Is Medicine A Science Or An Art? [past BMAT questions and interview questions.]

Question;  There is more to healing than the application of scientific knowledge.Explain this statement. What else is important in medicine

0789207133

Answer

Medicine is both a science and an art. It has a proud scientific basis;, the application of evidence based medicine and rigor of scientific logic but a consultation with a doctor often involves a lot more than making a diagnosis and treating.

The ‘art’ of medicine renders all appointments interesting and none routine. A good doctor-patient relationship and the development of trust is therapeutic in itself. Patients are much more likely to follow advice and treatment. We are familiar with the term ‘the doctor as the drug’. A doctor’s reassurance has been shown to reduce pain scores, panic attacks and other conditions even if no treatment is given. In General Practice, where patients are seen with many different conditions over a long period of time, even visits for minor conditions can augment an important  relationship where communication skills, sensitivity and empathy all play their part, often subconsciously.

I am reminded of the story of a team of management consultants who were asked to make efficiency savings for an orchestra. They saw that there were a number of violins all ‘doing the same job’ and cut the violins down to one. Then they started to look at other instruments. More and more cuts followed. At the end they had replaced the entire orchestra with a CD player – it did the same job and cost less didn’t it?  But of course something was lost!

Question: Not everything that can be counted counts and not everything that counts can be counted (Albert Einstein). What do you think is meant by this statement?Give examples of things that count in medicine which cannot be counted. To what degree should they count?

This essay question and the one above are describing the importance  of subjective experience such as  ’the art of medicine’. You could do a similar answer for this question. 

Advertisements

Gene editing could bring about the end of malaria.

genetic engineering

Imperial College London  researchers used CRISPR-cas 9 gene editing technology to wipe out a population of caged mosquitoes that are able to transmit malaria. They targeted the double sex gene, a genetic sequence that leads to male and female traits. Females with two copies of the mutated gene could not develop properly and could not reproduce but males fertility was unaffected and they transmitted the gene down to offspring. After 11 generations, they found that 100% of these mosquitoes were affected causing the population to collapse. The double sex gene is highly conserved and unlike previous attempts to alter fertility of male and female mosquitoes resistance has not been observed.

mosquitoes

Concerns have been expressed how this might affect the ecosystem but malaria was wiped out in Southern Europe with out major repercussions. There are about 4,000 different species of mosquito. The double sex gene is different in different insects so it should be possible just to wipe out the handful of species that cause disease leaving the rest to play their part in the ecosystem.

Whether this will work outside the laboratory is not known as yet but it raises exciting possibilities that we may be able to eradicate what is the most dangerous animals on Earth – the African malarial mosquito.

Remembering the 1918 flu pandemic

 

1918 Flu Pandemic Commemoration

Last week we remembered the 100th anniversary of one of the most lethal pandemics ever known to man. Known as the Spanish Flu it actually started in the USA and spread quite quickly around the  world during World War One.  It infected about 1/3rd of the world’s population [50-100 million] and killed about 10% of those affected, some  50 -100 million – more than died in battle in the first world war.

Usually influenza viruses are deadly in the very young or old who have a weaker immune system. In this case it was young, fit adults that seemed particularly susceptible. The virus originated from birds and had recently crossed over. It had not ‘adapted to humans’ and was very ‘visible’ to the human immune system. It therefore triggered a particularly large immune response which caused massive inflammation. People died from the overreaction of the immune system which lead to a ‘cytokine storm’ with white cells and ‘fluid filling up the lungs and drowning the sufferer. Therefore those with a highly reactive immune system, rather than the old, were those most likely to be severely affected.

