unsurprising that a study commissioned by the Scottish government this year found that almost 50% of people suffering from a mental illness would not want anyone to know1. Over a quarter of us will experience some form of mental illness in our lifetime: can we afford a society where ignorance and stereotype have a tangible effect on peoples’ health?

A key fallout of mental health stigma is the impact it has on illness behaviour. Several studies have found a link to people being less likely to seek help from their GP or other services2. This dislocation between need and treatment represents a major flaw in the way our society reacts to mental illness. It is almost unimaginable that someone with a physical illness, like flu or arthritis, would avoid pursuing treatment due to perceived stigma. We must face the uncomfortable dichotomy that someone with a mental health problem might. Thankfully, UK social attitudes surveys show that prejudices against people with mental health problems are (albeit painfully slowly) declining3.

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OVER A QUARTER OF US WILL EXPERIENCE SOME FORM OF MENTAL ILLNESS IN OUR LIFETIME

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Finding the courage to seek help in a prejudiced society is only the first hurdle, as the system charged with delivering that help is not always the most capable. It is difficult for patients to know where to turn if they feel in need of support. Websites and hotlines are available with advice, but are poor substitutes for personal, professional help afforded by NHS services.

Unfortunately, mental health services are spread widely and thinly due to structuring and funding issues4. This causes problems with integration of services for patients who straddle the guideline-imposed boundaries of mental and physical illness. Some areas have liaison psychiatry teams to help provide mental health care for inpatients being treated for physical conditions, but this should surely be nationwide5. Such limitations only exacerbate the gap between care of our minds and bodies.

It is easy to criticise mental health services without understanding their complexities.

There are several routes into and through care pathways for patients seeking mental support. In order to begin receiving care, someone may be referred by their GP or a crisis team, or in certain circumstances be apprehended by police. After a proper assessment, which could be the next day or up to a fortnight later according to patient needs, a decision will be made about how best to provide support. This could involve care from community mental health teams and other local charitable groups, self-care, or transferral to a psychiatric inpatient facility. If a patient is encountered in crisis and seems to be a danger to themselves or others, they may be detained under the Mental Health Act. Upon discharge from community or hospital care services, efforts are made to maintain contact with the patient and to construct effective risk- and crisis-management plans. Clearly, despite its best efforts, the system of mental healthcare is not always easy to navigate.

Provision of services is not equal, with different Clinical Commissioning Groups (CCGs) spending vastly different amounts on mental health6. Mental illness accounts

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for an estimated 23% of NHS illnesses, yet, for instance, the CCG for Northern, Eastern and Western Devon spent just 6.74% of its 2013 budget on mental health, and some patients with complex problems have been forced to wait up to two years for referral and treatment7. Furthermore, 8 out of 10 GPs asked this year stated that their local community mental health services were overloaded8. Failures of the system are exemplified in a case in Reading last year9. Forty-one year-old Timothy Painter had a long history of depression, and his family was concerned by his worsening condition. He was discharged from hospital without being seen by a consultant and took his own life just weeks later.

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8 OUT OF 10 GPs STATED THAT THEIR LOCAL COMMUNITY HEALTH SERVICES WERE OVERLOADED

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His case was not reviewed according to NHS guidelines, nor his family consulted about his discharge.

Clearly, the system failed to provide appropriate care for Mr Painter. The risk remains that other patients could slip through the cracks in a mental healthcare model in dire need of repair.

It is not just long-term patients who are let down by the system. At the end of last November, a 16 year-old girl with mental health problems was arrested and placed in a police cell, after which she was transferred to an adult psychiatric ward as no appropriate bed could be found on a children’s ward10. The Heath Secretary labelled this as a case of “poor communication on the ground”10, but errors in communication are no excuse for a child with mental health problems to be denied the care they need by a system out of touch with those it hopes to help. This incident has prompted a change in legislation that would see police cells being used strictly for adults, and then only as a place of safety where there are no other options11. Proper training for people who come into professional contact with people suffering from mental illness, especially those with severe acute cases, should be an obvious provision of a modern, integrated NHS. It is, however, impossible to keep grass at its greenest during a drought.

The NHS has been subjected to financial constraints in recent years, and mental health services have borne perhaps more than their fair share of the burden. According to a report this year from the Chief Medical Officer (CMO) Dame Sally Davies, mental health accounts for only 13% of the NHS budget, despite causing over 20% of illness and leading to a loss of over 70 million working days

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MENTAL HEALTH ACCOUNTS FOR ONLY 13% OF THE NHS BUDGET, DESPITE CAUSING OVER 20% OF ILLNESS

per year12. Calls have been made, goal of providing high quality, patientfrom officials such as the CMO and centred care. politicians alike, for increases in the We must adopt a more unified mental health budget. approach to mental health if we are to Increased funding certainly seems eliminate archaic attitudes, inadequate necessary: since 2012, seven mental communication, and mediocre health patients have killed themselves strategy - all of which culminate in while waiting for hospital beds, and unacceptably poor standards of care. in the past three years 2,197 out Of course, the reality of implementing of a total 18,924 beds have been change is not that simple. Massive cut13. There have been outcries from budget cuts to mental health services, institutions such as the Royal College though widely discussed as a political of Nursing, who say provision in the point in the press, seem unlikely to form of funding, nursing posts, and resolve themselves any time soon. hospital beds has fallen in a period Gross structural overhaul of the NHS where demand for mental health care seems less even likely because of is rising14. Whilst we may be suffering it. However, boundaries can still from the effects of financial austerity, be broken from the bottom up. An it is irrational for mental healthcare alteration in the way our society sees to suffer disproportionately. However, mental illness can force a change in NHS England suggested last year that the way it is treated, both socially CCGs should cut spending for mental and medically. If we can break our healthcare more than its physical own Cartesian prejudices regarding counterpart15. Whether this reflects illness of the mind and the body, we ignorance regarding the severity and will be able to pursue a renewed, prevalence of mental health issues holistic path.I in the UK, or just poor economic management, it is evident that a Full references available at: significant overhaul of professional www.omsg-online.com attitudes to mental health is needed Daniel Murphy is a second within the healthcare system. Without year medical student at Keble College. integration of services, we will be unable to attain the NHS’ idealistic

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NEUROLOGY AND PSYCHIATRY - DIFFERENT AND YET THE SAME? ANGELA SHEARD ARGUES THE CASE FOR NEUROPSYCHIATRY AS A NEW SPECIALITY 14

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hilst from some research perspectives, neurological and psychiatric disease may both be explored via similar neuro-reductionist approaches, clinical medicine maintains a definitive dualism. Despite the reality that both disciplines are concerned with a spectra of symptoms which overlap, patients are usually treated by either neurology or psychiatry (often on the basis of a decision made in primary care) by different clinicians using radically different approaches. It is well known that many patients with neurological disease also have symptoms that benefit from psychiatric intervention, and vice versa. But to what extent should these two disciplines be merged? Should psychiatric symptoms in the context of neurological disease be managed in the same way as those that exist in isolation?

I will attempt to answer these questions by using examples of patient care from different areas of neurology and psychiatry that are either synergistic or specialized in their approach. I will also consider current efforts to bridge the gap between these two specialties, and discuss what may be done in the future to further this. In order to examine the modern-day relations between neurology and psychiatry, however, it’s helpful to first establish how the foundations of this medical practice came about.

findings (such as

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AS GROWING NUMBERS OF PEOPLE ARE DIAGNOSED WITH DEMENTIA, THEIR CARE IS INCREASINGLY MANAGED IN THE COMMUNITY

DIVERGENT PHILOSOPHICAL APPROACHES? A HISTORICAL PERSPECTIVE Around the turn of the 19th century, James Parkinson described the condition of the “shaking palsy” or paralysis agitans. A physician himself and a keen walker, he had noticed a group of people plagued by difficulties with walking and holding themselves upright, who shook when they stood still1. During the 1920s, anatomical and pathological studies confirmed that the substantia nigra, in the midbrain, was at the centre of the underlying pathology1.

In a similar way, over the course of the coming century and beyond, clinical descriptions of important neurological conditions were being gradually connected with research unravelling the underlying neuropathology.

At around the same time, the field of psychiatry in Europe was dominated by two of the most influential scientists of all time: Sigmund Freud and Emil Kraepelin. Whilst Kraepelin and his students attempted to use the same process that they had used as neurologists, correlating clinical syndromes with neuropathology, Freud (having become discouraged by his lack of progress and inability to support himself in his own research) focused instead on in-depth interviews with patients. From this, he constructed his seminal theories of repression and infantile predisposition to disease, from which mental illness could be understood1.

These different approaches generated a model still used today, by which conditions associated with histopathological

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Alzheimer’s or Parkinson’s disease) were classified as “neurological” and ones without (such as major depressive disorder or schizophrenia) as “psychological”. But how does this model influence the care patients receive?

DIFFERENT SPECIALTIES, DIFFERENT PROVISION A wide variety of medical disorders fall under the remit of neuropsychological care. To illustrate this breadth I present three specific examples: dementia, antibody-mediated psychosis and non-epileptic attacks.

DEMENTIA Age-dependent neurodegenerative diseases are mounting in incidence in Western countries2. As growing numbers of people are diagnosed with dementia, their care is increasingly managed in the community with regular reviews by specialist clinicians. Many of these patients are managed under ‘old age psychiatry’, which places an emphasis on the psychological and social difficulties associated with dementia, practical arrangements and carer support.

Yet, some patients with dementia may also be managed via a cognitive neurology clinic, where less common and more challenging diagnoses of dementia tend to be made. This clinic focuses on a thorough cognitive assessment; patients may be on more complex drug regimens and tend to have greater participation in research trials. However, this clinic notably places less emphasis on the holistic care that predominates in old age psychiatry clinics.

Despite the different approaches of these clinics, there is a known association between dementia and a number of psychiatric conditions, including depression and psychosis3. In addition, many people with dementia have or go on to develop problems, such as movement disorders or aphasia, and may be seen by a neurologist in the future. Therefore, for an initial referral to tertiary care, holding a joint neurology and psychiatry review for these patients may prove more comprehensive in the long run.

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…NEUROPSYCHIATRY CAN AND DOES BENEFIT PATIENTS WITH OTHER HEALTH PROBLEMS ACROSS THE BREADTH OF BOTH SPECIALTIES 16

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THE WHO CONSIDERS NEUROPSYCHIATRIC DISORDERS TO BE THE MOST IMPORTANT CAUSE OF DISABILITY WORLDWIDE…

ANTIBODY-MEDIATED PSYCHOSIS Recent epidemiological data has shown that a significant proportion of patients with acute schizophrenia have auto-antibodies to the NMDA receptor, a key mediator of glutamatergic neurotransmission4. Since a syndrome of acute auto-immune encephalitis and psychosis was first described in young women with ovarian teratomas5, some episodes of acute psychosis are increasingly thought to be caused by auto-antibodies to a number of receptor- and ion channel-associated proteins6. These episodes of psychosis may be treated with intravenous steroids or antibody infusions and patients with recent-onset psychosis can be easily screened for this condition6.

Whilst in the setting of neurology, patients whose presentation includes psychiatric symptoms are routinely screened and treated for this condition, this process is not mirrored in psychiatry6. Many obstacles to such screening exist, including the need for more collaboration with plasma exchange facilities, a dearth of trained nursing staff to supervise these patients’ treatment, and also the cultural opposition to a ‘medical’ cause for what is termed a ‘psychiatric’ condition6.

NON-EPILEPTIC ATTACKS These seizure-like episodes are often brought to the attention of a specialist neurology clinic, where they are seen alongside patients with primary epileptic seizures and seizures caused by other medical problems. In clinic, the goal is to determine whether their attack is psychologically mediated or not; once their diagnosis has been established the patient is often discharged back to their GP with little else in the way of management.

The neurologist may occasionally mention to the patient the potential benefits of

psychological therapy, but even in these cases further input is expected from primary care practitioners or, further down the line, psychiatric services.

This routine practice poses a number of problems for patient care. As with many other conditions which are referred to as “functional”, there is a danger that the patient’s real physical and emotional problems are dismissed. The patient may lose trust in their doctor and so may disregard their explanation of the problem, or their recommendation for psychological treatment; which early trials have suggested is effective in reducing seizure frequency7.

Moreover, depressive symptoms have been correlated with poor quality of life for these patients8, as such, many may benefit from formal psychiatric review.

In all of these clinical examples, there are clear advantages to sharing some or all of the care a particular patient receives between neurology and psychiatry. Furthermore, neuropsychiatry can and does benefit patients with other health problems across the breadth of both specialties: including Parkinson’s disease, multiple sclerosis, epilepsy and many others. But to what extent is such care shared already, and does it make a difference?

AVENUES FOR SYNERGISTIC CLINICAL PRACTICE A number of approaches are used to facilitate synergistic care. These include liaison services, which aim to link medical and psychiatric practice in general hospital settings, and neuropsychiatry, which aims to manage co-existing neurological and psychiatric disease.

HOSPITAL LIAISON The need to integrate mental and physical health in a hospital context has been

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outlined by a number of official bodies including the NHS Confederation, several Royal Colleges and the Centre for Mental Health7. Psychological medicine (also known as ‘liaison’) is seen as part of a drive towards more integrated healthcare, which can be seen more broadly in initiatives such as vertical integration between primary care and hospital settings, and accountable care organizations8.

While this approach ensures that there is psychiatric support available to meet the growing needs on general hospital wards, it risks deepening the present divide between medicine and psychiatry. The situation where patients are being immediately “franchised out” to liaison services also risks de-skilling medical staff when it comes to dealing with mental illness, and reinforcing the stigma that can surround patients even in a healthcare setting.

NEUROPSYCHIATRY The WHO considers neuropsychiatric disorders to be the most important cause of disability worldwide, and the psychiatric complications of neurological disease are known to cause the most distress to patients and their carers9. However, a very small proportion of patients with these conditions are treated by specialist neuropsychiatrists. Instead, most patients are seen by a combination of liaison psychiatrists, old age and general adult teams, but more worryingly many patients with neuropsychiatric disease in the community receive no care at all9.

In order to improve national provision, the Neuropsychiatry Special Interest Group has recently outlined a modular curriculum for psychiatric trainees wishing to specialize in neuropsychiatry. A Joint Neuroscience Council has also been set up to examine basic neuroscientific training applicable to all neuroscience-related disciplines. The problem of inadequate

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provision in neuropsychiatry has been recognized internationally; indeed in Austria, Belgium and Italy, postgraduate training is seamlessly shared between neurology and neuropsychiatry9.

FUTURE APPROACHES Changes aiming to combine neurology and psychiatry need to be broad ranging, focused both on medical education and provision of patient care. Educational reform must begin during medical school where exposure to different neuroscience-related specialties could be achieved together, with a special focus on areas that traverse specialties. These changes could be reinforced in postgraduate and specialist training, with a common neurosciences training pathway including psychiatric training, and increased flexibility to switch between various training pathways within the neuroscience-related specialties.

Although the changes above are extensive, simpler measures could be implemented within the current system.

Currently, informal arrangements made by trainees to gain exposure across the neurology-psychiatry divide could be standardized and become part of the national training programmes in these specialties. Alternatively, placements in neuropsychiatry could be made part of specialist psychiatry

training programmes such as child and cdolescent mental health or old age psychiatry, which commonly liaise with neurology and neuropsychiatry services.

The present divide between neurology and psychiatry is pervasive and reflects the broader practical and cultural divide between psychiatry and the rest of medicine. In all of the recent new initiatives which ultimately aim to combine neuroscience specialties, the common area of division seems to be one which presently lies in the domain of psychiatry – that between psychotherapy and biological psychiatry. Whilst much medical practice presently classed under “neuropsychiatry” sits here, the real challenge in the long-term seems to be integrating and equivocating these two approaches. To do that, we require further advances in our scientific and conceptual understanding of disease. But, we also require clinicians with years of dual experience – and a healthcare system that recognises the two pillars of “neurology” and “psychiatry” as so equally important that they merge into one.I Full references available at: www.omsg-online.com

Angela Sheard is a fifth year medical student at Green Templeton College.

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NEUROPSYCHIATRY FOR THE 21ST CENTURY MARCO NARAJOS EXPLORES THE NO-MAN’S LAND BETWEEN PSYCHIATRY AND NEUROLOGY

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thology results from changes in the brain has increased, is psychiatry still a legitimate branch of medicine?

True, psychology contributes a top-down interpretation of the mind, whereas neuroscience endows us with a bottom-up approach in examining brain function. However, this divide largely arose from our historical lack of understanding of neural correlates – how the brain produces the mind. Now that our understanding of how psychopa-

Over one hundred and sixty years ago, history’s most famous brain injury survivor offered the first inklings that the brain produced the mind. Phineas Gage damaged his left frontal lobe following an accident that propelled an iron rod through his head. Despite fifty-pencepiece-sized entrance and exit wounds through his skull, Gage survived. Nearly four months after the injury, his doctor wrote that Gage’s mind did not make a complete recovery and that his friends considered him ‘no longer Gage’2. He transformed from a reliable, efficient, and hard-working man to ‘a child in his intellectual capacity and manifestations’. Here we see a historical basis for compartmentalising the brain into functional regions, but the question remains: would a neurologist or a psychiatrist treat Gage today?

f anyone were to blame for the boundaries between psychiatry and neurology, it would be Descartes. In one of philosophy’s most famous existential crises, the French polymath postulated that humans consist of two substances: body and mind. Over 300 years later, John Searle saw this a false dichotomy, and countered Descartes’s proposal with one of ‘scientifically-sophisticated’ common sense1, that the mind is a product of organic processes in the brain. Yet psychiatry and neurology continue to practise independently from one another. Descartes’ damage was done.

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TO DEFINE NEUROLOGY AND PSYCHIATRY IS TO DEFINE TWO SIDES OF THE SAME COIN ology of personality disorders, we also restrict ourselves by how we categorise mental illness. Patients with personality disorders, by DSM-V definition, must show impairments in social functioning, which is dependent on an individual’s social context and cultural background6.

Neither profession seems particularly equipped to handle such a case. Despite neuroscience unravelling various neural circuits correlating noradrenergic and serotonergic signalling with mood, especially in the context of pharmacological intervention3, there are still no definitive neurobiological causes4 or neural correlates5; cognitive neuroscience remains in its infancy. Therefore, while it would be useful for neurologists to understand the mood disorders of their patients, it would be absurd to ask neurologists to treat primary mood disorders.

