Saturday, June 27, 2009

Old & New

“It is as foolish to chuck out the old as it is to fully embrace the new.”

My early guru was referring to the changes happening in the field of psychiatry as the new benzodiazepines were being introduced. How right he was and the same view could well apply to other branches of medicine as well as psychiatry today.

“There is much we can learn from the past. One may even save a life.”
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
We have come full circle to some ancient Chinese CPR practice going as far back as 403 B.C.

Yet, the medical world has always been slow in accepting the new:

“His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.”
Cuckoo & Medicine: Dissent & Heresy

Brian Martin said in his book “Dissent and heresy in medicine: models, methods and strategies”:

“An orthodoxy that draws on the full range of resources, namely which exercises unified domination, is incredibly difficult to challenge. Many challengers subscribe to the myth of scientific medicine as being based on open-minded examination of evidence, and thus handicap themselves, since in practice they are ignored or attacked”.
Orthodoxy and Knowledge

Yet the so called new may indeed have its root in the very ancient, like ORT:

“I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.”
Ancient Remedy: Modern Outlook

Back to psychiatry and the treatment of traumatic experiences:

“What was most surprising was how the group that had counselling generally faired worse, much worse than those without any counselling. The group that did best were the ones that drank, and drank a fair amount.” Trauma and Human Resilience

Back to psychiatric medication:

“Take one advice from me; think the opposite, the opposite to what the big Pharmas tell you. In pharmacology, shorter acting drugs are more addictive. That was what I learned in Medical School and is still true if you think carefully about it.”……
It Pays To Be A Taditionalist: Seroxat

In a most unlikely place I came by this:

“Ideas without precedent are generally looked upon with disfavor and men are shocked if their conceptions of an orderly world are challenged.” Bretz, J Harlen 1928.
Dry Falls-Thinking Outside The Box

Popular Posts:

Old and New: Multiple Sclerosis & Elgar
Madness and Modernity, Bobby Baker & The Peril of Diagnosis
Teratoma: One Patient One Disease?
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D. : 95% vs 5%
Picasso, Medicine and Lloyds
Picasso and Tradition

Grand Rounds: Medscape Grand Rounds for June 30

Wednesday, June 24, 2009

Conditioned Overeating: Fat, Sugar & Salt

Sea Salt Dark Chocolate, Lindt

As major chocolate companies unashamedly offered chocolate with sea salt and other similar combinations, former F.D.A. chief David Kessler who dealt with the Tobacco Industry during his reign there has now uncovered the food industries' biggest secret in a new book:

“The End of Overeating: Taking Control of the Insatiable American Appetite”

After his stint at the F.D.A. he was famously fired in 2007 from his $540,000-a-year post as dean of the Medical School at the University of California, San Francisco, as a result of questions he had raised about the institution’s financial accounting.

He may be luckier with his new book as it is already a New York Times Best Seller.

The Washington Post took up his story:

“‘Highly palatable’ foods -- those containing fat, sugar and salt -- stimulate the brain to release dopamine, the neurotransmitter associated with the pleasure center, he found. In time, the brain gets wired so that dopamine pathways light up at the mere suggestion of the food, such as driving past a fast-food restaurant, and the urge to eat the food grows insistent. Once the food is eaten, the brain releases opioids, which bring emotional relief. Together, dopamine and opioids create a pathway that can activate every time a person is reminded about the particular food. This happens regardless of whether the person is hungry.”

“Not everyone is vulnerable to ‘conditioned overeating’ -- Kessler estimates that about 15 percent of the population is not affected and says more research is needed to understand what makes them immune.”

85% is affected though!

Kessler offered his own cure:

“The key to stopping the cycle is to rewire the brain's response to food -- not easy in a culture where unhealthy food and snacks are cheap and plentiful, portions are huge and consumers are bombarded by advertising that links these foods to fun and good times, he said.”

“Deprivation only heightens the way the brain values the food, which is why dieting doesn't work, he said.”

“What's needed is a perceptual shift, Kessler said. ‘We did this with cigarettes,’ he said.”

“Kessler said he's made that shift in his own life, eating small portions of foods that contain fat, salt and sugar, part of a "food rehab" plan he suggests in the book. He has certain rules -- no French fries, ever -- that help him navigate through vulnerable moments.”


“He has embraced spinning -- the first time he has regularly exercised. ‘I hated physical activity, all of my life, mostly because I was fat and it was hard to do,’ he said. ‘But I just wanted to do something. I picked spinning because you can't fall off the bike.’

