Blue Monday and resilence

stress-and-depression

Today is ‘Blue Monday’ supposedly the most depressing day in the year – originally thought to be the 3rd Monday in January. It was probably first suggested by Cliff Arnail. His equation has six factors:  debt (d), time since Christmas (T), weather (W), low motivational levels (M), the feeling of a need to take action (Na) and time since failing our new year’s resolutions (Q).

blue monday equation

Although I am not sure how scientific this all is it certainly seems to fit in what we see as GPs and counsellors seem to be busiest and booked up in January.

Of course stress is not limited to just one day a year. It is just that it seems to peak about now. Christmas often brings us face to face with realities of family life [divorce lawyers have their busiest month], credit card bills start arriving and the optimism of the New Year and new year resolutions start fading.

For students, January often means mid-year exams.  Students have left the cosiness of home where they have usually been looked after and return to essay deadlines, exams, doing their own cooking and cleaning etc. First years have got over the excitement of starting University and second and third years have the pressure of knowing that all marks contribute to their degree grades. The short days and the darkness make it hard to get up in the morning and to motivate yourself. Some people do suffer from SAD, seasonal affective disorder where a lack of light can lead to depression.

Stress, anxiety and depression are very common anyway. A new report published a couple of days ago by ICM claims that 55% of interviewees said that stress caused by their employment has an adverse effect on their mental health and day to day life. As a GP 1 in 4 of my consultations are about stress, anxiety and depression. That is far more than any other condition, including all respiratory infections such as ear, throat and chest infections combined!

Medical Schools repeatedly remind interviewers that students and doctors who fail and cause concern do so, not because they are not clever but usually because of stress and a lack of ‘emotional resilience’. The medical course is long, intensive, full of exams and students and doctors constantly see distressing events. Empathy is important but it is always important to keep a professional distance and take care of yourself.  Therefore many candidates if not most, will be asked questions on how they cope with stress or how do they think that they would manage a heavy workload and extra curricular activities.

By now you should have evolved ways of learning, dealing with exams,managing your workload  and developed ways of relaxing. To avoid feeling overwhelmed some people make lists, it is important to prioritise tasks,delegate or even cross off tasks further down your list.  It is difficult but sometimes necessary to be assertive and to speak to people who have unrealistic expectations; for example a teacher who seems to ‘forget’ that you have other subjects apart from hers. Managing time effectively, (using travelling time to read the student BMJ or this blog for example!) is important. Demonstrating self discipline e.g. by getting up early before school for rowing practice would be worth mentioning. It is also important to have ways to unwind. Exercise is a great way of burning off stress hormones and boosting endorphin levels, as is music and singing. True friendships areinvaluable and bring a sense of self worth. And anyone having difficulties should seek help as soon as possible and realise there is no shame attached to this.Macho – ‘I can cope’, ‘soldier on’ attitudes are very much frowned upon.

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Winter Crisis

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ambulances outside hospital  A and Es which are full of patients waiting to be found beds on already full wards

With winter comes the cold and therefore more illness. This puts a strain on the NHS. The NHS has a budget of £116.4 billion annually, this is only 8.5% of the UK’s GDP and is much less than the amount that is spent by the other G8 countries. For example, France and Germany spend 11.5% of their GDP on healthcare, this is almost 50% more than the UK. The USA spends over double this amount spending 18% of its GDP. With the strain of what many would consider to be an inadequate  budget on the NHS and the demand for healthcare increasing, winter brings many problems and pressures.

In the NHS bed occupancy is high. The UK has 2.61 beds per 1000 people compared with 6.1 in France and 8.1 in Germany per thousand people. Bed occupancy runs over 90% in the UK, this means that in the busy winter months it often runs over 100% causing patients to be left in trolleys in corridors or transported hundreds of miles to find a suitable bed far away from families and friends.'I only got up for a drink of water, and a queue's formed next to my bed.'

