JUDGEMENT OMSG 64 (1)
10
TUNNEL VISION
11
JUDGING ‘NORMAL’
16
THE DARK SIDE OF MEDICAL PRACTICE
70
MENTAL GAIN’Z
Crossword Puzzle
OXFORD MEDICAL SCHOOL GAZETTE COMMITTEE Editors: Nicola Kelly & Amrit Gosal Sub-editors: Emma Pencheon, Laura Munglani, Nick Aveyard, Bing Tseu, Stuart Mires, David Gleeson, Campbell Stewart, Claudia Snudden, Giles Neal, Alex Barry, Lauren Passby, Suzanne Harrogate Peer Review editor: Thomas Hine Book Review editor: Reza Khorasanee Design Lead: Evie Kitt Design team: Lara Hibbs, Rosalie Brooman-White, Hannah Thompson 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 News Editor: Elizabeth Whatling 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. 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 modeling, 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 © 2014 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.
Across
Down
1. Supersonic jet loses tail landing on tiny worker, in agreement (10)
1. Viewpoint where email precursor follows endless race in reverse (6)
5. Long distance and advancing years make a successful leader for the right! (6)
2. I, myself, for example, study effective knots (9)
7. Part of Thames is doubled (4) 9. European Union adds some logic and Spanish to farewell message (6) 11. Abbreviated Royal Navy wage, when altered, makes for a loud German (6) 12. Run when you hear the tram! (5)
3. Frivolity throws SIM at centre of search for reason (6) 4. Island nation; rhinoplasty in India perhaps? (9) 6. Donkey begins to lay down the lay for very confused French (7) 8. You get into messy DIY and get a hernia! (8)
14. Predator hunts messily on WW1 battlefield (5)
10. Beginning in springtime, common language has spectacular end (10)
16. Ignores: wordplay, say? (5)
13. Crumbling bank takes public transport (3)
17. Insert leading Russian (5)
15. Iberian beverage and boozy honey make painful exit from waterside field (4,6)
18. Unable to walk, LA gangster begins pleading (7) 20. Mountain hints at biliary obstruction (3) 21. I rave, palm selects heart for block (9)
19. Bring back, about and legally I have contracted (6) Answers to appear online soon.
22. O Christ! I feel that in the privates! (8) 23. Ridiculing the French, moon with prime start (7) 24. Prehistoric platform infi ltrated by unity (5, 3)
Killian Donovan is a fourth year medical student at St John’s College.
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First Impresssions
8
Judgement vs. Impartiality
David Gleeson explores the importance of appearance
Nathan Riddell suggests that judgement and impartiality can never be mutually exclusive
10 Tunnel Vision
Gina Sangha ponders how cognitive biases narrow clinical perspective
11 Judging ‘Normal’
Marco Narajos asks whether “normal” is a helpful or harmful label?
14 I’ll take your word for it…
Josephine Holland contemplates how we evaluate the advice and opinions of others
15 Last Rites
Bing Tseu listens to a priest’s discussion of his experiences at the bedside of those at Death’s door
16 The Dark Side of Medical Practice
Claudia Snudden investigates how doctors are involved with torture
18 The Mad, the Bad, and the Law…
41 Holding Doctors to Account
Nicola Kelly looks into the rising number of complaints brought forward against doctors in the modern NHS
43 Medicine in the News
Elizabeth Elizabeth Whatling Whatling reviews reviews somesome of this of this yearsyear’s top top stories. stories
46 Can innovation save the National Health Service? Service?
Samuel Samuel Folkard Folkard illustrates illustrates the potential the potential for us forallustoall to contribute contribute to thetodevelopment the development of a better of a better NHS.NHS
49 The SJT – a step in the right direction or an unfair unfair randomiser? randomiser? Guy Stephens Guy Stephens findsfinds out. out
53 How can we judge who will make the best doctor? doctor? ElliottElliott Carande Carande considers considers the the different different attributes attributes assessed assessed in junior in junior doctors. doctors
55 The growing use of practitioners practitioners in the in the NHSNHS
non-medical
ApurvApurv Sehgal Sehgal discusses discusses handing handing over over responsibility responsibility to to non-medically-trained non-medically-trained professionals. professionals
deterministic deterministic approach approach within within the the law, law, highlighting highlighting society society as a potential as a potential underlying underlying causecause of criminality. of criminality
57 Ketamine: the perfect anaesthetic or a dangerous dangerous recreational recreational drug? drug? Steffan Glaze and Alissa Gutnikova debate Steffan Glaze and Alissa Gutnikova debate 54
20 Does Neuroscientific Progress spell the end for the for the Concept Concept of Free of Free Will?Will?
60 Calling the shots
Edward Edward Matthews Matthews explores explores the the needneed for for a a
HenryHenry de Berker de Berker explores explores the impact the impact of neuroscience of neuroscience on on this fundamental this fundamental feature feature of human of human nature. nature
62 PKU - A History of Misjudgements
22 Insight in Schizophrenia
Francesca Francesca JohnsJohns questions questions the the impact impact of insight of insight in in schizophrenia schizophrenia
Elizabeth Howell Platt Fu tells looks theat tale how behind attitudes the test towards for this debilitating family planning disease vary around the world
65 Contraception: Are you really being judged?
24 Judgement
BalajiBalaji Ravichandran Ravichandran invitesinvites us to think us toabout thinkthe about thinthe line thin between line between judgement judgement and prejudice. and prejudice
Annabelle Elizabeth Painter Platt explores looks at what howthe attitudes science towards really tells family us about planning supplements vary around the world
67 Anti-oxidants: the hidden dangers
28 Moral Judgement in Medical Ethics
James Annabelle Kuht questions Painter whether explorespopping what the pills science or glugging really tells coffee uswill about helpsupplements us flourish in our medical school exams.
Daniel Daniel K Sokhol K Sokol explores explores what what thisthis ideaidea really really means. means
30 What's Neuroethics doing to Understand - and and maybe maybe affect affect - Morality? - Morality? Professor Professor James James Giordano Giordano explores explores neuroethics’ neuroethics’ perspectives perspectives on the onneurological the neurological basisbasis of moral of moral thought. thought
33 Neurodevelopmental Consequences s of Childhood Childhood Maltreatment Maltreatment
Howell Ruth Fu tells Mitchell the tale discusses behindthe thedifficult test for decisions this debilitating underlying disease. UK vaccine policy
of
70 Mental gain’z
BrianJames Phillips Kuht discusses questionsa whether novel technique popping pills in Stroke or glugging Prevention. coffee will help us flourish in our medical school exams
73 The Watchman
Brian Phillips discusses a novel technique in Stroke Prevention
DavidDavid Rowland Rowlandinvestigates investigatesthe thedevastating devastating consequences consequences of early of early childhood childhood maltreatment maltreatment on brain on brain development. development
74 Peer Review (Archive)
36 Dying for an Answer?
79 Book Reviews
RhysRhys DoreDore examines examines the consequences the consequences of near-death of near-death experiences. experiences
39 An Interview with Sir Richard Thompson
Charles Charles Coughlan Coughlan hearshears Sir Richard Sir Richard Thompson’s Thompson’s views on views clinical onjudgement. clinical judgement
78 App Reviews 81 Tear-Out Subscription Form 83 Crossword
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A Note from Design You might notice that OMSG looks a little different. In this issue, we wanted to imbue OMSG’s creative and dynamic layouts with a cleanliness and professionalism that reflects its content. Welcome to 64(1) - we hope you enjoy 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 With special thanks to Rosalie Brooman-White, Hannah Thompson, Lara Hibbs and illustrator Ruby Carrington design@omsg-online.com
Full image credits available at: www.omsg-online.com
Evie Kitt is a Fine Art honours graduate of The Queen’s College
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64(1) EDITORIAL
From the mundane to the life-changing, every day humans across the world make countless judgements. As doctors, we may begin our day pondering humdrum choices, such as what to have for breakfast, and end it having made decisions that will shape the course of our patients’ lives. In this issue we think our writers have tackled this vast topic with creativity and aplomb - and hope you will agree. We begin, rather aptly, with David Gleeson’s conjectures on the importance of fi rst impressions. Whilst his playful words may prompt you to update your Tinder profi le, he shrewdly highlights the crucial impact of appearances on the doctor-patient relationship. Admittedly, the word ‘Judgement’ is frequently associated with a plethora of negative connotations. Nathan Riddell dispels this assumption, exploring the extent to which judgement plays a positive role in a doctor’s daily practice. Claudia Snudden delves into more troubling and sinister exploits of the medical profession. Her consideration of the contentious issues surrounding the involvement of doctors in facilitating torture will surely give pause for thought. As always, our writers continue to challenge us to think philosophically. Henry de Berker and Edward Matthews probe whether there is any basis to the notion of human free will – and, if not, are we truly the protagonists of our own lives? The poignant commentary of Balaji Ravichandran cannot be overlooked. Although simply entitled, Balaji’s eloquent musings will linger long in your consciousness. In this issue, we are honoured to include an article penned by the acclaimed medical ethicist Daniel. K. Sokol. In his detailed analysis, Dr Sokol discusses the moments when doctors - and medical students - may need to draw
upon their own sense of morality. An equally noteworthy contributor, Professor James Giordano, discusses perspectives on the neurological basis of this morality. We then move from the philosophical to the practical. The Gazette could not ignore the reality that, with the introduction of the Situational Judgement Test (SJT), the decision-making abilities of today’s medical students are under greater scrutiny than ever before. Guy Stephens discusses this topic in a clear and informative article, whilst Elliott Carande succinctly speculates whether the foundation programme application system can reliably discern the best doctors. On a more global scale, judgement is addressed through Elizabeth Platt’s examination of the barriers limiting access to contraception. Meanwhile, Annabelle Painter’s somewhat surprising revelations on the potential dangers of so-called “super foods” will certainly pique your interest. The issue concludes on a light-hearted note; with exams in mind, James Kuht asks whether popping pills can ever trump the humble cup of coffee? This year we are delighted to introduce our News Editor Elizabeth Whatling to the Gazette team. With the increasing coverage, and critique, of medicine in the media it seems fitting that the Gazette should feature a handful of the hottest stories. We are also thrilled to welcome our marvellous design lead Evie Kitt. The hard work and talents of Evie and her team have been invaluable in creating the Gazette we proudly present to you today. It is an honour to lead the team this year and we must thank our predecessors, Joshua and Barnabas; who have been nothing short of brilliant in their guidance and support as we have found our feet. As always, we love to hear from you, our readers - so please do not hesitate to be in touch.
The OMSG Editors-in-Chief, Nicola Kelly and Amrit Gosal
editors@omsg-online.com | www.omsg-online.com
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You never get a Second Chance to make a First Impression? David Gleeson explores the importance of first impressions in the modern day, and in our role as health care practitioners.
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e all know first impressions are important. Yet to what extent do they really shape our modern-day social interactions, dominate global marketing strategy, and, as health care professionals, affect our interactions with patients? To start with, here’s a short puzzle. You have to pick a new world leader based solely on the following descriptions of each candidate:
Candidate
A:
willingness to engage with the constant streams of advertising surrounding us have forced marketing firms to evolve with us, producing a new generation of creativity, and unleashing waves of ‘shockvertising’. Characterised by blunt, unapologetic slogans, graphic imagery and sometimes seemingly gratuitous “The explosive growth nudity, these campaigns seek to make an instant impact, to burn a brand of Tinder exemplifies our or product into our memory generation’s obsession with the name – an increasingly difficult task.
Associates with crooked politicians, and consults with astrologists. He’s had two mistresses, chain smokes, and drinks 8-10 martinis
superficial”
a
day.
Candidate B: He was kicked out of office twice, sleeps until noon, used opium at university, and drinks a quart of whiskey every evening. Candidate C: He is a decorated war hero, a non-smoker, a vegetarian, a faithful husband, who loves his own people and rarely drinks. Based on your first impressions of the men, most (if not all) of you will have chosen candidate C, thereby selecting Adolf Hitler as your new world leader – over Franklin D. Roosevelt and Winston Churchill, candidates A and B respectively. Obviously, first impressions are not always reliable. Our dependence upon first impressions pervades throughout every aspect of our lives; for example, we rely upon them to rapidly assess and evaluate the plethora of new products that companies thrust upon us daily. Our shortening attention spans and dwindling
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However, bold marketing strategies and instantly memorable advertising are hardly a new phenomenon. What is far more interesting, are the modern social trends dominated by appearances, wherein one’s first impression is all-important. The explosive growth of Tinder exemplifies our generation’s obsession with the superficial, commodifying one’s looks more potently than ever before. With nothing more than a handful of photos to sum a person up, how a person chooses to
present themselves, and the first impression they make, have never been more key. In the social environment of Tinder, where rejection is just one swipe away, perhaps the phrase “You never get a second chance to make a first impression” has never been truer.
say seriously, or listen to any advice we give them. In a modern world with such a wealth of medical knowledge just a few clicks away online, anyone can now feel able to diagnose their latest malady by themselves, making the diagnostic role of the doctor appear somewhat redundant. As a result, doctors now have to prove their worth more so than ever before, to convince the “Does a winning smile and patient of their greater understanding kind demeanour have more and expertise. These are battles that can easily be lost with a poor first impact than public health impression, making our jobs even harder to carry out, and leaving the rhetoric?” patient more frustrated than ever.
In the more serious context of the professional workplace, how we present ourselves in the future as doctors is crucially important. Our competency will be assessed by both patients and colleagues alike, and the impressions we give off may strongly colour their views. This in turn could affect the trust they place in us, and have a direct impact on the effectiveness of the care we can provide for our patients, for example with regards to treatment compliance. What patient would blindly follow the advice of a doctor they had no trust in, whose first impression had been so underwhelming that they deemed them to be incompetent? Often, no subsequent correct diagnosis or pertinent drug prescription can rectify that initial judgement, which raises the potential for unnecessary harm to be wrought. So often, we make snap decisions about patients based on initial inspections of them, jumping to all kinds of conclusions just from the end of the bed. Whilst this is often an incredibly useful exercise in diagnosis, we would do well to remember that we too are being placed under the microscope. Our patients will study our body language, our use of vocabulary, our tone and general demeanour, mostly likely making conclusions of their own. But most importantly, they will be assessing our competency, our ability to connect with them, to pinpoint their key concerns and allay their fears. They will be deciding whether to take anything we
How can this challenge be addressed? Should we re-introduce white coats for doctors, sending a clear statement of authority and knowledge concerning medical matters? Or would this be a regression back to paternalistic medicine, undoing much of the good work to drive healthcare towards a more patient-centred approach? Maybe it is simpler than this. Potentially the best way to circumvent this dilemma is to win our patients over as best we can from the outset. Likewise, in the growing climate of dissatisfaction with the NHS with wave upon wave of newly emerging hospital scandals, a winning smile and kind demeanour may have more impact than any amount of public health rhetoric. Perhaps, in medicine as much as social media, first impressions have never been more important than they are today. Full references available at: www.omsg-online.com
David Gleeson is a fourth year medical student at Oriel College.
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Judgement vs. Impartiality Nathan Riddell considers judgement’s role in a doctor’s daily practice his point, turns back
T
hroughout their medical education, the doctors of tomorrow are encouraged to be globally judgemental in their diagnostic approach.
“So Nathan, why do you think Mr Smith was in hospital recently?”
the consultant asks, as Mr Smith stares blankly at me. I can see cigarettes in his breast pocket, ‘irresistibly chocolatey’ biscuits poking out of his bag, a chocolate milkshake in his hand, and I know I’m in a bariatric clinic.
“Um...myocardial
infarction?”
I reply, acutely embarrassed, talking as though Mr Smith wasn’t six feet away. Satisfied that I’ve somehow proved
8
the consultant yet we are taught to approach to the patient. each patient with a clean slate. “So how is the new diet going?” In my snap diagnosis of Mr Smith’s condition, my immediate thought was that he clearly didn’t care about the increased risk of “Judgements are inextricably major cardiovascular incidents he was exposing himself to. influenced by prior experience that We are inherently judgemental, yet we are taught to approach forming opinions based on minimal evidence such as each patient with a clean shaking hands and exchanging slate” pleasantries. Doctors must objectively use this intrinsic ability; is my patient being entirely honest, are they doing their physiotherapy, are they taking This feigned ignorance their medication? Mr Smith regarding a patient’s lack of self- reported that he had improved his diet, was smoking 10 rather preservation and the important than 20 cigarettes a day, and skill of assessing health using exercising more. The consultant shrewd observation presents had to judge Mr Smith’s an interesting dichotomy: honesty and assess whether he judgements are inextricably was making a significant effort influenced by prior experience, despite the observations on which
“Personalised medicine is becoming increasingly realistic” I based my ‘diagnosis’, delivering a verdict without patronising the patient or implying mistrust. In a financially restricted system where decisions are increasingly affected by monetary cost, it is difficult to know whether clinical judgement is becoming easier or harder. Payment by results in particular dictates practice in primary care. GP surgeries have to hit quotas – for example, threshold percentages of registered patients must not have high blood pressure or bonuses are lost1, a reductionist approach that clearly influences a clinician’s decision in borderline cases. Arguably this method provides complete impartiality, creating a system where patients routinely receive treatment on the basis of quantitative parameters without the subjective influence of history or emotion. The idea of personalised medicine is becoming increasingly realistic, making a clinician’s judgement vital. An example, which can present an ethical dilemma, is race-based treatment. The HPV vaccine protects against strains responsible for 70% of total cervical cancer, but these strains
only account for one third of HPV infections in African-American and Hispanic women2. A doctor explaining to an African-American patient why she’s being given a different vaccine to the white woman sitting next to her could not be blamed for feeling uncomfortable, as it may be argued this amounts to racial profi ling regardless of best interests. Perhaps instead we need to consider judgement and impartiality not as mutually exclusive entities, but rather as synergistic parts of an overall system for medical practice; judgement allows us to assimilate more information about a situation so we can apply our knowledge more accurately. Provided we do this without becoming emotionally involved, judgement never has to become a negative concept, instead being a procedural step to initiate best practice.
“Judgement never has to become a negative concept”
Full references available at: www.omsg-online.com
Nathan Riddell is a fourth year medical student at Green Templeton College.
Judgement and impartiality: synergistic parts of an overall system for medical practice 9
Tunnel Vision
Gina Sangha ponders how cognitive biases narrow clinical perspective
D
ecision-making is a critical aspect of clinical practice. The thought processes that underlie diagnostic reasoning have therefore been extensively explored over the years in order to increase our understanding of the intricate mechanisms integral to clinical judgement. A proposed dual-process theory suggests two separate but interacting systems of decision-making1,2. Both have their limitations, representing a trade-off between speed and certainty.
be influenced by the thoughts of the intermediary doctor2. Intuition comes into play if the clinical presentation is pathognomonic for a particular disease, yet this unfortunately error-prone approach carries a misdiagnosis rate of 10-15%5. Here, symptoms are indicative of a lower urinary tract infection, more common in pregnancy, with vomiting and anorexia potentially due to emesis gravidarum6.
Cognitive biases are a major cause of diagnostic error. Over 100 One system is instinctive and have been identified with anchoring intuitive - it relies on primed “The implications of and confirmation bias representing recognition of diagnostic patterns biases in clinical judgement prominent examples5. Anchoring yet can also engender uncertainty. Improving with experience, this are potentially dangerous” describes a tendency to lock onto salient features of a presentation, thus is the basis for early diagnostic impressions based on clinical narrowing perspective. Subsequent presentation. Its drawback is the confirmation bias encompasses potential for rapid, atypical patterns ‘search satisficing’, tailoring signs of illness to be missed. For example, the diagnostic and symptoms to a diagnosis. Intuition is mostly error rate for acute coronary syndrome is 10-fold successful, but not always. It is clear that the implications higher when patients present without chest pain3. of biases in clinical judgement are potentially dangerous: The second system is analytical and logical, employed when greater availability of resources permits rationality and critical thinking. This is typically used by relatively inexperienced junior doctors and in cases of rarity. During sleep deprivation and fatigue it may secure safe decision-making4 but it is comparatively slower and more resource intensive.
2 days later, the symptoms have not resolved and the patient becomes more unwell. Further investigation reveals a perforated appendix, a possible complication of which is foetal loss. Acute appendicitis can present like this in pregnancy; urinary symptoms resulting from an inflamed appendix irritating the ureter, with inflammation proximal to the bladder causing pyuria. Many elements of bias influence diagnostic decisions. Leukocytosis is physiologically normal in pregnancy. Consider this clinical scenario: The junior doctor reports to the registrar on-call. An 18-year-old woman is admitted having suffered diffuse lower abdominal pain since yesterday, with anorexia, vomiting and diarrhoea. She is in her first trimester and complains of urinary frequency and dysuria. On examination, she has a fever. There are leukocytes in the urine with full blood count revealing leukocytosis. Ultrasound is normal. The patient is diagnosed with acute cystitis and discharged on a course of co-amoxiclav for 3-7 days. Some fidelity may be lost in relaying information; handover creates scope for the introduction of interpretation bias where information provided may 10
Metacognition and raising awareness of the abundance of cognitive biases affecting clinical reasoning may well help to eliminate them7. Regulating judgement requires continued surveillance and mindfulness of one’s own intuitive behaviour. Research is needed to establish effective de-biasing strategies so that instead of looking through a tunnel, we go down the rabbit hole and feel our way around. Full references available at: www.omsg-online.com
Gina Sangha is a second year graduate entry medical student at Magdalen College.
Judging ‘Normal’ A helpful or harmful label?
M
edicine is an intrinsically judgemental institution. Doctors label patients with subjective terms like ‘healthy’, ‘normal’, ‘abnormal’, or ‘pathological’...
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If the word normal is taken to mean ‘conforming to a convention’, this typically implies that the normal person falls within the same range as 95% of apparently healthy people. The question thus arises as to whether those people generally regarded as exceptions, such as Albert Einstein and Stephen Hawking, are statistically normal. Regardless of the validity of psychometrics, many claim that the IQs of these two physicists are well above the normal range. Surely, then, we can diagnose these two with an abnormal intelligence?
India. Today, people are becoming more accepting of genders outside of the typical male-female dichotomy. These distinctions are increasingly significant in the modern world and medicine, especially due to our greater understanding of intersex conditions. An important question to ask is whether being outside of the rigid heterosexual and cis-gender ‘norms’ is pathological, and if this would ever warrant treatment. For example, asexuality is a rare sexual orientation that involves not experiencing sexual attraction to people of any gender. This may be considered pathological if causing personal distress or anxiety, rather than difficulties merely due to a lack of widespread societal acceptance. The DSM-V states that if low desire is explained by selfidentification as asexual, then a diagnosis of male hypoactive sexual desire disorder (or the corresponding female sexual interest/arousal disorder) is not made.
“The statistical normal cannot be readily applied to qualitative conditions”
The role of medicine is not to judge people, but to determine the parameters of health and disease to guide decisions as to when and how doctors should treat people. Earlier this year, NICE published a draft guidance stating that doctors should offer statins to patients with a 10% or greater chance of developing cardiovascular disease, contrary to previous guidance proposing a 20% threshold1. In this case, quantitative data can tell us where to place the threshold. But what about depression? Many people experience episodes of low mood, but is that pathological? Should we treat depression if it is due to a bereavement? The DSM-V2, the latest edition of ‘The Psychiatrist’s Bible’, has recently removed the bereavement exclusion for the diagnostic criteria of depression, which has led to some criticism3. This is the limitation of modern medicine: the statistical normal cannot be readily applied to qualitative conditions.