The result:

“Kessler's weight is relatively stable at 162 pounds. (At 5-foot-11, Kessler's weight has swung from 160 pounds to 230 pounds and back, many times over. He owns pants in sizes ranging from 34 to 42. ) But there's something else that's changed. As he has come to better understand himself, the food cravings and the resulting anguish he felt have subsided.”

"After 30 years, I'm at peace."

WSJ Interview.

Watch out: Ice Cream too.

The Book:
“The End of Overeating: Taking Control of the Insatiable American Appetite”

Popular Posts:
Picasso and Tradition?
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
House M.D. : 95% vs 5%

Sunday, June 21, 2009

Winter’s Tale: Blood, Entrails & Hansard

Rulers of the world are confidently doing what they like! Could it be that Apollo has taken early retirement or has Apollo appeared in some different guise?

These are questions I asked myself after my recent visit to the Courtyard Theatre for a performance of The Winter's Tale at the RSC, Stratford-Upon-Avon.

I overheard some guide telling a group of tourists that in Shakespeare’s days, in order to please everybody, animal blood and entrails were used as props. At least we were spared of entrails and I was sure that Hermione’s blood stained post-partum garment was not of animal origin.

Hermione's blood stained post partum garment

RSC Website.

The audience loved the bear-a paper puppet of enormous proportions thus sparing Antigonus actual bodily harm on stage and so no blood or entrails here. In the play he was of course devoured by the bear, in the act of preventing the King’s attempted infanticide.

Rough justice indeed! Or was it Shakespeare’s insight and warning to those of us daring to disobey.

Apollo chose to kill King Leontes' heir brought him to his senses but by then it was all too late. As he left the stage the two giant bookcases that we barely noticed started to collapse towards the middle of the stage with all the “books” falling onto different parts of the stage. It was real and scary. Civilisation must indeed be coming to an end!

Tristram Kenton Guardian

Our party was sitting by the stage and so we all tried to pick up some of the torn pages: WOW!

All the books were indeed hard cover bound Hansards. (Hansard: The Official Report of the proceedings of the main Chamber of the House of Commons, United Kingdom.) How topical. One page was Hansard 1950 with questions on the new NHS. We duly put the pages back on stage for re-reuse.
Most if not all reviewers missed this powerful metaphor.

More powerful than blood and entrails.

Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.

Reviews: Telegraph. Independent. Guardian. Times.

Popular Posts:
Teratoma: One Patient One Disease?
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
House M.D. : 95% vs 5%
A Brief History of Time: Anorexia Nervosa
Picasso and Tradition
Grand Rounds: Leveling the Field at Florence dot com.

Saturday, June 20, 2009

NHS Wales-Why? Why? Why?

I happened to browse the GMC document sent to me and was surprised by what I found:

Newid mawr i GIG Cymru (All change for NHS Wales)  

“The NHS in Wales is undergoing wide-scale restructuring that will replace all trusts and local boards with seven new integrated health boards.”

Not another of those reforms that made things worse than before! I read on.
“In April 2008 the Health Minister, Edwina Hart, announced the proposals for a major change in the structure of the NHS in Wales in order to reduce bureaucracy and improve patient care throughout the country.”

Where is Wales, I asked!

“The new structure follows the signing by the coalition Labour/Plaid Cymru Government of the One Wales document which contained a commitment to abolish the internal market in the Welsh NHS.”

"The changes herald a unified health organisation, with executive responsibility for health being vested with the seven NHS local bodies at a national level. The new structure will be made up of two main bodies: a National Advisory Board and a National Delivery Board. Primary and secondary care (NHS Trusts and LHBs) will be merged into seven strategic Local Health Boards."

I tried to look at the dates to make sure the year was the right one! Not 1950!

Then I read this in Dr Crippen:

"A lunchtime phone call from a godson.He qualified as a doctor last year. He has just coming to the end of his F1 year. He wants to be a surgeon. A properly trained surgeon. There are a total of 41 F1s in the region in which he works. Twenty of them (he knows for certain, there may be more) are applying for jobs in Australia. He is one of them."
And this in Jobbing Doctor:
Too much ranting?

"Well, it's too late, and the NHS as we used to know it has now started to sink under the weight of the attacks of asset strippers and crooks."
How sad!
Dr Tony Jewell, Chief Medical Officer for Wales:

“The end of the internal market in health is part of the wider Welsh Assembly Government determination to make co-operation, rather than competition, the bedrock of public service delivery in Wales.”