A problem is ‘bed blocking’. This is the long-term occupation of hospital beds, usually by elderly people, due to shortage of residential and nursing home places. Councils often have to fund such places and carers at home and their budgets for social services have been cut. While the patient is being looked after by the NHS that patient is not a drain on their budget. Many propose combining health and social care so there are no longer separate budgets and there is better coordination.

General practice is at present underfunded and there is a shortage of GPs. GP workload has gone up and GPs now carry out 50% more consultations than they did 10 years ago this still does not satisfy demand and getting a GP appointment is difficult and some people go to A&E instead. 90% of all treatment in the NHS occurs in general practice. A decrease in capacity of 10% in general practice can lead to an increase in the A&E departments of 50 -100%.

In winter  infectious diseases such as flu and pneumonia  are more common. Heart attacks and strokes are also more common in winter due to the extra stress the cold can put on the body. There has been an increase in reported flu cases over the last couple of weeks.

The NHS like any healthcare system in the West is under pressure due to increasing medical technology and expectations, an ageing population and obesity.  The NHS generally does well, the World Health Organisation and The Commonwealth Institute (a well regarded American think tank) have both recently declared the NHS to be the most egalitarian and efficient healthcare system in the world but of course it is under pressure particularly in winter and the gaps become more apparent.

 

Goodbye 2017

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There was a depressing start to 2017. It felt that science was had been given a shove backwards. Science itself  seemed under attack. Politicians in Britain declared that ‘People have had enough of experts’ and Donald Trump tweeted ‘Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn’t feel good and changes – AUTISM. Many such cases!’  Robert Kennedy Jr, a prominent vaccine conspiracy theorist was appointed to chair a commission on “vaccination safety and scientific integrity”.  Scientists, medics and statisticians who actually understood data, it seemed had no place.  The new anti vaccine film ‘Vaxxed’, directed by discredited anti-vaccine activist Andrew Wakefield who was struck of for fraudulent research and unethical behaviour was given publicity by major channels such as Fox News.

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The Trump administration carried out the the freezing of research grants, and a gag order was placed on scientists in the EPA regarding dissemination of their research findings. In February 2017, William Harper a Trump science adviser with described  climate science as “really more like a cult” and its practitioners “glassy-eyed” This led to the Science March on April 22nd  to protest against ‘The misrepresentation and exclusion of scientific knowledge in policy decisions.’

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CRISPR-Cas9

Despite the bad start to the year and despite politicians, scientists have made astonishing progress. We seem to be on the cusp of amazing advances in the field of genetics. Research and techniques such CRISPR-Cas9 has made the transformation out of the lab and in to clinical practice and genetic disease are being conquered at a breathtaking rate.

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Haemophilia A

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This disease is caused by a genetic defect that means those affected do not produce a protein – factor 8 needed to stop bleeding. They need expensive injections with factor factor 8 twice weekly and suffer painful bleeding in to joints and skin and gut frequently. Thirteen patients were given the gene therapy at Barts Health NHS Trust. All are now off treatment with 11 producing near-normal levels of the protein.

Sickle Cell

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A French teenager’s sickle cell disease was reversed using similar treatment to change his DNA. A virus was used to infect the bone marrow with new, correct instructions so it made healthy red blood cells. So far, the therapy has worked for 15 months.

Butterfly Children

These children have junctional epidermolysis bullosa – a genetic condition in which the epidermis [top layer of skin] does not stick to the dermis. This leaves skin as fragile as a ‘butterfly’s wings’. Few children live past their teens. Hassan was being treated with palliative care. A piece of his skin was taken, its DNA was repaired in the laboratory and the modified skin grafted back on. After nearly two years, the new skin appears completely normal.

Bubble Baby Syndrome cured

Three babies are born each year in the UK with an immune deficiency condition which leave them at constant risk of developing life-threatening infections. If left untreated, infants need to be kept isolated from the outside world, which is why the condition is known as “bubble baby syndrome” and usually die before school age.