This case is unique; in which other specialities does one need to consider culture when making a diagnosis?

Certainly not in neurology: a paralysed hand in the Philippines is still paralysed in the UK. On the other hand, there really is no philosophical distinction between psychiatry and neurology.

We can make the same argument Take for instance the phantom limb for other psychiatric conditions, partic- pain that many amputees develop. ularly those that we might describe as We classify it as neurological, but if more psychological than neurological. it is indeed a central nervous system Personality disorders enter this category. dysfunction as many researchers Psychiatrists define a personality as argue7, as opposed to a peripheral a persistent and pervasive pattern of one, then what makes it different from behaviour, cognition, and affect6, and a delusion or hallucination? There a dysfunction in personality occurs is no ontological distinction, only an primarily in social domains. Not only epistemological and historical one. do we not understand the pathophysi- Perhaps, in the future, a neuropsychiatric approach to treatment will be of greatest clinical benefit, combining

MOOD DISORDERS ANXIETY DISORDERS

EPILEPSY

DISSOCIATIVE DISORDERS 20

There is therefore need for a third speciality, neuropsychiatry.

The neuropsychiatrist respects the ways in which the two branches consider illness, works at the interface between the brain and the mind, and encourages the difficult conversations that will further progress in both fields – in education, clinical practice, and research. A challenging discipline, it seems, but until we have a grand unified theory that satisfies Descartes’ existential crisis, it will have to do.I Full references available at: www.omsg-online.com

CHOREIFORM DISORDERS

PSYCHIATRIC

SCHIZOPHRENIA SPECTRUM DISORDERS

In my opinion, to define neurology and psychiatry is to define two sides of the same coin: the study of the nervous system, its pathology, and its treatment. Neurology simply invests its attention on systems-level detail, whereas psychiatry concerns itself with phenomenology, as well as how a brain interacts with the other brains around it. Scientific advancements are providing an increasingly richer description of the neural landscape of mental disorders. Conversely, we now observe more psychiatric symptoms in neurological conditions, such as depression in Parkinson’s disease; the boundaries are becoming increasingly blurred over time. The mind-brain dichotomy is false, but a complete merger of specialities is not a practical avenue either.

INFECTIONS

PERSONALITY DISORDERS

EATING DISORDERS

psychiatric interventions like Cognitive Behavioural Therapy8 and neurology’s famous mirror-box therapy9 as staple treatment for phantom limb pain.

DEMENTIA

PAIN

Marco Narajos is a second year medical student at Christ Church College.

CEREBROVASCULAR DISEASES

NEUROLOGICAL

PARKINSONISM

SLEEP-WAKE DISORDERS

MULTIPLE SCLEROSIS

TIC DISORDERS INJURY

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THE TORTURED GENIUS NATALIA COTTON SETS OUT TO UNCOVER IF

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GREAT ART IS REALLY BORN FROM GREAT PAIN

o be a genius it seems we must suffer. For thousands of years society has embraced the notion of the tortured genius, appearing in the works of Plato, Aristotle and Shakespeare, among others. More recently, the suicide of actor Robin Williams, who suffered from severe depression, has brought this stereotype back to the forefront of public consciousness. We are bombarded with the image of the creative genius suffering from the burden of his own brilliance.

Many have tried to disentangle the apparent connection between creative genius and mental illness over the years, with varying degrees of success. In 1891, the Italian physician Cesare Lombroso declared that genius was a disease, frequently accompanied by signs of degeneration.

In his work The Man of Genius, he claimed all great men have disordered minds and attempted to associate

some more unusual characteristics with brilliance, namely left-handedness, vagabondage and ‘unlikeness to parents’.

Thankfully, research in this field has since progressed, although the notion of a link between creativity and psychopathology remains highly contentious.

No less contentious is how we should define creativity or genius. One of the most widely accepted definitions of creativity dictates that it involves the production of something that is both novel and useful. Novelty and utility require two separate cognitive processes: the generation of original ideas, and the selection of those to be developed further. Creativity may stray into genius when the outcome of this process is both incredibly original and extremely useful. There is a marked difference between that which the genius has achieved, and that which existed before him.

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In 2001, the Centre for Disease Control estimated that around 450,000,000 people were living with a mental health problem. Regardless of how widely we choose to define creativity, it is inevitable that the number of ‘creative geniuses’ will be hugely less. This vast numerical difference tells us that creative genius cannot possible accompany mental illness in all cases. Nonetheless, creativity and mental illness could well still be more subtly connected. Recent research suggests creative genius may instead require us to lean towards psychopathology without developing a mental illness per se. In 2012, a group of Swedish researchers found that, except for bipolar disorder, people in creative professions were no more likely to have a mental illness than controls1. However, the siblings of autistic patients and first-degree relatives of people with anorexia nervosa, schizophrenia and bipolar disorder were significantly overrepresented in the creative professions.

In addition, numerous studies have found that creative individuals tend to have characteristics that could counteract the effects of psychopathological symptoms, such as high intellect and a strong ego. It therefore seems plausible that these traits could act as protective factors against the debilitating effects of mental illness, allowing enhanced creativity while keeping psychopathology at subclinical levels. These findings lend weight to the idea of an ‘inverted U’ relationship between creativity and psychopathology, whereby mental illness symptom severity and creativity increase together until a certain point past which creativity diminishes. Although many famous writers, artists and musicians have been diagnosed with a variety of mental illnesses it seems likely that their best work was produced not during periods of florid mental illness, but rather phases of relative sanity. Only now are we beginning to decipher one of the most intriguing dilemmas of all: how psychopathology might lead to an increased propensity for creativity.

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Increasingly, the medical community is recognising the presence of supra-sensory experiences in patients with bipolar disorder; non-psychotic phases of enhanced sensory perception that are typically experienced during manic phases. These experiences have even entered diagnostic criteria2. Patients report that their general sensory experience becomes more vivid, with some individuals even describing feeling more creative during these periods.

Could the increased creativity seen in bipolar patients be, at least partly, due to enhanced sensory experience? If so, it would make sense that creative people with bipolar disorder would produce work rich in sensory imagery.

This does appear to be the case. For example, the poems of T.S Eliot, Percy Shelley and Alfred Tennyson, who are all now believed to have suffered from bipolar disorder, are replete with sensory details. Although this explanation initially appears at odds with the ‘inverted U’ model outlined above, it is important to note that these experiences seem to be more common in bipolar II. This disorder, consisting of periods of depression intermixed with hypomanic episodes, is often described as a ‘milder’ form of bipolar, thus supporting the idea that severe mental illness is not compatible with the creative process.

Why might these supra-sensory experiences occur?

Interestingly, it has recently been found that bipolar patients exhibit deficits in sensory gating, the process in which the brain filters out redundant and unnecessary environmental stimuli. It therefore seems plausible that reduced sensory gating could leave the mind open to explore novel and unconventional stimuli and facilitate the generation of original ideas – a key component of creativity.

This mechanistic overlap between creativity and psychopathology seems to be in no way unique to bipolar disorder.

Schizotypy describes a collection of personality traits present, to some degree, in all people, such as unusual perceptual experiences and magical beliefs. Such personality traits may increase vulnerability to schizophrenia-like symptoms in the future. A recent fMRI study found that schizotypy and creativity showed overlapping patterns of brain activity amid creative processes3. During a creative idea generation task, reduced deactivation of the right precuneus, an area located in the parietal lobe, was associated with originality. Intriguingly, individuals with increased schizotypy also showed an inability to suppress the precuneus during creative thinking, suggesting that similar cognitive processes could underlie both creativity and psychopathology.

Control over these cognitive processes appears to be key in preventing the development of mental illness. In 1999, researchers in Germany compared the behaviour of three groups of people: creative people, people with schizophrenia

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and normal controls4. When instructed to be original, the ‘creative’ group responded with highly original behaviour, on a par with or even greater than the schizophrenic group. However, when told to rein in this ingenuity, the creative group were similar to controls, whilst the schizophrenic group continued to generate unusual responses.

Although both the creative group and the schizophrenics had capability to generate novel ideas, only the creative group were able to control this, and tailor their response to appropriate situations. As discussed earlier, in order to be truly creative, ideas generated must be both novel and productive. Deactivation of right precuneus has been found to be associated with goal-directed information processing; in other words, the suppression of general and unsystematic information gathering. Perhaps reduced deactivation of this area, as observed amongst the highly schizotypic subjects, could be related to the inability of schizophrenic individuals to select appropriate ideas. With this in mind, it seems we are finally determining how extreme creativity might stray into mental illness.

Ultimately, both creativity and psychopathology require us to be different: to think what others do not, to see what others cannot. If we are wrong we can become ill. But when we are right we become geniuses.I SYLVIA PLATH (1932-1963) was an American poet and novelist who famously married the English poet Ted Hughes in 1956. Plath suffered from severe depression throughout her adult life, culminating in her suicide on February 11th 1963 when she gassed herself in her oven. In perhaps her best-known work, the semi-autobiographical novel The Bell Jar, she describes with great emotional clarity her first breakdown and suicide attempt.

ALBERT EINSTEIN (1879-1955) was a German-born theoretical physicist who developed the theory of relativity. He is considered the most influential physicist of the 20th Century, to the point that his name is now synonymous with genius.

However, Einstein also exhibited a number of unusual personality traits, which have led some to posthumously diagnose him with Schizotypal Personality Disorder5. He displayed echolalia from childhood, struggled to attribute mental states to others and was both dreamy and distracted. He and his first wife Mileva Maric had a son, Eduard, who was diagnosed with schizophrenia, suggesting a genetic predisposition to schizophrenia in the Einstein family.

WILLIAM BLAKE (1757-1827) was an English poet, painter and print-maker. From a young age Blake described having visions, typically of a religious or spiritual nature. At the age of four he described seeing God at his window, and at eight claimed to have seen a tree full of angels. These visions persisted throughout his life and are thought to have influenced his works, with religious concepts and imagery featuring as central themes.

ADELINE VIRGINIA WOOLF (1882-1941) was an English writer and prominent member of London literary society. She was known for her mood swings and bouts of deep depression, now believed to be the result of bipolar disorder. Woolf had several nervous breakdowns, one of which resulted in institutionalisation following the death of her father. She committed suicide by drowning at the age of fifty-nine.

Full references available at: www.omsg-online.com

Natalia Cotton is a fourth year medical students at Hertford College

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DEATH AND THE MEDICAL STUDENT A MEMENTO MORI

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I LEARNED ABOUT A LOT OF THINGS IN MEDICAL SCHOOL, BUT MORTALITY WASN’T ONE OF THEM.

- Dr Atul Gawande, Being Mortal (2014)

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s Oxford medical students we cannot quite say the same as Dr Gawande: we are all given a lecture entitled ‘Death and the Doctor’ at the start of clinical school. But why is death not discussed earlier, and is one lecture really enough?

The Communication Skills course that runs throughout fourth year aims ‘to help students develop effective patient-centred consultation skills which are relevant to their clinical practice’, and yet, somehow, the word ‘death’ does not appear once in the handbook. What is more, the fifth year Palliative Care rotation is just a few days long.

From a patient’s perspective, not only is death inescapable, when it does occur it will often be preceded by a state of utter weakness and vulnerability; a time when help and support are needed the most. Death also has a profound effect on a patient’s friends and family; more so, it could be argued, than any other condition they have experienced throughout their lifetime.

If we concentrate on these reasons, then perhaps we can be encouraged to think and talk about death more.

Then again, perhaps not. The reality is that death is a deeply emotive subject – because in some nebulous This all seems rather strange when we way, we are all aware that we too will remind ourselves that death is quite eventually die. And quite naturally, we simply the most common condition would rather not dwell on that fact. that we will encounter as medical professionals. It has an incidence of Our current culture is such that 100%, 100,000 in 100,000, and is increasingly, death is viewed as a the longest-running, most widespread failure of medicine. If not directly at pandemic on record. On this basis the bedside, this becomes indirectly alone, death should receive more of apparent through the belief that in a our attention than any other medical decade or two (depending on which condition - but in reality, it receives newspaper you read) a particular almost none. disease will probably be curable.

Unfortunately, these beliefs give false “THE BEST PLACE TO HIDE hope to both clinicians and patients IS IN PLAIN SIGHT!” – and make the task of approaching

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death sensitively and realistically even more difficult.

In a way, the idea that medicine ought to be able to combat death is perfectly reasonable. As patients, we go to doctors and surgeons because we need help, and in the most severe circumstances we might be at risk of dying without it. Usually, when successful, this help takes the form of restoring our former health. When we subsequently feel better, death quickly returns to being the very last thing on our mind. But this does not mean that we have become any less mortal than when we were ill. Et in Arcadia ego. Health is merely the absence of illness or injury, a state of normality; and, in fact, there is nothing more normal than death.

Of course, there are an increasing number of ways in which modern medical intervention can avert life-threatening conditions, as well as greatly improve the prognosis of patients living with long-term morbidities. Still, the idea that medicine allows us to cheat death overall is little more than wishful thinking.

Regression analysis of data from multiple countries has shown that

DEATH IS QUITE SIMPLY THE MOST COMMON CONDITION THAT WE WILL ENCOUNTER AS MEDICAL PROFESSIONALS.

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there is no significant relationship between life expectancy and the number of physicians/hospital beds per 100,000 population, or healthcare expenditure as a percentage of GDP. Rather, associations were found between life expectancy and sanitation, clean water, income, and literacy rates1,2,3.

Worldwide, mean human life expectancy has more than doubled in the last 300 years, having previously remained at a level not much greater than the lifespan of non-human primates living in the wild today (see Graph).

This rapid increase coincided with industrialisation, and indeed, in so-called post-industrial countries like the UK, our longevity is now increasing at a dwindling rate. In the last 50 years or so we have seen an explosion of scientific information that has greatly enriched our knowledge of the world around us, and no field of research exemplifies this better than biomedicine in the genomic era. However, to draw a link between this very recent wealth of information and the gradually receding spectre of death is clearly a mistake.

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This is not news. The Hippocratic Oath says nothing about trying to forestall death; instead, it is much more concerned with not inadvertently bringing it about. Although written over two thousand years ago, it seems as though the old oath is still apt in striking this balance. A study published in 2010 showed that compared to standard oncologic therapy, providing early palliative care to patients with metastatic non-smallcell lung carcinoma resulted in patients living 30% longer, as well as reporting clinically meaningful improvements in both quality of life (physical, functional, emotional, and social wellbeing) and mood (measured using the HAD scale)4. Furthermore, significantly fewer patients who were given the opportunity to express their own priorities in the palliative setting received aggressive end-of-life care, whilst at the same time out-living their counterparts in the test group.

The palliative care that produced these benefits consisted of an assessment of the patient’s physical and psychosocial symptoms, establishing goals of care, assisting with decision-making regarding treatment, and coordinating care on the basis of the individual needs of the patient.

These may seem like relatively straightforward measures but, crucially, they require both the patient and doctor to acknowledge the terminal nature of the patient’s condition.

Of course, this is far more easily said than done, but the potential benefits to the patient are plain to see.

With this in mind, and in the context of an ageing population, it has never been more important that medicine concentrates on giving patients what they want, rather than what we know how to do; and that we medical students learn to overcome the fear, sadness, and uncertainty, and start getting used to talking about death.I

Full references available at: www.omsg-online.com

Jonathan Attwood is a fourth year medical student at Brasenose College

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THE IDEA THAT MEDICINE ALLOWS US TO CHEAT DEATH OVERALL IS LITTLE MORE THAN WISHFUL THINKING.

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CARER vs. DAUGHTER vs.

MEDICAL STUDENT

y the bike racks outside Sobell House, we gather to digest what we have seen and learnt on our palliative care placement day.

A chance to make sure that everyone is coping.

We reflect on what we saw and heard, instinctively recounting the episodes that touched us most. One of the girls in the group tells us about how her patient, dying from progressed ovarian cancer, said she wanted to die and end it all, while her daughter sat by her bedside holding her frail hand.

“I just can’t imagine what it would be like to be someone’s daughter, holding their mother’s hand and hearing them say ‘I want to die’”. In that moment in time, I wished that I could say the same thing. But I couldn’t. I know exactly what it is like.

My mother is severely disabled with Multiple Sclerosis. Her diagnosis cannot be compared to terminal cancer, but the impact on her life and those around her can be. I can still remember the time when my mother would cook dinner or tuck me in for the night. Those times seem like the distant past now. Since I was 12, I have seen her condition drastically deteriorate to the extent that she can no longer move, not even wiggle her finger. It has been I who has cooked and helped her be comfortable in bed for a while now.

There is an expectation for people to look after their parents in old age, once they themselves have developed and matured. It is when that caregiving role reversal occurs between a child and their parent that one is forced to question where the boundaries lie – what roles should a young carer be expected to fulfil? How involved should they be in their parent’s personal care? Should they be expected to understand the legal and social implications of their position?

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I remember coming home one day to find that my mother’s catheter had bypassed and needed replacing. As a carer, I immediately assessed the situation and saw that something had to be done. As a daughter, I wanted nothing to do with the situation as it made both me and my mother feel uncomfortable. As a medical student, I knew that I had the skills and training necessary to relieve my mother of the unpleasant situation, but also that legally there was nothing I could do in the circumstances. This conflict of roles is infuriating!

Parents have an innate desire to protect their children from the misfortunes of the world. Unfortunately they cannot always succeed in doing so; from concealing a mother’s diagnosis to her children until they take on a caregiving role or express an interest in studying medicine, to expressing their frustrations at their own situation. My mother is no longer able to do anything for herself. She is completely dependent on other people – no easy notion to come to terms with for anyone, and especially not for a woman who gave so much to others.

Even expressing her simple requests and desires is a challenge. My mother’s speech is quiet and strained.

When she is tired, barely any noise escapes her lips, so it is a combination of lip reading and knowing what she would usually say in that situation that result in a laboured communication. For me, it is a test of patience. The carer side of me wants to be attentive to all of my mother’s requests and needs, but the self-involved daughter wants to be able to get on with her plans for the day, going out to see her friends or getting on with revising for the exams that are always just around the corner for a medical student. For my mother it is frustrating and upsetting. Her language used to be so eloquent and colourful, however it is now reduced to concise phrases and monosyllabic words if possible. I remember when she would give me advice on how to be a better person or give me precise instructions on how to tidy the house. I used to get annoyed with her remarks and nagging. Now I miss them – the reminders that I still have so much to learn.

