Stoic Week

Today, Monday 24^th November 2014, is the first day of Stoic Week – an annual event started by the Stoicism Today team at the University of Exeter. The team at Exeter are some academics, philosophers and psychotherapists who run a blog that offers resources to explain Stoic philosophy and show how it can be useful in people’s lives.

I’ve taken a casual interest in philosophy since my school days, through until now this has been limited to a few popular philosophy books and internet comics, like this one. 

Superficially at least, I’ve always admired the Stoics, maybe because they feature early on in most popular histories of philosophy so I actually get to their chapter before giving up on the book. My understanding of stoicism is mostly limited to the word as it is commonly used; a stoic person is noble and uncomplaining, carrying themselves with a dignified and stereotypically British stiff-upper lip “mustn’t grumble” attitude. This ideal is basically the opposite of my usual snivelling, moaning personality and so I am quite keen to find out more about Stoicism and how it might improve my attitude to life.

To shoehorn some relevance to medicine in here, participants in last year’s stoic course reported a 14% increase in life satisfaction and a decrease in negative emotion. Like mindfulness and cognitive behavioural therapy (which are proven to be effective in treating depression), it seems likely that courses in Stoic resilience might have similar benefits in improving mental health.

Stoic Week is an event that invites people all over the world to spend a week thinking about the basic ideas of stoicism, on each day there is a different theme and some exercises to practise. The impact of stoic thinking on attitudes, behaviours and wellbeing is also assessed using online wellbeing surveys taken before and after the week. The website has loads of information about stoicism in general and includes a downloadable copy of the stoic week handbook and information on how to take part in the week.

So I signed up to the course at www.modernstoicism.com. After completing 4 brief questionnaires designed to reveal my levels of contentment (or otherwise) I was given a quick summary of Stoicism from Epictetus’ handbook. I’ll try and summarise the summary as I understand it here:

Stoicism is an ancient school of philosophy founded in Athens about 301BC, by Zeno of Citium. Other important Stoics include Epictetus, Marcus Aurelius and Seneca. The core view of stoicism is that the highest authority is reason, and Nature, life and death exist as they appear to. Nature is governed by rational principles that we cannot change nor should desire to. In contrast, emotional responses are not subject to reason; they are falsehoods. So we can control our judgements through rational thought use this to inform our actions, and our voluntary actions are the only important thing; they are our true self.

Our body, health, possessions or status are often not due to our voluntary actions, we have no control and so it is not rational to be distressed with these things. By remembering this a person can meets hardship and even their own mortality with dignified acceptance; harm cannot reach one’s true self.

A much better summary can be found on the Exeter blog: http://blogs.exeter.ac.uk/stoicismtoday/what-is-stoicism/

The first day of the course suggests spending time thinking about the level of control a person has over there situation. Stoics think that confusion between what you can control (your thoughts and actions) with what you can’t (everything else) leads to unhappiness. Broadly speaking this is good advice; I try not to get annoyed when I get caught in traffic on the way to placement or when the teaching session I drove in for is inevitably cancelled. And the reverse is true too, it doesn’t make sense to feel too smug when things go well; the fact that I don’t have any real concerns regarding my shelter, health, safety, finances, education or future are not due to my thoughts or actions, they are lucky by-products of the accident of my birth.

But overall I’m not entirely sure I can get completely on board with the stoic thinking. There're far too many unwell, unhappy, or dying people in hospitals, and most of them do indeed meet their challenges with dignity and grace. I don’t see how a person with a terminal illness (and there are plenty of them) can choose to be not pissed off even if they have no control over their situation. I guess they are supposed to realign their thoughts with their reality, and accept their fate without emotion, but this seems to me a heartless and impossible expectation. Good stoics would argue that virtue is all that is needed for happiness but I think that an absence of terrible circumstance is important too. Maybe I've not fully understood the stoic attitude here, I suppose it is only day one.