DSM-V states that a mental disorder involves a clinically significant disturbance in a person’s cognition, emotion, or behaviour, which reflects a dysfunction in mental function. It also states that confl icts between the individual and society are not mental disorders, unless the deviance results from an internal dysfunction in the individual. That is to say, if you were an outspoken liberal in Nazi Germany, you did not have a mental disorder. However, the definition of dysfunction can be unclear; it may refer to neurophysiological, psychological, or sociocultural norms. Consequently, judgements and definitions of dysfunction and normality should be considered from both a scientific or statistical stance, as well as from societal attitudes, to capture the zeitgeist, however different that may be to what we now consider normal.
“Societal attitudes do make an impact on the judgement of normal in science and medicine”
Gender and sexuality are examples of such constructs. The Kinsey scale attempts to quantify sexuality by creating a seven-point scale, arguably failing to encompass the diversity present in today’s world. For example, the original Kinsey scale did not cover asexuality, concepts like romantic orientation, or gender and sexual fluidity. Gender binaries are also being broken – but is this and should this be considered normal in medicine? For example, in some cultures, there are institutionalised third genders like the xaniths in Oman and hijras in
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History has shown that concepts of normal in both society and medicine do change and that science plays
Indian Hijras have no exact match in the modern Western taxonomy of gender and sexual orientation and challenge Western ideas of sex and gender. an integral role in judging normal. Homosexuality per se was only removed from the DSM-II as a ‘sociopathic personality disorder’ in 19744. A distinct condition became known as ego-dystonic homosexuality when a person wishes that their same-sex attraction were different. This was only removed in 19875, largely because homosexuality became ‘normal’ and psychiatrists said that the distress arose from a homophobic and heteronormative society, rather than anything psychiatrically abnormal with being homosexual. It may seem surprising that just 50 years ago, people who ‘committed homosexuality’ were criminalised. One of Britain’s war heroes, Alan Turing, was convicted and chemically castrated for his illegal acts of ‘gross indecency’6. More recently, the president of Uganda has signed the Anti-Homosexuality Bill into Ugandan law based on purported findings that homosexuality was a learnt behaviour due to lack of identifiable causative genes7. Thus, it is clear that societal attitudes do make an impact on the judgement of normal in science and medicine.
“Our concepts of normality and dysfunction are becoming increasingly dynamic” A transgender identity is an arguably different case to homosexuality, as a transgender person’s gender identity is different to their biological sex, accompanied by internal incongruence. If a transgender person felt no distress about their gender identity then transition to a different gender expression would be unnecessary. Furthermore, it is known that procedures like sex reassignment surgery and psychotherapy can reduce anxiety. In one survey of 647 patients who had sex reassignment surgery, 98% were happy with the outcome and felt it was a positive experience8. If being transgender were to be considered normal and achieve a status similar to that of homosexuality, then no transgender person would receive gender reassignment treatment, to the detriment of the trans community. It is therefore my opinion that a transgender orientation should have a status whereby it is only considered a mental disorder if
it causes clinically significant distress or impairment in function. This is the stance that the DSM-V currently takes, under the label ‘gender dysphoria’ as opposed to its previous ‘gender identity disorder.’ The removal of this term ‘disorder’ is key in the trans community’s slow but eventual progress into normalisation. Our concepts of normality and dysfunction are becoming increasingly dynamic. There is no doubt that a person today considered normal may well be considered abnormal in the future, and vice versa. Redefining the norms and boundaries is something that should be established by the people and research knowledge of the time, in the same way that Thomas Jefferson noted that the Constitution of the United States belongs to the living, and not the dead9. Psychometrics reveals that the average IQ of humans is increasing, so maybe one day our judgement of normal will evolve to the point where Albert Einstein and Stephen Hawking could be diagnosed with an abnormal lack of intelligence. Unlikely, yes. But nevertheless, possible.
Full references available at: www.omsg-online.com
Marco Narajos is a first year medical student at Christ Church College.
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I’ll take your word for it…
Josephine Holland contemplates how we evaluate the advice and opinions of others 14
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hen asked to name a reference for an application, we are often faced with a dilemma. Should I choose the person I get on well with; who holds a lesser rank but I know will write a glowing reference? Or should I choose the professor, a world leader within the field; whom I have met a couple of times, but whose praise is unlikely to stretch beyond deeming my work “satisfactory” ? Classic psychology research, such as that of Sherif 1 in 1935, has looked at stereotyping and the effects of source on influence. This was subsequently labelled ‘prestige suggestion’ – a persuasive message delivered by or attributed to a highly respected or admired source to maximize its credibility, such as when a celebrity endorses a commercial product on television2. Pornpitakpan reviews five decades of literature within this field3, teasing apart subtle factors that contribute to this effect. One of these is the timing of source identification; if a source is rated as highly credible, naming them at the beginning or in the middle of a message4,5 renders an argument more persuasive than if their identity were only revealed at the end. Researchers have also explored whether the persuasiveness of an argument is more heavily influenced by the prestige of its proponent, or by the strength of the argument itself. Their fi ndings showed that study participants were (perhaps unsurprisingly) most likely to act on a high quality argument put forward by a highly credible source. Interestingly, however, a poor quality argument put forward by a highly credible source was deemed less influential than any argument from a less prestigious voice. So, this suggests that if you are going to receive a positive reference from an eminent source, then this is the way forward. However if the positivity is in doubt, then choose a less prestigious but more glowing reference to avoid being damned with faint praise.
would be the rank or level of knowledge of the person consulted. Another aspect is the relative importance of trustworthiness or expertise. McGinnies and Ward6 showed that a communicator described as trustworthy carried more influence than an untrustworthy one, whether or not he was viewed as an expert. Despite this, others have found trustworthiness alone is not enough. For example, two studies7,8 found that a source who stood to profit from persuading the audience was judged to be less reliable and tended to produce a smaller change in attitude than if they were also thought to be an expert. Without the presence of this specialist knowledge or capability, whether or not a source was considered trustworthy did not change the audience’s outlook. It is likely, however, that contrasting results were due, at least in part, to differences in methodology. It is doubtful as to whether informing someone of a person’s trustworthiness is the same as allowing people to judge this for themselves. Individuals are likely to show significant variation in how they assess trustworthiness, expertise and source credibility. It could also be argued that judgements made whilst taking part in a psychology study are likely to be very different from those made day-to-day on the ward. Demand characteristics, coupled with a desire to present oneself in a positive light during an experiment, may lead to elaborate thought-processing of the information presented, in contrast to late-night snap decisions as the house officer on call.
One further factor that you may not have realised can sway your estimation of source credibility is their attractiveness. A study presented subjects with an opinion presented by female sources, varying in levels of attractiveness and expertise9. If the source was judged to be an expert, physical attractiveness had little impact on the persuasiveness of the message. However, participants agreed more with the high compared to the medium and low physical attractiveness sources if they were judged to be non-expert. The authors argue that when more objective characteristics are not available, we fall back on otherwise irrelevant cues for judgement. This illustrates the worrying fact that, whilst we may view Where else does source credibility emerge in ourselves as impartial and systematic judges, we are medicine? When we need to guide our practice, still susceptible to an array of ever-changing internal a whole range of factors may affect whether we and external signals that shape our attitudes to others. view a source as dependable; the most obvious
“Which is more important – trustworthiness or expertise?”
Full references available at: www.omsg-online.com
Josephine Holland is a third year graduate entry medical student at Somerville College.
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“In truth, I feel privileged to be part of someone’s death”
medicine - it’s just another part of life”
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ou know I’m going to have to be at least a little bit religious about it all,” Justin begins, smiling goodnaturedly. “You can’t expect to have a priest talk about his experiences with the dying without at least a few passing references to the divine, but I do promise that I’ll try my best to stop this from becoming a sermon.” He clasps his hands together and leans forward onto the table. “I used to spend a lot of my time working in hospices, called in for a chat, for prayers, to be asked the hard questions.” He pauses, as though for dramatic effect. “I probably have just been blessed with an impeccable sense of timing, but the patients seemed to pass very quickly after I’d been to see them. The nurses used to call me the Angel of Death.” He laughs, “a bit sinister I know – but it really was uncanny. I can’t explain it, but it’s as if the people that I visited were just craving for permission to die –some form of religious validation to release them. I know it’s not so simple, but it’s a thought that gives me comfort.” Justin sighs loudly before continuing. “As for what the dying would request of me, I am probably most often asked for my judgement, as if I could play the role of St. Peter and balance the good and the bad of their lives on a set of golden weighing scales – have I led a good life? Will I get into heaven? – all the questions that you might want to ask when you’re heading off into the unknown.” He slowly removes his glasses and begins to clean them before resuming. “I think
Last Rites
Bing Tseu listens to a priest’s discussion of his experiences at the bedside of those at Death’s door
we often have the tendency to try and avoid answering the really hard questions and we should really fight against it. If the dying want to talk about these things, someone should be there to empower them. I have to say that it is a rare occasion that I end up dispensing pearls of wisdom. I may be a minister, but I usually end up feeling more ministered unto by the dying and the bereaved. I find that there is such a strong sense of grace that flows through them.” “In truth, I feel privileged to be part of someone’s death,” he continues, nodding his head gently, “very often people open up near the end. They make confessions they have never made before. In the face of their own mortality, all their foibles, prejudices and embarrassments melt away. They just lie there, no makeup, no fancy clothes, no gadgets, no pretensions. They drop all their psychological masks and I think that there’s something that’s simply raw and beautiful about that.” He pauses briefly and chuckles softly. “This is going to come across as profoundly morbid, but I much prefer a good funeral to a wedding. Many weddings these days are all about the spectacle, whereas there is something much more candid about feting the end of someone’s life. I think humanity is currently wrapped up in a sort of necrophilia of modernity.” He pauses, raising one eyebrow slightly. “I should probably explain myself a bit better – we are all obsessed with death and spend so much time and energy staving it off. I think we need to make sure that everyone understands that death is not the failure of medicine – it’s just another part of life. Death might be frightening, but it’s not something that we should fear – once you accept the reality of death, there’s nothing left to do but to live your life.” Full references available at: www.omsg-online.com
Bing Tseu is a fifth year medical student at Christ Church College.
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The Dark Side of Medical Practice Claudia Snudden investigates how doctors are involved with torture
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octors aided US torture at military prisons, report says’ – this recent BBC headline1 provokes the question of how doctors are connected to torture. Over the past decade, countless articles have been published reporting on the involvement of medical professionals in the abuse of suspected terrorists or prisoners. The association between torture and the medical profession is complex. With their knowledge and skill sets, doctors have the capacity to play a key role in treating and empowering survivors of abuse, yet this expertise can be misused to aid and facilitate torture. Participation by doctors in the interrogation and torture of prisoners is widely accepted to violate medical ethics (see Box 1). International declarations2, 3 and medical oaths4 condemn and forbid such behaviour – how and why then have these accepted principles come to be ignored? Although these principles may appear undisputable, there is a considerable
“The ‘enhanced’ interrogation program was “designed to psychologically ‘dislocate’ the detainee”” history of incidents involving gross misconduct by physicians. Under the Nazi regime, atrocious human experimentation was infl icted by physicians
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on prisoners held in concentration camps: tests ranging from exposure to freezing temperatures, to deliberate infection with malaria, to bone and muscle transplantations, all typically resulted in death or
“These medical personnel appear to be serving the interrogation process rather than the patient” permanent disability. As a result, The Nuremberg Code was created with the intent of establishing guidelines for medical research, stressing the need for voluntary consent, and limiting what governments could demand from physicians. Despite several further international declarations5, 6, direct participation in torture by physicians has continued over the succeeding decades. Evidence has accumulated that during the various South American military dictatorships of the 1970s and the 1980s, doctors were involved in the monitoring of prisoners being tortured and the advising of interrogators on the ability of prisoners to survive further abuse7. In Chile, for example, physicians falsified reports and issued death certificates indicating good health following torture; testimonies from survivors also reveal medical personnel were present during interrogations8,9. Under the governance of Brezhnev
in the Soviet Union, psychiatric diagnosis by physicians was misused for the detention and treatment of dissenters, based on political rather than mental health-based criteria10. Following imprisonment, many dissenters were subject to electro-convulsive therapy. The most contentious issue currently connecting the medical profession with participation in torture is the use of ‘enhanced’ interrogation techniques by the CIA following 9/11 in the war against terror. This interrogation program, started in 2002, was “designed to psychologically ‘dislocate’ the detainee, maximise his feeling of vulnerability and helplessness, and reduce or eliminate his will to resist our [CIA] efforts to obtain critical intelligence”11. Though details remain classified, reports have revealed several of the procedures used – from waterboarding to prolonged sleep deprivation to induced hypothermia12. Additionally, health professionals have been confirmed to be involved at every stage in the development, implementation, and legitimisation of the torture programme13. In the International Red Cross’s 2007 report on the treatment of 14 detainees in CIA custody14, three principal roles for health personnel are described: monitoring of ongoing ill-treatment; performing medical checks; and providing healthcare, both as a consequence of ill-treatment and to treat natural health problems arising from sustained periods of detention.
Allegations against health personnel directly participating in the infl iction of ill-treatment include monitoring oxygen saturation using a pulse oximeter during suffocation by water, and recommending the continuation of stress standing positions with adjustments following the measuring of legs for signs of swelling. The accepted role for physicians working in official places of detention does not encompass judging the extent of, or facilitating, physical or psychological ill-treatment. Monitoring in real-time the effects of interrogation techniques by medical professionals, as required according to CIA guidelines15, places physicians in a position of calibrating pain and suffering rather than treating and preventing illness and injury. In undertaking participation in interrogation procedures, medical personnel appear to be serving the interrogation process rather than the patient, representing a failure to uphold ethical medical values. Amounting medical evidence clearly shows that methods such as the CIA’s ‘enhanced’ interrogation techniques constitute torture, violating human rights standards and causing physical and mental suffering criminalised under international laws and declarations12, 16. Is there a need therefore for health professionals complicit in torture, violating ethics or the law, to be held accountable through criminal prosecution and/ or loss of their licence to practise? In 1975, the World Medical Association published The Declaration of Tokyo, stressing explicitly that a doctor “shall not countenance, condone, or participate in the practice of torture” under any circumstances, not even threat17. Threat, however, can be a central factor in decision making by health professionals; medical personnel
Principles of medical ethics relevant to the role of health personnel in the protection of persons against torture, UN, 19822 Physicians charged with the medical care of prisoners and detainees have a duty to provide them with protection of their health Physicians may not be involved in any professional relationship with prisoners or detainees if it is not to solely evaluate, protect or improve their physical and mental health Physicians may not engage, actively or passively, in acts which constitute participation or complicity in torture or other cruel, inhumane or degrading treatment Physicians may not apply their knowledge and skills to assist in the interrogation of prisoners and detainees Physicians may not certify the fitness of prisoners or detainees for any form of treatment or punishment that may adversely affect their physical or mental health Physicians may not participate in any procedure for restraining a prisoner or detainee There may be no derogation from these principles on any grounds
may face making the difficult choice between becoming accessories of the perpetrators or becoming the victims themselves 18 . Extreme pressure from dictatorships or the military can prevent doctors from speaking out against human rights abuses. Breaching orders can result in detainment or even murder – in Iraq, for example, nine doctors were arrested after refusing to amputate the limbs of healthy people under Saddam Hussein19. How can idealistic medical students end up being complicit in torture? I can see three possible explanations: firstly, that doctors are forced into it under threat; secondly, that their principles are gradually eroded over time so that their role takes on a new form; or lastly, in the most extreme case, that they are inherently cruel individuals. In performing their clinical role, health professionals have a unique capacity to identify instances of abuse, both from direct conversations with detainees and from clinical examination for signs of abuse. It is
Box 1. important not to forget that large numbers of physicians worldwide, both in the past and presently, undertake huge risk to provide pro bono services to victims of torture and testify against human rights violations. Ultimately, medical professionals will always have a duty to protect and treat patients first above other obligations, regardless of the situation. For this to be achieved however, support and protection – perhaps from human rights organisations – is needed for those endangering themselves for the sake of morality and conscience18 . Only then will the principles condemning medical participation in torture be fulfi lled. Regardless of where we are in our career, as health professionals it is vital we should always remain true to international principles and morals – irrespective of the circumstances. Full references available at: www.omsg-online.com
Claudia Snudden is a third year medical student at New College
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The Mad, the Bad, and the Law... Edward Matthews explores the need for a deterministic approach within the law, highlighting society as a potential cause of criminality
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ost people do not think about determinism in everyday life. Indeed, it would be very hard to live normally whilst constantly upholding the idea that your actions were not the result of ‘free choice’, but rather the inevitable outcome of cause and effect. It soon becomes logically difficult to take a deterministic standpoint, because within such a framework, logic itself ceases to be an objective tool for understanding the world. However, I think aspects of determinism do have a role within our society. Given that psychological and neuroscientific evidence indicates that our choices are heavily influenced by environmental and genetic conditions, it is important that we integrate some deterministic understanding into the way society works. Arguably, one of the most valuable settings in which to do this would be within the judicial system. The impact of determinism on moral responsibility is a key issue of contention. How can we hold a person responsible on moral responibility is a for their criminal actions if key issue of contention” there was no way in which they could do anything other than those actions? Largely, our judicial system is built upon the idea that people actively choose to commit crimes instead of abiding by the law, and therefore should be punished. However, there are exceptions, such as the defence of insanity. The M’Naghten Laws, which set out this defence, date back to 1843. They are named after Daniel M’Naghten, who fatally shot civil servant Edmund Drummond in the back with a pistol after mistaking Drummond for the then Conservative Prime Minister, Robert Peel. At the time, it seems M’Naghten was suffering from paranoid (probably schizophrenic) delusions about the Conservatives. He said the day after the shooting that “The Tories… follow, persecute me wherever I go, and have entirely destroyed my peace of mind”. During his trial for murder, M’Naghten was found not guilty by reason of insanity. The case sparked a debate that underlined the need for clarification in English Law regarding instances where someone could be deemed not guilty if they were mentally ill. To this day, the defence of insanity is used, and although widely considered out of date, it is indeed employed successfully in around thirty cases a year. Formally, the laws hold that an individual is not guilty of a crime if it can be proved that due to a “defect of reason” or “disease of the mind”, they did not know “the nature and quality” of their act or that it was wrong. Interestingly, the insanity defence therefore acknowledges a situation
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where someone should not be deemed responsible for the coalition, seeks to find ways of affecting the way their actions, if such actions are a product of a diseased we behave through the manner in which information mind. Most brain diseases affect our consciousness is presented to us. For example, small changes in and decision-making at some level (through psychosis, wording on the website through which people apply for altered mood, deficits in cognitive processing or memory, a driving licence has led to an estimated 100,000 more for example) and diseases of the mind people signing up to carry organ are considered diseases of the brain. donor cards. Nudge has also used Thus, through the M’Naghten “A deterministic understanding knowledge of behavioural psychology Laws, we implicitly accept that of behaviour already permeates to increase the speed with which our actions are the product of our people fi ll in their tax returns. We through to several areas of our brain. In this way, there is already see, therefore, that a deterministic an element of determinism within understanding of behaviour already society.” the judicial system, specifically permeates through to several areas the realisation that our choices of our society. Determinism is are a product of our brain, which everywhere: most people already itself is a product of external and genetic factors. acknowledge it, albeit often unwittingly. However, within the judicial system, I think there is a scope for But why stop here? Why do we not also acknowledge a more formal and conscious acknowledgement of that the decision-making of a healthy mind, the output the reasons why criminals have committed crimes. of brain function, is not fully under our control? There Furthermore, this appreciation can be justified by is a wealth of evidence from psychology illustrating the our increased understanding of how brains function. effects external factors have on our perceptions and deeds. The famous experiments by Milgram in the Of course, the idea of determinism carries an inherent ‘60s, demonstrating obedience to figures of authority, danger. There is a deep, nihilistic strand running through found that 65% of subjects would administer what it that would render us worthless: nothing but the output of they thought was a lethal electric shock to a stranger, a chain of cause and effect, worming its way through time if told to do so by an authoritative experimenter1. and space. Our entire worldview would collapse around us if we lived permanently in the belief Alongside psychology, research that everything to come is predestined. into epigenetics is shaping our To deny our power to decide our future understanding of how interactions “To deny our power to would crush the defining feature of between genes and environmental decide our future would humanity. Happily, we do not have to factors give rise to our unique brain functions. A twin study in crush the defining feature of extend the idea to such a grave degree. There are benefits to enjoy if we 2005 found that the heritability of humanity” embrace some practical implications subjects’ stance on controversial of determinism (like speedy tax political issues was over 50%2. If asked, most people would probably returns), and some rather interesting defend their political opinions on rational grounds, points to consider in the management of criminality. believing their views to be born of clear thought and consideration. However, a heritability as high as 50% Ultimately, I advocate a perception of criminality that suggests that in fact, much of our nature may well be accepts society as an underlying cause. Just as we accept genetically determined. It therefore seems scientifically that a disease of the brain can be a reason for criminality, arbitrary to distinguish whether someone is responsible we should accept that some influences on a healthy brain for their actions on the grounds of whether their brain can also be instrumental. Such an attitude does not is functioning healthily or not. The behavioural output mean we have to abolish punishment, because this is in of both brain categories is ultimately determined itself a conditioning factor. However, it does force us to by the interactions of the same factors – genes and consider its effects on shaping behaviour. There ceases environment – albeit interacting in different ways to be any justification for punishment that does not (a subset of which have been deemed pathological). reduce wrongdoing, and such punishment becomes akin to revenge. A deterministic outlook means society has It is clearly apparent from something as ubiquitous as to accept responsibility for having created criminality, fashion that the environment around us conditions our but also highlights the potential for society to combat behaviour. Advertising agencies have been trying to criminality through positive environmental influences. harness such environmental influences for a long time, in order to dictate the way in which fashions flow. Our Full references available at: www.omsg-online.com own government is also starting to realise the value of a deterministic approach. The Behavioural Insights Team Edward Matthews is a third (also known as the ‘Nudge Unit’ or ‘Nudge’), set up by year medical student at Brasenose College.
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Does Neuroscientific Advance Spell the End of Free Will?
Will a deeper understanding of decision-making in neuroscience undermine this fundamental feature of human nature?
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he concept of free will is integral to our understanding of the human race. Most people instinctively believe in it without having ever considered the case against free will, and the implications that endorsing free will has in our society. With this brief article, I hope to highlight some ways in which modern science might be undermining the notion of free will, and to raise some interesting issues regarding to when a patient’s free will is encroached upon by disease, and by the medical profession.