As a medical student, I am in that difficult position that I know what the future holds for my mother, both through studying the science behind her condition and my exposure to other patients. MS does not itself lead to death. It is the acquired infections, DVTs, cancers etc. that cause death.

These can be unpredictable, despite best efforts of prevention. One cannot blame my mother for feeling helpless. For wanting the pain to end. For being tired of waiting for the inevitable. This is spurred on by guilt due to the belief that I have made sacrifices in order to care for her, despite my reassurance that this is a choice I have made.

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I am lucky that I am not alone as I have the support of family and friends. There are many young carers who deal with their circumstances in solitude. The challenges they face will be very different from my own, but nonetheless they will face confusion and distress. Luckily, in the UK, we have services in place to support disabled individuals and their families.

It can take a little while for my peers to understand the workings of the system, a system that I have come to know very well (despite the vast volumes of paperwork). I shall be eternally grateful to the wonderful team of carers who tend to my mother’s personal care during the day, allowing me to study full-time, and selfishly, pursue my own development.

My mother is not yet considered a palliative care patient. However, she is unlikely to regain many points on a quality of life questionnaire. Through my personal experiences and talking to patients at Sobell House I have learnt that the language of those waiting for their life to end is universal; the same wants and fears, similar regrets. But every story is different.I

The author would like to remain anonymous.

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OH, HOW LOVELY! RUBY CARRINGTON REFLECTS ON WHAT IT MEANS TO BE AN OBSTETRICIAN “WHICH ROTATION ARE YOU ON AT THE MOMENT?” “OBS AND GYNAE” “OH HOW LOVELY; DELIVERING BABIES!” This is an exchange I had multiple times during my obstetrics and gynaecology attachment. Almost without fail, my questioners’ faces would light up when I told them what I was learning about. As the placement progressed, I found myself pondering this response and considering the extent to which I agree.

Before beginning the rotation, I certainly didn’t think obstetrics was going to be all roses – simply bringing lovely healthy babies into the world via normal deliveries - and I don’t think the people who respond as above think that either. There is, however, an assumption that being involved in bringing new life into the world, in whatever way, is an amazing and ‘lovely’ thing. On the whole, with the benefit of the clinical experience I had over the ensuing weeks, I would agree. Excluding rare and tragic complications, I found that witnessing or being involved in the birth of someone’s child is a truly amazing and moving experience.

What I have come to contemplate, however, is whether you can fully appreciate this experience as an obstetrician, and in fact whether being able to detach yourself from it would make you ‘better’ at the job.

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STANDING IN THE MIDDLE I HAD A DRAMATIC VIEW

rous woman, gestation 36 weeks, presented to triage in labour. The baby was found to be breech; the decision was made for a Category 2 emergency Caesarean section and plans quickly put into action.

This was to be the first C-section I had witnessed. A mixture of fear, surprise and excitement could be seen spreading through the young A particular event that highlighted parents-to-be, as they were ushered this dilemma for me happened during into theatre. They were about to be a night shift on Labour Ward. At united with the baby they had been 2.15am, a 23 year-old primipa- excitedly anticipating for months but

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certainly weren’t expecting to meet today, only hours after they had been sitting in the cinema watching The Hunger Games! The spinal anaesthesia was given, the obstetricians scrubbed and a sheet was pinned up to create a visual barrier between the parents and the surgery beyond.

The significance of this screen became apparent to me as the operation progressed. Standing in the middle I had a dramatic view. On one side, two tired registrars were using their full body weight to stretch the abdomen

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open wide enough while using as small an incision as possible. On the other a young girl was looking into her partner’s eyes, waiting excitedly to hear the first cry break from their baby’s lungs, all the while blissfully unaware of the brute force being used beyond. As the baby was pulled out in a somewhat “ALIEN”-esque scene, quite understandably pulling a face and making a noise one might expect from someone being woken up by their alarm too early, it was quickly thrust towards the midwife and taken around to the expectant parents. A happy, healthy baby was born and the

experience of the parents seemed to be as remarkable and awe-inspiring as the normal vaginal deliveries I had seen. It was at this point, however, that the divide between the two sides of the screen became even wider. Whilst the mother and father smiled and laughed, overcome with joy at the sight of their daughter, the obstetricians continued with what could be described as quite gruesome abdominal surgery, working hard to deliver the placenta and prevent blood loss. Was the screen demonstrating the distinction between ‘obstetrics’ and ‘the miracle of birth’?

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THE DIVIDE BETWEEN THE TWO SIDES OF THE SCREEN BECAME EVEN WIDER

Over the next 30 minutes, the surgeons completed their important and highly skilled job; leaving a healthy mother and a uterus suitable not only to house another baby in the future, but also strong enough to withstand the contractions necessary for a vaginal delivery. The mother was then cleaned and covered up and the screen taken down. The registrar who had delivered the baby looked at the mother and said: “Congratulations on your – oh, was it a boy or a girl?”

The obstetricians had been so focused on their task that despite physically delivering the baby, there was no time to allow themselves to become involved in the ‘lovely’ experience of bringing this new being into the world. In this situation, I think most people would agree that being able to detach themselves from the situation made them better at their job. On the other hand, knowing the sex of the baby and sharing in the mother’s excitement might have made her feel more at ease, thus strengthening the doctor-patient relationship. This led me to question which people are more suited to becoming obstetricians; those who can act efficiently and make quick decisions under stressful situations, or those who immerse themselves in the ‘lovely’ experience of delivering babies? Ideally, of course, it would be both - but realistically, does the latter inhibit the former? Fortunately, most of the doctors I came across on my placement managed to strike a balance between the two, but ultimately I do think you have to sacrifice at least some degree the delightful experience of delivering babies in order to be an excellent obstetrician.I Full references available at: www.omsg-online.com

Ruby Carrington is a fifth year medical student at Green Templeton College

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DOCTORS UNDER SCRUTINY YONI DENNIS EXPLORES HOW THE RISING EXPECTATIONS OF THE PUBLIC ARE AFFECTING THE PATIENTDOCTOR RELATIONSHIP

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ncidences of civil unrest over the last decade have highlighted a growing discontent amongst the general public directed towards public services, which some would argue is the result of people wanting more control over their lives and communities around them.

Governments struggle with a severe lack of trust from the public, while the police force is often subjected to accusations of discriminatory practice and inappropriate situational judgement. Protests over university fees, the 2007 riots over a police killing, and recent riots in Ferguson Missouri across the pond in America, demon-

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strate that the public have their own views on how the law and other public services should operate. This is very much at odds with current legislation and practice. The healthcare system has thus far been immune to many of the public perception issues that trouble other such sectors, and is almost uniquely appreciated for the service it provides. A discussion in its infancy that may soon come to the fore is: to what extent should members of the public who are not medically trained be able to dictate how doctors practise, and how are these new pressures going to impact on doctors?

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The times of doctors being unwaveringly revered and unchallenged by patients are quickly being forgotten by a new generation of tech-savvy and independent patients, who bring not only illness but also an air of scepticism to our hospital beds. I like to describe our time as the age of transparency. Innumerable sources of information, paired with the ever-evolving arms of social media, are empowering people to be able to understand, discuss, and question their experiences in all aspects of life. An article in the Journal of Patient Care has estimated that 210,000 deaths in the U.S. were caused by medical errors in one year1. Statistics like this bring into question whether the sanctity of what goes on behind a closed door or drawn curtain will remain private, and for how much longer clinicians will retain their autonomy and freedom to practise without intense public scrutiny.

The fabled story of patients coming to GPs convinced they have condition X or demanding medication Y may just be the beginning of a reimagining of the doctor-patient relationship.

How long is it before patients demand that their procedures be recorded and made freely available for people both qualified and unqualified to critique? And when a patient regains, say, 80% function after hand surgery; will we see floods of lawsuits claiming an inadequate performance by the surgeon, or that the best technique was not used? There is an intrinsic inequality in the patient-doctor relationship, which can probably never be balanced. However unlike past generations, nowadays people do not want to view their care as wizardry that they can’t understand. They see doctors more as service providers, and want to know exactly what is going on. By the same token, the relationship is changing from the medical profession’s end, too. Doctors no longer work 100-hour weeks, devoting their entire life to being a clinician; instead, they are increasingly involved with teaching, research, and writing, as well as other hobbies.

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A NEW GENERATION OF TECH SAVVY, INDEPENDENT PATIENTS BRING AN AIR OF SCEPTICISM TO OUR HOSPITAL BEDS

The aforementioned problems that governments and law enforcement face manifest themselves, ultimately, as impediments to the day-to-day work of politicians and police officers on the street. Making their job more difficult only serves to reduce the quality of the service they can provide to us. Doctors are no different; we must not let the fear of public outcry and professional repercussions encroach on a physician’s confidence to practise with autonomy and exercise his or her best judgement in a particular situation.

As we move forward, evidence-based medicine will become more and more prominent in clinical decision-making – particularly regarding surgery choices and therapeutic management regimes. It is important to note that a wealth of treatment options highlighted as the best option, or at least better than traditional methods, by so-called evidence-based medicine, are not actually implemented in practice for a myriad of

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reasons. There is a limit to how well guidelines and flowcharts can treat a patient; the elements of a physician’s experience and intuition after seeing and examining a patient in the flesh are invaluable to clinical decisionmaking and as a predictor for patient outcomes. It would be foolhardy of us to usher this out of healthcare in this country, and we must not reach a point where doctors feel unable to proceed with a treatment plan through fear of repercussions down the line.

There must of course be accountability and discussion about professional practice, as there are undoubtedly justifiable reasons for which people have had concerns.

Individual isolated mistakes or incidences of malpractice are one thing, but beyond that I think that it is the attitude and manner in which doctors practise that interests the public. From 1990 to 1995 between 30 and 35 babies died at the Bristol Royal Infirmary, in what was dubbed the Bristol Heart Scandal2. An enquiry found ‘an old boy’s culture’ among doctors, a lax approach to safety, secrecy about doctors’ performance and a lack of monitoring by management to be at fault. These are

exactly the attributes that foster negative public attitudes, and it is because of these that some level of healthy scrutiny is paramount to ensure patients are receiving the best care possible.

It is widely acknowledged and approved that we are moving towards more patient-centred care, both through policies implemented by government and the ability of patients to access an almost infinite pool of information online or through social media. The government’s “no decision about me, without me” aim from the white paper “Equality and excellence: Liberating the NHS” strives for the provision of accurate and accessible information for patients to make decisions. If done correctly, it is likely to improve outcomes, reduce the burden on doctors, and improve disease prevention through better education with regard to diet and exercise. The challenge is to integrate this idea without completely stifling doctors.

As medical students and professionals, we can be blinkered by our medical education into thinking patients should not be involved with deciding or even suggesting therapeutic pathways. If a patient is able to become informed on their condition through mediums such as the internet, why wouldn’t they? In an age where nothing is more than a few clicks away, it doesn’t make any

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IF A PATIENT IS ABLE TO BECOME INFORMED ON THEIR CONDITION THROUGH MEDIUMS SUCH AS THE INTERNET, WHY WOULDN’T THEY?

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PATIENT CENTRED CARE IS SEEN AS THE GOLD STANDARD OF HEALTHCARE

sense to remain ignorant to what’s going on within your body. A slightly satirical take on this was explored in the popular medical television series House, in which a patient posts his symptoms on a forum and decides he wants treatment for the condition that has the most votes by people on there. Presuming everyone who answers is a doctor, logic would say that the opinion of fifty doctors should be more reliable than one, but it is an almost untenable situation for the actual doctor within the hospital to cope with. These ideas are among the most important challenges for the NHS to negotiate in the coming years.

healthcare professionals, it is incredibly important that we practise in an inclusive and non-patronising way towards patients, and do not dismiss patients’ concerns or thoughts on their condition. I do not believe it is necessary or productive to completely protect doctors from any reprisals whatsoever, but as we move forward in trying to encourage patients to take a more active role in their care, we must cultivate an environment which allows doctors freedom to express themselves – and to work without fear of grave legal consequences based on decisions that are very difficult judgement calls. When deciding how to act upon information given by doctors, Finally, a little question to ponder is whether anyone if you’re not a scientist it is ultimately a matter of trust. who is not medically trained can be considered able to However healthcare evolves in this country, it is my belief make an informed decision? This is not a comment on that this trust will remain paramount in ensuring the best anybody’s right to decide, but I wonder whether you can outcomes for patients.I ever properly appreciate the context of information you Full references available at: read or are told without having at least some medical www.omsg-online.com background.

My closing thoughts on the subject are that firstly, as

Yoni Dennis is a fourth year medical student at Wadham College

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THE ALL-SEEING EYE: GMC REGULATION vs. DOCTOR’S PRIVACY MICHAEL GACH QUESTIONS WHETHER THE PRIVATE LIVES OF DOCTORS SHOULD BE REGULATED

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he General Medical Council’s (GMC) document ‘Good Medical Practice’ says doctors must “make sure that [their] conduct justifies patients’ trust in [them] and the public’s trust in the profession”1. Interestingly, this statement does not limit good conduct to the workplace, but implies it should extend into doctors’ private lives. Niall Dickson, chief executive of the GMC, explains that the GMC “already investigates complaints about a doctor’s actions outside work...”2. Last year the GMC investigated 1442 actions, including possession of child pornography and repeated drunkenness3. However, in a 2010 review of the GMC’s guidance, an online public poll revealed that 94% of 1167 respondents believed that doctors should not be regulated beyond the workplace4. So is the current level of regulation really required or is it an unnecessary intrusion into the private lives of doctors?

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In the case of Bolton v Law Society, regarding a lawyer suspended for misconduct, it was said that “the reputation of the profession is more important than the fortunes of any individual member” 5. This phrase has since been used in cases against doctors. Clearly, preserving patients’ trust in health professionals is vital; the doctor-patient relationship can only function if both parties work together.

Yet, a recent poll indicates that public opinion of

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doctors has been high and stable for the last 25 years, despite a number of high-profile events which could have undermined their reputation, most notably the Shipman scandal6.

Whilst some believe that trust can only be maintained with tight regulation, the consistent confidence in doctors may suggest that GMC regulation is excessive, especially when the conduct is lawful and does not put patient safety at risk.

In the case of unlawful behaviour, some people argue that it is unjust for a doctor to be upheld to standards differing from those applied to the rest of the public. It means doctors can be punished twice if they break the law; once when convicted of a criminal offence and a second time by the GMC. However, if a doctor commits a crime such as assault then there are also grounds to believe that the doctor may not be fit to practice. Therefore, by investigating unlawful behaviour, the GMC takes into account not only patient trust but also, importantly, patient safety.

Excessive regulation could negatively affect doctors; some may feel restricted or intruded upon in their personal lives.

It could also cause doctors to be fearful and overly cautious in their actions. Psychiatrist Dr Christopher Pell explains that when he uses social media, “each time I’ve hesitated before clicking ‘send’ for fear of potential repercussions or misinterpretations”. Investigations and sanctions on doctors are even linked with increases in depression, anxiety and suicide.

For example, a GMC internal review found that between 2008 and 2014, twenty-four doctors committed suicide whilst under investigation7. A response to the GMC poll says: “The public realise that doctors are also human beings who enjoy life outside of work as much as anyone else - let us be real people, it will make us better doctors”. As important as it is for doctors to be role models, Dr Melissa McCullough, medical law and ethics lecturer at Queen’s University Belfast, explains: “There will be doctors that smoke, drink, have affairs, overeat or have other forms of addiction. At best, their struggles can sometimes increase their empathy for patients in the same situation or even inspire patients facing the same challenge”.

Full references available at: www.omsg-online.com

Michael Gach is a third year medical student at Lincoln College

A balance of patient safety, confidence in the healthcare profession, and the wellbeing of doctors is very important.

Regulations probably have a role in achieving this balance, but we need to establish exactly how far they should extend.

According to Dr Philip Fielding, a GP in Cheltenham: “We should always be aware of the need for high probity whether we be wearing our stethoscopes or not. But the question of regulation sounds heavy handed. Can we not start with the bankers first?” It seems, therefore, that regulations are a controversial issue. Debate must now focus on delineating the boundaries between regulation that is excessive or insufficient.I

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IN DEFENCE OF LA MODE FRANÇAISE

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f there’s something the French do well, it’s fashion. And failing that, it’s medicine. Of this I was acutely aware as I approached le bloc operatoire of Bordeaux’s bustling hospital, ready to spend a few days shadowing a pre-eminent neurosurgeon. This was no time for an open-neck shirt; I had donned my best suit and tie, determined to do homage to the country’s cult of professionalism.

You can imagine my horror, then, when the surgeon in question met me wearing a polo shirt, slacks, and faded pumps, finished off by the white coat of days gone by. “We are looking rather chic, are we not, Monsieur Ballard?” he remarked, with more than a pinch of Gallic irony. I was to discover that all Bordelais medics, students included, wore incredibly casual clothes on the ward, invariably capped with the iconic coat.

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Being an Englishman, I was naturally outraged by this continental unorthodoxy; yet the following days were some of conversion. I now see myself as a prophet sent to proclaim the sense of this mode française to every reluctant Rosbif. I am convinced that the combination of casual dress and formal coat strikes a palatable balance between proximity and distance, allowing the establishment of an entirely appropriate

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LA MODE FRANÇAISE IS A PRECURSOR TO EXCELLENT CLINICAL CARE

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THE WHITE COAT INCARNATES THE FUNDAMENTAL DIFFERENCE BETWEEN PATIENT AND DOCTOR

patient-doctor boundary. As such a boundary is the cornerstone of an effective working relationship, it follows that la mode française is a precursor to excellent clinical care.

Now, prepare to be convinced.

We doctors, and students, are emphatically individual. We know this.

The NHS knows this. Goodness, any reasonable patient knows this.

And yet we try to hide our innate individuality behind starched blouses and khaki chinos. We are warned that facial hair may undermine our professionalism, or that brightly coloured socks could jeopardise our practice.