Ebola and homeopathy

A few months ago I wrote a fairly patronising summary of the ebola situation as was, and optimistically opined that perhaps the problem had been exaggerated by the media. Annoyingly, the disease has yet to burn itself out and the most current data from the WHO reports that there have now been at least 13,700 cases and 4,900 deaths.

In the UK there has been only one, imported, case of ebola. This was William Pooley, who contracted the disease in Sierra Leone and was transferred to London in August. He was treated with the new drug ZMapp, made a full recovery and has returned to Sierra Leone to continue his help.

The vast majority of cases remain in the West African countries Guinea, Liberia and Sierra Leone, and so it remains quite unlikely that infected people from these areas will reach the UK and transmit the virus here. The risk is certainly not zero however, and so Britain is currently continuing with preparations for this possibility. Most trusts have published protocols and guidance for dealing with suspected ebola cases.

Spotted in a Birmingham Hospital's ITU

I attended a lecture at my hospital on the subject, and learnt about the procedures to reduce the risk of infection, such as extra PPE and keeping such patients isolated in negative pressure rooms. Importantly, the staff were warned not to transfer suspected blood samples to the lab via the pneumatic tube system we would usually use, in case the blood vials were to break and effectively aerosol the blood and virus all around the hospital.

Ebola not welcome: A sign on the entrance to an Edgbaston GP Practice

Perhaps the most important intervention will be the use of homeopathy to combat the epidemic. Resources should clearly be diverted to the development and distribution of a homeopathic cure, you can help by signing a petition to urge the WHO to do just this. Sign it HERE*.

The good news is that a team of homeopaths have been mobilised to frontline West Africa to begin this important work.

A cynical person might suggest that sending homeopaths to ebola zones is evidence of natural selection at work. This is a cruel joke, and meaningless too because evolution doesn't exist.

Some homeopathic pills to treat Malaria

Anyway, you can already easily buy homeopathic treatment for most diseases online, including pills for dengue, meningitis and tuberculosis.

And of course mercifully there are several homeopathic clinics in Africa many of which offer cures for HIV and AIDS. Not sure if I've mentioned on this blog but I went to Tanzania earlier this year. I’ve seen a little of how devastating HIV can be to communities and individuals, but luckily charities exist that aim to help reduce this suffering. This is one of them, http://www.homeopathyforhealthinafrica.org/ and it has characteristically virtuous aims:

- To relieve the suffering of HIV/AIDS patients using classical homoeopathy
- To identify the homoeopathic remedies most successful in treating HIV/AIDS
- To spread this knowledge throughout Tanzania and Africa
- To produce formal, ethical research
- To prove to the world what homoeopathy can do

For the unenlightened, homeopathy involves taking an ingredient that causes harm and diluting it significantly, thereby releasing its healing power. The standard dilution (such as for the linked cures for dengue and meningitis above) is “30C”, meaning the original drop has been diluted by 1 drop in 100, 30 times. So 30C means one part in 1060.
This level of dilution, such that there are zero molecules of ingredient left in the treatment, is vital for the homeopathy to work.

Regrettably however, the benefits of homeopathy are denied by some groups – for example educated people and "scientists". For example, some of these “scientists” published a paper in the Lancet that compared 110 studies of homeopathy with 110 conventional medicine studies and concluded that the effects of homeopathic interventions are merely placebo effects. (1)

The 2009 official WHO statement is similarly closed minded:

“There is no place for homeopathy in treating serious illness such as HIV, TB, malaria and infant diarrhoea in developing countries.”

Quite clearly a needlessly obstructive and unhelpfully negative attitude.

In all seriousness I wish the homeopathy team in Africa the very best and sincerely hope that they manage to avoid infection,  and especially so to prevent the spread of the disease further.



*Please do not sign this stupid petition


The reference for the paper I mentioned is:
1. Shang A, Huwiler-Müntener K, NarteyL, Jüni P, Dörig S, Sterne JA, et al. Are the clinical effects of homoeopathyplacebo effects? Comparative study of placebo-controlled trials of homoeopathyand allopathy. Lancet. 2005;366(9487):726-32.