NICE has agreed that NHS will fund gene therapy for the first time, with a £500,000 treatment for “bubble baby syndrome” produced by GlaxoSmithKline. One treatment is enough to produce a life long cure.

Embryo editing

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Scientists have, for the first time, successfully freed embryos of a piece of faulty DNA that causes a deadly heart disease to run in families. 10,000 of different genetic disorders  are passed down the generations . The US and South Korean team allowed the embryos to develop for five days before stopping the experiment. Gene editing Crispr was used to make precise changes to the genetic code. Its applications in medicine are vast and include the idea of wiping out genetic faults that cause diseases from cystic fibrosis to breast cancer.

Huntingtons

This autosomal dominant genetic disorder lead dementia, movement disorder and death.  The disease is caused by an aberration in a section of DNA called the huntingtin gene. The error corrupts a healthy protein and turns it into a killer of brain cells. Epigenetics – is the science of the reading of genes. What makes cells to read some genes and ignore others. Epigenetic manipulation has been used to silence the huntingtin gene by blocking the messages it sends to the cell’s protein-making factories. This could be the first treatment to slow or prevent any degenerative brain disease. UCL is conducting trials at the National Hospital for Neurology and neurosurgery in London. 46 patients had the drug injected into the fluid that bathes the brain and spinal cord [cerebrospinal fluid].  This human trial showed the drug was safe, well tolerated by patients and crucially reduced the levels of huntingtin in the brain.

Truly exciting – what will 2018 bring?

 

 

 

The Drunk Consultant.

 

depressed doctor

You are a junior doctor and your consultant [your boss, the head of your team] arrives for the morning ward round smelling of alcohol. You confront him and he confides in you that he was drinking because he was upset because his wife left him the day before and asks you not to tell anyone. How would you handle this situation?

It is important to consider this scenario from the view point of all involved.

Your consultant’s point of view: He is going through a difficult period in his personal life and now by coming to work in this fashion he is jeopardising is career and standing in the hospital. However it is much better that he takes sick leave, the stress as well as the drinking would make it hard to concentrate and mistakes which in medicine can have terrible consequences are almost bound to happen. He should not feel that it is a weakness to seek help, we are all vulnerable and there are services such as occupational health, BMA counselling services that are available free of charge to doctors. It is important that he has insight and does not worsen his situation by trying to ‘soldier on.’

The hospital/NHS point of view:  The hospital has a reputation to protect and will be sued for any mistakes made. If the consultant is off hand or rude this may lead to complaints. It certainly cannot have its staff coming to work intoxicated. However the consultant is a very skilled, experienced member of its workforce and has given many years of loyal service so be treated with empathy and compassion. He should be encouraged to use the counselling services available and given time off work but it should be made clear that coming to work in this manner is unacceptable.

The patient’s point of view: – the most important. Patients have the right to be treated safely and courteously by attentive staff  that have their full wits about them. Medicine has the potential to cause serious harm as well as good.

Your view point: As a junior doctor your consultant is your team leader, mentor and teacher. He will also be the person who will give you a reference for future jobs. It is therefore important to still treat him with respect and courtesy. He as a person going through a difficult time deserves sympathy and empathy. However you have a duty to your patients and patient care and safety trumps all – ‘make the patient your first concern.’ It would be going against the GMC rules and probably hospital policy if you tried to cover up, even if no one came to harm. It may be the first time you have seen him like this but other occasions may have occurred and there may be a repeating pattern.

You should ensure that your consultant stops working, that he goes home [by taxi, does not drive]. That all patients he has seen have their notes reviewed, that you inform the relevant authority and seek help with that day’s work.

A GP in your pocket!

cherry picking

Cherry picking – to selectively choose the easiest or most desirable

Smart phones are being used for most things. You do not need to visit a bank nowadays, most financial transactions can be done online so why not use your phone instead of visiting your doctor? Numerous private companies have already started offering GP consultations online. Babylon is one that has ‘teamed up with the NHS ‘ and can offer patients the choice to register with them and have their consultations funded by the NHS.