But the truth is that patients look to be treated by a person, not by a profession. They want their doctor to be competent, of course, but also to be human, and a fundamental part of humanity is individuality. If casual dress allows a patient to speak more openly to, and work more effectively with, his doctor, then casual dress is most certainly indicated in the British healthcare setting.

“Preposterous!” cry the naysayers, “What of patient safety? What of fragile sensibilities?”

I am not proposing that practitioners wear whatever takes their fancy, regardless of impracticality or explicit content.

Rather, I say that clinicians should use reasonable judgement to select a more casual wardrobe that will neither stop them doing their job, nor offend any sensitive souls under their care.

In such a way, our clinicians might just begin to resemble the people whom they serve.

The second pillar of la mode française is the white coat.

This icon has received much justified criticism in recent years; it harbours not only infection, but also a paternalistic hierarchy that has no place in effective modern medicine. Yet I present the coat once more to you, dear Reader, as a perfect tonic.

The chief danger of using casual dress to approximate doctor to patient is that the patient-doctor boundary may become excessively blurred. It might be forgotten which party is more trained in matters of medicine, which acts as a gatekeeper to care, and which is legally accountable for downstream consequences. Whilst a patient and doctor are equal, a patient is emphatically not a doctor (most of the time), and in the clinical setting Doctor and Patient are playing very different roles indeed. Equality does not equate with homogeny.

And so a white coat serves to remind both parties of this difference. It bears witness to the fact that a patient and his doctor are not ‘mates’, nor is their medical expertise necessarily on a par. It is not an attempt to deify doctors but rather to underline the solemn responsibility of service that a medical professional bears, and which patients ultimately do not.

The white coat incarnates the fundamental difference between patient and

doctor, so that neither party might forget it.

So to the climax of my thesis: to wear a white coat atop of casual dress is a very bold thing indeed.

It is to embrace both a doctor’s humanity and responsibility. It is to draw a doctor close to her patient whilst maintaining an absolute professional distance. And it is to recognise the equality of patient and doctor whilst simultaneously acknowledging differences immutable.

Indeed, the French are masters of fashion and medicine alike. Let us follow suit.I Full references available at: www.omsg-online.com

Dominic Ballard is a fourth year medical student at Green Templeton College

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DUTIES OF A DOCTOR? RACHEL McGALLIARD ARGUES NHS REGULATIONS SHOULD STOP SHORT OF TEA AND COFFEE BREAKS

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he expectations faced by medical students seem to be increasing daily.

From the tacit assumptions of “The Medical Profession”, to our future employer the NHS, our patients, the formidable General Medical Council and perhaps even more ominous – relatives’ expectations; our behaviour seems under constant scrutiny. Nevertheless, given recent media coverage reporting that NHS employees in Leicester have been banned from having hot drinks in public places (it ‘gives the impression staff are slacking’1); I believe it is time to protest that the expectations of doctors have reached their limit.

I agree with the principles of ‘The Duties of a Good Doctor’; undoubtedly, the care of patients should be our first concern. In practice, however, something appears to be going wrong. It seems ridiculous that the doctors working on ICU might be heading towards acute kidney injury comparable to the patients under their care2. Surely, therefore, a beverage would be the recommended course of action for treatment and prevention?

From the start of clinical school, we are reminded to ask the patient if they have any expectations regarding their care, as an important component of ‘I-C-E’: Ideas, concerns and expectations. Interestingly ice is also a crucial part of a Frappuccino, which can’t just be a coincidence.

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Instead of denying staff their daily caffeine boost, managers should wake up and smell the coffee. What dragging clinic hasn’t been revived by the welcome sight of a mug in hand? It does not stand to reason that this in any way impedes patient care or turns a staff member into a “slacker”. It is irrefutably less professional to nod off in clinic than to take a sip in the presence of a patient.

rachel

There’s a lot to be learnt from the time-old wisdom of general practitioners. The tea break is scheduled into daily clinic to allow discussion of challenging and nuanced cases. Rather than being seen as a waste of time, this is understood as a simple and cost-effective McGalliard intervention that additionally facilitates team bonding, problem solving and leadership, ultimately improving productivity and efficiency.

In this era of evidence-based medicine, I am still looking for randomised controlled trials, or even NICE guidance, suggesting that depriving doctors of caffeine will improve professionalism and patient care. Training as a doctor can feel like trying to become a modern-day Atlas, as we strive but struggle to uphold a huge burden of responsibility on our shoulders. But, managers be mindful, we are not Titans! So at least let us make a valiant attempt to bolster ourselves with some caffeine.I Full references available at: www.omsg-online.com

Rachel McGalliard is a fifth year medical student at New College

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HIGH TIME FOR CHANGE - WHAT’S STOPPING US? EDWARD MATTHEWS ARGUES FOR THE NEED TO REEVALUATE OUR STANCE ON DRUGS

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id you get ‘the drugs talk’ from your parents? My mother gave me mine in several instalments, usually as she sipped her red wine in the evenings.

Because I’m from a suburban, Times-reading, Kettle Chips-eating kind of family the message was clear and conservative: “drugs are awful so never go near them or they will ruin your life”. I can now see that this view was probably exaggerated somewhat by maternal protection, but at the time considering myself to be an enlightened teenager, I could only find it ill informed and annoyingly hypocritical. Nearly everyone uses drugs to some extent, and humans have done so since time immemorial; they can be dangerous, but also extremely enjoyable with a beneficial role in our lives. Therefore, our approach to drugs should be thoughtful, flexible and grounded in evidence. At the moment, politics, the media and misguided public opinion obstruct such an attitude in the UK. As a medic, you know that any ward in any hospital will demonstrate the significant impact of recreational drugs. The insidious effects of smoking and alcohol in particular cause or complicate countless diseases. Then there are the illegal drugs, with hospital admissions in England from illicit drug poisoning

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OUR APPROACH TO DRUGS SHOULD BE THOUGHTFUL, FLEXIBLE AND GROUNDED IN EVIDENCE

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totalling 12,238 for 2012/20131. Aside from the direct burden on the NHS, drugs place considerable strain upon society, with binge drinking, violence and addiction – not to mention the associated poverty and policing – posing significant cultural and economic challenges. The need for boundaries to prevent and reduce the harms of drugs is therefore evident. Currently in the UK, most of those boundaries are blurred, and crudely formulated by illegality and criminalisation.

Hard-line prohibition arose as a product of the ‘war on drugs’ in the early ‘70s, itself conceived a decade or so after the UN Single Convention on Narcotic Drugs in 1961. The UN Convention talks of “the evil of drug addiction” and recommends that governments “should do everything in their power to combat the spread of the illicit use of drugs”2.

Then in 1971, the same year that the UK introduced the Misuse of Drugs Act, President Nixon named drug abuse as “public enemy number one” and called for a “new, all-out offensive”3. In this context, drugs were considered a moral evil that needed to be fought, and the emotive moralism applied to drug use has endured since this turning point, being one of the greatest factors impeding effective harm reduction. It shuts the door on rational debate, fuels a drugs war void of good science and provides a platform for media sensationalism and scaremongering.

The war on drugs has failed to reduce supply or demand. A 2003 report by the No.10 Downing Street Strategy Unit, initially suppressed by the Government before eventual publication, found that “the drugs supply business is large, highly flexible and very adaptable”. As a result, “despite interventions at every point in the supply chain, cocaine and heroin consumption has been rising, prices falling and drugs have continued to reach users”4. A more recent examination of the drugs war by the London School of Economics states that “[the war on drugs] has failed based on its own terms. Evidence shows that drug prices have been declining while purity has been increasing. This has been despite drastic increases in global enforcement spending”5.

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THE EMOTIVE MORALISM APPLIED TO DRUG USE IS ONE OF THE GREATEST FACTORS IMPEDING EFFECTIVE HARM REDUCTION

Not only is it a very expensive failure, the drugs war is actively damaging. Whilst efforts are made to bring down high-end suppliers and dealers, users are commonly arrested by police in the UK. They constitute an easier and more prominent target, often being small-scale dealers themselves. As a result, ill people are criminalised and subjected to disruption that complicates and hinders their attempts to get clean. As drug addiction and poverty go hand in hand, it is a particularly vulnerable subset of society who are affected in this way.

But the times, they are a changin’. We see this in the USA, where three states have now legalised recreational cannabis use, which is arguably less harmful than alcohol use6, with more states to follow.

We see it in Switzerland, Denmark, Canada and other countries where illegal drugs like heroin can be consumed safely and without fear of arrest in

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NOT ONLY IS IT A VERY EXPENSIVE FAILURE, THE DRUGS WAR IS ACTIVELY DAMAGING

clean, specialised, state-endorsed facilities – rather than publicly in dirty alleyways or parks. We see it in Portugal, where decriminalisation of drug use and the introduction of drug dissuasion commissions have improved access to treatment and education. Ever so steadily, people are realising that the heavy-handed war on drugs does more damage than good. Prohibition is being replaced by alternative, subtler means of regulation. Such progressive improvements can provide an alternative to ineffective, damaging, and crudely directed UN-driven policies.

Whilst evidence on the basis of which to make firm conclusions is lacking, changes to UK drugs policy have the potential to benefit users, taxpayers and society at large. However, these do not seem to be openly discussed or debated by politicians. The Home Secretary, Theresa May, suppressed the release of a report comparing international policies on drug regulation for three months before its eventual publication in October 2014, potentially because it

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did not fully support the Conservative stance on drugs. This suggests a lack of political will to move towards evidence-based drug policy reform.

Norman Baker MP, who resigned at the time of the report’s publication, said “I regret that in the Home Office, the goodwill to work collegiately to take forward rational evidence-based policy has been in somewhat short supply”7. It’s not just the Coalition Home Office that demonstrates this lack of will: in 2009, Labour Home Secretary Alan Johnson showed a disregard for evidence-based policy by sacking Professor David Nutt, Head of the Advisory Council on the Misuse of Drugs (ACMD), when he spoke out against the government’s decision to reclassify cannabis as a Class B drug8.

This political obstacle to reform is interesting because it does not reflect the views of most politicians. A UK Drug Policy Commission (UKDPC) in 2012 found that 77% of MPs thought current drug policy was ineffective and 76% agreed that policy should be more informed by research and evidence9. So why are they not pushing for evidence-based reform?

We can guess at the answer by observing David Cameron. As a young ‘Tory contender’ sitting on the Home Affairs Select Committee in 2005, he supported “fresh thinking and a new approach” to drug regulation9. Earlier, in 2002, he had said during a House of Commons debate that “drugs policy has been failing for decades”10. Since becoming Prime Minister, however, Cameron has insisted that “what we are doing is working” and that he does not believe in decriminalising illegal drugs11. So, it would seem he changed his mind after gaining a position of greater prominence and power. Evidence and argument may have persuaded him that he was wrong. But perhaps instead, it is because he now considers publicly advocating drugs reform politically

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unviable. Like healthcare reform, drug policy is clearly a political minefield.

The moralisation of drug issues arouses strong opinions and makes politicians wary of arguing their views. Indeed, the 2012 UKDPC report found 75% of MPs think drugs reform is too controversial a topic for objective debate9.

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PROHIBITION IS BEING REPLACED

BY ALTERNATIVE, SUBTLER MEANS OF REGULATION

Full references available at: www.omsg-online.com

Edward Matthews is a fourth year medical student at Green Templeton College

This controversy over drugs has its roots in the moralism introduced during the ‘60s and ‘70s.

It is now perpetuated by the media and, as a result, in public opinion.

Professor David Nutt argues that “prejudice, ignorance, and irrational fear fuelled by parts of the media” are the biggest obstacles to reform12.

Tabloid newspapers in particular have been responsible for oversimplifying complicated research. For example, The Mirror and The Sun received criticism from a 2010 UKDPC report that found them to have oversimplified research linking skunk with schizophrenia, suggesting a clear causality when the research itself had only demonstrated correlation13. The Daily Mail also paired their article on this research with an unrelated piece of news detailing how a schizophrenic man had stabbed his parents. In doing so they “deliberately tried to reinforce the relationship between skunk, schizophrenia, and violence”13.

This media storm around the dangers of cannabis was soon followed by the reclassification of cannabis from Class C to Class B, more than doubling the maximum custodial sentence for possession. By pushing through this legislation, Gordon Brown’s government ignored clear evidence provided by the ACMD which did not support a reclassification. It seems extremely likely that they were swayed in their decision to disregard evidence by the overt media opinion that cannabis is an evil thing.

refusal to downgrade the classification of ecstasy from Class A to Class B. Again, the media play a role here because their reporting of ecstasy-related harm is disproportionate, with deaths from ecstasy significantly over-reported. An interesting Scottish study from 2001 showed a 1:1 ratio of ecstasy deaths to media reports (as compared with 5:1 for heroin and 48:1 for diazepam)14. Media fascination and the subsequent international scramble to decrease the availability of ecstasy has arguably led to increased production and circulation of similar, but more dangerous, compounds such as para-methoxymethamphetamine (PMMA), consumed unwittingly by drug users. These have occasionally been confused for ecstasy (MDMA) in media reports of drug deaths, establishing a darkly ironic feedback loop15. The Scottish study found that other rare forms of drug deaths caused by the likes of aspirin, barbiturates and triazolam were not reported, suggesting a particular fixation on ecstasy14. Imagine how thick newspapers would be if they reported all alcohol-related deaths.

If we are to progress with drug reform then it is important that politicians do not fear media reprisals against it.

Society needs to start having its own drugs talk in a very public way, with evidence conspicuously at its heart.

That the majority of politicians are in favour of reform is encouraging, but we need leaders to wade through the controversy to the forefront. These leaders must be rational, and impeccable in their use of evidence. Above all, let us shift this moralistic understanding of drug use; it is a relatively new outlook but has become peculiarly entrenched. Doctors are surely some of the best-placed professionals to ignite this culture change, capable of pressing for reform while remaining compassionate and seeing the human The same government also ignored being behind every opinion, and every the advice of the ACMD with its overdose.I

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THE PHILOSOPHY OF COGNITIVE ENHANCEMENT ENHANCING YOUR COGNITION; IS THERE MORE TO THE

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ARGUMENT THAN MENTAL GAINS?

ecent studies have demonstrated medical stimulants at an increasing it has been suggested that our levels of doping that should be condemned? Or is risks minimised?

that academics across all professions are using rate1, 2. Medical students are no different – in fact, illicit use may even be higher3. Is this academic this a reality that needs to be addressed, with its

IS THERE EVIDENCE OF EFFECT IN THE HEALTHY? A single dose of Ritalin (Methylphenidate) has been shown to benefit memory in healthy subjects, as well as increase their subjective ratings for interest, excitement and motivation in a novel mathematical task4. The assertion that the generally established effect or side effect profiles of medications used off-label for cognitive enhancement are equivocal to the conditions justifying their use is unscientific. If we look at the evidence, we find a relatively stark contrast in healthy people who use Ritalin in particular. The demonstration of a benefit in executive function for novel tasks has shown to come with an impairment in previously established performance5. Furthermore, in sleep-deprived individuals using Ritalin, studies have shown that people overestimate their own performance with only a mediocre improvement of attention when measured objectively6,7.

The evidence for cognitive enhancement in the healthy is also particularly problematic to obtain. It is difficult to establish baseline values for variables such as intelligence, wakefulness or cognitive ability. In addition, the majority of studies are single dose, although drugs like Ritalin are known to follow non-linear kinetics in healthy patients8. Prior to any decision being made, it is of the utmost importance to acquire and analyse studies of the dose dependent and population specific effects of medications used to enhance cognition. However, subjective outcomes like educational success are better understood as being attributed to multiple factors. This interwoven nature of cognition renders it difficult to assess specific avenues of cognitive enhancement by only considering the efficacy of a person performing novel cognitive tasks9.

A RESPONSE TO JAMES KUHT’S ARTICLE: OMSG 64(1) RELYING ON A SUPPLEMENT Medical students conducting their training under the influence of enhancement medications may distort their ability to accurately discern their level of competence without the drug, rendering them dependent on the drug to maintain confidence in providing adequate patient care3,10. Although this may be an accurate analysis it relies rather strongly on the naturalistic fallacy. In what substantive way is this level of reliance different to the ubiquitous caffeine addictions of medical students and doctors? The truly discernable difference between medications and a cup of coffee seems to be that the dose is variable in the latter and the side effect profile unknown in the former. As an aside, it is interesting to note

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that the use of Ritalin has been implicated in lowering, not elevating, the future abuse of stimulants11.

INEQUALITY OF ACCESS The important aspect I am discussing here is curtailing the use of these potentially hazardous drugs, whilst maintaining the autonomy of the individuals in our society.

The ideal policy for a government to adopt would not condemn, but through education, would remove the incentive of taking these drugs. Although, equality does not apply absolutely, especially in terms of access to technology and even being able to afford a cup of coffee. It is not the responsibility of the government to ensure all people have equal access to medications for augmentation; rather it is to ensure all people have equal opportunities. The government needs to step in when there appears to be a competitive advantage to the augmented in terms of access to job opportunities, which is a debate the current medications don’t provide for.

IMPLICIT AND EXPLICIT COERCION If there was a competitive advantage to the augmented, then individuals may be explicitly or implicitly coerced into using these medications following the utility calculations of corporate bodies12. Furthermore, if we are to accept an inherent advantage provided by access to and usage of these drugs, we may logically believe the augmented are placed in a better position than the drug free13. Even if this were so, the overriding ethical principle here is that of personal autonomy, and restrictions to this adequately justified lest they be deemed paternalistic, arbitrary, and not legitimate. The potential for coercion does not fulfil this

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requirement, even if these medications did provide a competitive advantage.

A BASIC PHILOSOPHICAL DEFENCE OF COGNITIVE ENHANCEMENT If we could ascertain that the use of cognitive enhancement medications would enhance a future doctor’s utility, then the benefits to society may be self-evident – and, if this led to an acceleration of medical breakthroughs, then this may satisfy Jeremy Bentham’s consequentialist basis for his Utilitarian moral philosophy14. This theory states that the moral outcome is the one that leads to the greatest good for the greatest number. Although this is an exaggeration of the potential effects of the current medications, it is no more so an exaggeration than the extreme side effect profile that is believed, in the absence of substantial evidence.