How to Become an F1 Doctor - The Illusion of Choice

Some, including yours truly, may find it difficult to believe that in August 2015 I expect to begin life as a junior doctor. If everything goes to plan then I will nervously sweat and mumble and spread infection in a hospital – like what I currently do as a medical student, only more so (and with more direct consequences for the ill people I come into contact with).  

The most junior doctors in hospitals used to be called House officers, but since 2005 are now called FY1 doctors – because they are in the first of two years of the foundation programme. A complicated nationwide online system is used to match the 7000 or so applicants to their foundation programme jobs and hospitals. Put simply, each candidate ranks the available jobs in order of preference and is allocated one based on the number of points they can scramble together. Points mean prizes, and the prize here is precedence in allocation of your application choices.

I foolishly spend far more time complaining about the application process (see current whinging blog post) than actually thinking about my own application; the deadline is this week.  Now and then I become self-aware enough to feel a little ashamed of complaining and realise how good we have it as medical students; unlike almost every other degree programme in the UK nearly all of us that pass medical finals will get a job, somewhere. For the last four years there have been more applicants than jobs for them but for example last year in 2014 96% (7114)  where allocated jobs in the first round and places were eventually found for all 235 remaining on the reserve list.

So bearing that in mind, here is where I whinge at length about the system, conveniently grouping my complaints into two categories thus:

1) The points system is not perfect

Some jobs and some parts of the country are more desirable and therefore more competitive than others.  You can’t make every finalist happy (see current whinging blog post) and allocating randomly is clearly madness. So a system has been devised to rank students from best to worst such that the better get to go where they want and the worse have to go where they’re told. This is done by ascribing each student a score out of 100:

The educational performance measure (50 points max)

An applicant gets between 34-43 points for their decile in their medical school exams to date. I don’t think there’s a particularly strong correlation between exam score and competency as a doctor, common sense and teamwork and time management are more important than memorising textbooks (but maybe that’s me being defensive since I’m not top of the year by a considerable margin). Also some question whether the points awarded per deciles should be equivalent across all medical schools as is currently the case, despite different entry standards, different syllabuses, and different exams  (though this argument is usually made by those individuals with a snobbishly high regard for the calibre of their own institution.) Admittedly this system might change in years to come.

There are up to seven extra points given for other degrees, depending on how advanced the degree is (bachelors, masters, doctorate) and its classification. Again the number of points are standardised between degree subjects and institutions and includes intercalated degrees, all of which vary considerably. I spent three years getting a degree in biology. It was quite tough, sometimes it was fun and interesting, and I like to pretend it’s given me some life experience and a bit of a broader knowledge base, but I’m pretty sure that this doesn’t make me a better prospective doctor. Essentially I’m getting rewarded for being indecisive about my career.

Finally there are up to two points available for publications, the same number of points for having your name attached to any pubmed number regardless of its relevance, the quality of content or the journal it's published in. I think this leads to a pretty cynical approach where research is regarded primarily as a means to build and decorate CVs, and it is depressingly a feature of the entire medical career structure.

The situational judgement test (50 points)

The other 50 points come from the situational judgement test (SJT), a curious exam sat by every applicant. It uses 70 multiple choice or ranking-type questions to assess whether a candidate is able to make safe and sensible non-clinical professional decisions.

Here it is theoretically possible to score anywhere between zero and fifty– making this 2 hour 20min exam far more important for the job application process than the performance across an applicant’s entire medical degree (where the difference between top student and bottom student translates to only 10 points).

In reality the SJT isn’t quite so discriminatory; over 80% of applicants are within the 10 point band between 35 and 45, in a negatively skewed approximately bell shaped distribution. The average score in 2014 was 38.95 (SD 4.25). The SJT is perhaps more useful in its function as a safety net - candidates that score very poorly are flagged up to assess whether they are suitable to work as a junior doctor despite being able to complete medical school.

2013 SJT results distribution

Given that I have not taken the test yet (I’ll sit it in January) I can’t really comment on its particulars, but I suppose that I am relatively impartial because it hasn’t been used to assess me yet. The test has been used since 2013, an inauspicious inaugural year that was distressing for the applicants as after jobs had originally been declared the tests were remarked, many scores went up or down and so changed the outcome for many.