My other posts:

Friday, June 19, 2009

The Fly Catcher: The Science

From Discover Magazine

“On Tuesday, June 16, President Obama dazzled audiences during a CNBC interview by performing a difficult feat: He swatted a buzzing fly in one swift motion, leaving the creature lifeless on the carpet of the White House's East Room.

“His swift blow was no small task: Flies are notoriously difficult to swat. In fact, they possess special skills that allow them to evade both flyswatters and human hands. They can place their body weight on their middle pair of feet—like all insects, they have three pairs—before they take off in flight,
according to a study in Current Biology. This ability leaves them in a prime position to launch themselves in the opposite direction from where they anticipate the flyswatter will fall.

“The insects are also covered with tiny hairs, called cilia, which sense even the minuscule changes in air pressure caused by a rapidly approaching hand. Additionally, their eyes have evolved to sense changes in light extremely quickly, thanks to a series of lenses that focus light and a vision system well-suited to their tiny size. That means the little buzzers quickly sense the shadow of an approaching object—such as a fly swatter—enabling them to flee before your hand can reach the table or wall. This is in sharp contrast to human eyes, which sense visual images with a single lens, allowing us to see detailed images but sacrificing some speed in our ability to see light changes.”

Watch: the Fly Catcher!

Tuesday, June 9, 2009

Abilify/aripiprazole: Akathisia-gate

It must be beyond anyone’s imagination that Richard Nixon’s Watergate scandal has added “gate” to whatever scandal that affects not just politicians as it has now moved to the medical world and it involves major pharmaceutical companies.
Getty Images

I was grateful for Carlat Psychiatry Blog for a series of articles on the matter of Abilify/aripiprazole and the ways Bristol-Myers Squibb tried to downplay one of its major side effects: akathisia-restlessness of all kinds to the sufferers.

From the Carlat Pscyhiatry Blog:
Akathisia-gate Scandal in Wall Street Journal
Thursday, May 14, 2009

"Akathisia-gate, Bristol-Myers Squibb's ongoing efforts to distract attention from the major side effect of its blockbuster antipsychotic drug Abilify, has expanded into a scandal that was covered on the front page of today's
Wall Street Journal."

"Staff writer Shirley Wang profiles Andy Behrman, a man with bipolar disorder who gained notoriety when he published the book Electroboy: A Memoir of Mania. According to the article, representatives of BMS approached Behrman after the book's publication and asked him to do promotional speeches for Abilify, which was about to gain FDA approval for the treatment of mania. He initially signed a contract for $40,000, and eventually made up to $10,000/day.The problem is, soon after he started taking Abilify, Behrman noticed restless sensations in his legs--akathisia. He said he told his BMS handlers about the side effect, which the company denies. At any rate, apparently the money he was receiving was just too good for him to tell the truth about his side effects, and he continued providing glowing endorsements. He said that the company provided him with talking points, and instructed him to reiterate in his talks that Abilify had no side effects and to avoid mentioning that he was being paid by BMS."

"Of course, the company denies any malfeasance, claiming that Behrman requested an exhorbitant $7.5 million for further talks, and that the company refused the offer. The implication is that Behrman is simply a disgruntled former hired gun. We may never know the entire truth of the matter. But knowing the sordid history of pharmaceutical marketing tactics, I'm giving Behrman the benefit of the doubt here."

Abilify and the Great Akathisia Cover-up, Part 2
Tuesday, May 12, 2009
He quoted a CME presentation:

"Adverse event dropouts; you always want to know, How well were these drugs tolerated? And in this first study it was pretty darned good. I mean, it looked very placebo-like in terms of ability to stay on the drug. The data for both studies when they’re put together in the package insert have a dropout rate of about 6% for aripiprazole. So it’s a bit higher than placebo. A lot of restlessness, a lot of akathisia, you know, people sort of a little bit unable to sort of stay still, but they could tolerate the drug. That’s 23%, 25% in the package insert. So some side effects, but overall pretty good tolerability."

I remember many of those at The American Psychiatric Association Conferences in major hotels in Chicago or New Orleans. Perhaps not anymore?

Other Posts to read:
Abilify, the Journal of Clinical Psychiatry, and "Akathisia-gate"
The Journal of Abilify Psychiatry: A CME Activity

Not Just Scotland: Quetiapine (Seroquel) & Other Drugs in Stanford

This time it is not Harvard but Stanford.

At University Diaries: A widely read blog by an
English Professor in Washington D.C.
Stanford University had on its faculty…
… a profound drug addict, a liar, a man who took a plane up at night and crashed it, killing himself, because he flew with about twenty different drugs in his system. He had “a long and well-documented history of substance addiction and abuse.”