We already have ‘private providers’ working along side traditional suppliers for many aspects of health care. The NHS already pays for private companies to offer scans, physiotherapy services and funds private hospitals to carry out operations to shorten waiting lists. These private providers are often accused of cherry picking patients. For example most private hospitals providing NHS operations have exclusion criteria and will not treat the very elderly, the mentally ill and those with complex medical conditions. These will be left for traditional hospitals to treat. Treatments attract an ‘item of service payment’ so a patient with complex medical problems who may take twice as many days to recover from a hip replacement will attract the same fee as a fit younger patient. Private providers have been accused of cherry picking the easier more profitable patients. Babylon’s GP at hand service states that a consultation will not cost the NHS any more than one at a traditional surgery. However it is younger, fitter, more educated patients who do not require an examination that are likely to consult so they are likely to be attracting the easier patients with simpler problems.

There is a lack of GPs. These companies will employ a lot of GPs, who will consequently do less work for the NHS which may pay them less and provide them with more complex more stressful work. This would exacerbate the NHS GP workforce crisis. GP and journalist Margaret McCartney fears that it may ultimately derail our health service. “These schemes may mean that you end up having to wait even longer to see your NHS GP, as the workforce becomes more depleted,”

The NHS was founded to provide ‘free and equal health care for all’. Margret McCartney states.  ”These companies are essentially using market forces to determine access to GPs rather than need. GPs working in these companies will probably make more money and have a less stressful career. However, patients are far less likely to benefit. This might work in your favour if you are basically healthy, need a one-off appointment and have the money to pay to put yourself in the front of the queue. But if you have an ongoing condition, or multiple or complex needs, the research shows that your care will be better if you have continuity and are looked after by a team that can care for you holistically.”

 

Good luck in the BMAT ! Some more Essays.

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People injured whilst participating in extreme sports should not be treated by a publicly funded health service. Explain the reasoning behind this statement. Suggest an argument against this statement. To what extent, if any, does the statement justify a change in public attitudes to personal risk taking?

The statement states that people who voluntarily take risks with their health because they participate in extreme sports such as sky diving cannot expect tax payers to pay for their medical care if injured. It is a statement regarding social justice[fairness] because health systems such as the NHS are cash limited so that funds spent on such people will mean that less money is available for treatment for others. In a private or insurance based health system people who take risks would probably have to pay a higher premium.

A person’s autonomy has to be respected. They have a right to decide how to live their life and to do extreme sports if they wish. It is important to be non judgemental and act in the best interests of that patient which means treating injuries. If those participating in extreme sports are denied medical treatment for their injuries a slippery slope may be created in which those suffering from illnesses which may be in part also ‘self inflicted’ such as smoking or obesity related diseases may in future also find themselves excluded from state funded treatment.

At present ethical principles held by most, including the medical profession would value the principles of autonomy and beneficence over the idea that in doing so we would not be fair to others. The statement does put a valid argument to change attitudes to personal risk taking however because of the reasons outlined in paragraph two I disagree with a change of attitudes in this ‘rights versus responsibility debate.’

 

There is money to be made by not curing a disease. 

We spend a lot of money on our health services.The NHS is the biggest employer in this country. The NHS budget is about £120 billion per annum , this is about 8-12% of GNP per annum for most European countries. In the US it is over 18% of GNP per annum. In US today anyone in workforce works about 6- 7 weeks a year to create resources they will then ‘consume’ as health care. Pharmaceutical companies have grown to be the immensely successful giants that they are by providing treatments for long term conditions such as diabetes and hypertension. Long term conditions generate a lot of money for the payment of health workers and for drug companies e.g The treatment of diabetes costs over 10 billion [10% of the NHS budget]a year in the UK. Pharmaceutical companies spend a lot of money on new treatments for diabetes because the financial rewards are so great.