“Most people instinctively believe in free will without having considered the case against
it”
Investigators working in the early ‘80s claimed that they had found a ‘readiness potential’; an EMG signal (maximal at the vertex) present 250-300msecs before subjects were aware of making a conscious decision to perform a simple motor task1. Despite various methodological criticisms, including that it required participants to self-report their
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awareness, it raised an interesting debate about whether the brain, as distinct from the conscious mind, is capable of driving decision-making. Interestingly, in Tourette’s patients, readiness potentials do not precede an outburst, suggesting that this signal is isolated to conscious decision-making. Even without the presence of a readiness potential, some believe that with technological advance, we may eventually visualise nervous activity associated with decision-making at the level of an individual neurone. This might present a mechanistic view of decision-making that is irreconcilable with free will. The concept of a mind separate from the brain (dualism) may be the saviour for free will in the face of the advancement of neuroscience. Under these circumstances, a complete understanding of the circuitry of decision-making would not weaken the concept of free will2. Determinists believe that all events, including human action, are ultimately determined by factors external to the human will3. This theory sits more comfortably with advances in neuroscience, and is at odds with the belief in free will. The 1978 fi lm, The Boys From Brazil, exposes the implications of this school of thought. It tells the story of a group of Nazis who flee to
“Does medical intervention represent society’s attempts to bend the will of others to fit a pre-determined norm?” Germany, and meet in Paraguay. They plan to raise a group of ‘Hitlers’ by subjecting a number of adopted boys to the same life events that Hitler experienced (such as the death of his father etc.). The boys go on to commit some terrible acts, but the question is raised: ‘who is responsible for their atrocities?’ Is it the boys themselves, or the men who conditioned them to act in such a way? The answer to this question may be that both parties are to blame; the Nazis made it more likely that these boys would behave like this, but ultimately the boys remained masters of their own destiny. However, this may be based on our intuitive belief in free will above all other influences. Unfortunately, this is almost impossible to study without generating some sort of Truman Show-esque debacle. Behavioural genetics give further
credence to determinist theories by investigating the genetic basis behind personality traits and disorders of personality. For example, it has been demonstrated by numerous studies that impulsivity has a heritability of ~0.454. This implies that before we are born, the way in which we approach decisions is partially decided. It is difficult to claim that personality is separate from our will, but that might be based on the premise that personality develops as the result of experiences and decision-making, rather than the underlying dopaminergic (or indeed serotonergic) genotype5. Neuroeconomics seeks to explain decision-making by attaching value to different options in order to identify the optimal course of action. Those suffering from substance addiction attach inappropriate value to drug-taking behaviours, which in turn significantly influences the outcome of their decisions. Indeed, many addicts show deficits in decision-making that are seen in patients with ventromedial prefrontal cortex lesions6. This area is involved in risk judgement and emotional processing, and lesions can result in deficiency in compassion, guilt and shame. From these observations, is it fair to state that free will is encroached upon by substance addiction, or is a disease of judgement separate
from a disease of free will? Much of the debate as to whether psychiatric conditions or medical interventions affect free will depends on our approach to these factors. If such conditions are seen as exogenous influences, then they impinge upon free will, and potentially the use of drugs to counter these conditions might represent a facilitation of free will. However, a psychiatric disorder, particularly one with a high genetic heritability, might only be considered inappropriate in a certain context, and indeed may have developed as an evolutionary strategy to respond to other environmental conditions. In this setting, does medical intervention represent society’s attempts to bend the will of others to fit a pre-determined ‘norm’? I personally believe that our conscious will is determined by a number of factors, and given that some of these are extraneous, I would not describe it as free. I think that science will continue to endorse that standpoint, as it will struggle to entirely eliminate a belief in individual will entirely. Ultimately, your beliefs surrounding free will shape the way that you treat others, and view your own actions. This makes it a challenging and complex issue, but one well worth considering as a future medical professional.
Full references available at: www.omsg-online.com
Lesions on the ventromedial prefrontal cortex, the area involved in risk judgement and emotional processing, can result in deficiency in compassion, guilt and shame
Henry de Berker is a third year medical student at Lincoln College.
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Insight In Schizophrenia Francesca Johns questions the impact of insight in schizophrenia
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providing a basis for researchers to look for specific brain areas which may be involved in insight. The prefrontal cortex is important for the synthesis of information, critical thinking, self-monitoring and exerting control over behaviour7; executive functions which are potentially relevant to the awareness of illness. Neuroimaging studies have noted reduced frontal lobe volumes in patients with schizophrenia compared to healthy controls8, and subsequent may represent associations have been made between the degree of insight and In everyday language, insight is a cognitive deficit secondary frontal lobe integrity9, suggesting defined as the capacity to gain an to frontal lobe pathology in that areas of the frontal cortex may accurate and deep understanding of schizophrenia” be important for insight. Executive things; in psychiatry, insight refers functioning deficits, similar to those to awareness of aspects of oneself. seen in patients with frontal lobe Historically, insight in mental lesions, have also been observed in illness has been viewed as an ‘allthese patients on the Wisconsin Card or-nothing’ phenomenon, however over the years 10, 11 Sorting Test . These findings support the hypothesis we have come to realise that it comprises multiple that poor insight represents a cognitive deficit overlapping dimensions3. These can be divided into secondary to frontal lobe pathology in schizophrenia12. three core aspects: awareness that one has a mental illness, recognition and acceptance of the need There are extensive discrepancies within the for treatment, and the ability to re-label unusual literature, which could be due to the way in which mental experiences as symptoms of the illness4. insight is assessed in different studies. Clinically, a multidisciplinary team will assess insight continuously It was once thought that the lack of insight in throughout their interaction with the patient; schizophrenia was a form of denial, a defensive arguably this subjective interpretation is more useful coping strategy to avoid the unpleasant reality of the than an objective scale for the purpose of informing illness3,5. Increasing research into the pathophysioloindividual care pathways and risk assessment. gy of schizophrenia, however, is highlighting lack of However, increasing interest in the role of insight insight as a symptom of the underlying pathology, in mental illness has required the development with neuropsychological and neuroanatomical of standardised measures to facilitate replicable correlates. For the last century, neurologists have research (Box 1). That said, the classification described patients who lack awareness of primary and diagnostic criteria of mental illnesses have sensory or motor disturbances attributable to the changed over the years, which has led people to direct effects of brain dysfunction. This phenomenon query how appropriate it is to judge someone’s is called anosognosia – a term introduced by Babinski view of themselves against a standardised scale3. in 1914 to describe the denial of motor impairment (left hemiplegia) resulting from focal lesions within the right cerebral hemisphere6. Similarities can Why is insight important? be drawn between anosognosia and impaired insight; in both cases there is persistent unawareness It can be difficult for patients when they believe that of any deficit, despite evidence to the contrary3 they do not have a mental illness, yet everyone around tudies have shown that 50-80% of patients with schizophrenia do not believe that they have a mental illness1. These patients demonstrate impaired insight, now considered a common symptom of schizophrenia2. Whilst it is recognised that people with mental illness suffer judgement from society, it is interesting to consider how the affected individual’s assessment of their own mental state affects their treatment and outcomes. “Poor insight
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Empirical measures of insight Insight and Treatment Attitudes Questionnaire (ITAQ) McEvoy et al, 198919
11 items. Response score 2 = good insight, 1 = partial insight, 0 = no insight. Uses a limited definition of insight.
Scale to Assess Unawareness of Mental Disorder (SUMD) Amador and Strauss, 199020
74 items rated on a 5 point Likert scale. Semi-structured interview to assess past and present awareness of illness, signs and symptoms, benefits from treatment and psychosocial consequences.
Schedule to Assess the Components of Insight (SAI) David et al,19904
Uses David’s three components of insight.
Positive and Negative Syndrome Scale (PANSS) Kay et al 198721
Lack of judgement and insight item. Rates subject’s awareness of symptoms, need for treatment, and consequences of the disorder. Scale of 1-7.
them insists that they do. Such patients may feel that In one study, patients with schizophrenia who they are being imprisoned in hospital and forced to received CBT showed no increased awareness of take unpleasant medication against their will. It has their mental illness, but did show improvements in been shown that lack of insight is compliance with treatment and the one of the key factors in treatment ability to re-label their psychotic non-compliance13-15, which in experiences as pathological16. The “30 50% of turn places a huge burden on challenge is getting patients with mental health services. 30-50% schizophrenics report that little insight to engage in such of schizophrenics report that they therapies. Future research aimed they do not believe that they do not believe that they need at identifying the dimensions of medication, or would stop taking insight that might have a stronger need medication” it if the option were available3. neurobiological or psychosocial Perhaps an improvement in patient basis may help in the development insight might in turn improve of more effective treatments12. compliance. As medical professionals, we want to improve insight to That said, many patients who lack insight do take improve compliance and management of the patient. their prescribed medication despite not believing that From a patient’s perspective, what is the benefit of they will gain any benefit from treatment. Often, insight? Many studies have in fact demonstrated that this is merely passive compliance because it is what higher levels of insight are associated with depression the doctor advises they should do. From a clinician’s in schizophrenia17. It has been proposed that the perspective, it has been argued that it matters little depression may result from factors such as internalised whether or not the patient truly believes that they have stigma about mental illness, the implications of having a mental illness, as long as they accept treatment3. But a mental illness and feelings of helplessness and low I challenge you to think how you might feel if your self-esteem18 . Despite increased understanding of doctor made you take a drug with numerous adverse mental illness, there is still a stigma attached to it in effects when you did not believe you needed it? Another our society – by tackling this prejudice, we may be frequent scenario in secure psychiatric hospitals is able to improve global outcomes for those who have a that compliance lasts only for as long as it takes for the mental illness. It seems ironic that many patients with patient to gain their freedom. This presents challenges schizophrenia are unaware of their illness, yet as a for long-term care of patients who move on from society we cannot seem to look beyond their diagnostic secure psychiatric hospitals – with poor compliance label. Perhaps we are the ones lacking insight? being associated with increased risk of relapses, violence, re-offending and rehospitalisation3, 13-15. Acknowledgements: The author would like to In view of the reasons described above, people have thank Dr Das, Consultant Forensic Psychiatrist, begun to explore whether there are ways to improve insight in schizophrenia. Cognitive behaviour and the staff and patients of Broadmoor Hospital therapy (CBT) is aimed at helping patients to identify Full references available at: errors in their thinking and develop alternative www.omsg-online.com explanations for their delusions and hallucinations. Francesca Johns is a fourth year medical student at St. Hilda’s College.
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Judgement This year, on the day of the vernal equinox, I met up with a friend of mine, who, after fi nishing an undergraduate degree in biochemistry, has begun a graduate course in medicine and is now nearing the end of his first academic year. We met at a café near Richmond Park, and, as the weather was mild and pleasant in London, we proceeded to walk along the southern bank of the Thames towards the Kew Gardens. It is a favourite walk of mine, especially in spring, when the marsh marigolds begin to bloom, the elms and cherries come to leaf, and paired swans renew their life-bond. A healthy antidote to my friend’s lengthy lamentation about the difficulties of being a medical student. He bemoaned the need to memorise the names and insertions of every muscle in the body, the individual steps of the Krebs Cycle, and even lengthy stretches of DNA sequences that he’ll probably never need as a practising physician. Nor did the prospect of what lay ahead in the coming months provide much comfort—pathology and pharmacology merely meant more names to know and lists to memorise. At some point, I mentioned to him in passing that I had been invited to write a piece for the Oxford Medical School Gazette. I had, I confessed, not even thought about what I was going to say, although the piece was due fairly soon. This stopped him in his tracks, and he looked at me with an expression of genuine surprise and curiosity. They want you to write an article for a medical magazine? he said. Yes, I replied. On what? Medicine in literature? No, no. The theme, I’m told, is judgement. But, I haven’t been given any other remit. But why? What do you mean? You’re not a medic, though. So, why did they ask you? The intensity of my interlocutor’s response unsettled me. After all, we had known each other for a few years now, and I thought he knew me well enough not to ask such a silly question. Indeed, a mutual friend, who knew of my former existence as a medical student, had introduced us to each other in part because she thought I might have some insights to share with him about applying for medicine, which he was under pressure to do by his parents. That said, over the years, I have come to realise that people are prone to forget those aspects of my life and past which are also the most painful and the least forgiving, and only select such snippets as would best suit their own visions of who I am, or might be. So, with patience, I replied. I used to be a medical student too, remember? I said. Admittedly I quit in my third year. But, I did do medicine for quite a while. Oh yeah, of course, he said, and was silent for a few minutes. Yeah, I completely forgot, he added, with a twitch of embarrassment. Where was it again that you did medicine? Madras Medical College, I said. Where’s that? India. South India, to be precise. Yes, yes. I remember now. You know, for someone of Indian origin, your knowledge of Indian geography is appalling, I said. Guilty, I’m afraid. Is it big then, this Madras Medical School? Madras Medical College? Yes, fairly big. How many students? Oh, I don’t know. Hundred and fi fty, maybe? Right. Wow. Remind me though, why did you quit? I know it’s not for literature, because you only started learning German, what, two years ago? Funny, you remember that, but not the reasons why I left behind a career in medicine. He was silent. Yes, well, I said, as with most actions in life, there was no one reason behind it. But, the main spur was that I got an internship with the British Medical Journal in London, and then the editorship of their student journal for a year. The school wouldn’t let me break my studies for that long, and I didn’t want to miss the opportunity to come to London. So, I quit. Just like that? Just like that. In order to come and work for the BMJ? Mainly, yes. Did you have friends or family in London when you came here? No, I didn’t know a soul here. Weren’t you scared? Not really. But, he said after a short while, didn’t you tell me you enjoyed doing medicine? I think it was you who
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told me about dissecting a cadaver from head to toe on your own. That’s right. And yes, I did enjoy medicine. Very much so. But, there were other reasons behind why I quit. Like? The fact that I fall in love with men, not women. Oh yeah, it’s illegal there, isn’t it? It is. I remember reading about it last year. It was made legal a few years ago, but they made it illegal again or something. Is that right? Yes. And I had lost two gay friends to suicide the year before. I needed to get away. He fell silent. Were you out at medical school? he asked. Not really, I said. Most of the professors I knew were extremely homophobic, as were most of my friends and colleagues. It would have been a social and professional suicide. You’re kidding. No. The first article I wrote for the BMJ was about homophobia among doctors and medical students. With the exception of psychiatrists, they all thought it was a mental disorder. And even among psychiatrists, aversion therapies are not uncommon in the subcontinent. I can’t imagine that helps India in its battle against HIV. No. Gay men and women usually fi nd it incredibly hard to get tested and get adequate treatment. Now with it being illegal again, it’s all the harder. Things are slightly, only slightly better, for transgender people, only because they exist outside the law, so to speak. But, being gay or bisexual can still be, quite literally, a death sentence in India. Okay, I get why you wanted to leave India, but, why not continue your medical training here? You forget that I come from a very poor family, that I came here with £40 in my wallet. You do know it costs roughly £35,000 per year for a non-EU citizen to study medicine in this country. Remind me, what did you do for your undergraduate degree? Mathematics and neuroscience. And how much did that cost a year? £25,000 a year. But you got the funding for that? Yes, a scholarship, somehow. Did Cambridge field the money? No. Most UK universities have little funding for non-EU students, certainly not at the undergraduate level. I’m funded by a private body. Who, can I ask? I myself don’t know. You don’t know? No. It’s all anonymous. What, like Pip? Like Pip. Though I hope I don’t have a Miss Havisham as my backer. Wow. I don’t know why you sound so surprised. I’ve told you all this before, when we first met. Did you? Hmmm. I’m so sorry man. But, I don’t remember us ever having this discussion. I know you did medicine, but not all this. I had begun to wonder whether indeed I had told him all this or not. It was not impossible, the possibility that I misremembered having told him all this. When I was put on anti-epileptic drugs last year for an illness that still remains ill-defined, certain corridors of my memory became sealed for good, whereas others left a small opening or two through which I could only dimly remember certain events or conversations. We were now approaching the entrance to the Kew Gardens, and I asked him if he fancied going there for the afternoon. He agreed, and we entered through the riverside gate. So, I said to him, you probably understand why they asked me to write for the OMSG. Yeah, it makes sense. How long did you work at the BMJ for? A year. I edited the Student BMJ. Oh yeah, I read that from time to time. Forgive me, but… Yes? If you can convince someone to give you funding for a degree in sciences, and now in humanities, I can’t see why you couldn’t convince someone to pay for a degree in medicine. It was a fair point, and I didn’t know how to answer him. I thought about it for a while, and said: I suppose you’re right. But, at some point, I no longer wanted to do medicine. Why? Because it’s hard? No, no. All things worthwhile in life are hard. It just wasn’t for me. When did you realise that? Did you have patient contact in India? Oh yes, it begins in our second year. And I enjoyed clinical work too. But, it wasn’t for me.
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How did you come to realise that? Now, I had to think. We were walking along a path planted with vertiginous dawn redwoods on one side and an assortment of cypresses and evergreen firs on the other. As I stopped to look at the redwoods, I remembered the pile of drowned bodies I had seen in a hamlet by the sea, just two days after the Boxing Day tsunami. I was assisting with the relief efforts in one of the worst-affected coastal regions, and I remembered struggling to cope, amidst the throng of screaming voices and suddenly orphaned children. A week later, a week of a thousand different diseases and deaths later, something inside me snapped, and I remember fi nding the entirety of my studies, its aims and its purposes, its scope and its methods, futile and hopeless, where once I saw nothing save nobility and honour. It was the beginning of a depression that wouldn’t last another year or so, and it may be that, had I stayed in India, I might have rediscovered my love for medicine as a vocation. But, the fates had tied the winds to create a perfect storm that year, I now said to my friend, and in order to survive, I had to forge a new existence altogether. We fell into a spell of silence, and walked slowly to the Pagoda now emerging into our view. So, my friend asked me as we arrived at the tapers, do you know what you’re going to write about for the OMSG? I confessed I had no idea. I imagine, he said, you’re going to take the line that judgement in general is a bad thing. I don’t know, I said. Is it? He raised his eyebrows in false mockery. But, I said, medicine is a science predicated on judgement, surely. From deciding whether what you hear through a stethoscope is a heart-murmur, to rushing a patient to the operating theatre for appendicitis, every step is a question of judgement, isn’t it? I’m not sure, he said. Okay, what comes to your mind then, when I use the word ‘judgement’? He was silent for a few seconds, and said: Do you remember when we first met? Just after we were introduced and Carrie told you I was doing biochemistry? Yes… The first question you asked me was when I was going to start medicine. Oh, yes, I said. You assumed that because I look Indian, right? Yes, I admitted with no small degree of discomfort, but, it was an ethnic in-joke, I added. I mean, you know how many Indian parents are desperate for their sons and daughters to become doctors, right? It was just a… No, you don’t have to, like, defend that. I know you didn’t mean any harm. But, that’s what I think of when you say ‘judgement.’ What? Racial or ethnic stereotypes? Or sexual, he added, helpfully. But, surely you’re confusing judgement with pre-judgement, that is, judgement with prejudice. How do you mean? he asked. Say I come to you at a GP clinic, and you see that I’m of Indian origin. If you immediately assume that I’m likely to work for an off-licence or a curry restaurant, that’s prejudice. If you examine me, fi nd that I’m overweight or something, and then advise me that I’m more likely to get diabetes or heart disease, in some part due to my ethnicity, that’s judgement. The second is at least neutral, if not positive. Right? So, you’re saying prejudice is always negative, whereas judgement depends on context. Not necessarily that. I’m not sure human beings are capable of being non-judgemental, or even without prejudice. Rather, prejudice must always be held up to scrutiny, but judgement needn’t. But, if you don’t subject your judgements to scrutiny, how do you distinguish between prejudice and judgement? I’m not sure. You see, our judgement, I feel, can often be influenced by our instincts and our intuitions, and that is not necessarily a bad thing. A complex product of both what we know and what we experience, if you will. I think that can save lives more often than they do harm. Prejudices, on the other hand, seem inherited from culture or inculcated by society. No more unnatural or unusual than instincts or intuitions. But when they influence our own values and judgements, they can prove toxic. You say ‘values and judgements.’ When you judge something, surely you put a value on it. Surely not. Judgement is not merely about declaring something to be good or bad, right or wrong, though they can be these— I can see why you’re more suited to the humanities— Hmmm. As I was saying, judgements needn’t be all about values. If you diagnose someone as having bipolar disorder, say, then you judge, based on the recorded signs and reported symptoms that your patient exhibits a certain pattern of mood swings and behavioural fluctuations that best fits that moniker. Right? Right… Except that the DSM criteria for most mood disorders seem so blatantly arbitrary. True. But that’s beside the point. At any rate, your description of the criteria as arbitrary tells me that you’re capable of true judgement. It is a bad doctor who accepts the DSM or the ICD as his diagnostic Bible and rushes to prescribe lithium or lamotrigine. But, are you telling me that you don’t fi nd it distasteful or offensive when people judge you, on the basis of your skin colour, on the basis of your sexuality, or because of your mental health condition? I think you’re once again confusing prejudice for judgement. All three cases you describe are instances
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of prejudice, not sound judgement. Maybe we have diluted the idea of judgement to such an extent that it has become synonymous with prejudice. I don’t know. Hmmm. The word ‘judgemental’ does not exactly mean clever-clogs now, does it? No. But, I am wary of saying that to judge at all were bad, or that we should refrain from all forms of judgement. It seems disingenuous at best and vacuous at worst. It is in our nature to judge. How so? Oh, all our faculties, our senses and our brain, are built to judge, to discriminate, be it sound from sound, colour from colour, taste from taste— Yes, yes, I’ve done my neuroscience, thank you very much. But, aren’t you guilty of the very dilution that conflates judgement with prejudice? One dilutes it to condemn judgement. The other to celebrate it. But, I’m not celebrating it. I’m just asserting that judgement is inherent to human nature, however you defi ne it. What I’m not sure is that prejudice, though we might be prone to it, is built into our nerves. So, for an audience of medical students, what exactly is your message? Be good at diagnosis and prescribing, but please don’t be prejudiced against your patients? Isn’t that a bit— Trivial? You said it. Maybe. But, I’m less keen to ward off prejudice than to defend the importance of good judgement, which, as I said, I think is the foundation of medicine. Prejudice maybe a weed, but sound judgement is the soil on which medical practice is built. I would have thought science is the soil, to use your metaphor, on which medicine is built. I used to think that too. But, in hindsight, and having done pure science, I realise that science is an instrument, an indispensable instrument, mind you, but an instrument, rather than the foundation. Science gives you the harrow and the sickle of your field, it is the means with which you till your soil, but, if you don’t water your crops, don’t remove waste and weeds, or fail to heed your weather warnings, you can’t expect a good harvest, can you? Oh god, what has literature done to you? I laughed. What I’m saying is, science gives you the means to probe and the means to diagnose, but you cannot do away with things like patient history or a detailed physical and mental examination. After all, this is what doctors in India still largely rely on, I added. And ultimately, the good doctor relies on his or her own judgement, a judgement that comes only in part from knowledge, but to a greater extent from experience and intuition. So, how does the good doctor avoid acquiring prejudice, as you see it? How should I know? I’m not even half a doctor. Oh, now you’re pleading your past, after this lengthy lecture? Answer the question. How do you avoid becoming prejudiced? I don’t know. I admit, the line is very thin, almost imperceptible, between judgement and prejudice. But, something tells me that if you keep your patient’s interest at heart, and not your own ego,— Which as we both know, interrupted my friend, with no irony lost in his tone, is not at all a problem in my profession— As I said, if you keep your patient’s interest at heart, and are not intent on being a mouth-piece for your own ego, I think it’s highly unlikely that you’ll cross that line. Thank you Dr. Phil, my friend said, as we walked back to Victoria Gate. The sun was about to go down, and I saw blackbirds and parakeets hop from tree to tree across the vermilion sky. As we parted, my friend asked me if I have ever regretted leaving medicine behind. Honestly, I said, no. Okay, he said, but if I asked you whether it was right for you to have abandoned a career in medicine, and to have left behind India, when you could have remained there and perhaps helped thousands of poor and suffering people— You are not the first person to ask me that, nor will you be the last, I said. But would you feel as if I were judging you? By asking me whether it was right, I said, after thinking about it for a moment, whether it was right for me to have left behind my past, to have abandoned, as you put it, medicine and India, you are suggesting, aren’t you, that I was selfish to do what I did, to put my own life ahead of the poor and the suffering, correct? He was silent. Yes, I said to my friend, I would feel judged. No, I do feel judged. But, whether it was a question that had my best interests at heart, or it was a question that was meant to shore up your own sense of self-worth, I’ll let you decide. He was silent, his head down as if deeply repentant. But, I was in no mood to reassure him. Instead, I turned away and began to walk back towards the overground station. Wait, he shouted after me, and came and stood by me near the zebra-crossing. Did I hurt your feelings? he asked. I did not reply. The pedestrian signal turned green and began to bleep, at which point, I decided to cross the road and walk away. Don’t worry about it, I said, quickly but disingenuously, and hurried across the crossing to the overground station. I did not look back to see if he was still standing there. Balaji Ravichandran is a graduate student at The Queen’s College.