In a philosophical sense, opponents of this utilitarian approach often take a deontological defence, arguing that the act of using drugs to enhance your personal cognition is hedonistic and not justifiable. However, Immanuel Kant also argued that the categorical imperative could be interpreted through reason alone to delineate what firm or inviolate rights are15. If we accept the inviolable right in this debate is the right to enhance personal utility, then attempts towards that are justifiable, regardless of the outcome.

Currently the unregulated access to Ritalin and other cognitive enhancement medications by healthy individuals is unjust, but that is not the end of the philosophical debate. Personal autonomy, utilitarian and deontological ethics are more relevant to the debate than a misconstrued sense of unfair advantage. In this way the use of these medications may be defensible if long-term research can prove that the risks are negligible and the outcomes tangible.I

Full references available at: www.omsg-online.com

Chad Beyer is an elective student from Stellenbosch University

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BIONIC EYES: THE NEW WINDOWS TO THE SOUL? ANTONIO JI XU CONSIDERS THE USE OF VISUAL PROSTHESIS TO RESTORE SIGHT IN THE BLIND

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ust a couple of decades ago, the idea of using a bionic eye to give sight back to a blind person was nothing more than a science fiction cliché. This was certainly not due to a lack of imagination; as early as 1755, the French physician Charles Leroy electrically stimulated the brains of blind patients by discharging a large capacitor through their heads. These patients described seeing “flames descending downwards”1. With the recent advances in the field of visual prostheses, there is little need to resort to such extreme methods. Indeed, patients who previously suffered from retinal forms of blindness are already able to see more than mere rains of flames.

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TO LEGALLY BLIND PATIENTS, EVEN SLIGHT IMPROVEMENTS MAKE A HUGE DIFFERENCE 50

Sceptics may question whether we need bionic eyes at all, and stem-cell enthusiasts wonder if these cells could not provide the solution. Technical issues aside, the main problem with stem-cell therapy is that in cases of advanced stage retinal cell degeneration, the underlying disease will kill off the transplanted cells after treatment2.

For these patients, a more radical approach is required. This was the case for Lisa Kulik, a 55-year-old woman from Arizona suffering from the degenerative condition retinitis pigmentosa. Fifteen years after her diagnosis, which followed her noticing mild difficulty seeing at night, she had to give up her driving licence and retire from her job as a veterinary assistant. Doctors told her there was no treatment available, yet she remained hopeful. “That didn’t stop me.

I knew someday, something was going to come along” she has recounted3.

Two years ago, she was proved right. She was the first patient on the West Coast, USA, to be fitted with Argus II, the first retinal prosthesis approved by the

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PATIENTS CAN ONLY SEE IN BLACK AND WHITE, AND ARE UNABLE TO DISTINGUISH THE FACES OF THEIR RELATIVES

FDA. Argus II, developed by Second Sight, consists of a camera recording real-time images that are transmitted to a sixty-electrode array stimulating the remaining photoreceptors in the retina. This visual information is then fed to the optic nerve and visual cortex, thereby overcoming the progressive loss of photoreceptors seen in retinitis pigmentosa4.

But, what does a patient with the Argus II device see? Put bluntly, not much at all. Patients implanted with the device describe seeing a pixelated image, consisting of patches of light and dark. Nonetheless, to legally blind patients, even slight improvements make a huge difference. Studies have shown that the prosthesis results in

dramatic improvements in orientation tasks5 and in grasping objects6. With some practice and rehabilitation, some patients can even read single letters and words7.

On the other hand, much remains to be done until bionic eyes become a medical reality. At a cost of £100,000 each, available visual prostheses have resolutions of around sixty pixels, which is still six times lower than the legal limit for blindness. Even though some rough shape discrimination is possible, patients can only see in black and white, and are unable to distinguish the faces of their relatives. Implanting a sixty-electrode array in the retina is predictably challenging, with serious potential for side effects, including retinal detachment and erosion of the sclera8. The question of whether the technique could be applied to cases of congenital and early childhood blindness poses a more theoretical dilemma, as the extent to which the visual cortex can regain its function past a critical period of development remains debatable9.

Perhaps the ultimate solution is to go back to Charles Leroy’s initial idea of stimulating the brain directly, which could potentially cure both cortical and retinal forms of blindness. To achieve this, however, we first need to accomplish the formidable task of breaking the neural code by which light is processed to give rise to vision. Meanwhile, although visual prostheses are by no means perfect, this technique is already starting to change the lives of blind people; like Lisa Kulik, who last year was able to watch the 4th of July fireworks for the first time in decades.I Full references available at: www.omsg-online.com

Antonio Ji Xu is a third year medical student at Wadham College

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A CURE FOR PARALYSIS? PEGGY FOOKS ASSESSES A MAJOR BREAKTHROUGH IN OUR EFFORTS TO REVERSE THE FALLOUT FROM SEVERE SPINAL CORD INJURY

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onsiderable effort and resources are invested in rehabilitating patients paralysed following spinal cord injury (SCI), usually with little success. However, a major breakthrough recently suggested that a cure may be near at hand. For the first time, led by Professor Geoff Raisman at University College London, researchers have successfully restored a paralysed patient’s ability to walk. This incredible feat has led scientists and physicians to speculate that paralysing SCI could become highly treatable in the near future – a welcome announcement for the 50,000 people currently living with SCI in the UK.

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BRIDGING THE GAP In contrast to those found elsewhere in the body, neurons in the brain and spinal cord rarely re-grow and re-form functional connections after injury.

Identifying the molecular mechanisms underlying this inherent reluctance has been a major focus for scientists hoping to understand SCI and develop effective treatments. Over the past decade, it has become increasingly clear that several interconnected inhibitory signalling pathways are activated following neuronal injury within the central nervous system.

Overcoming these signals forms the subject of much research, but no treatments allowing the neurons to fully regrow in vivo have yet been elucidated.

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WHAT DOES THIS RESEARCH MEAN FOR PATIENTS? While Professor Raisman admits that a mainstream cure for paralysis following SCI is still several years away, he remains optimistic that it will one day be a treatable condition. However, the wide variety of spinal cord injuries, resulting from different mechanisms of damage, limits the likelihood of a one-sizefits-all curative treatment. Although this cautious outlook may be less sensational than views reported in the media, it is surely preferable to the outrageous claims adopted by clinics in the Far East that promise desperate patients unproven ‘miracle cures’5. Only a phase three clinical trial can determine whether THE MAN WHO WALKED this new technique truly could have a AGAIN Darek Fidyka, 40, was paralysed from future in the clinic. Nevertheless, there the chest down in 2010 following a is no doubt that major new developtraumatic knife attack. The relatively clean ments lie tantalisingly close.I injury to his spinal cord made him an ideal candidate for a new pioneering Full references available at: treatment. Professor Raisman had spent www.omsg-online.com several years investigating olfactory Peggy Fooks is a fourth year ensheathing cells – support cells for medical student at Green neurons in the nose – that seem to Templeton College display growth-promoting properties.

Recovery after SCI was significantly improved in injured rats that received injections of these cells2, a finding supported by similar results obtained in Cambridge with paralysed dachshunds, whose disproportionately long backs leave them prone to intervertebral disc prolapse and SCI3. This research attracted the attention of the Polish neurosurgeon Dr Pawel Tabakow, who was prepared to try this new technique on a willing patient. Once Mr Fidyka had undergone the surgery, the researchers realised that he was making progress as the muscles in his legs began to grow and sensation in his legs started to return. After two years of intense post-operative rehabilitation, Mr Fidyka can now walk again, but researchers believe he will require another two years to yield the maximum benefits of the surgery4.

Research has therefore moved in the direction of techniques that boost neural plasticity and the formation of functional connections by collateral, undamaged cells. Many American researchers have focused on electrical stimulation of the dura mater over affected areas of the spinal cord via indwelling electrodes. One recent paper highlights four patients, two with completely severed cords, who were able to carry out voluntary movements immediately following the stimulation procedure1. The short duration of effect limits the current utility of this electrical stimulation, but this is an area that appears to be making rapid progress.

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AFTER TWO YEARS OF INTENSE POST-OPERATIVE REHABILITATION, MR FIDYKA CAN NOW WALK AGAIN

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MAN EX MACHINA ALEC NOAR AND FREDDY THURSTON INVESTIGATE HOW NEURAL PROSTHETICS CAN INTERACT DIRECTLY WITH OUR BRAINS

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lurring the line between man voice concerns that the incomplete and machine has long enter- restoration of function leaves congentained the world of science fiction, itally deaf children stranded between and novel technological advances in two cultures, unable to fit in with engineering and neurophysiology are those of unimpaired hearing and rapidly bringing such ideas to the left outside of their parents’ forefront of medicine. The FDA have community5.

However, recently approved the first neurally recent work that allows controlled robotic arm, nicknamed precise cochlear the “Luke” arm in an homage to stimulation using the replacement for the limb Luke infrared 1 Skywalker lost fighting his father . lasers While neural implants to restore sensory function have become clinically established, the recent Revolutionising Prosthetics programme funded by the Defence Advanced Research Projects Agency (DARPA) has been a driving force behind translating complex motor neuroprosthetic technologies from theory to the brink of clinical implementation2. This reflects the needs of the growing number of military veterans and civilians who have lost a limb or suffered paralysis.

In June 2014, DARPA announced a $40m grant to develop a memory prosthetic to combat the cognitive problems veterans suffer due to head trauma, as well as the rising burden of dementia due to an ageing population3.

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The most successful neural prosthetic so far is the cochlear implant to treat hearing loss. The House 3M cochlear implant was the first to be made available commercially, in 19844.

Electrodes, implanted around the cochlea, stimulate the auditory nerve fibres in a pattern corresponding to sounds picked up by an external microphone. Despite widespread clinical use, cochlear implants have raised significant controversy.

Members of the deaf community

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COCHLEAR IMPLANTS HAVE RAISED SIGNIFICANT CONTROVERSY

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suggests that this may soon cease to be an issue, heralding development of cochlear implants that accurately restore hearing6. Similarly, visual prostheses, or bionic eyes, are being developed to treat blindness [see Antonio Ji Xu’s article in this issue].

It is now clinical reality that lost limbs can be replaced with mind-controlled robotic prosthetics. Alongside the “Luke” arm, Johns Hopkins University have developed the Modular Prosthetic Limb, with freedom of movement rivalling that of the human arm9. These prosthetics can be controlled by rerouting nerves from the amputated limb into redundant muscles in the stump, thus amplifying their electrical signal, which can then be detected by surface electrodes to move the prosthetic with incredible dexterity10. Sensory nerves can be rerouted to the skin in a similar fashion, and stimulated to provided

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NEUROPROSTHETICS OFFER EXCITING AND IMMINENT SOLUTIONS

tactile feedback from sensors in the prosthetic11. The first osseointegrated long-term prosthetic limb with sensory feedback has recently been developed. Anchored to the bone, this prosthetic could be used for over 18 hours a day for a year, and enabled the patient to resume work as a truck driver12.

Alternatively, recording neural activity directly from the motor cortex can facilitate control of prosthetic limbs.

The advantage of this technique, which uses implanted electrode arrays, is that prosthetics can be adapted for those with paralysis. Application of this technology has allowed a 52-year-old tetraplegic woman to eat unaided13. However, despite functional improvement current prostheses lack proprioceptive feedback, which is essential to natural and intuitive movement. Work in monkeys has recently shown that microstimulation of the sensory cortex can be used to encode proprioception, and incorporation of this modality will significantly improve future prostheses14.

In parallel to sensory and motor deficits, prosthetics are also being developed to restore higher cognitive functions. The Restorative Encoding Memory Integration Neural Device (REMIND) project, funded by DARPA, aims to develop the first neuroprosthetic to recover lost memory function, through replacement of the hippocampus, a critical structure in memory formation. Simultaneous recording from rat hippocampal inputs and outputs during a memory task, allowed researchers to use an implanted chip to mimic hippocampal firing, and rescue memory function in rats with pharmacological inhibition of the hippocampus. Furthermore, they showed that delivering these firing patterns in normal rats enhanced their memory performance. Perhaps most notably, these stimulation patterns could be transferred to other, naïve

animals and still result in memory enhancement15. This is a vital proof of concept for the practical therapeutic use in humans, as it would not be possible to pre-record hippocampal firing patterns before a patient presents in the clinical setting. This work is currently being performed on non-human primates, the last stage before clinical trials in humans16.

Clearly neuroprosthetics offer exciting and imminent solutions to major problems facing healthcare today, but this promise must be tempered by awareness of accompanying obstacles.

The primary issue is the exceedingly high cost per patient: it is estimated to cost $100,000 to fit a patient with a neurally controlled artificial limb17.

Furthermore, the operations involved are highly invasive, meaning that these prosthetics must be suitable for long term use, which can be hindered by factors such as glial scar formation around the sites of electrode implantation. Possible ways to avoid this include development of immunologically inert materials in electrode technology.

Looking to the future, we must ask ourselves what ethical dilemmas we will face if and when the performance of neuroprosthetics exceeds our own natural performance, as has been hinted by the REMIND memory prosthetic. Would we take the use of prosthetics to the extremes, as we’ve seen with cosmetic surgery, and electively replace our own body parts, despite the surgery being unnecessary and invasive? Whatever the answer to questions like these, it certainly seems that the boundaries between humans and machines are becoming increasingly distorted.I Full references available at: www.omsg-online.com

Alec Noar and Freddy Thurston are third year medical students at St. John’s College

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BOUNDARIES OF HUMAN COMMUNICATION DAVID ROWLAND DISCUSSES THE RESEARCH MOVING BRAIN-TO-BRAIN COMMUNICATION FROM SCI-FI FANTASY TO REALITY

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t’s 2052 and Peter is on a run in Oxford. Ideas are bouncing back and forth between him and a colleague in Australia.

Concepts are forming as their brainwaves interact. But Peter is struggling to concentrate; his dog Lola at home is distracting him with neural signals that she is hungry.

injuries2. A BCI allows someone to communicate with the outside world without use of the peripheral motor or sensory systems. In more simple terms, an individual’s messages are delivered by brain signals themselves, rather than muscular contractions of the vocal cords or limb movements.

Transcranial magnetic stimulation As far-fetched as this sounds, a future (TMS) is a non-invasive method to including mind-to-mind communica- depolarize or hyperpolarize neurons, tion could become reality with the allowing a computer to directly development of brain-computer inter- transmit signals to the brain. This faces (BCIs). This ‘hyperinteraction’ precise stimulation has lead to breaks free from the constraints of non-invasive computer-brain-intermotor and sensory signals, allowing faces (CBIs). Combine this with brains to communicate directly. BCIs, and the vision is born of Whether this represents a utopian or non-invasive, computer mediated dystopian vision is open to debate, brain-to-brain (B2B) communication though undeniably raises fascinating between subjects: hyperinteraction. questions.

In 2014 this idea became reality Brain-computer interfaces were first with the first human brain-todeveloped in the 1970s by Dr. brain interface; the first conscious Vidal and colleagues1. People were transmission of information between taught to voluntarily control their own two individuals without use of alpha rhythms to transmit a Morse peripheral motor or sensory systems. code, when an electroencephalo- Ruffini and colleagues used a BCI gram (EEG) was used as part of a in Thiruvananthapuram, India and a computer programme. His pioneering CBI in Strasbourg, France to transmit work sparked the recent development brain waves via email3. The BCI in of therapeutic BCIs for patients with India monitored EEG activity related to locked-in syndrome or spinal cord motor imagery tasks. This allowed the

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BRAIN-TO-BRAIN INTERFACES ALLOWING MIND-TO-MIND INTERACTION.”

participant to communicate, in binary code, the position of a target cue: presence of the cue in the lower right part of the screen corresponded to ‘1’ whilst presence of the cue in upper right part of the screen corresponded to ‘0’. The ensuing code was emailed to France and received by the CBI. Here, the signal was transmitted via TMS to stimulate part of the second participant’s visual cortex, inducing flashes in the corner of the receiver’s visual field.

This series of illuminations allowed the binary code to be deciphered, communicating simple words like ‘ciao’ or ‘halo’. However primitive this may seem, it was a crucial realization of non-invasive brain-to-brain communication. International media soon cottoned on with headlines abound of ‘telepathic emailing’ and ‘an inbox full of brainwaves’.

Other studies have shown the possibility of cross-species brain-to-brain transmission. A team at Harvard Medical School used B2B interfaces to facilitate transfer of information

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between a human and a rat4. Altering the degree of concentration of the human participant on a flashing light corresponded with changes in the EEG recoding. This was transformed into tail-movement evoking stimulation delivered to the brain of an anaesthetized rat. In short, focusing attention on the light allowed the participant to have remote control over the rat’s tail movements.

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ONE COULD IMPLANT AN IDEA WITHOUT CONSENT

This study touches a science fiction nerve, sparking futuristic ideas of industrial control over individuals.

Perhaps a more interesting avenue for potential application is reversing the direction of communication i.e. from non-human animals to humans.

This could be used for enhancing our sensory systems, improving our sense of smell when linked to a dog, or in a less anthropocentric manner to understand the animal kingdom to a greater extent. In the case of Peter, he could simply find out when his dog is hungry.

Linking brains through B2B interfaces clearly presents a wealth of possible applications. Much of the funding for this technology has been from the military; it is possible to think of various reasons why. B2B transmission could allow a secret agent to communicate discreetly while on a James Bond style mission. ‘Epidermal electronics’ have recently been developed, small grids of electrical sensors the thickness of the human epidermis could be placed under hair to allow discrete transmission acting as both recording EEGs and stimulatory TMS. The US government is funding the Defense Advanced Research Project Agency (DARPA) for a ‘Silent Talk’ initiative; developing a BCI helmet that

would allows soldiers to communicate through their brain waves. DARPA are attempting to identify universal ‘pre-speech’ word specific impulses in humans that could be recorded via EEG and transmitted for covert communication. These B2B could even provide enhancement of soldiers’ capabilities. Linking a solider on the ground with a control base counterpart receiving video links of the soldier’s surroundings could allow faster reactions to potential dangers.

With neural inputs, the solider would react before he had even sensed danger.