It is unethical and extremely rare for doctors and scientists to withhold ‘cures’ in order to carry on treating the patient. I do not believe conspiracy theories that ‘big pharma’ has cures for conditions but does not want to release them. However when scientists apply for research grants pharmaceutical companies with their enormous R and D budgets will look with more interest at research which is likely to lead to profitable drugs rather than cures which would limit the need for their drugs. The need to generate a profit for share holders may be counter productive  in the quest for cure. In my opinion there it is sad but probable that businesses will focus on treatment rather than cures. Pharmaceutical companies have provided major breakthroughs in the past [eg Sir James Black discovered B blockers and then Tagamet] but over reliance will be detrimental. We face a world threatened by increasing  antibiotic resistance.  Dame Sally Davies the Chief Medical Officer as called on governments to fund research as there is not much incentive for drug companies to fund antibiotics that are just usually taken for a few days while a new blood pressure pill may be taken continuously every day by a patient. Dame Sally said action was needed to overcome this “market failure” and stated that this should be taken up by the ‘Innovative Medicines Initiative’ – an EU funded body whose aim is to promote the development of new medicines. Bill Gates has poured a lot of money into the research of drugs which can cure diseases in the third world where drug companies would not be able to recoup costs. He has also supported GAVI a charity which funds vaccine research to prevent illnesses in the first place. The new rota virus vaccine which kills many children in the developing world has been funded in this way.

We need charities, university research departments and governments to also carry out research, particularly into cures because over reliance on pharmaceutical companies would probably mean more money is spent on research into treatments rather cures.

More BMAT essays.

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a glorious enterprise

 

Science is a great and glorious enterprise-the most successful, I argue, that human beings have ever engaged in. To reproach it for its inability to answer all the questions we should like to put to it is no more sensible than to reproach a railway locomotive for not flying or, in general, not performing any operation for which it was not designed.
What do you understand about the statement above? Explain why it may be argued that science should be expected to answer all the questions that are put to it. Discuss giving examples, the extent to which science has its limits.

Answer

Science has made astonishing progress in increasing our knowledge about how the Universe works. However as the writer points out there are other forms of knowledge as well as the observational and deductive logic that science relies on. A person will use emotional knowledge to tell him whether he likes a piece of music or a painting. The quote tells us critics who complain that science does not have all the answers are right but that does not detract from the value of scientific work.

In an increasingly secular world many people see science as replacing religion. People are attracted to the open values of science and its evidence based approach. They feel that scientific methods could be applied to other forms of knowledge such as psychology and economics. The involvement of science in fields such as the arts has led to the expectation that eventually science will tell us everything, even such matters as why we are attracted to certain people as humans are just products of their biology.

Science will always have limits. Every new discovery will lead to many more questions. In a near infinite universe we cannot know everything. ‘The greater the island of knowledge the longer the shoreline of uncertainty’. Science cannot tell us how to resolve an argument, how to love or what is right or wrong. Empathy, [emotional knowledge] and ethics are different but important forms of knowledge. Science can be used in good or bad ways, for example the germ theory of disease can be used to prevent transmission of disease or in biological warfare. Scientific development should always be within an ethical framework.

We Don’t Live in a World Of Reality, We live in a World of Perception. What do you understand the above statement to mean? Provide examples of how we live in a world of reality and how we live in world of perceptions. What is the common ground between reality and perception.

 

Blind men and the elephant

Answer

Descartes, the famous philosopher imagined a world controlled by an evil demon creating false illusions; he concluded that the only way he could be sure that he existed was because he could think. The film, the Matrix, was based on this idea.  Our view of the world is limited by our perception. Our vision, often regarded as our most important sense only detects a narrow range of electromagnetic wavelengths. Our other senses are similarly limited.

We live in a world of reality to the extent that our senses do not seem to lie. If I touch my desk it feels solid and occupies the space my vision tells me it does. When I call my sister she does hear me. This tells me that we do live in a world of reality. However science tells me that my desk is made up of atoms with enormous spaces between them and even within the atoms there is much more space than solid. Are my senses deceiving me by making it appear solid? We all know of examples of when perception is completely misleading such as in mirages.