The SJT is still a relatively unknown quantity, and as such it is fairly odd that our futures are so dependent on it. The existence of the SJT seems to curiously disincentivise one from working to do well in medical school exams, and adds an almost completely random element to the application process. We are advised that it is a test that is impossible to revise for, but that hasn’t stopped entrepreneurial organisations from offering wide ranges of dubious and expensive preparation materials and training courses.

2) Choice is an illusion

I am chronically indecisive. I have no clear view of where I want to be in five years, or what sort of doctor I want to be (if any: plan A is still scratch card windfall). During my time at medical school I haven’t been able to exclude many specialties from my list of potential jobs or careers and I’m not drawn to any particular part of the country for any reason. Plus some people say I overthink sometimes (see current whinging blog post).  I therefore seem to find the applying for F1 less straightforward than many people I know.

The foundation programme is usually six different 4-month rotations, during each the junior acts as dogsbody to senior doctors in a specific area of medicine. There are several levels of apparent choice at work before a job is allocated, firstly the area of the UK (there are 21 “foundation schools”), the hospital, and the specific clutch of six rotations themselves.

Each coloured block here is a foundation school
The first decision is ranking these in order of preference

So with just these three factors there are many hundreds of possible combinations available to consider. Unfortunately, outside of the hospitals I’ve been placed at around Birmingham I have no knowledge of the relative merits of any other part of the UK, or any other hospitals. And I also have no real knowledge about what are the differences are between different F1 jobs. More uncertainty is introduced because all foundation jobs are “subject to change”; I know of people who ended up frustrated with three completely different FY1 rotations to the three they applied for (and were allocated to).

Further considerations that might affect how much you would want a job include the team you will be working with and the consultant you’d be serving under –unfortunately both of which are impossible to know until you start work. You might also attempt to guess where your friends might end up, which is at least as confusing as attempting to predict the future for yourself.

According to the Mental Capacity Act 2005 (completely unnecessary tenuous reference) a person’s choice is valid only if they fully understand the benefits, risks and alternatives of a decision. I don’t feel at all confident that I meet this charge. There is a huge amount of information online comparing different areas to work by every imaginable characteristic, so much information that it becomes impossible to digest it. Deciding what is important (City or Rural? North or south? Medicine or surgery? Is it too competitive? Known or unknown? Accommodation? Old friends or new people? Things to do outside of hospital? And so on?) is difficult and often arbitrary, and the decision is never completely informed due to the uncertainty that remains as to the true nature of the location, hospital and job you apply for.

Perhaps most confusing is that applicants rank all the deaneries before we know our scores – as mentioned above the SJT is shrouded in mystery and ensures that no one is at all sure how strong their application will be until after the results. Perhaps I’d apply to a competitive deanery if I was sure I had enough points to secure a decent hospital and job were I to get it. But regrettably I still don’t know what I want, and anyway it’s quite hard to even guess which deaneries and which jobs will be competitive since this seems to change a great deal from year to year.

So maybe I'm a little defeatist and pessimistic but I feel completely overwhelmed by the scope of possibility for next year, and I have gained almost no useful predictions as to where I will want to be, what I want to do or what level of control I have in effecting my choices. It’s not ideal that I take the same fence-sitting approach to clinical decisions too. One thing I am sure of is that after what will be seven consecutive years of being a student I’m really looking forward to getting a job. Any job.

Languages (and Lack Thereof)

One of the best things about the West Midlands is the diversity of people that can be found here; there are slightly more than one million people living in Birmingham and almost a quarter of these were born outside of the UK. I like to think that the small snapshot of Birmingham life I see in the hospitals represents a charming microcosm of the Midlands and, if you allow me a small extrapolation, is something of a model of our terrific multicultural and international planet.

Most recently I’ve been placed in West Birmingham, an area of high ethnic diversity even for the midlands – overall only 53% of Birmingham residents identify as “White British” compared with 92.4% of those from nearby Worcestershire. 