The act of linking two brains raises ethical issues. If the monitoring solider purposefully gave incorrect commands, or an accident occurred, who would be responsible? Or in the building of ideas through B2B interfaces, who owns the intellectual property if it is formulated by two brains? Considering the brain’s lack of ability to refuse stimulatory activity, one could implant an idea or piece of information without consent. Similarly, if neural activity is connected to the internet, the prospect of brains being hacked is fairly terrifying.

The development of genome sequencing was accompanied by considerable efforts to protect genetic information, precautions that must be echoed in the progressing field of B2B interfaces. Brain-computer links open up a vast field of potential research.

Implications of this work are exciting and frightening in equal measure, and undoubtedly will have a huge impact on the centuries to come.I Full references available at: www.omsg-online.com

David Rowland is a fourth year medical student at St. Catherine’s College

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MAGIC NUMBERS: SOCIAL CIRCLES AND COMMUNITY IN THE 21ST CENTURY CHARLIE COUGHLAN SURVEYS THE SHIFTING SANDS OF OUR SOCIAL NETWORKS

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he American outdoor clothing company Gore-Tex is an intriguing oddity in the cut-throat world of business. Since the company was established in the 1950s, its leaders have sought to cultivate a sense of community amongst their employees. When its founder, Bill Gore, walked into a huge new factory and promptly felt lost in the sea of his new employees, he was anxious to tinker with his business model.

Through a process of trial-and-error, he noticed that productivity fell and social problems became

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rife in workforces exceeding 150 members. All future factories built for the corporation were rigidly capped at this number, and if booming business prompted expansion, an entirely new structure for 150 would be built next-door.

Employee satisfaction soared, business was never better, and it seemed that Gore had stumbled upon a magic number.

Several decades later, Professor Robin Dunbar, now Head of the Social and Evolutionary

Neuroscience Research Group in Oxford’s Department of Experimental Psychology, published a ground-breaking paper that has transformed the way we think about human social groups. By extrapolating from estimates of primate neocortex volume, Dunbar theorized that the number of stable social relationships that we are each capable of maintaining is set by rigid cognitive constraints1. This number, which now bears his name, perhaps unsurprisingly averages out at 150. The imprint of Dunbar’s number on our evolutionary history and contemporary social habits is indelible. Ancient hunter-gatherer societies, modern Amish communities, military companies and even Christmas card networks2 all seem to conform to this rule.

With forces such as globalisation, urbanisation and social media threatening to change the way that we interact and communicate, research in this field has taken on new significance.

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SOCIAL CIRCLES ARE BOTH MULTIPLE AND CONCENTRIC, WITH EACH LAYER CONTAINING MORE AND MORE MEMBERS WITH WHOM WE ENJOY LESS INTIMATE RELATIONSHIPS

Whilst Dunbar’s number provides a snapshot of the casual friendships that we enjoy at any one time in adulthood, membership of this core “social circle” fluctuates in different circumstances. Moving house, starting a new job, and other forms of social upheaval inevitably entail the loss of old friendships and the forging of new ones.

Some friends may fall out of this core social group into the category of acquaintances; others may become close confidantes. Social circles are therefore both multiple and concentric, with each layer containing more and more members with whom we enjoy less intimate relationships. Dunbar and his colleagues have identified a rough ‘rule of three’ that governs the distribution of individuals in these social strata. Embedded within our core social circle of 150 are 50 ‘good friends’, 15 ‘close friends’ and around 5 ‘best friends’. Furthermore, we can all list 500 acquaintances, and put names to the faces of 1500 people.

The key constraint on the size of these circles appears to be time. As a species, we don’t hedge our bets when it comes to social pursuits; 40% of our total “social time” is devoted to the 5 members of our innermost circle; 60% of the total to our “top 15”. This disproportionate investment strategy reflects the fact that social bonding is firmly rooted in performing activities together. Investing so much time in just a few individuals engenders tight social cohesiveness, encouraging altruistic behaviour of benefit to each individual in the group.

This raises an important point about social media. Not a day goes by without a tabloid newspaper lamenting the insidious influence of Facebook, and the imminent collapse of society that social networking sites are sure to bring. However, our clear natural preference for intense personal contact – a relic of our ancestors’ grooming behaviour – is so strong that only face-to-face meetings can truly provide the lifeblood necessary to maintain a close friendship3. Social media

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can slow the decay of a relationship, acting as a form of life-support that can prolong the inevitable, but it is incapable of altogether reversing the trajectory of a dying friendship. As Dunbar puts it: “you’ve got to see the whites of the eyes.”

The terminology surrounding social media is also highly misleading; many people claim to have thousands of “Facebook friends”, when in fact they are merely collecting acquaintances, as we do each day in the offline world.

Various studies suggest that that the average Facebook friend count lies in the region of 150-250 per user4, conforming strongly to Dunbar’s number.

The notion of social media tearing down barriers between social circles seems unlikely given our innate hardwiring, making the prospect of the Facebookdriven social apocalypse seem rather distant indeed.

Perhaps unexpectedly, globalisation and urbanisation seem more likely than social media to clash with our ingrained preference for cohesive social groups.

Large cities – New York, Lagos and Mexico City to name but a few – are caricatured as crime-ridden dystopias, full of lost souls. With friendship groups becoming increasingly dissipated both nationally and internationally, and urbanisation eroding an age-old “village mentality”, the intrinsic policing and self-regulation seen in tight-knit communities is likely to become a thing of the past. Dunbar fears that these inexorable forces are likely to prove “extremely counter-productive” and “create dysfunctional societies” in the future. Their potential impact on factors such as social justice, mental and physical health – even migration and town planning – is massive, but has been consistently ignored by governments for decades. We will soon reach a tipping point. Nonetheless, Dunbar remains optimistic - in his eyes, digital technology may hold the key to offsetting the negative aspects this new world.

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SOCIAL ISOLATION IS AS STRONG A PREDICTOR OF MORTALITY AFTER MYOCARDIAL INFARCTION AS HIGH CHOLESTEROL LEVELS, SMOKING, AND HYPERTENSION

Having identified time as the key currency underpinning the composition of our social circles, research has moved towards characterizing the biological substrate for social bonding. The underlying mechanism appears to be an endogenous psycho-pharmacological effect mediated by endorphins.

Humans have successfully captured and perpetuated primitive behavioural mechanisms that hijack this system, such as laughter, singing and dancing.

Now deeply embedded both in culture and religion, these activities rapidly foster a sense of belonging for all involved. The secret ingredient for this collective benefit is synchrony, which, according to Dunbar, “ramps up the endorphin effect with no extra effort.”

In 2009, his research group cleverly manipulated the relationship between endorphin release and pain perception to investigate the effects of synchrony in a group of 12 male rowing Blues.

Synchronous rowing activity was associated with a significant increase in median pain threshold5. Similar results have since been obtained in people actively making music6, or engaging in social laughter7. The additional endorphin kick provoked by synchrony effectively widens the ‘grooming effect’ by a factor of three, transforming a one-to-one activity into a more time-efficient bonding experience for all members of a small group. The rituals that form the bedrock of modern religions – praying, singing and rites of passage – clearly tap into the mechanisms described above. It will be fascinating to see whether the socially destructive forces of globalisation and urbanisation will cause more and more people to turn to religion, in their search for an elusive sense of community.

So, what does the future hold for this field? The answer may lie in healthcare. Dunbar’s number has captured the attention of epidemiologists, who have slowly come to appreciate the

stark effects of social support on health and wellbeing. Studies first performed in the 1980s demonstrated that social isolation is as strong a predictor of mortality after myocardial infarction as high cholesterol levels, smoking and hypertension8. In the decades since, social support has also been shown to profoundly influence mortality amongst breast cancer survivors9, stroke victims10 and diabetics11. A more comprehensive understanding of the impact of social support on mortality in older men and women – a group burdened by high levels of chronic disease – could transform our health and social care policy. A shift away from expensive drug-based therapy, towards an approach centred on broadening social networks and fostering a sense of community, could reap considerable rewards for the patient, the masses and the exchequer.

Whether a government with sufficient mettle to promote this social investment will ever come along is another matter entirely.

Social circles are clearly flexible in terms of membership, but rigid in their overall structure. One can only forge effective friendships by investing heavily in them, and partaking in behavioural and cultural mechanisms – laughter, singing, dancing and countless others – that have evolved over the course of two million years.

The great American poet and essayist Ralph Waldo Emerson clearly struck gold when he said, “The only way to have a friend, is to be one.”I

Acknowledgments: The author would like to thank Professor Dunbar for generously giving his time to take part in a short interview.

Full references available at: www.omsg-online.com

Charlie Coughlan is a fourth year medical student at Magdalen College

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WHEN EAST MEETS WEST: FRONTIERS IN YOGA JULIE BOLITHO-LEE THINKS ABOUT WHAT IT MEANS TO LIVE A ‘YOGIC LIFE’

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ome of the greatest living Indian yogis attribute the West with ‘saving yoga’ – quite a statement when one thinks of overpriced, name-brand leggings and studios with advertisements that promote rock-hard bodies instead of spiritual enlightenment. Nonetheless, in some senses, these spiritual yogis are right: the West did ‘save yoga,’ insofar as bringing it into a cultural mainstream and making it more accessible to a variety of people who otherwise would have never been exposed to this 5000-year-old philosophy that incorincor porates practices of mind, body and spirit. Yet, the difference between the life of an Indian yogi (usually men who have been trained since boyhood in this ancient tradition) compared to the life of a western yoga teacher (usually women who have embarked on a second career) are vast. Yogis in India can spend their entire lives ‘training,’ while in the west, yogis can take part in an intensive month-long course to become a certified, bonafide (and insured) yoga teacher. While yoga is a way of life for many aspiring yogis in India, it tends to be a weekly 90-minute class for most yoga students in the West. Some may question if the two can even be called the same thing. (The savvy yogi or yogini might remark that yoga in the West is based on the asana practice—or the physical practice of yoga—whereas there are actually eight limbs to the philosophy in Patanjali’s Yoga Sutras—the asanas only being one of them.)

yoga, I have experienced the criticism of definition. A local Ashtanga teacher (who I saw smoking marijuana and drinking vodka one Friday night—not exactly aligning to yogic precept of saucha or purity) said to me that she ‘just didn’t see aerial as real yoga.’

Another local Iyengar teacher said to one of my aerial students that I probably wasn’t even a ‘real yoga teacher.’ Of course, their incredulousness begs the questions: What is real yoga and what is a real yoga teacher? And possibly even more important: Can we define it and does it even matter?

My personal yoga journey began over ten years ago when at the age of nineteen, I was diagnosed with papillary thyroid cancer, which had metastasized to the majority of the lymph nodes in my neck, as well as destroyed my thyroid and parathyroid glands. This came after five years of managing Hashimoto’s Thyroiditis and living on a typically poor Midwestern American diet.

Recovering from surgery received at the Mayo Clinic in Rochester, Minnesota, I was advised by my small-town GP in northern Michigan to consume milkshakes laden with sugar and candy bars after I stopped eating due to the nausea of the pain (as I refused to take the painkillers themselves as they induced even worse bouts of nausea).

During the post-surgery treatment phase, while being advised to consume these high-fat, high-sugar foods, I was disallowed any thyroid medications. This potent combination left my Even within the western yoga community, already overweight body ballooning to there are fusions and dichotomies, as the heaviest weight it had ever been. well as dogmas to be debated, adhered The lethargy and tiredness I’d experito or broken. Being a teacher of both enced for much of my teenage life a more traditional style of yoga, as well from the Hashimoto’s Disease increased as of a fusion style known as aerial exponentially and I longed for the days

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in which a walk didn’t leave me breathless and fatigued.

Despite the previous lethargy and overweight physique, prior to the cancer, I was part of my college’s diving team and regularly participated in morning ‘land practices’ and daily afternoon pool practices. At the time of my treatments though, the idea of even swimming a lap caused fear of drowning due to my exhausted body’s complete inability to cope. I felt trapped and frustrated… and then one evening, at ten o’clock at night, lamenting my woes to my best friend, I asked her if she had ever done yoga. Neither of us had; we’d only heard of it – and in northern Michigan at the time, there certainly were no yoga studios, and yoga was still seen as ‘dangerous’ by local Christian groups, as if it were a gateway sport into Indian voodoo and other cult-like perils.

Always having been a night owl (which I’ve learned is a kapha tendency according to Indian Ayurvedic medicine), I dragged Ashley, my friend, to the local Meijer—a Michigan version of Asda or Tesco Extra—and went to the fitness DVD section. It was here that I picked out a DVD entitled, Denise Austin’s Fat-Blasting Yoga! For this DVD, all I needed was myself and an exercise ball (which

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I pilfered from my mother’s collection and ironically have never seen used as a yoga prop since). We arrived home at nearly 11pm, and Ashley, being a dedicated friend, agreed to try the DVD with me. By the tenth minute of the hour-long session, we were both panting and cursing the petite, blonde Texan woman on the screen.

Despite being ready to collapse onto my bedroom floor, we persevered after hitting pause on the remote several times and taking many water breaks.

It was well past midnight by the time we finished, but something in this strange, incredibly fitness-oriented, mainstream DVD, hooked me. Ashley came nearly every day for the summer of my recovery to support me in my efforts to acquire some basic level of fitness again. We stopped cursing poor Denise after the third week.

During my yoga teacher training at the Kripalu Centre for Yoga and Ayurveda, one of the interns led us aspiring teachers in a brief metta

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meditation, asking us to send gratitude to the first person who brought yoga into our lives. I giggled as I said my own little yogic prayer for the woman who eventually became a core member of George W. Bush’s Council on Physical Fitness and Sports. At no point have I ever cared if Denise Austin can really be called ‘a yoga teacher.’ She was my first regardless of definition or spiritual qualifications, and for that, I will always be grateful.

It is in this same vein of gratitude that I have learned to be open—to approach matters within the yoga community, as well as matters within the wider community, including that of the western medical establishment, without rigidity. In my career as a patient, as well as my career as a graduate student in Literature and Medicine, I have met many medics who have tried to unhelpfully define me (vegan, yoga teacher, alternative researcher) and I have also met many would-be patients who tried to unhelpfully define western medics (dogmatic, pigheaded, narrow), forgetting that these same medics could save their lives. Had I ever known to be so narrow within the yoga context, I never would have found it. Had I blindly followed some of the medics who treated me, I also never would have found a diet that supports me and sustains me most effectively in both body and spirit. Likewise, without western surgical techniques, I could quite easily be dead or left without the voice for which I seem to be known when I teach my yoga classes. I am eternally grateful to the surgeon who left a large J-shaped scar on my neck, as it represents not a disfigurement, but a triumph—a triumph of medicine, of this surgeon and his career, and of the burgeoning yogini waiting to be let out.

This is not an article about the benefits of yoga (though there are innumerable benefits, and encouragingly, information about yoga and many of those benefits can be found on the NHS Choices website), but this is more an article about how we navigate our world. The beauty of yoga’s current global position is that it is so changeable so difficult to define in any one sense. To even have an ‘east,’ one must have a ‘west,’ and vice versa—and yet on a round globe, those boundaries are always changing too. Much like the Chinese yin-yang symbol exists yoga’s relationship to the modern world. Beyond other laudable yogic ideals (acceptance, compassion, balance, etc.), the way in which yoga is situated in such undefinable terms lends itself to living better, to defying definition, to exploring and experiencing those things that serve you regardless of what others may say. There is no one path to living a yogic life, much as there is no one path to any life. It is simply in the living, the traveling in this body, that we can cross over boundaries, or rewrite or dismiss maps entirely.

As the Buddhist nun, Pema Chödrön says, ‘Start where you are.’I

Julie Bolitho-Lee is a writer, Kripalu Yogini and Aerial Yoga Teacher living and working in Oxfordshire. She strives to bring both her creative writing and yoga students acceptance and love, as well as spaces of compassion in which to practice. She can be reached through her website: www.sanctuarygrace.com.

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MEDICINE ON THE EDGE NICOLA KELLY OPENS OUR EYES TO MEDICINE IN EXTREME ENVIRONMENTS

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eorge Mallory – one of the most celebrated mountaineers to succumb to Everest – was once asked why he felt such a strong yearning to risk life and limb trying to summit the mountain. His famous reply was simply “Because it’s there”.

Perhaps the most obvious example of medicine at the boundaries of human existence is space medicine.

Sixty-two miles (100km) above mean sea level lies the eponymous Karman Line – the edge of space1.

The Virgin Galactic Spaceline, Richard Branson’s futuristic brainchild, asserts Humans, it seems, have an innate that only 547 people have been to desire to push our bodies to the space since the beginning of this extreme. We climb mountains, run so-called ‘space age’. The company across deserts, swim and sail the hopes to change this by helping oceans, and our thrill-seeking ordinary tourists become astronauts2. behaviour is not confined to the earth. Humanity’s need to discover However, a trip to space might has inspired decades of technolog- not be such a holiday after all, ical advancements. We have seen because weightlessness or ‘microhot air balloons become aeroplanes, gravity’ has devastating effects on only to be replaced by rockets that the body. Bones become deminerallow humans to travel into space. alised, muscles waste away, and the Meanwhile in contrast to these vestibular system goes haywire3. On computer-reliant astronauts, free departure, astronauts have achieved divers have continued to test the limits the peak of physical fitness, and on of our physiology without the luxury of their return many are barely able to hi-tech apparatus, often with serious stand4. implications on their own health.

The relevance of space medicine Why would someone put their mind is rapidly evolving. If Branson’s and body through such ordeals? The Spaceline does take off, the motivations are diverse; adventure, complications of space travel may scientific advancement and existential one day sit alongside DVT on our crisis may all play a part. Yet often differential for the returning-holithese challenges are faced involuntarily daymaker. Interestingly, Dr Alyson – when Mother Nature places adversity Calder, senior registrar in anaesin our path responding to physiological thetics and organizer of the annual stress is not a question of choice, UK Space Medicine conference, but survival. Regardless, as long as hopes that space medicine may people continue to take their bodies help more than just budding astroto extreme environments, doctors will nauts5; ‘The bedbound lady in the be there; sometimes trying to under- geriatrics ward who develops muscle stand human physiology, but inevitably wasting, orthostatic intolerance and learning how to handle ill health far disuse osteoporosis may, by proxy, away from the reassuring corridors of be helped by research carried out in space.” the John Radcliffe Hospital.