No, it is not about any drug addict. It is about a doctor who was a neurosurgeon.

Silicon Valley’s Mercury News picked up the details:
Cocktail of drugs found in Stanford doctor who died in solo plane crash
Bay Area News Group
Posted: 06/05/2009
"The Stanford neurosurgeon who died in a solo plane crash near Lake Tahoe in August had a dizzying cocktail of drugs in his system, including cocaine and Prozac, according to findings by the National Transportation Safety Board.
Doyle John Borchers III, 41, was a student pilot and not authorized for the perilous night-time flight from the Palo Alto Airport to Reno on Aug. 7, a report by the NTSB notes. His only night training came the evening before the accident, and there was no record he had ever flown farther than 50 nautical miles.
The accomplished doctor, known for his work on the neuropharmacology of addiction, had a long and well-documented history of substance addiction and abuse himself, the report adds."

In addition to cocaine and Prozac, toxicology tests by the FAA turned up opiates, mood stabilizers and Quetiapine (Seroquel). One of the drugs, buprenorphine, was among those Borchers prescribed to patients suffering from heroin addiction, according to his own online business profile.

“At the time of the accident, Borchers was in his second year as a clinical instructor at Stanford University School of Medicine. He was working alongside Dr. John Adler, inventor of a device called the CyberKnife used in the treatment of brain tumors. Adler told the Bay Area News Group in August that Borchers had come to him with an idea to use the technology to treat the neurological roots of addiction.”

Medical board probe:

“But records show that Borchers was also under investigation by the Medical Board of California and in danger of losing his medical license.”

“According to the NTSB, an April 22, 2008, accusation by the board ‘documented a history of substance dependence and abuse for more than 10 years preceding the accident, involving the misuse of at least four different substances (including alcohol) and treatment through at least six different programs for substance-related disorders during that period.’”

Six different programmes! Perhaps we should have a more realistic view on such programmes as they might be less effective than they claim to be.

List of drugs in his body:

Monday, June 8, 2009

New Street Drug in Scotland: Quetiapine/ Seroquel

The Scottish Sunday Mail
Drug addicts getting high on mental health pills
Jun 7 2009 Norman Silvester

"JUNKIES are popping pills used to treat schizophrenia patients."
"Heroin and cocaine addicts are buying Quetiapine (Seroquel) tablets prescribed for mental illnesses, including bipolar disorder.

"Detective Sergeant Kenny Simpson, of Strathclyde Police, said: 'Any abuse of this type is dangerous and it cannot be controlled.'"

Read the full report here.

“Some addicts even feign mental illness to get the drug, which sells on the streets for around £5 a tablet."

Can Drug Addicts sue for side effects? Interesting point.

Prison too:

“The Scottish Sunday Mail was also told the drug is being abused in jails, with inmates faking symptoms to get the pills.
“The Scottish Prison Service deny there is a problem but admit Seroquel is prescribed to inmates.
“They said: ‘It is a drug that prisoners have access to.’”

Related Posts:
Bipolar and ADHD: Boys and Breasts
Seroquel and Sex: Tigger and Eeyore
Antipsychotics: Really?

Other Posts:
Old and New: Multiple Sclerosis & Elgar
Madness and Modernity, Bobby Baker & The Peril of Diagnosis
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
Picasso and Tradition
Picasso, Whitechapel Boys and Freud.

Sunday, June 7, 2009

Old and New: Multiple Sclerosis & Elgar

“Would you like to come and try the Davydov Stradivarius? If you like it, you can have it.”

It is not everyday that a young musician gets a call like that, and it is not often that some generous person would part with a few million pounds to give a cello to a young artist. As it happened, it was not this young cellist’s first Stradivarius, as she already had another previously given to her anonymously.

That of course was Jacqueline Du Pré. She went and played the Davydov and loved it. It became her instrument.

Anonymous philanthropy.

It is unusual nowadays to attend a concert (including the BBC Proms) with an all familiar programme. The Cockroach Catcher was happy to have been at the Royal Festival Hall on the 5th of June for the London Philharmonic Orchestra concert. This was his wife’s choice, and a relief after Lulu of the previous night.

I have in previous posts maintained that there is something “re-vitalising” listening to familiar music. La Mer and Beethoven 5th did the trick nicely helping the brain to re-generate some memory proteins.

The Elgar Cello Concerto was a totally different proposition.

One of my earlier collections of black vinyl disc is of course the Du Pré / Barbirolli recording of
The Elgar Cello Concerto.