It was known as the Spanish Flu because it was reported most in Spain as was not involved in the war and had not been subjected to press censorship. The other European countries and the USA had downplayed the pandemic as not to affect morale.  One  hundred years on annual flu epidemics are part of winter life. An influenza pandemic is a global outbreak of a new influenza A virus that is very different from current and recently circulating human seasonal influenza A viruses. Influenza A viruses are constantly changing, making it possible on very rare occasions for non-human influenza viruses to change in such a way that they can infect people easily and spread efficiently. The Centres of Disease Control monitors flu strains in order to be ready for the next flu pandemic. Flu pandemics still represent one of the greatest threats to mankind.

Fake News, The Kremlin, Russian BOTS and MMR

 

Measles is becoming a major problem again. In the first half of the year in Europe 41,000 people contracted measles and over 14 have died. In 2002 the USA declared itself to measles free but that sadly is no longer true. The vast majority of those infected in developed countries had never been vaccinated.

Measles is one of the most contagious diseases known to man, it requires vaccination rates of 95% to contain it and create ‘herd immunity’ and prevent epidemics.  A twenty year old fraudulent study by the British doctor Andrew Wakefield still holds enormous influence over the vaccination debate. This study, published in the Lancet, linked MMR to autism  but the findings were widely rejected.  The study was based on a tiny sample, other studies tried to replicate the results and failed.  It was full of flaws and he had carried out unnecessary, invasive investigations on children and he had not disclosed large payments made to him by anti-vaccine lawyers. He was struck off and lost his license to practice in May 2010. Study after study has shown that there is no link between  measles and autism yet it is still a commonly held belief by many and Andrew Wakefield is held up as a hero by the anti vaccine movement. He lives in a palatial home in the USA, is supported by Donald Trump and is dating the supermodel Elle Macpherson.

Image result for andrew wakefield

Russians, thought to be backed by President Vladimir Putin’s government have made use of social media to influence elections such as the US election and the Brexit vote and erode trust in US and European Governments by spreading “fake news”. Kremlin-sponsored social media accounts have promoted the discredited views of Andrew Wakefield to sow doubt in the West over the safety of vaccines. Russian government “trolls” voiced support for Vaxxed, a film made recently by Andrew Wakefield.  One site claimed that three quarters of the children in a Mexican village had died as a result of vaccination.[An example of a pro Russia anti-vaccine site is   https://prepareforchange.net/2016/03/05/putin-exposes-vaccines]

Infectious diseases were the most common cause of death 100  yrs ago. According to WHO and most experts, vaccinations have contributed more than even antibiotics to the amazing success in the fight against infectious diseases. When a small group of Spanish invaders arrived in South America they were able to conquer it because of the diseases they bought with them as the natives had no immunity. Measles and other viruses led to the death of  an estimated 90% of the population of modern day Mexico!

Why do vaccines now cause so much uncertainty and parental angst?  In part vaccinations have become a victim of their success. We have learnt not to fear diseases such as a polio and diptheria; they have become remote and ‘unlikely’. We are tantalising close to eradicating polio but smallpox is the only disease that has been truly eradicated world wide, probably because of compulsory vaccination. Italy and France recently made MMR compulsory to try and halt the rising incidence of measles; should we do so as well? What do you think?

 

What’s in a name?

junior doctor

Dame Sally Davies, the Chief Medical Officer of England has said that name ”junior doctor’ or ”doctor in training”  is confusing. Patients often fail to differentiate junior doctors, who carry out most of the medical work in a hospital and  may have been doctors for over 10 years from medical students or even ‘work experience students’.  She stated that doctors needed job titles that give them “the respect they deserve”.

The abolition of doctor’s white coats and the trend for younger doctors to introduce themselves simply by their first name adds to the confusion. There have been many moves to democratise hospital care to to equalise  the ‘power imbalance’ in the doctor patient relationship but this undoubtedly reduces the respect given to them and anxious patients  feel more confident in a show of authority.

It was thought that poor understanding of the role of junior doctors meant less support for them during the junior doctor strike and I remember trying to explain that trainee doctors were fully qualified to a patient who wondered why they got paid at all if they were training.