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HUMANS HAVE AN INNATE DESIRE TO PUSH OUR BODIES TO THE EXTREME

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Whilst intergalactic exploration poses unique medical and physiological challenges, so do many environmental extremes here on earth. A 2007 BBC Horizon documentary, ‘Everest: Doctors in the Death Zone’, followed the Caudwell Extreme Everest Expedition. This group of doctors, nurses and scientists travelled to earth’s highest mountain and

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WEIGHTLESSNESS OR ‘MICROGRAVITY’ HAS DEVASTATING EFFECTS ON THE BODY

volunteered themselves as subjects, in order to conduct research into the human response to hypoxia.

The title, whilst dramatic, is no overstatement. Ascent to high altitude is associated with a number of syndromes, including acute mountain sickness, high altitude pulmonary oedema, and high altitude cerebral oedema, which may be life threatening.

At altitudes higher than 8000m you find yourself in the ‘death zone’.

Here the body fails to acclimatize to the thin air and hypoxia is inevitable: you become confused, and without supplemental oxygen you rapidly fall unconscious. At this point, death is almost unavoidable. Intriguingly, the way the body copes and the huge variability in individual responses to ascent are seemingly unrelated to baseline physical fitness.

Studies like the Caudwell Expedition, examining human physiology in extremis, are directly relevant to the increasing numbers of tourists keen to climb mountains for leisure. Its members also hope the findings will improve treatment of ‘critically ill patients suffering a similar challenge at sea level’6. In contrast, skeptics such as the physiologist Robert Roach question this assertion, saying “The mountain is a perfect model for the mountain… There’s very little to be learned [about acute respiratory distress syndrome and other conditions] from going to Mount Everest.7” The merits and generalizability of high altitude research aside, one has to question the rationale of these doctors. With successful careers and many with young families, they choose to accept huge personal risk when alternatives such as hypobaric oxygen chambers seem both safer and more economical. Although not specific to mountaineering medics, research has been done on the psychological factors motivating high

altitude ascent. Personality profiling carried out on climbers planning an Everest summit attempt found them to score more highly on extraversion and psychoticism with lower scores on the neuroticism scales than controls8. Other studies have looked at “sensation-seeking behaviour” and hazard-aversion – collectively, the results seem to suggest that some humans are simply programmed to enjoy putting themselves in risky situations.

Amongst any cohort of medical students there will, no doubt, be those that aspire to become wealthy consultants with lucrative private practices. Others will be driven by academic goals and international acclaim, and there will be those for whom work-life balance is essential.

And, perhaps, there will always be those like the doctors featured in the BBC documentary, who find excuses - and funding - to practise medicine in extreme environments. Whether in space, up mountains, in conflict zones or on a night shift in A&E, doctors are constantly required to maintain mental composure during moments of physical stress. Those travelling to environmental extremes not only put their own resilience to the test, but also have a privileged exposure to the boundaries of human understanding. It has been estimated that nearly one in ten children9 want to be an astronaut when they grow up – a figure that exemplifies the inherent curiosity of the human psyche. If you were one of those children, then why not consider NASA’s Aerospace Medicine Elective? You never know, your dream may still come true10.I Full references available at: www.omsg-online.com

Nicola Kelly is a fifth year medical student at The Queen’s College

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READ THIS IF YOU DON’T HAVE TIME JAY GHANASHYAM SHETTY EXPLAINS WHY WE SHOULD ALL MAKE TIME TO MEDITATE

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ime is the aspect of our lives that probably receives the most attention. We think about needing more, managing it better and we are usually running behind it.

An interesting collation of research in 2009 shared facts about how we spend the days of our lives.

by auction site madbid.com. This may be significantly less now thanks to the increase in use of Amazon, Internet shopping and banking. Women spend 136 days getting ready and men spend 46 (this is debatable).

A Readers’ Digest survey however suggests men spend 3,000 hours shaving (add that to the initial grooming We spend 653 hours waiting for trains. This may seem time). We spend 115 days laughing and 2,170 hours like a long time but in fact it is only 27 days. In compar- sunbathing. The average Brit takes 366 days off sick, ison, we spend 6 months queuing up at supermarkets, says the Confederation of British Industry. We spend high street shops and banks according to a survey 11 years watching a screen and a radically growing

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number on apps. We spend 5 months complaining and 38,003 hours eating. We spend 23,214 hours washing clothes and 46,800 hours on housework. Finally, we spend 26 years (potentially 1/3) of our lives sleeping, says the Organization for Economic Co-operation and Development.

Whether this summary makes you happy or makes you question your very existence we can quite confidently say that it would be extremely difficult, near impossible to completely change those numbers. We all want a life full of enjoyable moments as opposed to mundane tasks but there are some things that we all have to do. However, what if we could do something that would revolutionize our experience of every moment? How many of us feel that our minds are constantly on play?

Thoughts go round and round in our heads for weeks, months and years without us being able to find stillness, focus and the time we need to achiever our goals. Imagine having the ability to pause, rewind and fast-forward your thoughts so that you can think about what you want, when you want to.

Scientific research shared by the Harvard Business Review show meditation and mindfulness have phenomenal success in increasing productivity, enhancing everyday experiences and improving our ability to manage time. For 10-20 minutes a day people who meditate demonstrate superior performance on tests of self-regulation. Resisting distractions and making correct answers more often than non-meditators. In addition, meditation enhances parts of our brain that help us learn from past experiences supporting optimal decision-making. These are some of the proactive benefits of meditation but it has also been used to assist with stress and depression by increasing resilience and inner strength. Further to this Meditation affects areas of the brain related to perception, body awareness, emotional regulation, complex thinking and tolerance of pain. Neuroscientists believe these initial explorations provide great insights into the benefits of meditation for students, business executives, medical professionals and anyone who wants to enrich their experience of time. Rather than wasting our time by procrastinating, complaining, working to no end and feeling stressed meditation can guide us towards a life with no boundaries. Freedom comes from the ability of self-discipline and regulation giving us the power to overcome whatever slows us down.

I currently coach several organisations and individuals on the methods and benefits of meditation. At the moment there is a genuine search to find tools and techniques that can improve our lifestyle with minimum change. I believe meditation is that one thing you can add to your life that will nourish all others. Just as watering the root of a plant helps it grow, similarly meditating will help us cultivate all aspects of our being, mental, physical and emotional.

I hope when I look at a similar study in 25 years I see 425 hours a year spent meditating. That’s only 10 minutes a day.I

Jay Ghanashyam Shetty is a management consultant, meditation coach and ‘urban monk’

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A TRIPLE EXPORT OF CHILD HEALTH FROM OXFORD TO UGANDA THREE OXFORD GRADUATES ALL FIND THEMSELVES WORKING TO IMPROVE CHILD HEALTH IN EASTERN UGANDA AFTER HAVING TAKING DIFFERENT CAREER PATHS

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n Saturday 14th July 2007, Kathy, Jenny and I graduated from Oxford University Medical School. Fast-forward to Saturday 15th November 2014, and we are catching up on the last 2,681 days over a curry in Mbale, Eastern Uganda. Although we all arrived in Uganda within a couple of weeks of each other, our plans to work in this country were made completely separately.

Uganda is a landlocked country in East Africa, with a population of approximately 36 million. More than 80% of households are located in rural areas and rely on subsistence agriculture, with 38% of the population living below the international poverty line. According to the World Health Organisation, Uganda’s per capita government expenditure on health in 2012 was a little over $10 (compared to $3009 in the UK)1.

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With a total fertility rate of 5.9 some like-minded students following births per woman (third highest in work overseas in Cambodia, South the world), the population average Africa and Thailand. Since graduating annual growth rate is 3.3%2. In from Worcester College in 2007 2012, 48.5% of the population I have spent over half my career was aged under 15 years3. Children working in the developing world. growing up in Uganda suffer the consequences of poverty, poor health Following my Foundation Training I spending and limited education. In worked as a research clinician for 2 2012, the under-five mortality rate years on the Thai-Burmese border. was 69 per 1000 live births; the big It was during these two years that killers being malaria, diarrhoea (often I was introduced to the challenges due to poor water and sanitation), of neonatology in resource-limited respiratory tract infections and other countries and developed my passion communicable diseases. Though there for improving newborn care in such is a massive health burden, Uganda settings. During my Academic Clinical currently only has 1.2 physicians per Fellowship I undertook a 9-month 10,000 population (compared to clinical research post at Mulago 27.7 in the UK)2.

National Referral Hospital, Uganda, where I worked as project lead on a neonatal encephalopathy outcomes KATHY HEWITT SMITH study and led a study looking at the (NEE BURGOINE) outcomes of preterm births in Mulago.

During my medical degree I developed an interest in global health, founding After completing ST3, I applied for the Oxford Global Health Group with time out-of-programme to pursue my interest in neonatal care in resource-limited settings. In September 2014 I moved with my husband, an anaesthetist, and our 6-monthold daughter, to Mbale in Eastern

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Uganda. We are both volunteering at Mbale Regional Referral Hospital (MRRH), where Adam is working on improving obstetric anaesthetics and I am helping establish newborn care and a neonatal unit.

Over 7000 babies are born in the hospital each year, however until September, apart from the modest postnatal ward and the overwhelmed paediatric ward, there was nowhere to care for sick neonates. This meant that even preterm babies were being nursed alongside children suffering from infections like pneumonia and gastroenteritis. With the help of our charity Born on the Edge (www.bornontheedge.org), we have developed a Kangaroo Mother Care (KMC) room within the hospital for 8 mothers and their growing preterm babies. Here I have established a care package for the preterm babies involving spoon-feeding,

KMC, infection control and using the mothers as the main carers. There is always a “Champion Mother” who is encouraged to take the lead in ensuring the other mothers weigh their babies daily, record temperatures and feeds, undertake KMC and adhere to infection prevention rules.

With only two nurses to care for over 100 paediatric patients, this approach is proving successful. This month we have proudly discharged 4 preterm neonates from our new neonatal follow-up clinic. All four started life weighing just over 1kg and now weigh more than 2.5kg.

Reducing neonatal mortality in MRRH is a big challenge; our first month of data collection sadly demonstrated that 41% of our 138 neonatal admissions died, with over half of deaths due to sepsis. Despite this, the challenges of my work are both exciting and important to me. We hope that by the

end of our year here in Mbale, the staff working in MRRH will have both the knowledge and basic facilities to care for their sick newborns, and in turn that the number of unnecessary neonatal deaths will diminish so that more mothers can enjoy the gift of life.

JENNY SMITH (NEE WOODRUFF)

After graduating from Keble in 2007 I settled down to Foundation jobs in the Oxford deanery. I discovered how much I enjoyed paediatrics whilst doing my F2 in A&E – chatting to little people was a lot more fun than dealing with drunks. Seemingly incapable of dragging myself away from this part of the world, I ended up in the Oxford Paediatric Deanery, and have rotated through Milton Keynes, Oxford, Aylesbury and Reading in the last five years.

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My interest in working in Africa began following a conversation with an enthused colleague who said his three years working in Malawi had been the most influential and inspiring of his career.

ture monitoring scheme run by the mothers of the babies on the neonatal unit. This week there was a big discussion as to which mother deserved to be nominated as the Temperature Champion Mother of the Week, and keeper of the thermometer I arrived in Uganda in September and pen. It seems to be making an 2014 with my 11 month old impact, and the mums are definitely daughter and husband Nick (a GP), enjoying the responsibility. I’ve also following a successful application to been stretched when giving weekly the Royal College of Paediatrics and lectures to the local clinicians, who Child Health Global Links scheme. have seen far more of the conditions The idea of the Global Links scheme that I’m teaching them about than I is to foster relationships between have, yet are still gracious and keen low resource settings and the UK, to learn. by providing opportunities for African doctors to do placements in British I’ve really been inspired by the local hospitals, whilst allowing UK paedia- doctors and nurses; they do an tricians to work in Africa. incredible job in such difficult circumstances, whilst remaining positive I am based at the Jinja Regional despite the limits that they’re working Referral Hospital, a 500 bed hospital within. I’ve also been amazed at how in Eastern Uganda with a catchment emotionally strong the parents are – area of over half a million children. I am it is a joy to see parents grinning working alongside local staff to make when their sick child has survived long-term improvements to paediatric against the odds, and to be told services. Along with service redesign, ‘Doctor – well done’.

I’ve also been seeing patients with all sorts of conditions I’ve only read HELEN SIMS WILLIAMS about in books before now (Burkitt’s (NEE NYE) lymphoma, Gibbus deformity in TB of the spine, Kwashiorkor to name but After graduating in July 2007, a few).

I completed Foundation years in Reading and Oxford, before moving There seems to be almost limitless to Bristol for core medical training. need here, and there are frustrating After two years of Renal and General times every day due to a lack of Medicine in the Oxford Deanery, my resources; even things we should career took a less conventional have access to, like the WHO list of route when my husband Hugh essential medications, we don’t. This got neurosurgical run-through in means often parents end up going to the South Yorkshire deanery. buy drugs, cannulas, syringes, even I took up a locum post in writing paper for continuation sheets. the Sheffield Kidney Unit, increasingly I never thought I would miss the became pharmacist’s green pen scribblings, involved in teaching at or the infection control nurses raising the medical school, began a their eyebrows – it’s funny what being and Masters in Higher away from the NHS does to you.

Education at the I’ve had some successes here with University of service improvement projects, for Sheffield. example I’ve introduced a tempera-

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BY THE LOCAL DOCTORS AND NURSES; THEY DO AN INCREDIBLE JOB IN SUCH DIFFICULT CIRCUMSTANCES

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14kg, perhaps merciful since she is unable to stand or walk. Her mother, a widow, has five other children to raise. Remarkably she survived that episode, but she still has end-stage kidney failure with no prospect of dialysis or renal transplantation.

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THE CHALLENGES OF MY WORK ARE BOTH EXCITING AND IMPORTANT TO ME

In February 2014 my husband Hugh watched a presentation about CURE Children’s Hospital of Uganda (CCHU), a neurosurgical hospital specialising in the management of hydrocephalus and spina bifida (www. cure.org/uganda). To my surprise, his application for out of programme experience was accepted, and six months later we found ourselves on a plane bound for Uganda. Excitement was mixed, on my part, with apprehension: what could I usefully do in a paediatric neurosurgery hospital?

That encounter set the direction for the remainder of my time here in Mbale. After successful applications for funding and ethical approval (the hospital has its own ethics committee!) I began a follow-up study looking at renal outcomes in children aged 10-14 who had spina bifida repair here as babies. To date we have been able to find 71 of 86 children in Eastern Uganda, bringing them to the hospital for a number of investigations and questionnaires.

The research particularly focuses on “clean intermittent catheterisation” (CIC), the only possible measure to prevent chronic kidney disease here, but also fraught with challenges in this setting. We are also considering broader issues such as quality of life, school attendance, and understanding of spina bifida and its causes.

Within a couple of weeks I had become quite accustomed to the daily arrival of mothers and babies from all over Uganda and beyond, presenting with “increasing head size” or “swelling on the back”, and to the compassionate efficiency with which all these cases were managed. But one day in early September I was asked to help with the care of thirteen-year-old KO, admitted with urosepsis, anaemia and acute renal failure. KO had surgery for spina bifida in 2002 and has battled with numerous problems since, including hydrocephalus and shunt infection. She weighs only

Never before have significant numbers of children grown up with spina bifida in Uganda: this group is a new generation. While the research will undoubtedly produce very interesting results, it has perhaps been more exciting to work towards improving the long-term follow-up for patients with spina bifida. Alongside my study I have been promoting the development of a multidisciplinary approach to the care of these children, reviewing the CIC protocol, and strengthening links with other NGOs who can help with the long-term support of these families in the community.I

Full references available at: www.omsg-online.com

Helen Sims Williams is a graduate from Oxford University Medical School,, currently working in the CURE Children’s Hospital of Uganda

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BEYOND BARRIER NURSING CONTEMPLATING THE EBOLA CRISIS

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eliandou is a small village in southern Guinea, home to Etienne Ouamouno1. On December 6th 2013, Etienne’s two-year-old son Emile passed away, after having suffered from diarrhoea, headaches, and fever. Other family members soon followed, and what began as an isolated personal tragedy has precipitated unimaginable consequences. It is thought that Emile’s death marked the beginning of the current Ebola outbreak2, a public health disaster so damaging that this epidemic has claimed more lives than all previous combined3. As the death toll climbs, the wider socio-economic implications for West Africa and the global community become increasingly apparent. Amidst the terrible loss and destructive force of the disease, hundreds of volunteers and health workers have been fighting on the front lines to stem the flow of Ebola. What are the barriers facing these individuals, both in the field and when trying to return home?

Throughout 2014, Ebola gripped the attention of the world media. Whilst the focus was on the suffering and scale of disease in West Africa, this epidemic was not purely a medical problem. Heavily reliant on foreign investment and very susceptible to shock, the West African economy could not escape unscathed.

The failure of overseas organizations to differentiate between high and low risk areas means that West Africa as a whole has suffered5, including those countries as yet untouched by the disease.

Thus, the challenge of Ebola is compounded by the extreme poverty through which it rages. Lack of infrastructure and healthcare in affected countries means the international community has stepped in to provide necessary technical assistance. But this response has

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colonial overtones, echoing the archaic imperialist boundaries that still carve up much of the continent. Instead of a coordinated response, the UK, France and US have sent disproportionate amounts of aid to their former territories6. This divided response may make containing the epidemic across borders an even more difficult task.

The high Ebola mortality rates and ease of transmission means health workers face a conflict between duty of care and self-preservation. They are also subjected to stigma, violence, and psychological stress. Challenges exist as simple as dehydration and exhaustion from wearing heavy personal protective equipment (PPE) all day, meaning that people are only able to work short shifts in the full protective gear. If workers find themselves in a tricky position, the WHO advises: ‘health care and other workers have the right to remove themselves from a work situation that they have reasonable justification to believe presents an imminent and serious danger to their life or health’10.

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365 EBOLA CASES COULD BE LINKED BACK TO A SINGLE GUINEAN FUNERAL

Furthermore, cultural barriers confront international healthcare workers at every turn. It is easy to understand the alarm created by faceless, hazard-suited foreigners entering your home, taking one of your relatives, and spraying the area with a strange liquid. Next thing you know, that relative has died, out of sight and shrouded in security. The extreme of this fearful climate hit the press with the tragic story of eight people who were reportedly killed when trying to disinfect and educate a Guinean village7. Their bodies were later discovered in a school septic tank.