According to a Telegraph article from last year there are over a hundred languages spoken by school children in Birmingham. (As is always the case with internet articles, best to ignore the comments. Here they are even more reactionary, right wing and racist than you might expect given this newspaper.) This rich complex of languages spoken is fascinating,  but occasionally leads to some interesting communication problems.

For example, I have a few Asian friends (see I can’t be x-ist some of my best friends are x), and I’m often jealous when they’re able to whip out some language skills and converse with some of the patients better than I can. However I especially enjoy when patients and staff assume language based upon someone’s appearance or skin tone, so there are a few medical students getting frustrated by their daily apologies and explanations that no, sorry, I only speak English. Now and then I fake offense when patients assume that I won’t be able to speak Urdu just because I’m white(ish), though it would be more convincing if I learnt some phrases to justify this.

Almost always patients will speak very good English even if it is their second language, though occasionally they will require some clarification through a linguistically talented staff member or understanding relative. Sometimes translators are booked too, especially for outpatient’s appointments, though sometimes this seems unnecessary. I remember a series of appointments during my psychiatry placement where a translator was duly booked every week for a completely mute schizoprenic patient, whose partner could speak perfect english anyway.

Occasionally all of these solutions are absent; this week I met a young man who was both completely deaf and completely Polish. Further, he had fallen off a motorbike in Greece and provided his (Greek) medical reports. His mother knew Polish sign language and spoke no English so an additional Polish to English translation step was required. This made for slow progress. Luckily, he was able to read some written English so when I had to take some blood I prepared a few notes to pass him. The notes seemed to be understood and when I waved my sharps bin at him he gave me the thumbs up.  I still gave a pointless running commentary of the whole process though.

I recently was talking to another excellent Polish gentleman with a fairly nasty looking deep leg injury. He couldn't speak perfect English but made sure that his slight lack of comprehension was more than made up for with his compliance and positive attitude. Are you feeling better today? Yes! Is your dressing comfortable? Yes thank you! Yes! Are you in any pain today? Yes! Where is the pain? Yes! No problem!
I am a big fan of this attitude.

ITU

This post is a slight departure in tone from what I’ve written before; I feel the urge to write about some quite affecting and upsetting events from recent weeks, to make an attempt to record their significance and impact before I become hardened to the harsh realities of modern medicine. For confidentiality and out of respect for the privacy of those involved I’ve changed most of the details about what follows but remain honest in my attempt to convey how I felt. It’s difficult to communicate what I mean: writing it down helps a little, but I don’t expect what follows to be of much interest to anyone else.

Hospitals are an altogether unpleasant place to be. Unless a person is paid to be there (or , like me, is learning how to eventually be paid to be there), that person’s  visit to hospital is inevitably associated with an adverse event, it is either a trip necessitated by their own sub-optimum health, or a visit to someone close who is unwell. During my most recent attachment I spent some time on the hospital’s intensive care unit (ICU, confusingly aka ITU or CCU), that quiet part of the hospital reserved for the care of the hospital’s most unwell patients,  the patients who require close monitoring and often multiple organ support.  The patients are often sedated and ventilated, supported by a network of drains and lines connecting to various machines. Their existence is simplified to some matrix of data regularly reporting their oxygen levels and blood chemistry and other important values. A patient must be really quite unwell for admission to ICU, and so unfortunately many of them do not recover – about a third will die on the unit. There were ten patients on the unit at the beginning of my week’s attachment, of which a good outcome (eventual discharge home without serious disability) was only a realistic possibility for one or two. Patients with hypoxic brain injury and no chance of regaining meaningful function are depressingly common.

The consultant explained that the job is like spinning plates, supporting several patients at once by bolstering their failing organs until they either make some recovery of function, or they don’t. The doctor must also communicate with anxious relatives often, calmly and kindly explaining the situation and inevitably breaking bad news several times a day.