Dame Sally Davies feels that a name change would help morale but she has also been criticised by doctors and others who feel this is a distraction and there needs to be a change in working conditions so that junior doctors feel valued instead. The Times last week asked readers for suggestions for new names. One reader remembered a poorly skilled surgeon who was referred to as ‘the Hippocratic oaf’ another suggested that since a slang name for doctors is a ‘quack’ junior doctors could be called ‘quacklings’. Perhaps not restoring respect but amusing all the same. It seems that we will probably return to a similar nomenclature as in the past with the terms senior house officer, registrar and senior registrar making their appearance again as they seemed to work in the past and in fact were never totally abandoned.

Names are important. It is why companies spend so much choosing a brand name. Studies have shown that names have an affect of the life chances, jobs and the  character of children. A girl named Joy is apparently more likely to be happy and one named Rose more ‘feminine’. Trump was given a ‘head start in business’ by his name. Thinking about doctors in South West London were I work I know of Dr Cream, who used to be a dermatologist, Professor John Studd a gynaecologist, Mr John Dick a urologist who took over from Ms Waterfall [one of the  earliest female urologists]. All coincidence?

Medical mistakes. Dr Bawa Garba wins right to practice as a doctor again.Why it matters.

Dr Bawa Garba was found guilty of gross negligence manslaughter in November 2015 and contributing to death of 6 yr old Jack Adcock. The medical practitioners tribunal  suspended her for 12 months but the GMC appealed to the High Court and won stating that in order to maintain public confidence in the medical profession she  should be struck off the medical register.

A look behind the cover story shows however that there were a catalogue of alarming factors which contributed to an unsafe working environment in which mistakes could happen to the best of doctors. It was her first day, she had just come back from 13 months maternity leave and had not had an induction, she was unfamiliar with the hospital and the 6 wards on four different floors she was supposed to cover. She missed the hand over ward round that morning because she had to attend to a cardiac arrest and was therefore  completely unfamiliar with the patients. The consultant on duty that day was absent [he was lecturing on a different site] as was the other registrar, her paediatric SHO had been told to go down to the lab for a few hours and collect results as the hospital IT system was not working . She was doing the work of  4 doctors. She had not eaten or drunk anything all day.  Jack’s parents had given the little boy a drug, enalapril without telling the medical staff, it was not written up on the drug chart and it was not recorded. It lowers blood pressure and made it more likely that he went into cardiac arrest. Dr Bawa Garba wrongly mistook Jack for another boy because he had changed beds that morning and thought he was the original boy in that bed and not for resuscitation so halted it after a few minutes [this however was not thought to have made a difference. Jack was already too far gone.]

Professions concerned with safety such as pilots and medics talk about the Swiss Cheese Model where a catalogue of  problems leads to a disaster. Normally the holes in Swiss cheese do not line up but occasionally they do. It is not usually a single error made by one person but problems in the environment and therefore changes in the environment and checks and balances can lead to improved safety. Air safety has improved substantially using this attitude.

The judgement of the senior judges in this case has caused confusion and outrage. Justice Ouseley acknowledged that Bawa Garba  ‘before and after the tragic events was a competent, above average doctor’ but also stated that the events were something she had been trained to cope with.  He shows a complete misunderstanding of the work of doctors. No amount of training can enable you to do 4 doctors work safely.

What is also concerning is that as doctors we are encouraged to reflect on how we can improve our performance. It seems that Dr Bawa Garna’s reflections were used as evidence against her. This has led to calls to boycott the reflective portfolio that all trainees write and doctors some doctors are stating that in this current culture it is unwise to admit mistakes. Consultant cardiologist Peter Wilmhurst, a prominent campaigner for transparency and safety in medicine has referred himself to the GMC because he says that over four decades of practice he must have made mistakes some of which would have led to the deaths of patients, and he has encouraged other doctors to do the same. Doctors now fear that they will be made scapegoats when systems fail. Hence the campaign that followed #I am Hadiza.