It is important to realise that our picture of the Universe is limited by the perception of our senses. We only perceive a small fraction of the Universe. In the old story of the blind men and the elephant, one blind man felt the tail and declared it to be like a snake, another leg and said it was like a tree and so on. All of them were right but all were also wrong. We are stumbling around in the Universe in a similar blind way, reality and perception come together at times but we rarely see the full picture.

Should vaccinations be compulsory? [Ethical scenario of the week and past BMAT question]

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France and Germany are to extend the number of compulsory vaccinations for children. The government in Italy ruled that children must be vaccinated against 12 common illnesses before they can enrol for state-run schools. If children are not vaccinated by the age of six, the school starting age, their parents will be fined. Conspiracy theories about the health risks of certain vaccinations – largely based on the  – have circulated around the world, leading some parents to shun immunisation. Parents in France will be legally obliged to vaccinate their children against measles from 2018, the government has announced.  The French Prime Minister evoked Louis Pasteur and said it was “unacceptable” that children are “still dying of measles” in the country where some of the earliest vaccines were pioneered.

Immunisation may be the most important and life-saving medical invention, arguably saving more lives than antibiotics. A handful of Spanish invaders were able to conquer South America because the majority of natives died from the diseases they introduced [some areas decimated – reduced to 10%]. The 1st World War was responsible for more deaths than any war in history but the Spanish Flu, towards the end of the war in 1918  killed far more – an estimated  50 to 100 million people [3 to 5 percent of the world’s population]. Bill Gates [of Microsoft] has in his wisdom poured billions into vaccinations, via GAVI, as it is one of the best ways to prevent needless deaths and disability. The medical view is clear. There is overwhelming evidence that immunisations are relatively safe procedures that protect populations effectively against the risk of serious disease. When I was young my sister’s best friend’s brother was brain damaged because of measles. It is undoubtedly one of the major causes of the increase in life expectancy in the 20th Century. Bill Gates, with his intelligence, has chosen to invest much of the millions he made in GAVI, which researches into and provides vaccines world-wide. New vaccines are being added all the time for example rota virus and Meningitis B.  

There have been numerous scare stories about immunisations as any search on the internet will show. The last major scare involved Andrew Wakefield who appeared to show a link between the MMR vaccine and autism and a bowel disease [Crohn’s Disease]. It was later revealed that much of his research [which involved risky procedure on children] had been fabricated and he had been paid hundreds of thousands of pounds by lawyers acting for anti-vaccine court cases. The dip in vaccine uptake undoubtedly led to deaths.
However although the risk of harm is very low there are small risks involved. Vaccines like other medical treatments such as antibiotics are not 100% safe, 100% of the time. The risk of most vaccines is comparable with that of crossing roads; for example being seriously affected by measles is about 1/10 of the life time risk of getting struck by lightning[see http://besthealth.bmj.com/x/static/514517/decision-support.html%5D

Reduced uptake of vaccination results in more cases of the disease. If vaccination rates fall below 95% there will be a loss in what is termed ‘herd immunity’. Herd immunity occurs when the vast majority of a population is so resistant to an infection that that infection is undetectable in that population. Those who can’t be vaccinated for medical reasons or those with reduced immunity such as cancer patients are thus protected from the illness. In the USA it is compulsory to show that a child has been vaccinated when it attends school because a non-vaccinated child can be a source of an infectious disease.Donald Trump and other Republican candidates want to change this.