Cultural attitudes and misconceptions are a sensitive subject, forming an obstacle to effective management of the epidemic. One example is the difficulty of reconciling safe body disposal with long-standing funeral rituals. Tradition dictates that people should honour the dead through burial ceremonies. However, these often create the perfect storm of a highly contagious body and a communal gathering, so the practice is discouraged by international humanitarian agencies. It is thought that as many as 365 Ebola cases could be linked back to a single Guinean funeral8.

Where customs are at loggerheads with infection control,

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how can someone fulfill their duty of care whilst respecting cultural boundaries?

At the heart of these troubles lie poor public understanding and a lack of trust. If people are sensitively educated about the rationale behind precautions such as dissuading public burials, perhaps there is hope for change. Emergency aid organisations like MSF cannot be charged with fighting every battle, but a joint initiative to promote public understanding is needed to help combat this epidemic and prevent its future recurrence. In a positive step, Mercy Corps announced its plans in 2014 to work with trusted community leaders in Liberia to deliver Ebola education to 2 million people9.

It is not only in the field that healthcare workers come up against problems. What happens when public health initiatives contravene their individual rights? MSF volunteer Kaci Hickox returned to the US after treating Ebola patients and was ordered by the state of Maine to remain quarantined in her home11. Ms Hickox claimed that this went against her civil liberties, as she did not test positive for the virus.

A judge subsequently ruled in here favor, lifting the quarantine and simply saying the she must co-ordinate travel and movement such that she could be monitored, and must report any symptoms.

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HEALTH WORKERS FACE A CONFLICT BETWEEN DUTY OF CARE AND SELFPRESERVATION

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Such restrictions encountered on returning home may dissuade people from volunteering – so, to gain their much-needed help it is important to think about the interests of healthcare workers, too. We have a societal responsibility to break down these boundaries by helping those who return home. We run the risk of jumping to non-evidence based solutions12 , with the Centre for Disease Control (CDC) stating that returning Ebola medical workers do not need to be quarantined13. Debate will undoubtedly continue around what constitutes appropriate measures that protect public health whilst minimizing the risk of ostracizing healthcare workers, turning them into social pariahs.

Despite Ban Ki Moon saying that it is ‘unacceptable’ to discriminate against workers returning home, media hyperbole purports stigma and fear.

Ebola has shaken and shocked the international community.

Handling an epidemic on this scale highlights the caveats that accompany foreign aid, whilst the discussion surrounding quarantine shines a harsh light on the values of our own society - one of many instances of apparent conflict between individual human rights and protection of the masses. In its wake, Ebola has left thousands of lives devastated and families destroyed. The more lessons we learn, the less they are in vain.I Full references available at: www.omsg-online.com

Emma Pencheon is a third year medical student at Somerville College

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GAZETTE NEWS - MARCH THE NEWS IN REVIEW - ELIZABETH WHATLING MYRIAD OF MALARIA Mystery diseases inspire trepidation in the West. Buried in our psyche lies the idea that a new Black Death will one day appear, shattering the protection modern medicine seemingly offers. To throw salt in the wound, the Department of Health recently warned that another pandemic is “inevitable” and predicted up to 750,000 British deaths causing “socioeconomic crisis”.

We are, apparently, just waiting for the next big virus to strike. Perhaps, this goes some way to explain the panicked reaction to Ebola. But it’s hardly new.

surprised if there were not an increase in unnecessary malaria deaths in the midst of all this, and a lot of those will be young children.”.

feeding women were advised to avoid peanuts. This guidance was dropped in 2008 when studies failed to show any benefit and parents have been left in something of a limbo since The root of this problem has long then. This new research suggests that been suggested to lie with poor health parents following the old guidance may infrastructure and extensive poverty in have unwittingly made the problem these Western African nations. Yet of potential peanut worse. In total, there is hope. With foreign aid targeted 650 children were recruited into this at encouraging a basic health service study all of whom were considered rather than armies of aid workers that to be at higher risk from allergy with can undermine the existing health concomitant eczema or egg allergy, provisions, malaria deaths can be half received peanuts in the first year reduced. One of the greatest stories of of life and half did not. The results the last decade remains the extraordi- were dramatic; essentially if a child nary economic growth of sub-Saharan managed to eat peanuts in the first With recent reports downgrading the Africa – and how this is quickly trans- year of life they didn’t develop a Ebola threat and suggesting that its lating into poverty reduction, cutting peanut allergy. However we must progress has been halted, new data death rates from its everyday diseases. address the issue of the previous on the impact of infectious disease The war on malaria can be won. guidance. It is in essence not flawed. upon mortality has emerged in these If there is no exposure to an allergen nations and Malaria remains a far then an allergy cannot develop, but more lethal threat to Africa. Seventy A NUT A DAY KEEPS THE importantly, in practice it is almost times as many African’s have died DOCTOR AWAY impossible to avoid peanut exposure. from malaria since the start of the Nuts, nuts, nuts… edible, nutritious and So here, tolerance is to an allergen Ebola epidemic. And, many parts of the go-to snack for squirrels nation- achieved through extended exposure Sub-Saharan Africa remain at the wide. But love them or hate them, rather than evasion. Arguably, this long mercy of this preventable and treatable recent research has shown they’re more anticipated study is a game changer virus. With enough resources, malaria crucial than you think, particularly, in paediatric allergy. can be eradicated, as was proved in your formative years. Gideon Lack, a Sri Lanka in 1963 when a US-led professor of pediatric allergy at King’s NEWS IN NUMBERS campaign brought the annual death College London and senior author of 2014/15, officially the worst winter toll down from 92,000 to just 17, the study in the New England Journal for the NHS since the introduction of yet, malaria remains a bigger killer of Medicine has shown that “At least ED 4hr targets in 2004 now then Ebola is ever likely to be. with respect to peanuts, avoidance With a similar symptom profile to ebola may actually worsen the problem.”. 58%- 86% of derived news stories in the press contained similar exagger(fever, dizziness, head and muscle The study showed that a diet that ations in the press release from aches) many adults and particularly includes peanuts in the first year of researches a paper in the BMJ this children are not accessing healthcare life may greatly reduce the chance of month has found services due to a fear of containment developing peanut allergies in children in ebola infected wards. Dr. Bernard at risk for getting them.

75% the number of mice with Alzheimer’s receiving ultrasound Nahlen, deputy director of the U.S. President’s Malaria Initiative said in an Peanut allergy is a growing problem therapy who fully regained their interview in the Huffington Post, “It in the Western world, prevalence memory function after treatment would be a major failure on the part has doubled in the last decade and 30, the age at which intelligence, of everybody involved to have a lot of as many as 1 in 35 children are educational attainment and income is people die from malaria in the midst affected in some countries. In the greater if you were breastfed by your of the Ebola epidemic…I would be early noughties, pregnant and breast- mother for 12 months or more

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FRITH PHOTOGRAPHY PRIZE 2014 THEME: SIGNS (MEDICAL OR OTHERWISE)

TOP: 3RD PLACE ALICE BUCHAN 5TH YEAR MEDICAL STUDENT, BALLIOL COLLEGE

RIGHT: 2ND PLACE CHARLIE ZHOU 5TH YEAR MEDICAL STUDENT, NEW COLLEGE

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FRITH PHOTOGRAPHY PRIZE 2014 THEME: SIGNS (MEDICAL OR OTHERWISE) BELOW: WINNER LYDIA YARLOTT 6TH YEAR MEDICAL STUDENT GREEN TEMPLETON COLLEGE

RIGHT: OXFORD MEDICAL SCHOOL GAZETTE ESSAY COMPETITION 2014 WINNER: MADELEINE TURNER

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knowledge can be just as beneficial. on sub- specialism in medicine combined with recent advancements The medical community is increas- in equipment and technology17, ingly confronted with new ethical threaten to undermine this all-imdilemmas in both the process of portant doctor – patient relationship. development and the aims of the Pushing boundaries may even be In 2014, a new drug1 for the treatments themselves8. Many argue the undoing of effective care by treatment of atypical haemolytic that the more advanced treatments a doctor, and there are two main uremic syndrome was approved by that have become available today reasons for this. Decreased physical the NHS. It will cost an estimated are not morally viable, and that they contact and communication18 £58m in its first year to treat roughly breach ethical frameworks that should between a doctor and patient may 200 patients. It is a high-profile be upheld by the medical profession. present itself as a problem because breakthrough drug that will improve Recent developments in mitochon- as medical science has evolved, the lives of patients drastically2. In drial donation9 have caused much reliance on technology has meant 18553, a British nurse working in controversy, and this year the UK that doctors are less likely to do a military hospital in Scutari was government decided to become the physical examinations19 and listen undertaking a simple re-design of first country to permit this relatively to patients describe their symptoms. the hospital ward: beds would be new treatment. The most common Additionally, as medicine increasmoved further apart and ventilation form of mitochondrial donation10 ingly merges with science, doctors increased to prevent cross-patient involves using an extracted pronuclei today risk only focusing on the direct infection. Two significant advances in and putting it into an enucleated egg problem that the patient presents, medical treatment, one the product cell which contains healthy mitochon- rather than caring for them as a of painstaking laboratory research, dria. The pronucleus contains genetic whole person20. Dr Sherwin Nuland, the other resulting from experience material from the two parents, but a clinical professor of Surgery at therePRIZE is also genetic material present Yale Medical School, while giving and common sense. Is one betterESSAY in the mitochondria of the donated a lecture21 at the Anlyan Centre in than the other? egg cell. While this is a revolu- 2010, said that ‘technology has The UK experienced a period of tionary move in terms of effectively created a medical fascination with intensive change in healthcare in treating mitochondrial diseases (for the disease rather than the wellbeing the 1930s and 40s due to the which there are no other treatments of patients’. By saying this he was discovery of penicillin in 1928, and currently available), many people inferring that there are circumstances then the creation of the NHS in argue that it is wrong for a child when cutting edge medical science 1948. These events led the public to have three biological parents for can prevail over other areas of focus to believe that medicine could a number of ethical reasons, most that are equally valuable, and it is at answer every health problem they obviously the emotional and psycho- this point that the medical profession had, and the pioneering break- logical stress involved. Advocates should realise that they may have through with penicillin in particular of this treatment argue that the overstepped the boundaries. prompted the medical community to benefits surely outweigh opposing become obsessed with finding similar arguments, as the child would be Scientific advancements that have new drugs that could treat other born without mitochondrial disease, pushed the boundaries to create new conditions. This remains the case preventing an undoubtedly difficult drugs have been enormously benefitoday, with society fixated on new life. Nevertheless, one can’t help cial to society and it has not been treatments to eradicate any disease4 but wonder if in legalising this type my intention in this essay to attempt or problem they have, however this of treatment, the government are to dilute their importance. However it means that methods to prevent or opening the door to many more seems sensible to question whether just control a disease become lower radical treatments11. Professor Stuart the incessant focus on pushing the priorities; basic public health care Newman of the New York Medical boundaries of scientific advance and essential hygiene have been College went so far to say12 that always represents the best solution, subordinated. As an example of this an ‘attempt to improve future people for there are certain cases where dichotomy, drug companies have is not medicine, however, but a alternative approaches are equally recently been focused on trying to new form of eugenics.’ Mitochondrial or more productive. Simple healthfind a cure for Ebola5, so far without donation is undoubtedly pushing the care initiatives, especially involving success. And yet in October 2014 boundaries of medical science13, but educating sectors of society at risk, Nigeria was declared an Ebola free scientists14 involved may not wholly can be the most effective solution to state by the WHO6. This was not understand what the consequences specific new diseases. Equally, we because cutting edge technology or will be for future generations both need to keep an eye on the ethics medication was used, but simply due socially and genetically15. underpinning some of the boundary to their effective public health organchallenging research. Finally, the isation, and a clamp down on poor As medicine becomes more complex, focus on headline grabbing breakbasic hygiene. The actions taken in it grows ever more important for throughs risks minimising the Nigeria proved that there is no need doctors to have good communication importance of the overall doctor – to unnecessarily push the bound- and empathy skills. This is widely patient relationship. Perhaps what aries of medical science7 in order recognised in the training modules we need is a better understanding to successfully treat patients, but that medical students study16. Yet of where and when to push those that effective coordination of existing paradoxically, the increasing focus boundaries.

81 The medical profession is constantly pushing boundaries in an attempt to improve treatments and save lives.

Is this a good thing, or is it possible to push boundaries too far?

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FROM OUR ARCHIVES OMSG VOL. XVII, NO. 2

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Do No Harm: Stories of Life, Death and Brain Grain Brain: The surprising truth about wheat, Surgery carbs, and sugar – your brain’s silent killers Henry Marsh, Orion Books, 2014.

David Perlmutter £6.29 - Amazon £9.79 - Amazon

Cancer Virus: The story of EpsteinBarr Virus Dorothy Crawford £13.93 Hardback - Amazon

Recently retired neurosurgeon, Henry Marsh, takes us on a tour of his glittering career in his autobiography ‘Do No Harm: Stories of Life, Death and Brain Surgery’. At first glance he appears to be a monumental over-achiever – not only an eminent neurosurgeon, but also an Emmy award-winner for a documentary about his experiences in Ukraine. Whilst perhaps true, his story is more complex than one might expect. After completing a PPE degree at Oxford, he ran away from family to ‘find himself’ working as a hospital porter.

This inspired him to be a medic, but with no scientific qualifications the only medical school open to him was the Royal Free Hospital in London. Despite his privileged background, his story is inspiring to any of us who are late bloomers in medicine.

The Epstein-Barr Virus is a complex beast. Infecting 90-95% of the population, yet for most displaying few symptoms; some people have a tangle with glandular fever, but for the unlucky ones, EBV can take on a more menacing role. The more sinister conditions related to EBV include Burkitt’s and Hodgkin’s lymphomas (particularly post-transplant, just to compound the fallout of immunosuppression), nasopharyngeal and gastric carcinomas, and a whole host of increasingly bizarre tumours.

For a long period in history, the central question of this book seemed ridiculous: how could a virus cause cancer? An unlikely route finally opened up this intractable question, when, in 1958, Denis Burkitt described a rare childhood cancer in Africa’s tropical belt. This sets the scene for this book, which goes on to explore the history and science of EBV. Cancer Virus is both a historical account and a plea for more grant money, since EBV is far from fully characterised. The episodic approach to the history leaves some chapters a little impenetrable to the lay reader, with a heavy focus on the detection methods for the virus in lymphoma cells. As you can imagine, it is a bit heavy-going, but sections of narrative provide a welcome break; one surprising and morbid highlight was a discussion of the incidence of nasopharyngeal cancer in Chinese populations, setting up a fascinating reflection upon the ethnic histories of the Bai Yue peoples.

I cannot help feeling that contemporary Western society has developed an unhealthy obsession with healthy eating. New theories frequently emerge, only to be swiftly scrapped and replaced by even newer conflicting ones. Good intentions notwithstanding, it becomes virtually impossible for those of us committed to investing in a healthy lifestyle to gain any degree of assurance around our dietary choices.

I could therefore be forgiven for my initial scepticism at Perlmutter’s grand promise: to preserve my mental faculties in the long-term by revolutionising my attitudes towards food in the short term.

Perlmutter begins by attempting to combat what he perceives as defeatist attitudes towards brain disease, urging us to reduce our probability of affliction by altering our dietary habits. He emphasises the importance of early intervention, and seeks to shift attitudes to focus on prevention rather The book is essentially a series of anecdotes: than treatment. He also sets out practical tips to each chapter is named after a medical facilitate the challenging transition to healthier habits, condition which is defined clearly from the including a seven-day meal plan. start. These range from the clinical ‘medulloblastoma’ to the more existential ‘angor animi’. Perlmutter brands gluten with particular notoriety, Literally ‘anguish of the spirit’, it describes revealing its under-appreciated involvement in the patient’s belief that they are in the act neurological dysfunction. Gluten’s detrimental effects, of dying. This kind of variation is typical he asserts, are far greater than recognised – and of the book; matter-of-fact medical descrip- not just relevant to coeliac sufferers. He further tions sit alongside heart-breaking tales of challenges conventional understanding by trying to personal tragedy. Some of the stories are truly undermine the notion that fats are more harmful shocking, for patients and putative medical than carbohydrates. The conclusion: both our professionals alike. Most traumatising is that mental faculties and our waistlines would profit from of a young, considerate surgical registrar who favouring saturated fats over carbohydrates and, accidentally cuts through a nerve root during controversially, from forgoing the ubiquitous statin. a spinal operation.

While experts will inevitably quarrel over the validity Despite the tear-jerking parts of the book, of Perlmutter’s claims, his arguments are well there are also moments of humour and triumph. organised and convincing: citing prominent studies Marsh strikes the balance between the thrill and quoting peers whose views are in accorand tragedy of surgery well, resisting the urge dance with his own. His engaging style, albeit a to gloss over the effect of such long hours tad melodramatic, is both eloquent and accessible, on his spirits and personal life, ascribing the with entertaining anecdotes from his time in clinical breakdown of his first marriage to his devotion practice. to neurosurgery. It makes an informative tale for anyone intrigued by the specialty, since Overall, ‘Grain Brain’ is an enjoyable and he retains his passion for neurosurgery from thought-provoking read. Whether or not I take all his first experience as a junior doctor, but of Perlmutter’s suggestions on board, I will probably tempered by decades of mistakes and experi- make more considered dietary choices in the future. ence. I would wholeheartedly recommend the And will Perlmutter’s promise be fulfilled? Let me book as a brutally realistic tale of the life of get back to you in fifty years time. the neurosurgeon.

Emma Callanan Fourth year medical student, Exeter College

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Ashwini Arvind Third year medical student, Lincoln College

So, yes, it is an interesting read.

Cancer Virus is certainly worth a perusal, both as an introduction into tumour viruses generally, and as a history of this most enigmatic of viruses. And if you’re ever laid up with mono, just remember: it could be a lot worse.

Joseph Williams

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FREEDOM WITHOUT LIMITS IS JUST A WORD.

- TERRY PRATCHETT, 1948 - 2015

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