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Moral Judgement in Medical Ethics Dr Daniel K. Sokol is an Honorary Senior Lecturer in Medical Ethics and Law at King’s College London and a barrister specialising in clinical negligence and personal injury at 12 King’s Bench Walk, London. He is the author of ‘Doing Clinical Ethics’ (Springer, 2012).
M
oral judgement, in the context of medical ethics, tends to refer not to the product of deliberation but to ‘moral wisdom’ or ‘moral discernment’. But what exactly do we mean when we say that, confronted with a confl ict of values or moral principles, a doctor - or medical student - should exercise his ‘moral judgement’?
and other emotions can play an important part in balancing confl icting moral principles or selecting our guiding values. The equanimity urged by Sir William Osler (Regius Professor of Medicine here in Oxford in the early 20th century) to newly minted doctors was not a call for apathy, as some have claimed, but for metriopatheia, or measured emotion3.
In practice, how people exercise Philosophers have tended to use moral judgement is not entirely rather vague language when referring understood. Reason and emotion “Reason and emotion are to moral judgement. Kant viewed are two key ingredients in moral judgement as the ‘faculty […] of two key ingredients in judgement, but how they interact is determining whether something unclear. Recent work in cognitive moral judgement, but how stands under a given rule’4. Judgement neuroscience suggests that reasoning they interact is unclear” itself, however, is not rule-governed plays only a restricted, though and is defined by Kant as a ‘special significant, role. Greene and Haidt, talent that cannot be taught but only two North American psychologists, practised’5. Discussing the doctrine claim that ‘automatic emotional of the mean (i.e., the doctrine that processes tend to dominate’ and Greene et al. have every virtue lies between a vice of excess and a vice demonstrated that brain areas linked to emotion were of deficiency, so that courage is the ‘golden mean’ more active in personal moral dilemmas (e.g., keeping between rashness and cowardice, for example), money found in a lost wallet) than in impersonal and Aristotle considered moral judgement about where the non-moral dilemmas (e.g., choosing between taking the golden mean lies in the spectrum as a ‘perception’6. bus or the underground)1. These emotions influence moral judgement but are not necessarily determinative. There is a degree of interpretation required in applying They can, it seems, be overcome by reasons. prima facie moral duties (i.e., duties that are binding unless they confl ict with stronger duties). We must Although excessively strong emotions can decide whether or not a particular duty applies in a distort moral judgement, so too can a deficit of situation (e.g., the duty to tell the truth to the patient) emotions. Philosopher Nancy Sherman draws and, if so, what action should be taken to fulfi l this a link between emotion and moral blindness: duty without violating a stronger, countervailing duty (e.g., the duty to avoid great harm to the patient). The Moral situations don’t come pre-labelled. philosopher WD Ross - another Oxford don in the early Emotions help us to label them under specific 20th century - claimed that no rules existed to estimate descriptions. Those who lack moral perception, the relative stringency of confl icting prima facie duties:
who are obtuse about the moral dimensions of a situation, are often just those who have never cultivated their emotional repertoire2.
Moral judgement, then, should not be divorced from our emotions, for sympathy, compassion, kindness 28
This sense of our particular duty in particular circumstances, preceded and informed by the fullest reflection we can bestow on the act in all its bearings, is highly fallible, but it is the only guide we have to our duty7.
More recently, ‘moral particularists’ such as Dancy have attributed great importance to the idea of grasping the moral landscape by ‘discernment’. Whereas most followers of the influential Four Principles of medical ethics (sometimes called ‘principlists’) would claim that moral judgement should supplement principles to specify action, Dancy believes that moral judgement can replace principles entirely:
There is nothing that one brings to the new situation other than a contentless ability to discern what matters where it matters, an ability whose presence in us is explained by our having undergone a successful moral education8.
Arguing against the arbitrariness of moral judgement, Larmore continues:
We should realize not only that there are limits to theoretical understanding, but also that there are other kinds of understanding that are more appropriate for grasping the nature of moral judgment (his emphasis)11. To equate moral judgement with the balancing of norms or the systematic application of moral rules to individual situations is to ignore the emotional and individual aspects of moral deliberation. Charles Taylor alludes to this when he claims that resources for resolving confl icts ‘lie partly in our sense of our lives as a whole, the lives we are leading’12.
Responding to criticisms that the process of balancing the weights of prima facie duties is too intuitive, Beyond its rational aspects, there is Beauchamp and Childress - the something mysterious and deeply “Beyond its rational American founders of the Four personal about moral judgement, aspects, there is something Principles - offer conditions that, if met, akin to a moral ‘sixth sense’ acquired would justify infringing a prima facie gradually throughout a person’s life. mysterious and deeply moral norm9. These include the need This is not, in my view, a disappointing personal about moral conclusion. Aside from reflecting for better reasons to override the judgement” the reality of moral psychology, norm than not to override it, the it encourages us to expand our realistic nature of the objective, emotional, cultural and intellectual the lack of morally preferable horizons (Larmore recommends alternatives, the minimization of the negative effects of infringement, and reading ‘the great works of imaginative literature’) to impartiality. Morally acceptable judgements improve our moral judgements through a more reflective must therefore be supported by good reasons and insightful understanding of ourselves and others. which satisfy a set of conditions and which are based on relevant and accurate facts Good moral judgement will reduce the likelihood of (hence the need for good empirical research). making wrong decisions, revealing apparent dilemmas as merely epistemic ones (i.e., ones resulting from a Although moral judgement, through informed, lack of knowledge rather than intractable confl icts reasoned, context-sensitive, critical analysis, can of principles). But even then, Nagel notes, there are resolve most moral conf licts, it is not a moral moral dilemmas so complex that ‘judgment cannot panacea. As Larmore writes, ‘in many cases […] operate confidently’13. Even the wisest of the wise will judgment will be powerless to settle the [moral] hesitate in the face of a moral dilemma, especially on conf lict.’10 . An appeal to reasons and arguments that tempestuous sea that is the clinical environment. will not always yield a solution to moral dilemmas.
Acknowledgements Many thanks to Professor Raanan Gillon for his help with an earlier draft of this article. Full references available at: www.omsg-online.com
Dr Daniel K. Sokol is an Honorary Senior Lecturer in Medical Ethics and Law at King’s College London
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What’s Neuroethics doing to understand - and maybe affect - morality? Professor James Giordano explores neuroethics’ perspectives on the neurological basis of moral thought, decisions and behaviours I think therefore I am…but how do I think morally? Since antiquity, humans have looked inwardly – and at each other – and wondered about the nature of right and wrong, and good and evil. Rene Descartes’ renowned assertion, “I think, therefore I am” (‘cogito ergo sum’) has long been accompanied by reflecting upon, “what makes me what I am?” To be sure, such questions are philosophical, and became the axiomatic focus of the field of moral philosophy. The empirical and experimental trends of the late nineteenth century drew scientific attention to philosophical questions, and the queries of moral philosophy became the stuff of moral psychology. Without doubt, the twentieth century has evidenced a wealth of moral psychological inquiry, discourse and debate. Like much of psychology, such inquiry has increasingly entailed the natural sciences – biology, chemistry, and more recently, the multi-disciplinary study of the structure and function of the brain that has come to be known as neuroscience1.
“There isn’t a “moral centre” in the brain” brain” Advancements in neuroscientific knowledge and capability have surged, in part as a result of iterative development and use of ever more sophisticated techniques and technologies. Large scale international investments into brain research, such as the United States’ Congressionally-declared ‘Decade of the Brain” agenda (1990-1999), and current Brain Research through Advancing Innovative Neurotechnologies (BRAIN) 30
Quantitative Electroencephalography (qEEG) Magnetoencephalography (MEG)
Evaluate electrical and magneto-electrical activity in cortical layers and pathways
Functional Magnetic Resonance Imaging (fMRI)
Depicts active regions/ sites in brain through proxy determinations of blood oxygen level demand (BOLD) signal
Diffusion Tensor Imaging (DTI)
Depicts axonal tracts and directional network activity through detection of anisotropic signal of water molecules
Box 1: Neurotechnologies currently used to assess brain structures and functions involved in moral cognition, emotions and behaviours initiative, and the European Union’s Human Brain Project, have all furthered neuroscientific aptitude and momentum. One area of ongoing work in the neurosciences is dedicated to exploring, if not defining, the neurological basis of moral thought, emotions and behaviours. This has become known as – and a part of – the relatively new discipline called neuroethics.
Neuroethics’ “First Tradition”: (Attempts at) Mapping the “Moral Brain”
The term “neuroethics”, although first coined to describe ethical issues of neurology and the brain sciences2, has obtained broader meaning and use. According to neuroscientist and philosopher Adina Roskies, in its two emphases, or so-called “traditions”, the field addresses both the “ethics of
Hippocampus
Memory, and in relating memory to understanding the emotions of others
Parts of the amygdala
Emotional arousal
Ventromedial/ dorsolateral prefrontal cortex (vmPFC and DLPFC)
Emotional salience of various environmental stimuli and interpreting behaviours and emotional states of others
Posterior cingulate cortex (PCC) and precuneus
Interpreting bodily sensations (i.e.- “selfreferential cognition)
Temporo-parietal junction (TPJ)
Social emotions and behaviours
Box 2: Brain areas and networks putatively involved in moral cognition and actions Of note is that these brain areas are part of networked activity that functions in these cognitive and behavioural processes. neuroscience”, and the “neuroscience of ethics”3. Let’s delve into the first, and leave the second for later. I think that the “neuroscience of ethics” is a somewhat inaccurate description. More precisely, I offer that what is being studied are the structures and functions of the brain that are involved in the ways that moral thoughts (including emotions) are developed and processed, and how these are engaged in various actions in different environmental circumstances and situations. Our group refers to this as “neuro-ecology” - not to add yet another “neuro-neologism” to the fray, but to more accurately
describe both the ways that these neural processes function – and what the field is dedicated to studying4-6. Using several types of neurotechnologically-based assessments (see Box 1), studies have attempted to depict what brain regions are involved in various types of moral and ethical thoughts and behaviours. What is becoming clear is that moral cognitions and decision-making do not seem to be much different than any other form of socially relevant judgements – at least on a neurological level7,8 . Moral decisions and actions involve memories relating to others; reinforcements, anticipation of, and response to, reward and punishment; and emotions of pleasure, discomfort, and pain. There isn’t a “moral centre”, some “nucleus moralis”, or even a specific “moral pathway” in the brain. As shown in Box 2, current evidence has shown that a number of brain structures can be involved in what are construed to be moral decisions8,9, see also the work of W. Casebeer, J. Decety; J.D. Greene; J. Haidt; and/or J. Moll, and for overview, reference 10 . These areas are not uniformly activated when engaging in morally relevant thoughts, or deciding
“We are all ethical ” upon moral judgements or actions. Still, there are mechanisms and processes that are common to all. Every decision and action – whether considered to be moral or otherwise – involves a perception of the circumstances and actors involved, some orientation to a prior event that was similar or referential to the present situation, recall of actions – of self and others – and their consequences, and recollection of the
Depiction of brain areas shown to be involved in moral cognition and decision-making. Panels A and B depict the brain in side (sagittal) view; panel C shows the brain in frontal (coronal) view. Note: not all brain areas discussed in text are depicted (adapted from reference 14) 31
emotions that the actions and outcomes evoked. It’s also likely that we develop these functions as a result of interactions and experiences throughout our lifetimes. While humans are not “born moral”, we do appear to possess a good bit of sensitivity and capability to respond to cues, and learn from our environment and from others. We have innate skills that establish a proto-moral groundwork, and enable us to acquire a sense of “good”, “bad” “right”, and “wrong” from an increasing circle of others (e.g. family, friends, strangers and the not-so-friendly) and interactions with the environment(s) – including the communities in which we live and the formal and informal institutions, mores and norms we encounter. The functional patterns of brain activity involved in moral-type thoughts – and resulting decisions and behaviours – appear to differ based on a number of factors, including age (i.e. adolescents seem to be more self-centred, as if this were a great surprise)11, sex (i.e. females appear to be somewhat more perceptive and responsive to others’ emotions12; perhaps no great shock there either), group influence13, first or third person perspectives14, and outcomes (yes, it does seem that everyone appears to have “a price” that might make them change their mind about moral matters!)15.
Are there Conservative, Liberal Democrat, and Labour brains? No, but it’s likely that individuals who perceive and rationalize things in certain ways (because of their biological, psychological and social backgrounds) might find comfort in the community of a cognitively-aligned social (and/or political) group. Although we tend to use “preferred” or learned cognitive patterns and beliefs in our intuitions, rationalizations and judgements, it appears that each of us actually employs a range of cognitive reasoning functions and abilities when faced with a problem or decision that we hold to be “moral”
in its value and effect. In short, moral cognition involves reasoning and justification processes that are more of an admixture of ethical precepts. We are all ethical polymaths, at least to some extent.
Neuroethics’ Second “Tradition”: Making Meaning of the “Moral Brain”.
Insight to these neurological mechanisms can be of use to developing improved ways of teaching, reinforcing and guiding moral, ethical and legal thought and behaviour. Of course, certain styles of reasoning can be imposed, and/or individuals can be forced to behave in certain ways, but morals and ethics needn’t be enforced or heavy-handed. Herein lies the interaction with – and need for - neuroethics’ “second tradition”. If we consider the “ethics of neuroscience”, then we must address the ways that various techniques and tools are used in brain research, and how the results and products of brain science are used in larger contexts of medicine, public life – and even international relations and national security and defence. It’s important to remember that any ethical analysis begins with presentation of the facts. The fact is that addressing neuro-ecology (viz.- the “neuroscience of ethics”) demands ethical probity and prudence in the ways that we study the brain, interpret what we know and what we don’t know about the brain and its functions, and how we use – or misuse – such information and neurotechnological capabilities to assess and affect thought, emotions and behaviours16,17. Can neuroscience, and neuroethics’ “first tradition”, tell us what is “good”, and how to live our lives? No, not really; but we can learn how brains function in developing and processing moral cognitions, emotions, judgements and conduct. That’s still important – and powerful – information. Neuroethics’ “second tradition” provides a valuable resource – as a discipline and set of practices – to study how we study the brain, and to guide such investigations and the ways that neuroscientific information is put to work in the social sphere. In this way, when taken together neuroethics can be seen as both a lens – to peer into the workings of the brain that are involved in morality and ethics, and a mirror – to look back upon ourselves and foster a deeper understanding of what makes us what we are, how we think morally…and how we will use neuroscience in ethically sound ways. Full references available at: www.omsg-online.com
Professor James Giordano is an International Collaborator of the Oxford Centre for Neuroethics, and is Chief of the Neuroethics Studies Program at the Edmund D. Pellegrino Center for Clinical Bioethics, and member of the core faculty of the Department of Neurology, and Inter-disciplinary Program in Neuroscience at Georgetown University Medical Center, Washington, DC, USA, and is Clark Fellow in Neurosciences and Ethics, at the Human Science Center of the Ludwig-Maximilians Universität, Munich, Germany.
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Neurodevelopmental consequences of childhood maltreatment David Rowland investigates the devastating consequences of early childhood CHILDHOOD maltreatment on brain development MALTREATMENT PIC
C
urrently, 50,500 children in the UK are known to be at risk of abuse - with 13% of those under one year of age the subject of a child protection plan1...
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M
aladaptive brain development during this critical period, due to adverse or lack of feedback from a caregiver, is associated with increased chances of a psychiatric disorder developing. When an infant’s cries are met with food or comfort, this strengthens the neuronal pathways that help an infant to learn. In contrast, babies who do not receive positive responses to their cries, or whose cries are acknowledged with abuse, learn different, maladaptive lessons.
“Over 50,000 children in the UK are at risk of abuse” Child maltreatment can manifest itself in altered development of certain areas of the brain; including the amygdala, hippocampus and prefrontal cortex. This may lead on to the development of anxiety, cognitive and attention disorders. A study of children adopted from Romanian orphanages in the 1990s, who were considered to have undergone severe neglect, found they had significantly smaller brains than the average size of the population for that age – suggesting a decreased brain growth2. Is it this maladaptive brain development that can lead to psychological disorders in later life? Child maltreatment, including abuse and neglect, has been found to increase release of the stress hormone cortisol, due to effects on the hypothalamic-pituitary-adrenal (HPA) axis. This pathway mediates the stress response, maintains a diurnal rhythm, and is extremely sensitive to the effects of early life. Changes in cortisol release have been found to have a significant impact on brain development. Maladaptation of the HPA axis is most often observed in diurnal regulation, with one study finding blunted morning cortisol levels and higher cortisol levels at night in children who had suffered maltreatment3. Several brain regions (such as the amygdala, hippocampus, and frontal cortex) are particularly sensitive to cortisol dysregulation. Aberrant development may be due to a higher number of glucocorticoid receptors in these areas. There is a high incidence of anxiety disorders in children who have been abused or neglected, and up to a doubled risk of developing internalizing
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problems in later life4. The amygdala has a critical role in processing emotional information, including the perception of emotion in facial expressions, evaluating threatening information, and fear conditioning. Prolonged maltreatment, as modelled by children brought up in prolonged institutional care, yielded an association with an atypically large amygdala volume5. One study also found that maltreated children had greater amygdala firing in response to fearful faces, associated with poorer social competence and less eye contact6. It is increasingly clear that a larger amygdala, corresponding to a heightened sensitivity to threatening stimuli, may lead to the development of anxiety disorders in later life. The hippocampus plays an important part in memory formation, as well as in regulating the stress response. Decreased development of the
“There is a correlation between suffering child abuse and ADHD”
“Maladaptive brain development increases the chances of a psychiatric disorder developing”
hippocampus has been associated with dissociative identity disorder7, borderline personality disorder8 and major depressive disorders9. Worryingly, a recent MRI analysis of participants with high and low scores of self-reported measures of childhood maltreatment found that a smaller left hippocampal volume was associated with maltreatment10. Further studies have also found evidence for disrupted hippocampal functioning in maltreated children suffering from post-traumatic stress disorder (PTSD)11. In these children, reduced activation of the left hippocampus was associated with greater severity of post-traumatic symptoms during retrieval in a verbal memory task. Maltreated children show higher rates of attention-deficit hyperactivity disorder (ADHD) and problems with executive functioning12. The correlation between child abuse and ADHD may be due to the reduced development of the prefrontal cortex, which is responsible for executive functioning, including planning, memory, inhibitory control and allocation of attention. In fact, adults who experienced maltreatment in childhood demonstrate decreased grey matter volume in the prefrontal cortex13. Lastly, an fMRI investigation into the neural activation patterns during different tasks revealed that whilst non-maltreated children showed increased activation in the prefrontal cortex, maltreated children showed greater activation of the cingulate cortex14. This pattern of greater activity in the cingulate cortex is similar to those patterns observed in children with ADHD.
Full references available at: www.omsg-online.com
David Rowland is a third year medical student at St Catherine’s College
Undoubtedly, there has been a huge increase in the understanding of the neurobiological consequences of child abuse and neglect within the last decade. There is marked evidence to support that the resulting underdevelopment and altered neural activity in some areas of the brain can result in serious psychiatric disorders. However, there is hope – brain systems remain somewhat plastic throughout childhood, therefore children experiencing enriched environments following maltreatment can indeed demonstrate remarkable recovery. Nevertheless, over time the brain becomes less susceptible to intervention as developmental changes become less plastic. As a result, there is a considerable need for intervention programmes to be implemented promptly, with the aim of enhancing key aspects of children’s early care setting. These programmes cannot be limited to weekly therapy appointments, but must involve a total enrichment of the child’s life, providing consistent positive experiences so that the child’s brain can begin to adapt to a new environment – one that is safe, predictable and nurturing.
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Dying for an Answer? Rhys Dore examines the consequences of near-death experiences.
‘Seeing the light’ has on
long been associated with those their death-bed, and the notion has permeated through ancient literature into modern media and general thought. This is but one example of a near-death experience (NDE) in which patients experience visual or auditory cues in the months, days or even minutes preceding their death. 36
IMAGES/ROSALIE BROOMAN-WHITE
E
xtensive research of this phenomenon has found an array of possible causes such as the interactions of brain pathologies, neuronal hyperactivity, and hypercapnia with one’s own a priori expectations concerning death1. These conclusions have led to the common acceptance that NDEs are simply self-manufactured and of little concern to a clinical team. This ignorance is heightened by the fact that such events are also often regarded as resulting from drug-induced hallucinations or even progressive dementia. Therefore, irrespective of patients often being fully conscious and aware, it is unsurprising that many do not feel comfortable sharing their experiences due to concerns about being labelled or worrying their loved-ones2. Social stigmas undoubtedly have a detrimental emotional effect and prevent the appropriate recognition of NDEs, which have been shown to have significant short and long term effects.
Ascent of the Blessed, Hieronymus Bosch, c. 1504 - traditionally accompanies articles discussing near-death experiences.
“Clinical end points are not the only factors relevant to a patient�
The effects of NDEs are best analysed in those who have come close to death yet survived, i.e. following resuscitation. There exists anecdotal small-sample evidence for the induction of allergic and chemical sensitivities following NDEs but little significant evidence has been found for long term alterations in physical symptoms3. A large-scale survey of cardiac arrest survivors
discovered that NDEs had no significant correlation with any change in cardiac function4. This lack of overt physiological influence only strengthens the classification of these experiences as unimportant, yet it should be remembered that clinical end points are not the only factors relevant to a patient. Effects on mental health and wellbeing were established long ago with multiple case studies finding that surviving patients who experienced an NDE were more appreciative of life, had increased spirituality and concern for others, and exhibited a decreased fear of death5. Interviewing the nurses of end-of-life patients found that 89% of those reporting an NDE had had a calm and peaceful death in contrast with only 40% of those with no such occurrences, showing the short-term benefits of these changes6. Interestingly, the emotional value of the NDE has a significant influence on the likelihood of achieving positive outcomes, with visions of deceased relatives being deemed the most likely to provide comfort7. Contrastingly, visions that are usually comforting may confuse, worry, and scare others. Similar negative perceptions are unsurprisingly found in patients experiencing visions of hellish landscapes or eternal voids of nonexistence, which are not uncommon8. It has been argued that negative experiences may be advantageous in the long run
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as subjects may judge them as a sign to change their lives for the better9. Nonetheless, it must be recognised that these events could be distressing, even if only temporarily. Mechanisms to help patients discuss and understand their experiences may be helpful in such circumstances.