Crowdfunding raised £350,000 to appeal against the High Court Ruling and I am pleased to report that this time on 13/8/18 the High Court raised the restriction and supported the medical practitioners tribunal original decision to suspend her for 12 months . Jeremy Hunt, until recently the Health minister, ordered a review into whether medical manslaughter laws are fit for purpose. This review is eagerly awaited by anxious doctors who see a growing gap between ideal practice as described by the GMC and what can be realistically achieved given rota gaps [covering for colleagues] and multiple sick patients requiring attention at the same time.

 

 

 

Whistleblowing.

1332361939-whistleblower

Another NHS scandal erupts.  Last week serious criticisms of  St George’s Hospital heart unit were made by Professor Berwick who had been asked to undertake an investigation to the department when unusually high death rates were detected [3.7% for cardiac surgery compared with 2% nationally]. He declared  internal scrutiny was  “inadequate” and the department was riven between “two camps” exhibiting “tribal-like activity”. He commented further saying  “Some felt that there was a persistent toxic atmosphere and stated that there was a ‘dark force’ in the unit.” Conversations with staff revealed they were shocked by the death rate, but “most felt that poor performance was inevitable due to the pervading atmosphere”. Two surgeons have since been suspended from their posts but sources allege that these were surgeons who, rather than being responsible for the problems, highlighted them and attempted to blow the whistle on problems at the unit and have thus been victimised by the management at St Georges [St Georges denies this].

Whistleblowers are people who bring attention to the failings of the organisation they work for. They have been described as a combination of hero and disloyal sneak, which illustrates exactly what a difficult position they are put in. They are rarely popular, are denied promotion and often have to sacrifice their careers. The scandal at Mid Staffordshire NHS Trust was one of the last major scandals in the NHS. About 500 people were estimated to have died of negligence and appalling standards of care as a result of cost cutting by management. It emerged that staff who tried to bring the crisis to the attention of their superiors were bullied into silence. Sir Professor Brian Jarman of Imperial College heads the health analytical company Dr Foster which looks at hospital statistics [It was the statistical analysis from the Dr Foster unit at Imperial which first led to questions being asked about the standard of care at Mid Staffs] he stated that the NHS still continues to foster ‘a culture that allows suppression of the truth and victimisation of whistleblowers.’ Carol Parkes wrote in the BMJ at the time

If no one dares to ask the unpopular questions and everybody keeps their heads down, the organisation can succumb to poor thinking, poor strategy, and poor leadership.’

The GMC states ‘make the patient your first concern  Whistleblowing is an obligation. A doctor can be struck off the GMC registrar if he fails to report concerns. Patient care and safety should be a doctor’s primary concern. If you don’t report such matters you may not be an abuser but you can be viewed as a collaborator. It is always hard to speak out against your colleagues and employers but it is essential.

whistleblowers cross

NHS staff have the knowledge and the understanding to know when care is not being properly provided by their organisations. Patient feedback is valuable but enabling staff to speak up about faults within the NHS is probably more important in the effort to improve the NHS than employing countless expensive management consultants. The Francis Report into Mid Staffordshire stated that junior doctors [who frequently move posts as part of their training schemes] and are less inured or entrenched in the ways of working of departments ‘are the eyes and the ears of the NHS.’  In my local area the CCG has a  ‘MAD’ button on its website which stands for ‘Make A Difference’. Clinicians like myself press it if we feel there is a problem with care and I am pleased to say it is investigated.

Numerous scandals over patient care have occurred over the years. We had the Bristol Heart scandal in which incompetent surgeons operated on babies [the anaesthetist who reported it to the press had to find work in Australia], the Winterbourne Home scandal  and Mid Staffs. NHS staff spoke up in all these cases but were not listened to! More needs to be done to protect the whistleblower!

whistleblowers-cartoon

 

Matt Hancock – Our our new Health Secretary.