It was in the old analogue days of recordings and on the whole the engineers just made sure the system was not overburdened by the very loud passages. To this day I still prefer listening to old black vinyls.

It was a record and a piece of playing I treasure. Every time I listen, the music brings new insight into the young talent that was to be knocked down in her prime by Multiple Sclerosis.

In some way, the associated emotional memory has become a hindrance to listening to other performers, as one just feels that there is something not quite the same. The brain does not react in the same way as with other familiar pieces of music in your repertoire.

Just watch the vitality in the final bars of Du Pré’s performance of the Elgar.

Classical Archives

Torleif Thedeen, the cellist in the RFH programme, is not a name I know, but I was prepared to be open-minded. There was something different about his playing. I closed my eyes. Yes, it was a very gentle sort of interpretation and unfortunately at times he seemed overwhelmed by the orchestra.

No, he was no Du Pré, but perhaps I should be thankful as I am now more prepared to go to another Elgar Cello Concerto concert.

Barenboim first met Du Pré in 1964 at Fou Chong’s home, Fou Chong being the famous Chinese pianist and great interpreter of Chopin. Barenboim remembered it was not so much love at first sight as “Glandular Fever” at first sight, both of them being sufferers. Du Pré had it much worse, Barenboim remembered.

In 1971 when Du Pré complained to her doctor that her fingers were numb, she was told it was “stress”. She was on tour giving many concerts.

Then in February of 1973 she flew to New York for four performances of the Brahms Double Concerto with Pinchas Zukerman and Leonard Bernstein. At rehearsal she needed help to open her cello case and could not feel the strings with her fingers. She told Bernstein that she was unable to play.

"Don't be such a goose", he told her. "You're just nervous."

She only managed three of the concerts and was diagnosed as suffering from Multiple Sclerosis. It was not “stress” or “nervousness”. She never gave another cello concert again.

What fate! What a blow to the musical world! Could there be some connection between the Multiple Sclerosis and Glandular Fever? Multiple Sclerosis is something with which Medicine is still struggling. Whether a cure can be found, only time will tell. In the mean time Elgar’s Cello Concerto will always bring up images of the young and vibrant Du Pré: struck down in her prime. At least I still have the black vinyl record of old.

New advances in medicine and technology are always welcome. However, new is not always better. Think Stradivarius. Think Davydov. And Elgar.

Concert review: musicOHM Review
Barenboim and Du Pré on the internet:
Elgar 1, Elgar 2, Elgar 3, Elgar 4a, Elgar 4b
Gramophone review.
Cello Post:
Anorexia Nervosa: Bach

Other Posts on Multiple Sclerosis:
Multiple Sclerosis Treatment – an Update
Multiple Sclerosis, Iguanas and Wrong Foot
Chlamydia pneumoniae site: CPNHELP.ORG

Friday, June 5, 2009

ROH: Lulu & Booing

Should one boo?

Royal Opera House: 4th June, 2009 Lulu.
The Cockroach Catcher was there so was his daughter and musical friends in some other parts of the House. The Cockroach Catcher’s wife went with a friend to the
War Horse and without question she had a more enjoyable experience.

This much anticipated
Royal Opera House Lulu was perhaps too hyped for its own good.

Agneta Eichenholz as Lulu - from Royal Opera House press.
Photograph: Rob Moore/Rob Moore

There was no set. No set. No, I did not see any.

It was like a funeral scene with everybody in black. Well most of the time! But then some of the men are more suited to The Mafia version of Rigoletto.
Yes, there was baring of the body, not of Lulu or her lesbian lover, but of a man as wide as he is deep and I was worried at some point that he might really require CPR.

Lulu, I thought was about abuse and the aftermath of it, the worst of human behaviour was on stage: murder, suicide, infidelity of all kinds, incest and sexual abuse, prostitution and serial murder.

But why was this Lulu not sensual? Is there such a cultural difference in matters of sexual preferences? Here Lulu’s most attractive wear were her shoes! I tried hard to imagine her as a prostitute but had to admit that I totally failed when she turned up in her black dungaree!

It was a pity as the ROH orchestra was fantastic in one of Opera’s more difficult scores.

Agneta Eichenholz never quite lived up to the hype except she was no fat lady. Was she a survivor or a victim? She was certainly detached making it difficult for anyone to be engaged or enraged. She preferred Mozart.

Do not go if this is your first opera experience and do not pay more than four pounds either.

“Was that you booing?” My daughter’s friend swore he could hear her voice. It was.