“Any application or management of NDEs would need to consider the cultural, religious, and socioeconomic background of the person”
The type of NDE experienced, according to the cultural conditioning hypothesis, depends upon the personal background. Studies based in India found that patients more frequently see a Yamdoot (a messenger from the Hindu god of death) and feel like they have rightly or wrongly escaped death following these visions. In comparison, Americans often feel positive towards death following the typical visions of deceased relatives. These benefits, however, are rarely seen within Native Americans10. Therefore any application or management of NDEs would need to seriously consider the cultural, religious, and perhaps even socioeconomic background of the person. In terms of applications, induction of NDEs has been found in ketamine administration11. The ability to control these experiences, by solely producing positive effects, may be alleviating in a range of conditions. Terminal restlessness is but one example in which patients feel emotional suffering, seem distant from their religious faith, and show worsening of symptoms12. Cohen and Persinger’s ‘God Helmet’ is an experimental head device that has been found to produce similar feelings to those experienced in NDEs. It works by directing weak, fluctuating magnetic fields towards the brain, and has the potential to find frequencies and areas to stimulate that would produce specifically positive experiences13. Disappointingly, the initial results have failed to be reproduced suggesting a need for further investigation within this area. Nevertheless, research has too often focused on the causes of NDEs rather than the consequences. These experiences evidently have a significant effect on patient comfort and have been described by Brayne as an “intrinsic part of the dying process”2. This is hardly a recent discovery; even the ancient ‘Tibetan Book of the Dead’ raises the need for appropriate care for those undergoing NDEs14. Perhaps, with some revision, this practice could too be integrated into modern healthcare.
Studies based in India found that patients more frequently see a Yamdoot, messenger of Yama, the Hindu god of death - depicted here. From the Bardo Thödol, or the Tibetan Book of the Dead. Mid 17 - early 18th century. 38
Full references available at: www.omsg-online.com
Rhys Dore is a second year medical student at Worcester College.
An Interview with
Sir Richard Thompson Charles Coughlan hears Sir Richard Thompson’s views on clinical judgement and the challenges facing the NHS
S
ir Richard Thompson, KCVO, trained in Oxford (Worcester) and London before embarking on a distinguished career as a gastroenterologist at St. Thomasʼ Hospital. He led a clinical research laboratory for over 20 years publishing more than 200 scientific papers in the process - and for 21 years was a physician to Her Majesty The Queen. Sir Richard has served as President of the Royal College of Physicians since 2010.
Do you believe that evidence-based medicine (EBM) and clinical judgement are fundamentally at loggerheads? And if so, is there still a place for judgement in modern medicine?
and even important, that the doctor is in the position to make careful judgement while knowing the best evidence out there for a particular treatment. That, I think, is the most important thing about training in medicine - we train to think laterally if things arenʼt as we quite expect. EBM and clinical judgement work very closely together, but that relationship has shifted in the sense that previously clinicians had tremendous power, and nowadays thatʼs not so; as you go through your career, you have to keep up to date with the evidence base.
Over the course of your career, have you noticed a shift in attitudes amongst members of the medical profession such that today’s junior doctors are no longer encouraged to No, I donʼt think theyʼre at develop judgement as they once were? loggerheads. We have to use EBM because a lot of things done in medicine in the past have been completely wrong. We [must] base as much as we can on EBM - things like NICE guidance and audits but for any individual patient, it may well be that they donʼt fit with a particular evidence base. In that situation, itʼs perfectly reasonable,
a lot of horror stories, dare I say, litigation as well, so theyʼre worried about that. The third thing is that clinical tutors have less time to closely supervise what their trainee doctors are doing. Nevertheless, I think itʼs very important that we, as the more senior doctors, do at least encourage the trainees to make decisions…thatʼs the way theyʼll learn. If you went on television and said that, Paxman would say to you “so youʼre asking your trainee doctors to practise on your patients?” You couldnʼt deny that, but at the same time, youʼve got to learn, and as a trainee, youʼve got to learn safely on a patient. Weʼre going to have to balance those two things, to encourage judgement and responsibility.
Certainly itʼs true that many trainee doctors - I prefer that to juniors have difficulty in making decisions and clinical judgements. There are two reasons for that: one is that thereʼs a lot more to know, and two, thereʼs a lot more scrutiny. No-one scrutinised me when I was a trainee very much; nowadays there are
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From your perspective, what are the biggest challenges facing students and junior doctors today? I suppose that the main challenge is trying to keep up to date with the knowledge, which is increasing in every specialty all the time. We, as a College, are pushing the principle of generalism. In this country - where many people became specialists - I remained engaged in both gastroenterology and general medicine for the whole of my career. I suppose that was relatively unusual, but now I think that it will shift back. So, a challenge for trainees is deciding whether they want to be generalist or more highly specialised. Hopefully most people will mingle those two and become a hybrid position. Youʼve also got to think about the economy; generalism probably will be cheaper, as shown by evidence coming out of the United States, where they’re highly specialised and do endless tests. Another problem will be balancing general and acute medicine, balancing the increasingly elderly population, who need a lot more care, and trying to do that as easily as possible. Itʼs going to be very difficult, and I donʼt envy you.
Yes, absolutely. I think the main problem is the increasing number of admissions, particularly among the elderly who are fascinating, challenging and very difficult. At the same time, because of the increase in population, particularly the elderly population, there have actually been “true cuts” in the amount of money going to the NHS. It certainly is intolerable. From your point of view, trainee doctors are very stressed as well. They donʼt want to form the “Hospital at Night” team when theyʼre alone, and they have an unmanageable workload. We, as a College, are extremely worried by this, particularly with regard to acute and emergency medicine.
In recent months, several newspapers have drawn attention to a growing recruitment and retention crisis in emergency medicine. Do you think Dr Neil Dewhurst, the outgoing this crisis exists, and if so, what key President of the Royal College measures can be taken to address it? of Physicians of Edinburgh, It certainly exists - 50% of the recently remarked that doctors consultant posts are unfi lled. and nurses are being placed under Attendances in A&E are going “almost intolerable pressure” up, and the number of admissions resulting from staff shortages, through emergency departments cuts to hospital beds and growing is rising; thereʼs clearly a huge load, but not enough staff to admissions. Do you agree with him?
cope with it. We have suggested that people coming in for acute medical reasons (as opposed to alcohol, trauma, and that sort of thing) should be dealt with immediately by acute physicians. That would help take some of the load off emergency departments. Thereʼs a lot of talk from the leaders of NHS England about closing emergency departments to concentrate services, but all that does is double up the number of patients in any one place and increase the distance many patients have to travel to reach their local A&E. Iʼm not wholly convinced that widespread closure of emergency departments will save much money or improve clinical care. I think we have a terrible problem. How do you attract trainees to go into an emergency department? One solution, I think, is to offer a “hybrid” model in which some days of the week theyʼll be in A&E, others in surgery or medicine. The President of the College of Emergency Medicine, Clifford Mann, suggested that perhaps they should be offered more holidays rather than more money. If we said they could have 3-4 months off every year, they could fit with families, and it might be seen as an attractive option.
The author would like to thank Sir Richard Thompson for participating in this interview Full references available at: www.omsg-online.com
Charles Coughlan is a third year medical student at Magdalen College.
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Holding Doctors to Account Nicola Kelly looks into the rising number of complaints brought forward against doctors in the modern NHS.
A
s medical students we are in a privileged position Fitness to Practise – able to nonchalantly wander the wards, spend The GMC lays down guidelines on ‘fitness to practise’ hours taking elaborate histories, and then return home for doctors and medical students alike. For medical to sleep soundly in the knowledge that the doctors are students, failure to comply could lead to expulsion. taking care of all the scary stuff. But For doctors, the penalty could be upon graduation everything changes, restriction to practise or being struck and it seems that we will morph off the medical register altogether. from carefree medical students “The role of the GMC Cases can be brought to the GMC to frazzled F1s; afraid of making by patients or colleagues alike, mistakes, worried about putting a is not to penalise doctors concerned about the standard of patient at risk or incurring the wrath but to protect patient care offered by an individual. If of our seniors. So, what happens deemed serious, the case will be safety” when things really do go wrong? investigated and referred to the Medical Practitioners Tribunal Holding doctors to account Service (MPTS) and a hearing will The General Medical Council (GMC) be held to decide whether a doctor is is an independent body established in 1858 to regulate fit to practise1,2. It’s vital, however, to recognise that doctors in the UK. They set the standards for medical the role of the GMC is not to penalise doctors but to schools and control entry to the medical register, protect patient safety – an aim that is, hopefully, indisthereby playing a critical role in all of our careers1. tinguishable from that of most medical professionals.
A “rising tide” of complaints
Number of complaints received by the GMC (2007 - 2011) Figure 1 taken from reference [3]
Despite the move to an increasingly patient-centred service, complaints against the NHS have continued to rise over recent years. A 2012 press release from the GMC announced that complaints about doctors had reached a record high3, with the majority of these complaints coming from members of the public. However, the authors suggested that the rise in complaints did not necessarily mean a fall in the standard of medical care – with only one in 68 complaints about doctors deemed worthy of formal investigation3.
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The impact of complaints on doctors Receiving a complaint is a traumatic experience and it’s been postulated that the psychological impact may affect a doctor’s future practice. In 2012, the British Medical Association (BMA) launched a survey into doctors’ views and experiences of the medical complaints system (the IMPACT study). This study hopes to shed light on these concerns as well as identifying predictors of those particularly at risk, so that support can be offered at an earlier stage4.
“The rise in complaints did not necessarily mean a fall in the standard of medical care” This seems reasonable given that the GMC’s report found that certain groups were significantly more likely to face complaints; with overrepresentation of GPs, psychiatrists and surgeons – putatively due to the frequency or nature of patient interaction involved in these specialties (rather than reflecting traits of the doctors working in these fields). Moreover, it is also notable that almost three-quarters (73%) of all complaints launched were against men, despite only 57% of registered doctors being male. Although, this may be related to the fact that the rate of complaints also increased amongst older doctors, who are
proportionally more likely to be male. Somewhat reassuringly, the rate of complaints against medical students was less than 0.1% (381 complaints against a medical student population of 41,2683). The 381 students affected do, however, serve as a stark reminder that even before we qualify, our conduct and fitness to practise are under scrutiny.
Keeping safe
No one wants to see his or her name on the MPTS weekly schedule; no doubt you will already be wondering what you can do to minimise this risk. The GMC cites greater expectations, willingness to complain, diminished tolerance of poor practice and ‘media attention’ as likely contributors to the rising frequency of patient complaints. Given the continually growing availability of up-to-date health information (and sometimes misinformation) on the Internet, it’s unsurprising that patient expectations are rising. Furthermore, it seems likely that a clash between budget cuts and patient demands will trigger further escalation of the incidence of complaints. There is, however, a hint of practical advice; the report noted a recent, significant rise in complaints about the way doctors interact with patients. Specifically, there was a 69% increase in complaints related to poor communication. So, take a break from the library – perhaps ‘Comm Skills’ sessions really are the most valuable part of our medical training after all.
Full references available at: www.omsg-online.com
Nicola Kelly is a fourth year medical student at The Queen’s College
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“Even before we qualify, our conduct and fitness to practise are under scrutiny”
Full references available at: www.omsg-online.com
The News in Review, Elizabeth Whatling
The great statin debate rumbles on This month saw the debate over statins re-enlightened as the Daily Telegraph led with the front page, ‘Statins “have no side effects”’. Citing a paper co-authored by Bad Science’s Ben Goldacre from the European Journal of Preventative Cardiology, the broadsheet misinterpreted findings of the paper but served to highlight that this was indeed an interesting piece of work, with an unexpectedly odd result. By looking at the side effects of statins in randomised trials, specifically, and unusually, it compared the reports of side effects among people on statins in trials, against the reports of side effects from trial participants who were only getting a dummy placebo sugar pill. Remarkably, people reported typical statin side effects even when they were only receiving a placebo. The phenomenon of people experiencing unpleasant symptoms simply because they expect to is fairly well-documented. This nocebo effect serves as the evil twin of the placebo effect. So it begs the question, can a sugar pill have an effect? A paper published in the journal Pain this week looked at every single placebocontrolled trial conducted on a migraine treatment and analysed the side effects reported by the control group who received a sugar ‘placebo’ pill. Side effects were common and incredibly similar to those of the trial drug. The side effect profi le was dependent on the trial drug and no concordance across the sugar pill
placebo groups could be determined suggesting the apparent morbidity the participants felt was not attributable to the physiological impact of the sugar pill but instead due to the nocebo effect. So what are the real world implications for patients? Are we, as doctors, when advising patients about side effects, in fact exposing them to the risk of inducing these ‘nocebo-caused’ unpleasant symptoms? And how implicit does it make us in infl icting harm upon those we are sworn to help? Finding the balance between advising patients about potential side effects and scaremongering remains a fine art. With that in mind, we have a responsibility to try and establish good quality evidence on side effects, and in particular to nail down the extent to which these side effects are genuinely being caused by the drugs.
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How to mend a broken heart
With the advent of cardiac stem cell therapy in the last decade, the promise of new treatments for cardiac disease has attracted a significant amount of media, public and fi nancial support. Heart disease is the primary cause of death worldwide, and cardiomyocyte stem cells offer a chance to replace of damaged heart cells, potentially saving millions of lives. Heart tissue has no regeneration potential in its natural state so scientists have turned to pluripotent embryonic stem cells to produce beating cardiomyocytes in the petri dish. Transplantation of these stem cells into the hearts of small mammals has shown favourable effects and in a new paper in Nature this week , it was scaled up to a non-human primate model. Experimentally, a suspension of heart muscle cells, grown in vitro and beating in the dish, were injected into the damaged tissue 2 weeks after inducing a cardiac event. 40% of the damaged region grew back, and the cells showed physiological activity in
the cell and synchronicity. However, these cells are far from the perfect cure. The stem cells cause a transient period of rhythm disturbance after transplantation for 2-3 weeks, usually ventricular tachycardia. In the clinic, this is not a tolerable side effect for those patients who already have poor cardiac outputs. In addition, there is the issue of scaling this study to suit humans – current estimations cite requiring more than a billion cells to fi x a human heart.
Despite the apparent limitations of this paper, there remains hope that continued tweaking of stem cell therapy could meet the great, unmet clinical need in heart disease. Yet, a new study published in the BMJ attempts to open the door on this area of research. The researchers report that the results in this field are illusionary and the potential benefits of stem cells to treat heart disease are probably more modest than we have been led to believe. 133 reports from 49 clinical trials looking at bone marrow stem cell treatment for heart disease in humans, showed a number of discrepancies in the data. In particular, differences between the left ventricular ejection fraction (LVEF),
The danger lurking in your pocket:
‘WhatsAppitis’
In a correspondence to The Lancet this month, Dr Inés Fernandex-Guerro outlined a case report that she had encountered that encouraged the reassessment of the potential dangers of smart-phones. A 34-year-old emergency medicine physician, 27 weeks pregnant,
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which is the measure of improved cardiac function, were particularly damaging. Those with the highest number of discrepancies reported the most significant improvement in LVEF. Despite the different stem cell therapies outlined above, the inconsistencies in the data may highlight inconsistencies in the way in which this research is reported, potentially invalidating the evidence and thus prevent advancement in the field. In this month’s Cochrane review of stem cells for heart disease, this notion is supported: “the quality of the evidence is relatively low…and individual study results varied’. These studies fueled by hype and hope must be analysed in the cold light of day, where perhaps their fi ndings may be rightly downgraded to meet the quality of the evidence provided.
presented with bilateral wrist pain of sudden onset upon waking up one morning. She had no history of trauma and had not engaged in any excessive physical activity in the previous days. Hand examination revealed discomfort upon bilateral palpation of the radial styloid process and mobilisation of the thumb. The preliminary diagnosis was bilateral extensor pollicis longus tendinitis of the thumb. However, it was later found that the patient had previously been on duty on Christmas Eve, and the following day, she responded to messages that had been sent to her on her smartphone via WhatsApp instant messaging service. She held her mobile phone that weighed 130g, for at least 6 hours. During this time she made continuous movements with both thumbs to send messages. The diagnosis for the bilateral wrist pain was WhatsAppitis. Treatment consisted of non-steroidal anti-inflammatory drugs and complete abstinence from using the phone to send messages. The patient experienced a partial improvement but did not completely abstain from using her phone, with exchange of new messages on New Year’s Eve. This is not a new phenomenon. A so-called Nintendinitis was first described in 1990, and since then several injuries associated with video games and new technologies have been reported.
NEWS IN NUMBERS
25%
the target to reduce premature mortality from the 4 main non-communicable diseases (CV, chronic respiratory, cancer and diabetes) by 2025 (25 x 25 target)
127 start
the have of a
number of people that died in Vietnam since the measles outbreak last year
114
the number of countries found by the WHO to have antibiotic resistance beyond the realms of acceptable resulting in the call for urgent, coordinated action from global stakeholders
90%
the percentage of British women not eating their recommended 18g per day of f ibre
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the age at which Britons believe life begins, according to a YouGov survey
the number of developing countries so far this year meeting Millennium Development goal number 4, to reduce under-5 mortality by 2/3 by 2015
In Brief
Progress for multidrug-resistant tuberculosis:
figures by postcode. This collection of maps intends to show the geographic distributions of environmental factors and disease outcomes. As a man in the Carfax area of Oxford you have a 1.35-1.5 relative risk of skin cancer, which is significantly above the national average. Find out your risk at www.theguardian. com/uk and searching ‘disease and environment’.
A new triple combination therapy, PA-824, moxifloxacin and pyrazinamide has recently entered phase 3 testing. The trial, funded by the Bill and Mellissa Gates Foundation, aims to reduce the time on treatment from 2 years to 6 months and reduce morbidity and mortality associated with multidrug- Greater transparency on animal research: resistant TB particularly in the developing world. The government have announced a plan to ditch the rule preventing the release of laboratory information A British map of disease: an Environment in an attempt to encourage openness about such and Health Atlas has been released by researchers at work. It is hoped this will aid the spread of best Imperial College, which provides open access to disease practices between researchers but concerns remain over the safety and protection of staff involved.
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Can Innovation Save the National Health Service? Samuel Folkard illustrates the potential for us all to contribute to the development of a better NHS
S
ince July 5th 1948, Bevan’s principles have governed the policy of the National Health Service: meeting the needs of all; free at the point of delivery; and based on clinical need, rather than ability to pay. However, recent pressures from government funding have questioned the NHS’s ability to provide world-class care. A combination of rising costs and rising demand spell ‘the most challenging period in its 65-year existence’, according to the NHS Confederation1.
The use of statistics such as NHS pancreatic cancer outcomes by Republicans in the Obamacare debate2 highlight the perspective from across the Atlantic of the NHS as a sub-optimal service: ‘a sort of Russian Roulette with your life in the balance’3. Forbes, the American business magazine, described the NHS back in 2011 as ‘broken — and not in some superficial way that a simple tweak would fi x’, using the example of an innovative Cornish farmer who was forced to use equipment he used to examine his pregnant sheep to monitor his hernia because the NHS could not afford to4. Republican balking aside, it is clear to many that in its current state of funding, the NHS is headed for a financial crash as treatments become more expensive and the proportion of the population with chronic disease is ever increasing. NHS England themselves predict a funding gap of £30 billlion by 20205. So what are the possible solutions? Increasing government spending significantly in a time of austerity? Creating a two-tier healthcare system where your life-threatening conditions are treated but your quality of life is forgotten? Or could it be possible to maintain spending but have the NHS make its own money rather than be simply reliant on government spending?
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“Could the NHS make its own money rather than rely on government spending?” The NHS is the fi fth largest employer in the world, just 200,000 employees smaller than McDonald’s hires worldwide, providing a huge pool of ideas for business ventures where the NHS could generate its own revenue6. Six regional ‘innovation hubs’ have been set up over the past 10 years7 to bring together those specialising in making business ideas a reality and clinicians who think every day about how things could be done better. The ‘hubs’ aim to ‘help its staff translate their bright ideas into practical, commercial propositions for the benefit of patients’8. As well as providing a drive to improve patient care within the NHS, the ten most successful inventions reported by the hubs last year were estimated to have made the NHS a cumulative total of £395 million in profit. The launchers of a moisturising cream from Salisbury Hospital used to treat burns victims to the high street as ‘My Trusty Little Sunflower Cream’ expect to sell 20,000-30,000 bottles. The Liverpool Women’s Hospital baby pillow was the brainchild of neonatal nurse, Ann Parry. She became frustrated at the use of rolled-up bedding to keep neonates in a safe position during nasal positive airway pressure (nCPAP), used as a treatment in respiratory distress syndrome, and created an alternative. The innovation has now been sold to a private company, but makes royalties for the parent NHS Trust as part of this contract. Clearly, ideas rather than a full production line may be all that is required to improve
The Innovation Manager’s Perspective (Chris Sawyer, Innovation Manager at NHS Innovations South East):
“I have been working on healthcare innovations for several years and I am continually inspired by the inventiveness and creativity of NHS staff. I have been fortunate to have worked with many inventors, who experience the problems first-hand, and are able to invent solutions. It is important to recognise that innovation can come in many forms and ideas that may seem obvious or insignificant may be influential in improving the delivery of healthcare. We are proud to say that many of the innovations we have helped bring to market have exploited the latest scientific knowledge linked to cutting-edge technology. But it doesn’t have to be that way. They do say that some of the best ideas are often the simplest. Some of our most successful innovations, both commercially and in terms of their healthcare benefits, are far from high-tech. The contribution from NHS staff should not be underestimated in the development of healthcare solutions and if someone has an idea that addresses an issue, I encourage them to get in touch.” Chris Sawyer Innovation Manager NHS Innovations South East Mobile: +44 (0) 7917 550880 email: csawyer@nisehub.co.uk www.innovationssoutheast.nhs.uk patient care and make a tidy profit. Other inventions whose names could perhaps benefit from a Brand Manager’s input include the Kings Lynn anaesthetists’ needle and the Birmingham bone scraper9. In the Healthcare Innovation Awards 201310, it was revealed that Oxford University Hospitals Trust saved £528,000, directly related to a number of technological innovations it implemented last year. These included the electronic-controlling of the temperature of blood fridges and using hand-held computers at the bedside for transfusions. This has halved the number of nurses required to set up a transfusion, freeing them to focus on other aspects
“The best ideas are often the simplest” simplest” 47
Innovation Managers at NHS Innovations South East chose six projects to receive immediate funding for development
of patient care. These examples suggest that innovations can be driven by all employees and can improve both patient care and the financial prognosis of the Trusts that they are conceived in.