I found it odd then, how a doctor could be so professional, understanding and compassionate with the relatives but seemingly so ruthlessly frank, flippant, and perhaps even brutal when discussing the patient in private, within seconds the patient becomes anonymous and insignificant. Given the type of patient on the unit, and their bleak average outcome, it is understandable that the staff may become desensitised to the individual tragedy of every case and the devastation that such conditions wreak on patients’ families. Patients on ICU can become dehumanised. They can quickly come to be regarded as non-responsive fleshy masses in union with tubes and wires and bleeping machines, large and awkward Tamagotchis that inconveniently occupy hospital beds (an expensive hotel at around £2000 per night).

This is probably not at all as I’ve described it; I don’t doubt the competence, concern or sense of responsibility of the medical staff. They work tirelessly and do an excellent job. It would be impossible to become deeply emotionally involved with every patient and perhaps if one were to this may impair the ability to function as a good doctor. But I can’t help but be disappointed in the apparent absence of compassion; I don’t ever want to reach the stage where I regard a dying patient as just another occupied bedspace on the ward.

I verified my first death on ICU, with one of the junior doctors. A woman in her 50s had had a completely unexpected and catastrophic bleed in her brain and only survived for a few hours on the unit. The verification of death is a mundane responsibility for doctors in hospital, it is supremely common and necessary but I found it surreal and was a little shaken in taking part. There is no formal legal definition of death in the UK and so verification simply requires clear documentation that several normal signs of life are absent. This lady was completely and indefinably different in death compared to the appearance of living patients but paradoxically one could still regard her as simply sleeping comfortably. She was still warm when I checked her pupils, felt for her pulse and listened for heart and breath sounds. I tried to illicit a response to pain by pressing firmly on the bone between her eyes, and then mechanically and self-consciously uttered “time of death 09.25”, as if I were transported to a medical TV drama.

A short while later I accompanied the ITU registrar to an emergency call in A+E. As we hurried to the resuscitation room he explained that usually these alerts turn out not to be too serious, but since he’d had a long run of simple cases recently he thought this one might turn out to be significant, and his premonition sadly rang true. We arrived moments after the ambulance to a manic scene. A tiny toddler lay on a startlingly over-sized bed in the bay dwarfed by medical staff in a flurry of activity around him. He had no heartbeat and one of the junior doctors was performing chest compressions. 

Almost immediately the registrar took over the ventilation of the child with a bag and mask and I was ordered to ring for the ITU consultant. After what seemed like ages I got through to him and I quickly mumbled my panicky message: paediatric cardiac arrest in resuscitation, please come ASAP.  Soon there were 12 people around the bedspace, taking turns to perform chest compressions on his miniature torso. A nurse barked timings over the ordered chaos, cues to administer adrenaline and assess whether any signal could be picked up by the heart tracing. At one point the A+E consultant optimistically shouted “stop CPR! There’s activity on the monitor!” only to immediately concede “no activity, resume CPR.”  

By this point a small audience of medical students had gathered, awkward morbid voyeurs feeling helpless and hopeless and in the way but a grim curiosity rendered us mostly unable to tear our eyes from the terrible scene unfolding. I will remember the next 15 or so minutes as some of the worst of my life.  The boy’s inconsolable mother watched impotently as the boys whole body was jerked up and down by the compressions. The simultaneous assertive voices of the team strained to compete with the suffocating sound of drilling intraosseus access points into his tiny shin bones, because it was impossible to get access to his veins to administer fluids. Eventually there was a slow realisation of the inevitable which surpassed the atmosphere of panic. I couldn’t stay in the room.

After 40minutes without a heartbeat the team closed the curtains. Alfie was two years old when he died, from a cardiac arrest following a seemingly standard tonsillitis. He had been seen by his GP and prescribed the correct antibiotics, but tragically he had become septic, his heart starved of oxygen stopped, and he died. His father arrived at hospital moments later.

I spent the rest of the day thinking about this event. Whilst the parents howled and embraced each other I watched the medical team slowly file out of the room, each to return to their jobs, and their lives. Alfie was two years old. No amount of thinking makes the outcome okay, nothing about this story is fair.