 

2015 General Election - Cabinet

Matt Hancock was appointed minister for Health and Social Care replacing Jeremy Hunt who was promoted to foreign secretary. Like Jeremy Hunt and David Cameron he studied PPE at Oxford, before studying economics at Cambridge, then went on to work at the Bank of England before becoming George Osbourne’s [the previous Chancellor’s] chief of staff.

Earlier this year he was appointed Minister of State for Digital and Culture and in January 2018 became Secretary of State for Digital, Culture, Media and Sport. He launched his own smartphone app which a privacy watchdog called ‘a fascinating comedy of errors’ after the app was found to collect its users’ photographs, friends, and contact information breaching privacy laws.

Health professionals are concerned that like Jeremy Hunt he had no real experience of the NHS before becoming health minister. Jeremy Hunt once wrote a pamphlet supporting denationalising the NHS and suggested replacing it with “universal insurance.’’ Matt Hancock has received a total of £32,000 from an anti-NHS think tank in the past. He used one of his first speeches to praise Babylon, a private company’s virtual GP service saying that he no longer has an actual GP but uses their face time service. Babylon provides services to the NHS as GP at hand and allows patients to register with them instead of a normal GP. It provides the vast majority of consultations online/facetime and states that those with mental illnesses, long term chronic conditions or are pregnant are not suitable. GPs are paid on a capitation basis, per patient rather than per attendance so doctors’ leaders have criticised this development as it ‘cherry picks’ the young and fitter patients leaving the more complex and time consuming for other GPs in the area and risks destabilising GP practices that depend on ‘fitter’ patients to ‘subsidise’ their services. It is an unfortunate coincidence that politicians in charge of the health service tend to be well off and healthy men and represent those least likely to use and need the health service. They tend to bring about changes that they would like to see such as easier access whether by phone or by having out of hours appointments and hospital services [David Cameron wanted to introduce a ‘seven day NHS’ providing routine care all week and this led to the Junior doctors strike and friction with other doctors]. In other countries such as Canada the Health Minister is usually a health professional. Dr Sarah Woollaston a Conservative MP and chair of the Commons Health Select Committee would be an excellent one.

 

Exercise the wonder drug!

 

exercise

 

A study published this week and reported on by several national papers concluded that women who exercised in middle age had a reduced chances of dementia by as much as 90% compared with those who took no exercise. This was a population-based  prospective cohort study on women in Sweden which recruited women in 1968 and followed them over 4 decades.

These findings have give further proof that exercise should be regarded as ‘a wonder drug’.

If there was a treatment that could lead to the following;

  • up to a 35% lower risk of coronary heart disease and stroke
  • up to a 50% lower risk of type 2 diabetes
  • up to a 50% lower risk of colon cancer
  • up to a 20% lower risk of breast cancer
  • a 30% lower risk of early death
  • up to an 83% lower risk of osteoarthritis
  • up to a 68% lower risk of hip fracture
  • a 30% lower risk of falls (among older adults)
  • up to a 30% lower risk of depression

we would all be taking it, wouldn’t we? Well there is and it is called exercise. These figures were correct when people were randomised to 150 min a week of aerobic exercise [so they got sweaty and out of breath] or continued to do nothing. And this was true even if people did NOT LOSE WEIGHT. Most people generally know that exercise is good for the heart but few realise it has an effect on the immune system and leads to a decreased risk of some cancers such as cancer of the breast, colon, womb and even possibly lung cancer.

It is as good for depression or anxiety as counselling or anti depressants. When you exercise you ‘burn off stress hormones’ and get an endorphin [‘feel good’ chemical] boost. Feeling fitter, stronger and more attractive obviously wards off and prevents depressive feelings.http://www.rcpsych.ac.uk/expertadvice/treatments/exerciseandmentalhealth.aspx

Exercise relieves stress

We are all likely to live longer and the incidence of dementia will increase. How do we try and prevent this – with ‘brain training’ games? There is no evidence that these work – however the general maxim ‘What is good for the heart is good for the brain’ does hold. Much dementia is caused by atherosclerosis – furring up of the blood vessels to organs such as the heart and the brain. As the blood supply to the organs reduces they can not work so well and cells may die – in the case of the brain this leads to dementia. Alzheimers involves the formation of amyloid plaques in the brain. Cholesterol promotes the formation of these plaques.