The Biomedical Engineer’s Perspective – working with the doctors on innovation projects (Giovanni Milandri, ex-University of Oxford and now Project Manager for Medical Device Innovation Platform at the MRC, Cape Town):
“As a manager of medical innovation projects between clinicians, engineers and business, I’m convinced that frugal innovation in healthcare has an important role to play in the future of cost-effective medicine. However, I’ve seen that the diverse cultures and values of these professionals can threaten even the most promising of projects. Coordinating the strengths of these diverse parties requires a patient team that is willing to share leadership through the phases of product development. A balanced and goal-driven approach is crucial to reap the enormous potential benefits. So what is the first step, and where do are these ideas originate? Researchers in academia develop great technological innovations, but these are often so futuristic that they take time to make a practical impact. In-house innovations, however, are highly practical, and generally recombine proven existing technologies to address pressing everyday needs. Thus there is a need of the organisation to recognise the innovative ideas of its own employees. As a case in point, consider regulatory approval of health innovations. Who better to tackle the prime questions of safety and clinical efficacy than the clinicians who have first-hand knowledge of the clinical environment? A prime example is the principle of Continuous Improvement, or Kaizen in Japan, which transformed the automotive industry in the 1980’s. This used the principle of fuelling innovation with ideas from the factory floor, rewarding employees for improvements on the line. Over time this was a key policy which resulted in industryleading levels of Quality Assurance, efficiency and customer service. In terms of the business model, outside medical device companies often overlook the potential of lower profit margin, specialised products in the search for the next blockbuster device, or protecting their existing product line. This can lead to products which do not optimally suit the needs of the changing healthcare environment.” 48
The 2023 Challenge this year11 marked another first in this emerging environment of innovation in Oxford. £100,000 was awarded to develop project ideas put forward by junior doctors and medical students, which attracted submissions encompassing all areas of medicine. Six projects were chosen to receive immediate funding, and many more of the 57 projects submitted have benefitted from the support of Innovation Managers at NHS Innovations South East to help make them a reality. So the next time you find yourself thinking about how silly, inefficiently, or ridiculously something is done, perhaps it’s time to get thinking, play your part, and call the Innovation Manager. There is an intention to run a second 2023 Challenge later in the year in 2014. If you are interested in taking up the Challenge, further details will be available at :
http://www.tvwleadershipacademy. nhs.uk/2023-innovation-challenge
or follow on Twitter @2023Challenge.
Full references available at: www.omsg-online.com
Samuel Folkard is a sixth year medical student at Christ Church College
The SJT:
a step in the right direction or an unfair randomiser? Guy Stephens considers the Situational Judgement Test and its place in allocating jobs in the Foundation Programme
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he process of allocating final year medical students to foundation posts has always been contentious. With many of the London and other southern deaneries consistently being over-subscribed, there is a real need to effectively discriminate between candidates to ensure fairness and transparency.
Box 1 The target attribute domains measured by the FP SJT: Commitment to professionalism Coping with pressure Effective communication Patient focus Working effectively as part of a team Problem solving and decision making, and organisation and planning don’t feature as specific domains, as they are thought to be implicit to taking the SJT itself 2.
The system of allocation has recently been overhauled, and one’s performance in the Situational Judgement Test (SJT), a new ranking modality for final year medical students, is now the greatest contributor to deciding which of their preferred deaneries a student will be placed in. With such a large emphasis placed on the SJT- considerably more so than a student’s academic performance at medical school (see below)- it is vital that all medical students understand what the SJT is designed to test, and how they can best prepare for it. In general terms, an SJT is designed to assess individuals’ judgement regarding situations in the work place. Commonly used for short-listing large numbers of candidates to the latter stages of job applications, it defines a threshold level of attainment. SJTs are created after extensive analysis of the job role, along with inputs from subject matter experts (SMEs). They are designed to test general experience and ability rather than job-specific knowledge, which is particularly useful when candidates have
limited experience of the target job, as is the case with Foundation Programme (FP) applicants. SJTs have previously been used successfully in situations such as British Army Officer recruitment during the Second World War, and currently they are widely used in the Police Force. In the medical setting, an SJT has been used since 2007 as part of the selection for GP specialist training posts1. It is appropriate that candidates’ judgement should be assessed in such a process, as non-cognitive professional attributes are arguably as important for doctors as their medical knowledge.
What is the FP SJT designed to test?
Students’ aptitude for the FP is assessed with respect to their attitudes, ethical values and likely professional behaviours, without any attempt to test candidates’ clinical knowledge. In order to identify the desired attributes of an FY1 doctor, extensive FY1 job analysis was undertaken, consisting of interviews and observation of those currently in the posts, along with literature reviews 49
Box 2 SJT Preparation Advice Beforehand Familiarise yourself with the material used to develop the SJT: the results of ISFP’s job analysis2, the FP Person Specification10, and the GMC’s Good Medical Practice11. Spend time on the wards with Foundation doctors to learn how they approach scenarios. Do the practice questions on the UK Foundation Programme Office website, and read the rationales behind the correct answers12. Be wary about paying independent companies. The information they give may not be factually correct, and their practice questions not representative of the actual ones. During the test Answer solely based on values and professionalism; the questions do not require clinical knowledge. Similarly, do not make assumptions, but use only the information provided.
on the subject. From the professional attributes identified, five “target attribute domains” were defined (see Box 1)2. The questions are therefore written to specifically test one or more of these target attribute domains, either taking the form of multiple choice questions, or requiring answers to be ranked in descending order of best practice.
applying from non-UK medical schools), hence this overall score is also the basis for determining which students will not be placed on the primary list. In 2013, from 8206 completed applications, 7242 students were given posts on the primary list.
Whilst the means by which the SJT has been employed in FP allocation are generally very similar to how more influential in SJTs have been used successfully How is the SJT used in elsewhere (ie. following extensive differentiating a FY1 job analysis), the way in FP allocation? student’s overall score which the SJT scores are used here In the process of FP allocation, the presents an important difference. SJT is used in conjunction with an than the EPM” EPM” Typically, SJTs are used to Education Performance Measure short-list candidates to subsequent (EPM), a score generated mostly stages of an application process; from a student’s decile ranking once above a certain threshold, the within their own medical school, with extra SJT scores are not used to differentiate candidates points available for any degrees and publications any further. In the FP allocation however, the the student already has3. Both are scored out of SJT scores are used to differentiate candidates at a maximum of 50 points, but in reality they are all score levels. Currently there is very little data unequally weighted – as the range of SJT scores to suggest whether SJTs are fit for this purpose. spans 0–50, yet the minimum possible mark in the EPM is 34. Furthermore, whereas the EPM can solely be integer values, the SJT is scored to Why was the FP SJT introduced? two decimal places. Such discrepancies mean In 2008, the Department of Health produced that the SJT is far more influential in differen- a report that raised several concerns about the tiating a student’s overall score than the EPM. method of FP allocation at the time4. Previously, aptitude had been assessed by “white space” short Candidates are ranked nationally on the basis answer and mini essay-style questions. These of their overall score out of 100 to determine the were not taken under invigilated conditions, and order in which they will be allocated their preferred were time-consuming and subjective for both deanery (termed Unit of Application, or UoA). In applicant and marker. Furthermore, academic recent years, the FP as a whole has been over-sub- performance was assessed solely by a quartile scribed (in part as a result of more candidates mark from within the medical school, which made
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it difficult to differentiate applicants accurately. On the basis of this report, the Improving Selection to the Foundation Programme group (ISFP) recommended that an SJT be piloted with an EPM, as these were judged to have the highest accuracy and lowest cost versus all other allocation options5. Following various piloting stages, and a final test run alongside the standard application procedure in 2012, the SJT and EPM were finally introduced for the 2013 FP1.
Is the SJT successful in allocating applicants to Foundation Schools?
Importantly, at the same time that the SJT was introduced, the algorithm used to match the ranked list of applicants to the Foundation Schools was also changed. Previously, the algorithm worked to maximise the number of applicants getting their first choice School. Whilst this method meant that 90% of applicants were indeed matched to their first choice, the remaining 10% were allocated to schools as low as their 19th preference.
some shared variance between the assessment methods. However, some variance between the two measures persisted, suggesting the SJT is assessing somewhat different aspects to those of the EPM. To really judge the success of the SJT, it will be necessary to establish how those who have taken the test perform in their future jobs as junior doctors. Data on this is not yet available, although studies looking at the predictive validity of the SJT have been commenced. Furthermore, in the other medical setting of GP specialist training selection, SJTs have been shown to be a good predictor of future job performance7.
How have Oxford students performed in the SJT so far?
In both the 2013 and 2014 applications, all Oxford students were given a place on the primary allocation list; the only medical school to have achieved this. Of these students, over 90% received a place at one of their top five Foundation Schools.
“Now, more applicants receive one of their top five preferences”” preferences
In the new system however, each applicant is considered in turn depending on their overall national ranking, and allocated to their most preferred school that still has places available. In this way, more receive one of their top five preferences, and the possibility of strategic preference selection is eliminated1.
This change in matching algorithm is relevant because many of the reports considering FP selection measure the success of the new system by detailing the proportion of applicants that are placed in one of their top preference schools. However, this doesn’t assess the success of the SJT; what really needs to be asked is, “is the nationally ranked order of applicants correct?” Psychometric analysis performed on the first set of SJT results (those of the 2013 cohort) demonstrated that the SJT is indeed able to sufficiently differentiate between applicants6. It also showed significant correlations between SJT scores and both EPM decile and total EPM scores, suggesting
Oxford had the highest mean overall scores in both the 2013 and 2014 applications (85.4/100 and 83.08/100), and also had the highest mean scores for the SJT when considered on their own (43.02 and 41.03 for 2013 and 2014, respectively). In the two preceding years when the old system was in use, Oxford had the still-very-respectable fi fth and seventh best mean scores8,9. Oxford’s rise to the very top may indeed be due to the change in ranking process; the new EPM rewards students for having extra degrees and publications, which quite clearly favours students at an institution with a built-in Final Honours School. However, Oxford has also ranked at the top of the mean SJT scores. This may indicate that the course at Oxford is succeeding in providing its students with the skills necessary to perform well on the SJT. Alternatively, it could just be a testament to the achievements of the classes of 2013 and 2014 as particularly strong years. Either way, so far Oxford students seem to have got something right in adapting to this new method of Foundation Programme allocation; I hope the next few generations will fare equally well. Full references available at: www.omsg-online.com
Guy Stephens is a fourth year medical student at Brasenose College
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“Are the best doctors those with meticulous academic knowledge...”
“...or those with perfect demeanour and flawless patient manner?” 52
How Can We Judge Who Will Make The Best Doctor? Elliott Carande considers the different attributes assessed in junior doctors
I
n the competitive world of foundation programme (FP) applications, the current judgement of final year medical students is a necessary evil; one which may fail to accurately distinguish the best doctors. In simplified terms, the best doctors will never be the physicians who are only able to locate, and name, each of the mysterious vascular arcades of the large bowel. The clinicians with perfect demeanour and attitude towards patients and colleagues, but lack knowledge, will also fall short of this accolade. The best doctors are those that combine meticulous academic knowledge with flawless patient manner.
the non-academic aspects of doctors’ performances is also essential. Doctor complaints have risen 104% from 2007 to 20121, an alarming figure that the General Medical Council (GMC) ascertains may be due to worse standards of medical care, but maybe also “higher expectations from patients, better clinical governance systems and greater willingness to raise concerns”. These complaints – which may come from patients, doctors, the GMC or the police – show that 30% of total complaints stem from “clinical care”, whilst only 7% are due to “communication with parents”. However, complaints concerning “clinical care and communication” make up 24%. “Exam results do not This emphasises the importance of necessarily give us the full both elements of this discussion2.
So, how do we create an application process where both ends of the spectrum are judged? The concept of how to judge the best doctor picture of how doctors will will always be difficult, since Although it is extremely important interact with colleagues, views always clash concerning the that future doctors have the importance of particular traits patients and their families” necessary medical knowledge in the future clinician. In that for their job, exam results do not respect there will never be a perfect necessarily give us the full picture method of differentiation between of how doctors will interact with prospective candidates, and we must make do with colleagues, patients, their families, and indeed people logical systems to choose promising doctors. Academic in general. Clinical exams (OSCEs) are able to performance is certainly an integral component of assess a student’s patient interaction, but these scores a doctor’s attributes, and doctors should have the are combined with theoretical exams to produce necessary rigorous academic background for their job. a decile ranking. Therefore, we are unsure which As such, it is only right that academic results are used components have contributed to their score, albeit as a means of differentiating between aspiring medics. the student with the best patient skills will score more points, which should contribute to a higher Personal skills can be of similar importance, since – ranking! Potentially, exams relying on personal skills for example – a clinician with good bedside manner could be separated from the decile ranking, and will be more likely to clinch the diagnosis from this score could serve as a good marker for doctors’ patients who are willing to disclose vital information. attitudes. If necessary, a weighting could also be These skills will help to provide patients with the best applied to this ranking to alter the importance experience of their healthcare, and therefore assessing of this aspect of the student’s performance. 53
Moreover, medicine has become – as much as anything else – an extremely popular career, which is now seemingly groaning under the weight of excess demand applied to a product of fi xed supply. University entrance requirements, already high at my time of application, have increased by another grade for most institutions, reflecting the necessity for medical students to show academic aptitude and determination, but also showing the need to differentiate between cohorts of highly capable candidates. It seems correct that students with higher decile rankings are desirable for FP positions, but there is reason to state that this is also a symptom of over-subscription to the programme in the first place. The academic component of the application includes extra points for publications and intercalated/other degree performance. These markers are very much related to the scientific aspect of the medical world, and certainly demonstrate further hard work, determination, and enthusiasm in medicine. However, students involved in activities such as sports teams, student unions, or who have musical interests have nothing to add to their application form at this stage, yet when asked at interview to medical school, “so what can you offer the university?” these activities would have formed the basis for the majority of candidates’ answers. On the FP website, the reason given for not including non-academic activities on application is that “these attributes are assessed through [the] answers to the SJT, and it would be difficult to determine a reliable and valid measure of the impact and benefits of non-academic activities which does not double count the attributes already assessed on the application”3. Although sensible, as the Situational Judgement Test (SJT) and OSCE results perform a
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judgement of doctor’s non-academic strengths, other parts of the existing application procedure must also fall prey to “double count[ing]” with this logic. A medical student who has already completed a PhD will be much more likely to have publications, as well as having presented at conferences, since these go hand in hand with this line of work. Similarly, medical students who obtain three extra points on the Education Performance Measure (EPM) by achieving a 2.i on an intercalated degree course are also more likely to have participated in publications as part of their intercalation, further improving their EPM score. Strangely, interviews are not used for application to the FP, the only stage of a medical career where this is the case. This will potentially miss the opportunity to gauge important aspects of future doctors’ personal skills. Interviews however, do not produce a standardized method of selection, a criterion that the FP, correctly, strives for in its application process. They also utilise a hugely labour-intensive method of application, which would be time-consuming and expensive. The conclusion of the interviewer will also be highly subjective, and affected by where they believe a doctor should lie on the ‘spectrum’ we have previously considered. On a final note, the best doctors should “keep their knowledge and skills up to date… and maintain good relationships with patients and colleagues”4. However, there is a worry that the balance between these two requirements is not being met by our current method of judgement of applicants to the FP. Although arguably changes should be made to give more weighting to the ‘non-academic’ aspect of doctors’ skills, not all readers will agree, and would suggest that the system in place works just fine, thank you very much.
“Interviews are not used for application to the FP - this will potentially miss the opportunity to gauge important aspects of future doctors’ personal skills”
Full references available at: www.omsg-online.com
Elliott Carande is a fourth year medical student at Pembroke College
The Growing Use of Non-Medical Practitioners in the NHS Apurv Sehgal discusses how the NHS is increasingly handing over responsbility from doctors to non-medically trained professionals
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here is a staffing crisis in the NHS. The introduction of the European Working Time Directive, dwindling numbers of medical trainees, and problems with recruitment are amongst the main issues that have resulted in an estimated dearth of 20,000 doctors and nurses1. To fi ll this void, the NHS has been forced to ‘modernize’. One approach has been to encourage the rise of the non-medical practitioners; individuals drawn from the existing pool of nurses and other healthcare professionals, who train to assume responsibilities hitherto performed by doctors.
Hierarchical and nomenclature changes within the NHS are by no means new, and have kept the health service in a state of flux since its birth in 1948. However, this recent introduction of non-medical practitioners may have implications; not only for the future of the NHS and for the training of medical professionals, but crucially on patient outcomes. It is therefore of paramount importance to assess the impact of increasing non-medical practitioners on our healthcare service. The use of non-medical practitioners can be traced as far back as the 17th century. The Soviet Feldshers were ‘Physician Assistants’ who provided low-cost healthcare to the peasant
population of the USSR2. In the United States, non-medical ‘Physician Assistants’ are well established3, having served as part of the US healthcare model since the 1960s – and they now number over 90,0004. Here in the NHS, the introduction of this new brand of healthcare professionals was controversially
“The training of nonmedical practitioners requires less financial support”” support piloted in 1989.Individuals known as ‘Surgical Care Practitioners’ (SCPs) were appointed to harvest
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the long saphenous vein for coronary artery bypass graft surgery5. Today, SCPs and other non-medical practitioners are increasing in popularity and extend across most specialities. There are a number of reasons for the employment of non-medical practitioners. Through further training of nurses and other healthcare professionals, it provides a way to make up the shortage of doctors from people already working in the UK. Improved self-sufficiency within the healthcare system also serves to circumvent the recruitment of foreign medical professionals – a subject where issues such as immigration, competency and human capital fl ight remain contentious. In addition, it may also be more economical and efficient to train non-medical individuals for very specific, specialty-based jobs. Not only does such training require less financial support, but by forming consistent members of the specialty team, non-medical practitioners could also have an edge over their junior doctor colleagues, who may only be contracted for a few months at a time2,5. Both patient services and medical training could benefit from the
incorporation of non-medical practitioners into the NHS. Arguably, it may serve to reduce waiting times, improve efficiency and even enhance the standard of care. Doctors could also gain from this remodeled system; junior trainees are freed from less advanced tasks, allowing them to concentrate on and develop their expertise under the guidance of the consultant. Finally, this scheme could provide options for a wider range of healthcare workers to further their careers, assume more responsibility and be rewarded with remuneration. This may have the added benefits of building up morale within the NHS workforce, which is most certainly important in the current climate… However, there remain concerns with a model of healthcare where low and mid-level duties are affirmed to non-medical professionals. Of these concerns, perhaps the most worrying is the cut in nursing staff – where the shortage is even worse1. Moreover, inter-professional confl icts may increase with the creation of overlapping roles; expanding roles for non-medical practitioners is likely to leave
doctors with a loss of autonomy and direction7. Above all else is the question of competency – are non-medical practitioners able to uphold the standard of care for patients? In a 4-year audit conducted at St. Mary’s Hospital, London, data was collected on all patients managed by SCPs between 2001 and 2005. The results were positive, citing that SCPs reduced waiting times, were acceptable to patients and provided feasible and safe minor surgery. Nevertheless, this study is so far the only one of its kind, and so further evidence is required8. The NHS is at a crucial crossroads; faced with increasing demands, deficiency in support and mounting scrutiny, our healthcare service must somehow try and adapt. Attractive largely due to their cost-effective appeal, it seems that non-medical practitioners can provide the ideal ‘quick-fi x’ solution to the NHS staffing crisis. Questions as to their widespread utilization still remain, particularly as evaluation of the impact on patient care and outcomes is scarce. Notwithstanding, although such concerns remain valid, it is difficult to ignore the value of these staff to a clearly encumbered organization.
““Can Can NMPs provide a ‘quick-fix’ solution to the NHS’s staffing crisis?
Full references available at: www.omsg-online.com
Apurv Sehgal is a fourth year medical student at Lincoln College
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Ketamine: the Perfect Anaesthetic or a Dangerous Recreational Drug? Steffan Glaze and Alissa Gutnikova debate the pros and cons of ketamine anaesthesia
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etamine is soon to be reclassified as a Class B drug, so you might be surprised to hear that its first incarnation was as an anaesthetic. Dr Hilary Edgcombe, a consultant anaesthetist at the Oxford Radcliffe Hospitals NHS Trust, reflects with us on her experiences of administering the drug in its anaesthetic capacity; the first time being whilst abroad as a final year student on elective.
When she isn’t supporting oculoplastic or transplant surgery here in Oxford, Dr Edgcombe uses her leave to work in the developing world. This is where she has learnt a great deal about a very different style of anaesthetic practice, based on ketamine. It is a versatile drug – the only anaesthetic agent that has analgesic, hypnotic and amnesic properties, and generates a state of ‘dissociative’ anaesthesia1,2. Patients “experience a sensation of detachment from their bodies, can open their eyes, make reflex movements and even sing”, describes Dr Edgcombe; individuals will exhibit catalepsy, catatonia and amnesia but not necessarily complete unconsciousness. Most importantly, ketamine stimulates the cardiovascular and respiratory systems (whereas almost all other anaesthetic agents depress them). Consequently, patients anaesthetised with ketamine do not necessarily require ventilatory support. First developed as a PCP derivative in 1962, ketamine showed promise in initial investigations due to a shorter duration of action and fewer psychotomimetic
effects than its parent compound3. In 1970, the U.S. Food and Drug Administration gave approval for the drug’s use and it was routinely administered in the Vietnam War. Within a few years, however, it was being used as a recreational drug on the west coast of the USA – something many would first associate the drug with, rather than its medical applications. Ketamine is a non-competitive NMDA receptor antagonist, and this is the proposed mechanism by which it gives rise to anaesthesia4. However, it also interacts with a wide range of other receptors; modulating both cholinergic neurotransmission as well as the noradrenergic and serotonergic pathways implicated in pain mechanisms, thus providing analgesia in sub-anaesthetic doses5. It can be given in a variety of preparations, including intravenous and intramuscular. The latter renders it particularly useful in situations where gaining venous access is difficult; such as pre-hospital, emergency and paediatric settings. “When a child is agitated, or it is difficult to maintain an airway when someone is stuck in the wreck of a car, ketamine can be very effective in achieving some sedation or analgesia” explains Dr Edgcombe. In the UK, despite its apparently clear benefits over the cardiorespiratory-depressing anaesthetics normally in use, ketamine is seldom the intraoperative agent of choice. “Unlike low-resource settings, here we have a lot of tools and options. I know that my
“Ketamine is the only anaesthetic agent that has analgesic, hypnotic and amnesic properties” 57
“Ketamine is valuable in circumstances where resources, equipment and personnel are limited” patient will be able to have a safe recovery post-operatively, as we have the infrastructure to support the use of other agents that do have dramatic effects on circulation and respiration.” In her work overseas, ketamine is far more commonplace, but our understanding of the effects of this drug is still limited. When asked why many anaesthetists are reluctant to use ketamine here in the UK, Dr Edgcombe clarifies that the key issue surrounds its psychological effects on patients, which we shall discuss later. As to why current scientific understanding of ketamine is limited, a common issue in medical research recurs – “the drug is not used frequently enough in the West to encourage its study”. Accordingly, we must ask ourselves about the relative benefits and risks of ketamine in anaesthesia. Increasing and studying its application here in the UK could surely benefit those for whom other anaesthetics are not available. What factors do we need to consider?