Vaccinations are an emotive subject for many who are anxious not to take any risks with their health of their children. An injection intrinsically seems to cause much more fear than a tablet and as a profession I do not think we explain risks well. Risks are unavoidable in life and the risks from vaccinating are small, certainly smaller than the risk from large numbers not being vaccinated. We need to celebrate the success of vaccinations. They are a vital weapon in our armoury against infectious diseases. A century ago most people died from infectious disease, this thankfully is rare because of antibiotics and vaccinations. As antibiotic resistance grows vaccinations will become even more important

Should we make vaccinations compulsory? They protect a population best when there is herd immunity and the only disease eliminated by vaccination was smallpox which was backed by compulsory vaccination. However patients have autonomy, the right to refuse treatment and often [but not always] to refuse treatment for their children. To deny them this would certainly harm the doctor- patient relationship. So, as long as we are not dealing with an illness such as smallpox or SARS I think on balance it is better to leave the law as it is and put more effort into persuasion.

BMAT essays.

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My advice for tackling the BMAT essay is to practice writing them to time in the space available. You only have a small space to write in so you need to be very disciplined. It is too easy to get carried away with a point and write too much and not leave yourself enough space to make a balanced arguments with lots of different points. I think that time is not an issue so I would write your essay in bullet points in rough before writing it on the paper [you get rough paper in the exam].

I would usually use a the simple format of a three paragraph essay. The first paragraph exploring the question, the second exploring other points and the third paragraph summing up or providing a conclusion. However it is important to be flexible.

Here is an example:

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

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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. 

Here are a couple more BMAT questions for you to try – remember answer them in a space the same size as the box you will be given to write in.

Science is a great and glorious enterprise-the most successful, I argue, that human beings have ever engaged in. To reproach it for its inability to answer all the questions we should like to put to it is no more sensible than to reproach a railway locomotive for not flying or, in general, not performing any operation for which it was not designed.
What do you understand about the statement above? Explain why it may be argued that science should be expected to answer all the questions that are put to it. Discuss giving examples, the extent to which science has its limits.

Answers in a few days – [I will post answers on Wednesday]

We Don’t Live in a World Of Reality, We live in a World of Perception. What do you understand the above statement to mean? Provide examples of how we live in a world of reality and how we live in world of perceptions. What is the common ground between reality and perception.

Answers in a few days.

We Risk Losing Antibiotics

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approached-by-the-antibiotic-resistance

Antibiotic resistance  is according to our Chief Medical Officer, a far greater threat than the terrorist threat. It is already estimated to cause 5,000 deaths a year in Britain. No new classes of antibiotics have been developed for 25 years: the pharmaceutical industry has focused on more lucrative types of drug that are taken daily for years rather than antibiotics which because they are taken as a short course, are therefore less profitable. Dame Sally Davies, The Chief Medical Officer has warned that that resistance could ultimately make major operations and many treatments we take for granted too dangerous, and medicine will be forced back to the dark ages as effective antibiotics will not be available. She suggested last year that governments step in to help research funding. She is attending a conference in Berlin to address the global response to antibiotics resistance.

 

Infections [communicable diseases] used to be the commonest cause of death but now thanks to better sanitation, immunisations, and antibiotics they account for 7% of all deaths. The major causes of death in the UK are now what we call non communicable diseases such as heart attacks, cancers and strokes. [See my book Medical School Interviews The Knowledge p64] It would be appalling if antibiotics stopped working. As Dame Sally said ‘We won’t be able to do a lot of our cancer treatments or organ transplants’. People may die of a simple scratch again.

Why is antibiotic resistance increasing?

1. Over use of antibiotics by people. We do not need to use antibiotics for simple infections, many of which are viral and do not respond to antibiotics. If people do not take the full course or miss tablets it may allow resistant strains to grow by not completely killing all the bacteria. Although doctors in the UK are rightly criticised for over prescribing antibiotics they actually prescribe fewer than in most countries. It is also possible to buy antibiotics from pharmacies in most countries in the world without a prescription.

antibiotics and farmingimages

2. Overuse of antibiotics in farming. Animals actually consume more antibiotics than people. Infections are common in overcrowded dirty conditions so they are often given in small doses in feeds [this is cheaper than providing better conditions]. They are also used as growth promoters; if they are added to feeds they reduce the amount of bowel bacteria and animals put on more weight. In one study of Chinese pig farms Chinese and American scientists detected 149 unique resistance genes. The top 63 antibiotic-resistance genes were found in concentrations between 192 times and 28,000 times higher than “control” samples of manure or soil that were antibiotic-free. Salmonella, a bacterium found in poultry and infects humans who may eat undercooked chicken [barbecues are common culprits] has become increasingly resistant to antibiotics in this way.