 

Half an hour of exercise a day is probably more beneficial for my type 2 diabetic patients than all the multiple, expensive medication [with side effects] that they are on!

Figures published a few days ago by the NHS’s Health and Social Care Information Centre suggested that two thirds of men and half of all women are now overweight or obese. Only a third of adults manage 30 minutes of exercise once a week. It seems that the British are now the fattest in Europe!

What can we do about it? This week the BMA demanded a tax on sugary drinks and a ban on unhealthy food adverts targeted at children. This of course raises questions about the infringement of personal liberties. But in this country and others such as the USA and Denmark, which have introduced similar legislation, there is the growing realisation that unless we do some thing and try and tackle our unfit, overweight population our health systems might not be able to afford the consequences.diabetes ad

As a GP I promote exercise for it seems most disorders – from diabetes, menopausal hot flushes [helps temperature regulation and maintains bone density], to insomnia [promotes natural relaxation and sleep]. I often write a very simple exercise plan on a prescription to emphasise its value as a treatment. I refer the overweight to dieticians and gyms [they can attend for free – courtesy of the NHS] but doctors and dieticians get notoriously bad results – hence the rise in gastric bypass operations. Many have argued that we should pay people to lose weight and exercise, give them a monetary incentive and this would be far cheaper in the long run for the NHS. Some health bodies have already tried this. What do you think? Is this a step to far?

May be you agree instead with the solution in the cartoon below. -please feel free to comment.

http://blog.practicalethics.ox.ac.uk/2010/06/paying-people-to-lose-weight

obesity cartoon

Obesity, health and fat shaming.

obesity cancer research

Obesity has been in the news. Millennials have been declared the fattest generation ever and Cancer Research UK adverts have caused controversy for ‘fat shaming’ and ‘promoting eating disorders.’

Obesity seriously increases the risk of many diseases including breast cancer, bowel cancer, cancer of the womb, type 2 diabetes, strokes, heart disease, joint and muscle problems.  Only a third of adults manage 30 minutes of exercise once a week. It seems that the British are now the fattest in Europe!

Childhood obesity is a major problem in the Western world. The vast majority of obese children become obese adults. About 60% of children in the USA and 50% in the UK are over weight or obese.  These children will have major health issues and often psychological problems. They are not only deemed to be less attractive than their peers but less intelligent and lazy with poor will power. No wonder self esteem issues are the norm. Fat adults are likely to be less successful in their career and are passed over for promotion. However studies in the USA have shown that 75 % of parents of obese children do nothing about their child’s weight problem. The editorial of the journal of the Royal College of GPs quoted the UK National Child Measurement Programme which found that 79% of parents of overweight children do not recognise this fact and of those that do only 41% perceive this as a health risk. The state of Georgia in the USA has run a series of hard hitting adverts to try and change attitudes – see ads below.

childhood obesity ads 2

Critics argue that this is further stigmatising fat children and adults and will increase bullying. As a GP I have had a number of difficult consultations with patients. As a doctor I feel I have a duty to tell them that their weight is probably contributing to their suffering and long term health. Last week I explained to an overweight patient with backache and knee pains that her joints and muscles were having difficulty trying to support twice the weight they were meant for; that it is like carrying a grown up person around all the time and she would feel so much better if she could lose weight. The patient reacted quite angrily and told me she had come to terms with her weight and she objected to me raising the issue. Commenting on weight has become an ethical and social mine field that reflects the stigma and psychological suffering as well as physical suffering that is a consequence of being overweight.

anti anti obesity ads