The Positives
Ketamine is a bronchostimulant and preserves the laryngeal and pharyngeal reflexes, so poses a much lower risk to the airway than other anaesthetic agents1,2. In fact, most patients receiving ketamine at anaesthetic doses do not need invasive ventilation or even supplementary oxygen. Hence, ketamine is a valuable agent in circumstances where resources, equipment and personnel are limited; expensive anaesthetic machines are not essential, and it puts less strain upon the already restricted numbers of nursing staff available to care for patients post-operatively.
In a similar way, both the respiratory drive to breathe and systemic arterial blood pressure are preserved in ketamine anaesthesia1,6 which makes the drug extremely useful for emergency medicine. Individual responses vary and there may often be a large increase in blood pressure1 – helpful for a patient in septic shock. Combining these features with the fact that intravenous access is not necessary, it is clear that ketamine shows great promise for more widespread use in pre-hospital care: providing dissociative anaesthesia and analgesia to help the patient psychologically, whilst maintaining airway and circulation. Post-operatively, ketamine has been shown to reduce the dosage of opioid analgesia required by 25-50%5. It is also being increasingly recognised as a beneficial agent in the management of patients with chronic pain who are opioid-dependent, where “burst” doses of ketamine can successfully alleviate developing acute pain5. Ketamine is also effective in paediatric medicine. The capacity for oral administration makes it more tolerable for children requiring anaesthesia, and it is thus often used in short-lasting procedures1 such as burns dressings. In addition, hallucinations following ketamine anaesthesia are for some reason less common in children2, decreasing the primary risk commonly associated with using the drug in adults. Although ketamine itself is an ageing drug, recent developments in manufacturing techniques have enabled the production of a single enantiomer
Dr Edgcombe giving ketamine as an anaesthetic in Zambia. Note that the airway is still supported.
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preparation. Due to the chiral nature of the compound, ketamine typically contains a mix of the S and R versions, with an identical structure but two different arrangements The S enantiomer is more active, with pure solutions requiring a third of the dose for anaesthesia when compared with the original mix of both versions. This can potentially also decrease the psychological side effects.
The Negatives
Intra-operative use of ketamine is not without its problems. Producing no muscular relaxation, ketamine in fact causes an increase in skeletal muscle tone instead. As giving a muscle relaxant would negate the advantage of having maintained the respiration through use of ketamine, the surgeon must therefore be accustomed to operating with tone1,2. Dr Edgcombe remarks that whilst this is less often an issue when working with surgeons who have experience of such operating conditions, a UK-trained surgeon might have great difficulty attempting a procedure in this context. Another side-effect of note is that ketamine generates an increase in salivary and bronchial secretions1,6. This may lead to difficulties in airway management due to laryngeal spasm or obstruction, but these may be prevented by administering atropine1.
However the major concern for using ketamine, that limits its indication and causes the most worry, is the high risk of unpredictable psychological side effects. Conversely, such effects constitute the desired drug response amongst recreational users. They include hallucinations, euphoria, delirium, blurred vision, and patients can even experience disturbing flashbacks to life events on emergence from anaesthesia. Dr Edgcombe notes that research in this area is clouded: “We must consider that pre-hospital and military settings (the main settings in which ketamine can be studied in the UK) are, by their nature, traumatic experiences for patients. Therefore, the fact that patients develop anxiety and post-traumatic stress disorder may be in correlation to the events themselves, and not the drugs used”. Nonetheless, past traumatic experiences, such as work as a child soldier, are a significant contraindication for ketamine use in her work in elective surgery abroad. It is possible to counteract this occurrence by pre-medication with benzodiazepines1. Unfortunately, this requires great care outside of a hospital setting, when one of the prime uses of ketamine is in emergencies. Although there are potential long-term uses, case reports detail some significant side effects from chronic administration
of ketamine. These are not easy to study, given that the majority of these cases happen in recreational users there is considerable difficulty in ascertaining the exact frequency and concentrations of exposure. Neurological deficits such as depression and impaired memory have been reported7 and a recent literature review confirmed the increased risk of urinary tract toxicity in chronic users8.
Conclusion
As with many issues in anaesthetic practice, it is obvious that ketamine anaesthesia suffers from confl icting evidence and varying personal experiences of the effectiveness of its administration. Anaesthetists are often required to use their own judgement and expertise to guide prescriptions, but the question remains as to whether we will see more widespread use of ketamine in the future. And, perhaps more significantly, whether the UK could support great leaps in healthcare practice in low-resource settings by facilitating much-needed high quality research.
The authors would like to thank Dr Hilary Edgcombe for her support and advice throughout the writing of this article.
Full references available at: www.omsg-online.com
Steffan Glaze and Alissa Gutnikova are fourth year medical students at Green Templeton College and St Peter’s College
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Calling the Shots Ruth Mitchell discusses the difficult decisions underlying UK vaccine policy
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system. It is also argued that wider economic and he introduction of a new vaccine into national social impacts of a disease, such as reduced school or immunisation schedules has the potential to work performance and social exclusion faced by the dramatically reduce rates of an infectious disease, but ill and their carers, should be considered in analysis2. not every newly licensed vaccine is guaranteed a place. As vaccines become more sophisticated and licensing requirements stricter, “Vaccine safety is The JCVI assess data from immunisation becomes more and unpublished clinical essential if a vaccine is published expensive, so economic factors trials in order to predict vaccine feature heavily alongside scientific to be distributed across a effectiveness. Some vaccines evidence in the decision-makare licensed on the basis of large population” population” ing process. The body responsible large-scale efficacy trials where for making recommendations on immunisation has successfully vaccine implementation in the prevented or attenuated disease UK is the Joint Committee on in the vaccinated population. Vaccination and Immunisation ( JCVI). When a Others are licensed purely on the basis of the vaccine is licensed for use in Europe, the JCVI reviews immune response they generate (immunogenicity), evidence including disease epidemiology, clinical trial making their effectiveness harder to predict. data and cost-effectiveness analysis in order to judge the impact the new vaccine will have on UK health. Examples of vaccines licensed on the basis of
Efficacy and safety
Disease burden
Counting deaths versus cases is one way to calculate disease burden. For example, in 2000, there were an estimated 9531 cases and 75 deaths from pneumococcal disease in the UK1. However for other diseases this quantification may not be useful, because mortality is low or entire disease burden is unknown. Rotavirus, for instance, is rarely a direct cause of death, and the number of cases can be difficult to establish due to the similarity in symptoms to other causes of gastroenteritis. Because laboratory diagnosis does not alter management, it is often not carried out. GP consultations and hospital admissions attributable to a particular disease are another helpful quantification of the burden on the healthcare
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immunogenicity are the 13-valent pneumococcal conjugate vaccine, (PCV-13; box 1) and the meningitis B vaccine (4CMenB; box 2). Both vaccines induce robust antibody responses, which kill the target bacterium in vitro. Vaccines may be licensed in this way if efficacy trials are not feasible, or if the vaccine is replacing a similar vaccine with wellestablished immunological correlates of protection. Another consideration is vaccine safety, which is essential if a vaccine is to be distributed across a large population. Occasionally rare side effects may only become apparent postimplementation, such as the link between the 2009 influenza vaccine (Pandemrix®) and narcolepsy3, highlighting the importance of continued
post-introduction
surveillance.
““Economic Economic factors feature heavily alongside scientific evidence in the decisionmaking process” process” Pnemococcal vaccination
PCV-13 replaced PCV-7 in 20107, on the basis that it covered more pneumococcal serotypes, and produced non-inferior immune responses to PCV-7. Although its efficacy was unknown at introduction, recent epidemiological data suggest it successfully prevents disease8. In adults, PPV-23 (23 serotypes), offers short-term protection against meningitis and septicaemia9, but no reduction in pneumonia or mortality. It is recommended due to its broad coverage and low cost10 but may be replaced in the future by PCV13, which has been recently shown to prevent pneumonia and septicaemia in older adults11. Box 1
The meningitis B vaccine (4CMenB) Last year, the JCVI decided not to recommend the highly-anticipated 4CMenB because it would not be cost effective13. This unpopular decision was reviewed recently, and the JCVI has now recommended that the vaccine be offered to all UK children at 2, 4 and 12 months of age, assuming it is provided by Novartis at a cost-effective price14,15. Box 2
Universal hepatitis B vaccination? Because vaccine coverage is currently so poor6, the JCVI is considering adding hepatitis B to the existing pentavalent toddler vaccine. Trials are underway to ensure its addition does not compromise protection provided by the existing 5 vaccine components12.
Cost-effectiveness
Like any drug, a vaccine must compete for its share of the UK healthcare budget. Vaccines can be an excellent investment, with immunisation far cheaper than treating the disease. Cost-effectiveness can be judged by looking at factors such as the price of the vaccine, disease burden, and the vaccine schedule (including catch-up campaigns). It can be quantified in terms of cost per quality adjusted life year (QALY), with the upper limit for an intervention to be considered cost-effective in the UK set at £20-30,000 per QALY4.
The impact and cost per QALY offered by vaccination depends on both the direct protection of those receiving the vaccine and the herd immunity provided to unvaccinated individuals. For example, PCV-7 (box 1) provides herd immunity by preventing nasopharyngeal carriage of pneumococci, thereby reducing transmission to the unvaccinated population. During the time PCV-7 was in use, more cases of pneumococcal disease were prevented by herd immunity than through the direct protection of immunisation, greatly increasing the value for money5. Cost-effectiveness can also be improved if the vaccine provides cross-protection against other disease strains.
““Immunisation Immunisation can be far cheaper than treating the disease” disease”
If, after all these factors have been considered, universal vaccination is judged not to be costeffective, immunisation may still be offered to high-risk groups, such as those at increased risk of exposure or the immunocompromised. Despite this targeted approach, coverage of high-risk groups can be poor, making the case for universal implementation of vaccines such as hepatitis B6 (box 3).
Full references available at: www.omsg-online.com
Before a new vaccine can be introduced, its efficacy must be considered alongside epidemiological and economic factors, sometimes leading to surprising and controversial decisions. The assessment process does not stop after a vaccine has been successfully introduced (or rejected); vaccination regimens are constantly under surveillance and continue to be perfected to reflect new evidence and changing epidemiology.
Ruth Mitchell is a fourth year medical student at Merton College
The author would like to thank Dr Johannes Trück for his suggestions in the preparation of this article.
Box 3
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PKU:
A History of Misjudgements Howell Fu tells the tale behind the test for this debilitating disease
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T
he treatment of phenylketonuria (PKU) is considered a major success story in the history of modern medicine. Affected babies are identified at birth by a cheap universal screening program they are subsequently placed on a low phenylalanine (Phe) diet that allows them to grow up with no developmental delay and to lead normal lives. The journey to this point, however, has been peppered with some rather misguided decisions.
In 1961, Dr Robert Guthrie developed the blood-spot PKU test for screening babies at birth. This was a massive leap forward from the old ferric chloride test, which was only reliable at 8 weeks - crucially, after brain damage had already begun to occur1. The new test presented an opportunity to prevent mental disability altogether, through giving the baby a low-Phe milk formula from the very first week of life.
“Screening babies at birth meant an opportunity to prevent mental disability from PKU altogether”
Guthrie had a very much personal stake in the matter, as his niece had been severely affected by PKU, and left with a permanent mental disability2. Having developed a test that could save other children from her fate, he was powerfully driven to share it with the world. He consulted with Dr Elizabeth Boggs, president of the NARC (National Association for Retarded Children), which had partly funded his research. They knew that the normal process of scientific publication, trials and reviews would be cumbersome,
and so decided to take the radical step of approaching legislators and the public directly.
“The Children’s Bureau had adopted the slogan ‘Test Every Child For PKU’ before the first peer-reviewed article on the discovery was published” The impact was swift and effective. The findings were first published in the Journal of the American Medical Association in October 1961, although only as a letter to the editor2. Immediately afterwards, the NARC held a press conference to publicise his test. The following January, Life (a national magazine), ran an article that propelled it into the public eye; the New York Times and other media took up the story, and the Guthrie test was soon the subject of a nationwide debate. Earlier that year, President JF Kennedy had pledged to double federal funding for research into mental disability; when Guthrie’s new blood spot test was announced, the federal Children’s Bureau quickly awarded him a grant for a large-scale, 400,000-baby trial1, 2. The intense publicity around Guthrie’s test propelled policy-makers into an “act first, examine the evidence later” approach. The final (favourable) results of the trial were published in 1963, in the first ever peer-reviewed article on the discovery1. By this time, however, the Children’s Bureau had already adopted the slogan “Test every child for PKU”; Massachusetts, New York, and Rhode Island had introduced mandatory screening; and the federal government had
sponsored a massive advertising campaign to urge other states to do the same1. By the 1970s, screening was universal in the United States. This precipitous pace of events was viewed with alarm by some researchers. Despite public enthusiasm, not enough data had been gathered to know that the test could be truly relied upon. It was not until 1974 that the first large-scale evaluation of its accuracy was published. Guthrie had been adamant that no baby with PKU should be missed, and so made the test extremely sensitive - perhaps too sensitive. Despite the fact that each positive result had to be verified against amino acid chromatography, or a second Guthrie test, some contemporary sources claimed that half of the children on low-Phe diets did not actually have PKU1. Later, the study published in 1974 found that of all initially positive results, 95% were false positives3. At the very least, therefore, many parents had been unnecessarily put through the stress of being recalled for a second test. Furthermore, the need for retesting made the screening program significantly more expensive than the “50 cents per baby” originally envisioned4. Unless the test could be improved, therefore, it was doubtful whether the cost-benefit ratio favoured screening at all.
“A study published in 1974 later found that of all initially positive results, 95% were false positives”
A further issue was uncertainty over how long the unpalatable and expensive low-Phe diet (which 63
replaced natural protein sources with a powdered formulation) should be maintained. Even as more and more states made Guthrie screening mandatory, there was no scientific consensus on what to do with those test results. Quite simply, not enough data had yet been gathered. Magazines and health care brochures of the 1960s informed parents that affected children could eat normal food after the age of 5, when the brain had “finished developing”1. Unsurprisingly, these children subsequently suffered developmental delay. After these cases were reported, consensus settled on age 18, and children maintained on the regime developed normally throughout adolescence. In the 1980s, however, another hidden consequence of the screening program emerged - when they began to reach adulthood and have children of their own. The pregnant women with PKU were consuming food containing phenylalanine, which they could not metabolise themselves. As a result, Phe accumulated in their blood in massive concentrations.
Whilst it caused little harm to the adult women, it was a severe teratogen to their developing foetuses. Even though most of these foetuses were genotypically non-PKU sufferers (the disorder is recessively inherited), exposure to high levels of phenylalanine in their mothers’ blood led them to be born with microcephaly, developmental delay, growth retardation and congenital heart defects. Prior to the 1960s, this maternal PKU was almost unheard of: largely because PKU sufferers almost never had children. In the ‘80s, however, many more female sufferers were giving birth, after having themselves been tested and treated successfully. Tragically, their genotypically normal children were being born with greater disabilities than the original PKU sufferers. This possibility had in fact been considered by Guthrie and by other scientists in a 1967, but in the confusion of the time, no precautionary measures had been taken1,5. Again, a mixture of public enthusiasm and researcher uncertainty had resulted in a dangerous “let’s worry about
The blood spot (heel prick) test helps to identify a range of health conditions, including PKU
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the
details
later”
attitude.
Happily, all of these issues have since been addressed. Accurate and cheap tandem mass spectroscopy testing is universal in the UK and US; sufferers stay on the diet for life, or at least resume it before trying for pregnancy. Screening is universally accepted; failure to test for and diagnose PKU is recognised as clinical negligence, for which multimillion-pound damages have been awarded in certain cases. Although PKU is now a medical success story, its past has undeniably been marred by the consequences of incaution and haste. The excitement of a new discovery may overwhelm populations and governments; a healthy dose of scepticism is the only way to avoid being swept along.
Full references available at: www.omsg-online.com
Howell Fu is a first year medical student at Exeter College
Contraception: Are You Really Being Judged? Liz Platt explores how attitudes towards family planning vary around the world
1961
saw the UK introduction of one of decision, claiming that increased access may reduce the most important drugs known to adolescent pregnancies, as the process of getting a women: the oral contraceptive pill (OCP)1. A myriad prescription may deter younger girls from obtaining of options soon followed, including the intrauterine urgent contraception5 for fear of judgement. device (IUD), the implant, and the injection; manipulating female sex hormones and the physical In 2012, the most popular barriers faced by young nature of the womb in order to prevent pregnancy. people seeking all forms of contraception were All aspects of contraception require some form of fear of relatives finding out, and embarrassment judgement, whether it is an individual choosing in front of a health professional. 29% of British what kind will best suit, or a health professional and 42% of Asian-Pacific World Contraception deciding what type to recommend. However, certain survey respondents stated these as issues that areas may be clouded by a degree of negativity, had lead to unprotected sex6. These attitudes are particularly that of emergency contraception. This supported by a study analysing patient behaviour includes levonorgestrel, ellaOne, when levonorgestrel became the combined ‘Yupze’ method, available over-the-counter in 2 and the copper IUD. Knowledge “Levonorgestrel, ellaOne, the UK, in which there was a of the differing attitudes towards large shift towards pharmacy the combined ‘Yupze’ emergency contraception across purchases as opposed to visiting the world with regard to supply a GP for a prescription7. It method, and the copper is essential in order to understand appears that women may prefer IUD are clouded in how it affects the lives of women to separate their contraceptive and their partners today. negativity” needs from regular healthcare, but this is not without flaws. A In 2001, ‘Levonelle One Step’ Scottish study found that 10% became available over-theof pharmacies contracted by counter in the UK to those the NHS to provide emergency aged 16 and over at an average cost of £23. It is contraception failed to do so, some for ethical now legal in 140 nations and available without reasons8. More importantly, a mere 32.5% of the prescription in 60 of these3. In a recent attempt pharmacists discussed long acting contraceptive to advance contraceptive services in the United methods whilst dispensing levonorgestrel, States, the FDA recommended that the availability a statistic that could be vastly improved. of emergency contraception should be extended to those aged 16 and under without a prescription4. The situation surrounding contraception is However, this was overruled based on the fact particularly interesting in China, where sex that not all females of reproductive age would education has previously been minimal and be able to use methods such as levonorgestrel contraceptive services are only made available free responsibly3. Health professionals condemned this of charge in certain districts to married couples. 65
Levonorgestrel at a glance...
UK
US
Prescription
Cost
Generally not required if 16 or over in a pharmacy, unnecessary at specialist clinics. Consultation required in all situations. Required if 16 or under
Approximately £23, free from clinics and some pharmacies
China Not required
Approximately $50 The most popular brand, Yuting, costs as little as $2
Here, many women choose not to use the OCP due to concerns over weight gain, depression and endocrine disorders, despite its availability without a prescription3. A recent survey found that only 1.67% of married Chinese women aged 15-49 take the OCP, preferring highly user dependent methods such as condoms, withdrawal and natural family planning9 In a country where family size is still restricted, this surprising statistic may account for the high use of emergency contraception. A 2009 study reported that emergency contraception dominated the market of over-the-counter contraceptives, accounting for a staggering 70% of total sales. The most popular form, Yuting, costs just $23. Users are thought to be mainly women aged 20-25, with some reporting regular use as an alternative to hormonal or barrier contraception9.
“In China, many women choose not to use the OCP, despite its availability without prescription” Ultimately, this may be linked to the increasing rates of abortion, rising from 7.63 million in 2007 to 9.17 million in 20089. This evidence suggests that women in China feel confident to access emergency
contraception, but better judgement could be used by healthcare professionals and government regarding provision of longer acting, reliable methods. Levonorgestrel was first manufactured in the 1980’s, but it was not until confl ict in the Balkans a decade later that the drug became highly publicised, when used to aid women who had been the victims of rape and sexual assault.3 It is therefore important to consider areas of unrest in which women are extremely unlikely to have access to either emergency contraception, or legal, safe abortion. This problem is prominent in Cambodia, a country struggling to rebuild infrastructure following a civil war that now has one of the worst maternal health rates in the world. Despite abortion being legalised in 1997, a study in 2008 revealed high rates of unsafe termination, with 40% of women presenting at government clinics for legal abortion showing clinical evidence of prior illegal attempts10. This is not just down to conservative female attitudes and fear of judgement, but also linked to reluctance of the public sector to actually provide this service and weak implementation of the law. Furthermore, myths regarding contraceptive side effects are often propagated in small provincial areas and rarely dispelled, discouraging use11. In such areas, millions of young women could benefit from education and access to emergency contraception, but cultural acceptance, particularly in remote areas, may impede this process.
“In Cambodia, 40% of women presenting at goverment clinics for legal abortion showed clinical evidence of prior illegal attempts”
With the desire for smaller families and a rapidly increasing population, the provision of emergency contraception is incredibly important in modern society, alongside long term contraceptive methods which should always be made available where possible. In 2010, over 41% of the 208 million pregnancies were reported as unwanted6. Whether the reason for access be contraceptive failure or refusal of the partner to use protection, it is essential that women and men around the world are informed of the importance of emergency contraception, and unafraid to seek it. Full references available at: www.omsg-online.com
Elizabeth Platt is a fourth year medical student at Hertford College
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Anti-oxidants: The Hidden Dangers Annabelle Painter explores what the science really tells us about supplements
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ree radicals have a lot to answer for. Or so we are led to believe. According to the media they cause heart disease, cancer and ageing. As electron donors, anti-oxidants theoretically neutralise these free radicals, making them a health buzzword... 67
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he message has been simple: consume more anti-oxidants and you will stay young and ward off cancer and cardiovascular disease. There are a wide variety of anti-oxidants, ranging from the well-known, such as vitamin C, vitamin E and beta-carotene, to less familiar forms – including selenium, manganese, coenzyme Q10, and flavonoids. However, the mechanisms by which most of them work remain unknown.
“Supplement tablets represent a $500 million industry that continues to grow” The anti-oxidant hype began after observational cohort studies conducted in the 1990s demonstrated that individuals taking supplements were at reduced risk of cardiovascular disease and all-cause mortality1,2. As a result, anti-oxidants became a gold-mine. Supplement tablets now represent a $500 million industry that continues to grow3. The alleged health benefits of foods rich in anti-oxidants soon led to their branding as ‘superfoods’ by the food industry. This term, labelled by Cancer Research UK as 68
a “marketing tool” 4, has not been approved by dieticians or nutrition specialists. Ironically, there is evidence that some superfoods (such as forms of seaweed) contain natural toxins, including microcystins, which have been shown to increase the risk of cancer and liver damage5. Since 1st July 2007, the marketing of products as superfoods has been prohibited in the European Union unless accompanied by a specific medical claim supported by credible scientific Unfortunately, research6. the lack of evidence behind renowned superfoods has not reached the public at large. The problem with the data obtained from the studies in the 1990s is that observational studies are fundamentally limited. It is conceivable that the results were obtained simply because those individuals within the trials taking supplements
Many colourful fruits are rich in anti-oxidants, including blueberries, raspberries and strawberries.
were more health-conscious. To better analyse the relationship numerous randomized controlled trials (RCTs) have since been conducted, producing far less convincing results. Besides providing evidence that anti-oxidants have no effect on reducing cardiovascular disease and cancer, these studies revealed that supplementation may actually increase risk of disease7-12.