3. Antibiotics are expensive to develop. There is not much incentive for drug firms to develop new antibiotics as they tend to be taken for just a few days while a new blood pressure pill may be taken continuously every day by a patient. Dame Sally said action was needed to overcome this “market failure” and stated that this should be taken up by the ‘Innovative Medicines Initiative’ – an EU funded body whose aim is to promote the development of new medicines. David Cameron had a similar discussion with G8 leaders [ the leaders of the richest 8 nations]
Leading microbiologists say that there are only a small number of ways of attacking bacterial cells and these are being exhausted. If we squander the antibiotics we have we will not necessarily have new antibiotics to take their place. There have not been any new antibiotic groups since the 1980s.

What can we do?
1. We should reserve antibiotics for serious infections. I often think of Tolstoy who said ‘Time and patience cures most things’- unfortunately many patients don’t have the time to be ill and certainly not the patience! MRSA[methicillin resistant staphylococcus] and clostridium difficile rates in hospital have decreased in hospital since better practices were introduced but unfortunately there has been a rise in E coli and other infections.We need to look very carefully at farming practices. Antibiotics should not be used to make up for shoddy, dirty farming practices.

antibiotic resistance staph
2. Value our ‘good bacteria’. About 90% of the cells in the human body are supposed to be bacteria. We have trillions of bugs living in our gut and on our skin. Most of these cause no harm and some are helpful. Their presence stops bad [pathogenic] bugs growing by depriving these pathogenic bacteria of space to grow. We know that over washing can lead to more rather than less skin infections and it is common after a course of antibiotics to get other infections such as thrush [a yeast infection which grows into the space that had been occupied by good bacteria now killed off by antibiotics.]
Many teenagers may be taking antibiotics for acne. These work against Propionibacterium acnes bacteria which cause inflammation in sebaceous glands of the skin leading to spots. Recent studies seem to show that those teenagers without acne still have Propionibacterium acnes but of a strain that does not cause inflammation. Perhaps in the future a treatment using this ‘good strain’ may become available. [J. Bacteriol. January 2012 vol. 194 no. 1 202-203]
Probiotics– These have been shown in some studies to be helpful in treating diarrhoea. They contain harmless bacteria like lactobacilli which are supposed to displace harmful bacteria. Studies have shown that taking capsules of ‘healthy faeces’ known as a ‘faecal transplant’ also helps certain types of diarrhoea by re-colonising the gut with normal healthy bacteria!poop_by_a_ufo_lost_in_flames-d5qoq873. Bacteriophages are viruses that infect bacteria. They have been used for over 90 years as an alternative to antibiotics particularly in Eastern Europe and the Soviet Union. They are usually very bacteria specific – only acting on one type of bacteria. There has has been increased interest in them because of antibiotic resistance and since 2006 several types have been licensed including one against MRSA! However they are still not in common use

bacteriophage

There must be a global, coordinated campaign. In some parts of the world antibiotic resistance is much greater. New Delhi Metallo-beta-lactamase-1 (NDM-1) is thought to have emerged in India where poor sanitation and antibiotic use have helped resistance to spread. This multi-resistant bacteria has been found in the Delhi drinking water but due to international travel, cases have been detected around the world including in the UK. Britain misuses antibiotics much less than many countries where they can be bought cheaply without prescriptions. Drug resistance cases of bubonic plague have also been discovered in Asia raising the spectra of recurrence of a disease that some estimate to have wiped out a third of the population of Europe.