“Studies have revealed that supplementation may actually increase risk of disease” A Finnish trial evaluating the potential ability of beta-carotene and/ or vitamin E to prevent lung cancer in smokers was stopped early when an interim analysis demonstrated that those
taking supplements were 18% more likely to develop lung cancer7. These results were echoed in a similar trial in America stopped prematurely when participants taking anti-oxidants were shown to be 28% more likely to develop lung cancer8. It’s not just lung cancer either. Rates of skin cancer have been showed to be higher in women taking vitamin C, vitamin E, beta-carotene, selenium, and zinc9. In men, trials have found 17% more cases of prostate cancer in those taking vitamin E than those not10.
with increased all-cause mortality13. The effects seem to be dose dependent with risks increasing rapidly as the intake rises.
Aside from cancer, vitamin E supplementation is also associated with an increased risk of haemorrhagic stroke and heart failure12. A meta-analysis analysing the dangers of anti-oxidants in 230,000 patients using the Cochrane methodology concluded that beta-carotene, vitamin A and vitamin E supplementation are all associated
Increasing evidence suggests anti-oxidant supplements aren’t actually effective at preventing cancer or cardiovascular disease, and can even increase mortality. Supplements and superfoods might seem like a quick fix but they aren’t the answer a to healthier life. For now, we are just going to have to keep eating our greens.
If anti-oxidants are indeed harmful, why are fruit and vegetables, full of natural anti-oxidants, beneficial? There are several Those diagnosed with potential explanations. cancer are particularly Firstly, it may be that the likely to take anti-oxidant levels of these chemicals supplements. Many cancer supplied through the diet “There is a growing patients believe that the are beneficial but become health benefits associated harmful when increased concern that anti-oxidants with anti-oxidants will help by supplementation. could be interfering with them fight their disease. The interaction between Several conventional conventional chemotherapies” anti-oxidants and other chemotherapies, however, vitamins and minerals in work by producing oxidative fruit and vegetables could damage thus there is growing also produce a health concern that anti-oxidants could be interfering benefit. For example, the anti-oxidant effect with this process, reducing chemotherapeutic of flavinoid-rich foods seems to be due to efficacy. Studies in this area have found that the fact that flavinoids interact with fructose smokers taking supplements have a particularly in the food, stimulating the body to increase compromised response to therapy11. synthesis of the natural antioxidant uric acid14.
Full references available at: www.omsg-online.com
Annabelle Painter is a second year graduate entry medical student at Worcester College
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Mental Gain’z If you haven’t heard about that friend-of-a-friend who popped Modafinil like they were Smarties and smashed their thesis in a 30-hour sitting then, quite frankly, you’ve been living under a rock.
S
upposedly, around 10% of US University students have used a prescription drug to improve their performance - so here I am writing this article, because maybe, like me, you’re missing out1.
of the page. So what if I had a supplement that could improve my focus? ‘Well, can’t I buy one of those for £1.30 from GPEC’ I hear you say?
Coffee
Why would you want a supplement Price: £1.30 – for a GPEC latte, which contains for the brain? roughly 100mg caffeine (equivalent to 1 can of
Red Bull). You’re at Oxford, and you’ve already got a degree, so you’re not cognitively impaired. But part of what’s made you successful has likely been Duration: Peak plasma concentration around your drive to better yourself, or to be better than 15-120mins after ingestion, half life is 2.5-4.5 others. So what cognitive attribute would you hours. improve if you possessed some magic supplement? One of my flaws is my concentration span; one Side effects: anxiety and nervousness at high minute I’m conscientiously making notes on the doses. lecture, 10 minutes later I’m doodling on the side Evidence: Despite there being a large body of
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IMAGES/ROSALIE BROOMAN-WHITE
WHITE
“Well, can’t I buy one of those for £1.30 from GPEC?” literature on caffeine consumption available for review, the results are somewhat heterogeneous [for a comprehensive review see ref. 2]. This is due to differences in study design relating to baseline levels of caffeine drinking in subjects, amount of caffeine administered, and whether they underwent a period of abstinence before the testing.
Popping Pills Okay, so if I’m tired caffeine helps a fair bit, but personally even if I get my usual 8 hours of beauty sleep I still can’t concentrate in lectures - so let’s shift up a gear and try some pills.
nil (Provigil) – wake promoting drug for 1. Effects in non-fatigued subjects: Modafi narcolepsy.
Caffeine has no effect on active learning, short or long term memory. However it does act in a dose-dependant manner on mood; low doses Price: around £1 per 200mg pill, need to order seem to increase arousal, hedonic tone and reduce online from Europe. anxiety, whereas high doses increase anxiety and nervousness. It also appears to help sustain Duration: Peak plasma concentration at 2 attention to some extent during demanding tasks. hours, effectively eliminated at 10 hours.
2. Effects on fatigue:
In US Navy trainees subjected to 72 hours sleep deprivation, the equivalent of 2 cups of coffee significantly improved learning and memory tested by a range of neuropsychological tests. Perhaps more relevant to us, caffeine has also been shown to partially counteract the decline in performance, seen from morning to afternoon, in tests of cognition.
Side effects: Regarded as well tolerated,
however it does increase systolic blood pressure. (N.B all effects listed are statistically significant to p<0.05 versus lactose placebo3)
Mood: The subjects reported feeling more alert, attentive and energetic.
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Cognitive performance:
There has been a goal in mind, the placebo effect is going to be considerable appraisal of the effects of Modafinil. huge. Half of the problem with our concentration Listed below are two particular results of and memory is that we don’t sit ourselves down interest from a study of 60 healthy males. with a goal in mind and the time to achieve it! 1. In a spatial planning test, subjects who took Modafinil required significantly fewer attempts to obtain a correct result, and this difference was more marked when the difficulty level was increased. Interestingly, this was also associated with Modafinil taking subjects having significantly longer response latency. This seems to suggest that Modafinil improves performance by increasing the time spent evaluating a problem.
Drawbacks? So there may be some evidence that Modafinil makes you feel more alert, and helps your ability to evaluate difficult problems, but I’m sticking with the coffee. Here’s why;
-Medicine is a marathon, not a sprint. Our jobs will always have a degree of time pressure and stress, and relying on a supplement can’t be a 2. In a “stop-signal test”, where subjects make a long term solution to that. Now is the time for response as quickly as possible to a “Go” signal, us to be honing our time management skills. but make no response to a “stop” signal, the Modafinil group were just as quick to respond -There’s a lack of long-term studies of side effects. to a “Go” sign as placebo receivers, but were significantly more accurate at not responding -Naturally, there is an inequality of access to these to a “stop” signal. This suggests that the effect drugs (price and internet access), and this will on latency in the above task was not simply a widen the social divides in academic performance psychomotor slowing effect of the drug, but fits that are already so apparent in the world today. better with what many propose as its mechanism of action – pre-potent response inhibition. -In the US military, soldiers are legally required to take stimulants if ordered to, for the sake of But, are these results relevant to us? I’d like to make their military performance. You could argue two points: The relevance of the “Stop-Start” that in some scenarios this might improve the and spatial planning tests to performance in soldier’s survival and thus might be justified, medical school is doubtful. Furthermore, if but what if non-military employers started you go to the effort of buying a supplement and to make these demands on their workforce? setting aside the time to work, presumably with So the debate rages on. The ethics are questionable and the evidence base is small. If I were you, I’d buy a planner and have a cup of coffee. Full references available at: www.omsg-online.com
James Kuht is a fifth year medical student at Wadham College.
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The Watchman Brian Phillips discusses a novel technique in Stroke Prevention
A
trial fibrillation makes an individual five times more likely to suffer a stroke1,2. The rate increases with age up to 36.2% at age 80 to 89. Non-valvular atrial fibrillation (AF) is commonly treated prophylactically with warfarin; which has numerous drawbacks including significant bleeding, non-compliance and contraindication in pregnancy3. Although new anticoagulants expand the therapeutic armamentarium in stroke prevention, alternatives continue to be sought. To this end, over about five years, in around five UK centres, a new percutaneous approach has been developed. The technique uses
Having undergone WATCHMAN implantation myself I am familiar with the procedure, which is performed as follows: Under general anaesthetic, the device is introduced by catheter into the right femoral vein and guided to the right atrium. With transoesophageal echocardiography (TOE) it is passed by puncture of the left atrial septum into the left atrial appendage. Here it is secured with a locking device and checked for stability. The appliance is made of nickel, titanium and polyethylene. A membrane covers the surface; endothelium grows over this in 45 – 60 days. Implantation of the device is combined with antiplatelet agents, aspirin and clopidogrel. At 45 days a check TOE is performed. Designing the trials The CHADS₂ scoring system for prediction of stroke risk in AF patients has been used in selecting subjects in at least two clinical trials of these devices. This system relies on the presence of congestive cardiac failure, hypertension, age > 75, diabetes mellitus and prior stroke or TIA7. In the Swedish Stroke Registry, patients with CHADS₂ score 0 (AF risk only), had 76.4 deaths per 1,000 patient years. In those with a CHADS₂ score of 6 this figure rose to 593.7 deaths per 100 patient years. In fact less than half of those with CHADS₂ >1 survived more than five years. This is notable as a major clinical trial due for completion in January 2014 enrolled an estimated 2,500 subjects with a CHADS₂ score >1.
occlusion of the Left Atrial Appendage (LAA), where 90% of emboli in AF patients originate4. It is clearly important to assess the use of the LAA occlusion appliances, which include the WATCHMAN (illustrated), PLAATO and AMPLATZER PLUG. A randomised controlled trial in November 2009 compared occlusion of the LAA to warfarin in 707 subjects and resulted in 2.3 and 3.2 strokes respectively in 463 subjects and 244 subjects5. The WATCHMAN occlusion device was approved in the USA in 2009. Implantation must only be carried out in centres equipped for open heart surgery and undertaken by those with appropriate experience, so there has been has limited uptake so far. Nonetheless, two-thousand patients have participated in prospective studies of the WATCHMAN and there have been over 4000 patient years of follow up. It is worth commenting on the opposing views of two National agencies currently influencing the NHS, namely the NHS Commissioning Board and the National Institute for Clinical Excellence (NICE)6. The former has dismissed the clinical and cost of treatments of LAA unequivocally, whereas NICE accepts the efficacy of the device and its low risk of life threatening complications. My discussion with the Clinical Director of the National Heart Hospital in London and Dr Anthony Chow, my cardiologist, leaves me in doubt that NICE has reached the correct conclusion. Risks associated with LAA occlusion devices are relatively few and include8: Cardiac tamponade - seen in one patient of a series of 111 LAA cases. Cardiac arrest - occurred from device embolisation in one case in a group of 73. In the trial of 707 patients the same problem arose in three patients. In the 73 patient series, there was also instability of the device in one case. Pericardial effusion - occurred in 2%-5% of subjects in the 707 series.
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Peer Review (Archives) From Vol. XLI No. 3 Trinity 1991
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APPlying your Skills
Full references available at: www.omsg-online.com
Andrew Fahey is a fourth year medical student at Brasenose College.
With the vogue for medical apps ever growing, Andrew Fahey tries out a couple and gives us his verdict...
OSCE Skills
almostadoctor 2
£1.99. Available for Apple iPhone/ iPod touch, iPad and Android ‘coming soon’.
£1.49. Available for Apple iPhone/ iPad/iPod touch. OSCE Skills is the RonsealTM of the medical app market; it “does exactly what it says on the tin”. It was produced by the makers of OSCEskills.com and the content of the app is identical to the free-to-use website. The layout of the app is perfect in its simplicity. The home page contains icons of the various body systems and each system is split into any skills pertaining to that system. Clicking on a skill opens a set of step-by-step instructions and pictures on how to complete the skill or exam during an OSCE. All of the written instructions are easy to follow, and opening with the list of equipment you will require is particularly appreciated. I must also commend the app on the number of skills available (44 at time of writing) and can only hope this will increase with future updates. Despite this, I can’t help but feel it would really benefit from videos as opposed to pictures to truly capture the nuances of the physical exam. It is also unfortunate that, whilst listing the signs you’re looking for, there is no attempt to describe or explain them. Perhaps a link or two to Dr Wikipedia and Prof YouTube (as in the website version) wouldn’t go amiss here. All in all, the RonsealTM description remains apt: a solid and dependable app for those looking to cover gaps in their knowledge and preserve it. However, older years will be left wanting more. Liked -Interface -Straightforward instructions Rating:
3.5/5
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Disliked -Lack of videos -Lack of explanation or examples of signs
Sticking with apps from websites, the encyclopaedic resource that is almostadoctor.co.uk has released a new update to their app. At first glance, it attempts to be an entire medical education in your pocket; with a range of icons on the home screen including the expected systems, examinations and procedures but also interestingly pharmacology, data interpretation, scoring systems and emergency medicine. Whilst the scope of the app is commendable, one cannot help but worry that it risks over-reaching itself. Each section is subdivided into relevant conditions, skills or topics and within these is an attempt at a concise overview of any and all pertinent information. The results are variable with excellent, if slightly word dense, guidance on approach to patients and discussion of conditions. The choice of conditions themselves is spot-on for medical students, with all the essential conditions covered - over 100 in total. Unfortunately the in-section presentation really lets it down, with no subdivision of pages making navigating tedious and also a distinct lack of diagrams. My other major grumble is that some of the sections are yet to be completed or missing information. It’s pretty shoddy for a paid app to be lacking the goods. Overall this app is quite the Icarus, which is unfortunate as the potential is there and the website is superb. Liked -Breadth of topics -The actual content
Rating:
3/5
Disliked -Presentation and navigation -Missing content
What Doctors Feel – How Emotions Affect the Practice of Medicine Danielle Ofri Beacon Press (2013) Amazon Price: £8.89
The ECG Made Easy, 8E John R. Hampton Churchill Livingstone (2013) Amazon Price: £16.93
Reviewed by Abbie Taylor
Reviewed by Nathan Riddell
“What Doctors Feel” explores the emotional highs and lows of being a doctor in an unforgiving world. Ofri recounts experiences of her own, and of other doctors, to illustrate the ways in which our tiredness, grief, anger, fear, disillusionment, and occasionally joy affect the way we interact with our patients and each other.
ECGs have never made sense to me, despite the best efforts of Oxford’s elite line-up of cardiology lecturers. So, the promise of making those incomprehensible squiggles “easy” was a dangerous one. Could the holy grail of cardiac medicine lie in a mere 170 pages? Could these seven chapters potentiate my conversion from the cardiology cocoon into a pseudo-Jeremy Dwight? My journey to electrical enlightenment was about to begin.
There are no great revelations here: doctors get stressed, lawsuits are demoralising, and s**t happens. The book promises a thorough probing of the emotional responses of doctors and possible ways of ameliorating their detrimental effects on patient care. Instead, we are offered a collection of anecdotes and opinions. With her astute self-awareness and years of experience in a hospital serving a deprived population, Ofri is a good storyteller. She exposes herself to criticism – writing about the times she was humiliated on ward rounds, the times she missed a serious diagnosis amongst a host of medically unexplained symptoms, the times she could not bring herself to give a patient a true prognosis. Although this honesty is laudable, there is also the sense that Ofri is using this book as a confessional to deal with her own feelings of inadequacy. The underlying message of the book appears to be that doctors are human, and with humans come emotions. Sir William Osler’s notion of “Aequanimitas” (that doctors should leave their emotions at the door) does not come off well: “Garbage wrapped in tinsel is still garbage. He learned his bedside manner on cadavers.” Apparently it is in our patients’ interests that we embrace our 21st century emotions. Thankfully, Ofri acknowledges that there is no algorithm or formula to develop emotional awareness in our doctors. Ofri’s attempts at literary embellishment are sometimes exceedingly irritating: “It was one of those crisp fall days in which even New York City seems to brim with autumnal exuberance. The garden in front of Bellevue was lush with gold and scarlet. A gentle soughing of boughs beguiled the senses…”. However, if you can cope with a few pretentious descriptions and a lot of soul-searching, the book is an entertaining read. Just don’t expect an authoritative text on the affectivity of doctors.
Abbie Taylor is a fi fth year medical student at Green Templeton College.
Chapter 1 focuses on making the reader understand how the ECG is actually generated; with several helpful diagrams and a thorough explanation of each trace’s appearance, ECGs suddenly made more sense. Indeed each passing page seemed to yield a new secret of the ECG, ranging from axis deviation to the chest lead transition point and, vitally for an OSCE, how to report these. Each subsequent chapter effectively elaborates on a different ECG abnormality with a plethora of diagrams to support the text. The nature of it, being more of a handbook than a textbook, made for a rapid pace through some complex concepts with little consolidation. The author attempts to address this in a chapter 6 dedicated to “reminders”, but in reality I simply found it an overwhelming amount of text adding little clarity to the subject. In stark contrast, the “Now test yourself” section was excellent – ten archetypal, abnormal ECGs from clinical scenarios with clear explanations. Whilst my understanding of the previously elusive ECG was certainly improved by this book, I was admittedly left feeling slightly frustrated in places – with very little mention of any treatments for the abnormalities discussed, and an annoying need to keep referring back and forth to make sense of it all. Nonetheless despite my initial scepticism, The ECG Made Easy wholly lived up to its name, giving me a basic ability to recognise and report abnormalities on an ECG trace. Whilst in-depth information is a little thin on the ground, it is an easily digestible and valuable addition to any clinical student’s bookshelf.
Nathan Riddell is a fourth year medical student at Green Templeton College. 79
Spitting Blood: The History of Tuberculosis
The First 20 Minutes
Reviewed by Erika Lam
Reviewed by Nick Li
Despite its gory title, ‘Spitting Blood’ provides a very comprehensive, if at times dry, account of the impact of tuberculosis on the human race since their first prehistoric encounter. The book makes an excellent attempt at outlining how TB has affected human society – changing our approach towards translational research directed at infectious disease, generating ideas about managing population health and health policy, whilst influencing art and culture.
At first glance, New York Times journalist Gretchen Reynolds seems to have collated all the health advice one could ever hope for into a 250-page book. Not only does this gospel offer assistance with our exercise regimes, it will also help us to live longer, and best of all, Reynolds uses “surprising science” to back it all up. She leads us through various aspects of exercise and training: starting with how much exercise is recommended, sports nutrition, losing weight, fitness, and the associated health benefits. The book then arrives at a snappy conclusion, *spoiler alert* “Use it or lose it.”
Helen Bynum Oxford University Press (2012) Amazon Price: £14.00
Throughout her description, Helen Bynum weaves interesting anecdotes from the lives of eminent historical figures such as George Orwell and John Keats, who were themselves TB sufferers. She depicts the disease in various incarnations – from phthisis in the Middle Ages, to consumption until the nineteenth century, to tuberculosis as it is defi ned currently. Bynum’s narrative takes the reader through Europe – from failed (and somewhat bizarre) attempts at cures, such as a touch from the reigning monarch, to the work and achievements of Battista Morgagni, René Laennec, and Robert Koch in classifying the disease. During the late nineteenth century, as the understanding of how TB was spread became established, new hygiene policies were created; medication and education provided to those affl icted, free of charge. The core of the movement then shifted towards America, initiated by institutionalised treatment in sanitoriums prior to the seminal discovery of the first effective antibiotic against the disease – streptomycin. Despite a brief respite in global incidence of TB, with the advent of the HIV/AIDS pandemic in the 1980s surged a new wave of infection. Despite exponential improvements in the treatment and control of the disease in the past two centuries, Bynum’s conclusion warns that we are still some distance from controlling and eradicating tuberculosis. My recommendation? Worth a read for those at all interested in the background behind our current struggle with TB, although the history boffi ns amongst you may enjoy it more than others. Whilst at times a little heavy on esoteric detail, I especially enjoyed asides from the perspective of sufferers and artists, in contrast to that of scientists – particularly Verdi’s romanticised fi nale of the beautiful demise of Violetta in her lover’s arms, despite the reality of it being anything but. Perhaps also, as we despair whilst studying for those exams that plague us throughout medical school, we might indulge in John Keats’ conviction of suffering associated with genius: ‘Do you not see how necessary a World of Pain and troubles is to school an Intelligence and make it a soul?’. Likening TB to enduring the pains of revision? Maybe a tad melodramatic.
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Gretchen Reynolds. Icon Books Amazon Price: £6.29
Much of the emerging evidence for exercise and fitness is indeed surprising initially, and it is reassuring that this book is free of the confl icts of interest that infest fitness magazines. One can see how Reynolds has attempted to marry the world of scientific uncertainty with the scientifically naïve, black-and-white dichotomy of the lay public. Not everyone knows the meaning of the word “aerobic,” so it needs to be explained. It is however frustrating to skim through hundreds of explanations that are oversimplified and, occasionally, factually imprecise. Yet the deliberate omission of explanation to add weight to some arguments presented is unforgivable – and perhaps exploits an untrained audience. Reynolds’ writing style merges the dry de-facto summarising of scientific journals with anecdotes and wit, and occasionally a tone that makes the reader feel like a high school student again. Her wit renders the first chapter readable, but is unable to contend with the repetition thereafter. Moreover, attempts to appear clever and insightful fall short. For example, her use of the phrase “Nietzchean at the molecular level,” to describe exercise leaves the reader wondering if she had only heard of Nietzsche the day before writing that chapter. Sadly, Reynolds does not fare better than any self-professed health and fitness pseudo-expert from Men’s Health. Poorly presented arguments with poor quality evidence and a conclusion that comes out of nowhere, this is not a book for anyone unwilling to take things at face value. As with many health and fitness magazines, it is not the quality of style and content that compels us to keep reading, but the unfounded hope that we might glean some pearls of wisdom.
Erika Lam is a second year medical student at New College. Nick Li is a fi fth year medical student at The Queen’s College.
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Crossword Puzzle
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Across
Down
1. Supersonic jet loses tail landing on tiny worker, in agreement (10)
1. Viewpoint where email precursor follows endless race in reverse (6)
5. Long distance and advancing years make a successful leader for the right! (6)
2. I, myself, for example, study effective knots (9)
7. Part of Thames is doubled (4) 9. European Union adds some logic and Spanish to farewell message (6) 11. Abbreviated Royal Navy wage, when altered, makes for a loud German (6) 12. Run when you hear the tram! (5)
3. Frivolity throws SIM at centre of search for reason (6) 4. Island nation; rhinoplasty in India perhaps? (9) 6. Donkey begins to lay down the lay for very confused French (7) 8. You get into messy DIY and get a hernia! (8)
14. Predator hunts messily on WW1 battlefield (5)
10. Beginning in springtime, common language has spectacular end (10)
16. Ignores: wordplay, say? (5)
13. Crumbling bank takes public transport (3)
17. Insert leading Russian (5)
15. Iberian beverage and boozy honey make painful exit from waterside field (4,6)
18. Unable to walk, LA gangster begins pleading (7) 20. Mountain hints at biliary obstruction (3) 21. I rave, palm selects heart for block (9)
19. Bring back, about and legally I have contracted (6) Answers to appear online soon.
22. O Christ! I feel that in the privates! (8) 23. Ridiculing the French, moon with prime start (7) 24. Prehistoric platform infi ltrated by unity (5, 3)
Killian Donovan is a fourth year medical student at St John’s College.
JUDGEMENT OMSG 64 (1)
10
TUNNEL VISION
11
JUDGING ‘NORMAL’
16
THE DARK SIDE OF MEDICAL PRACTICE
70
MENTAL GAIN’Z