Mine too! One must boo for the sake of other good operas.

Reviews: musicOHM, Independent, Guardian.

Opera Posts:

Wednesday, June 3, 2009

“Wake-up Call” to British Psychiatry

Nearly a year ago, on the 200th birthday of psychiatry, the British Journal of Psychiatry published a letter signed by 36 psychiatrists, lamenting the downgrading of medical aspects of care in a “wake-up call” to British psychiatry:

“The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty’s future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty’s core values and renew efforts to use psychiatric skills for the maximum benefit of patients.”

The Times (June 27, 2008) picked up the story in:

Mentally ill are 'jollied along' rather than treated by psychiatrists
“Treatment is often little more than jollying people along,” said Professor Nick Craddock, of the Medical School at Cardiff University, one of 36 signatories of a letter published today in the British Journal of Psychiatry.

“If a GP suspected a patient had cancer, he wouldn't dream of referring him to anybody other than a cancer specialist. A cancer patient might need jollying along, but what he really needs is the correct diagnosis and treatment. That's what he gets from a specialist. But patients with mental illness are not automatically referred to psychiatrists. If they only see a social worker, there's every chance that mental illness, or underlying physical illness, will be missed. Patients are getting a bum deal.”

The desire not to stigmatise people has also done damage by implying that there is no such thing as mental illness. Patients are now known as “service users” rather than patients — even though, when asked, 67 per cent preferred the word patient and only 9 per cent service user. Treatments are provided at “mental health” centres, not mental illness clinics.

“For those with severe mental illness, to avoid medicalisation is at best confusing and at worst damaging or even life-threatening ... these individuals are being let down by the current state of affairs.”

Against this backdrop, it is not surprising that the UK Psychiatry recruitment crisis has come to a head.

Today’s Channel 4 Headline:
Psychiatry's UK recruitment crisis

“Britain's mental health services are facing a 'catastrophic' shortage of psychiatrists as the NHS increasingly has to rely on overseas doctors to fill posts.

"Mental health bosses say in some cases doctors are being appointed to posts despite reservations about their suitability, as fewer and fewer UK-trained medics apply for psychiatric posts and overall competition for places falls.

"The Royal College of Psychiatrists (RCP) says cultural awareness is essential to being a good psychiatrist, and warns of an over-reliance on overseas doctors to fill mental health jobs. “

In fact, this recruitment problem was already reported by The Times Higher Education a few days ago (26 May 2009):
Concern over shrinking numbers of UK recruits to psychiatry
“’The single most important threat facing psychiatry and the care of people with mental illness in this country is the inability to attract our own medical graduates into psychiatry,’ said Rob Howard, dean of the Royal College of Psychiatrists.

“Academically it’s a complete disaster because the very best people won’t think of coming into psychiatry, and scholarship won’t move on in this country.

“The proportion of UK nationals among the graduates sitting the college’s membership examinations has fallen from an average of between 15 and 20 % over the past decade to just 6 % last year.

“The changes came about under a scheme, New Ways of Working (NWW), established in 2005. GPs now refer patients with symptoms of mental illness to a team of up to eight people, which will include psychologists, nurses, social workers and a psychiatrist. “

This government (or the next one) must look at NWW again as the statistics speak louder than anything else. Why should junior doctors want to go into a profession where they see “service users” not “patients”, and where the consultant’s role is so much marginalised? It must also be noted that if psychiatrists are allowed to see only the severely disturbed, the emotional burden is extremely high. In time one will lose contact with the range of disturbances that one used to see in a more average psychiatric clinic so essential for the proper understanding of human nature. Also we need to learn how to tell the fakes from the real. No junior would want to be an expert on severe psychosis alone.

“Concern about the fall in applications is so great that the college has called on high-profile figures, including Stephen Fry, the actor and author who has spoken of his history of depression, to urge medical students to specialise in psychiatry.”

A sad day for psychiatry and a sadder one for psychiatric patients.
(Sorry, psychiatric patients do not exist anymore.)

Grand Rounds Vol 5 Number 38 : Jobbing Doctor
New Link:
Jobbing Doctor: What a way to run a service.
Dr Grumble: The BMA wakes up

Monday, June 1, 2009

Cuckoo & Medicine: Dissent & Heresy

The RSPB reported on May 28, 2009:
Cuckoo joins list of threatened birds

The official list of the UK's most threatened birds has recorded a 37% decline in the cuckoo since the mid-1990s.
Photograph: Mark Hamblin/RSPB/PA

“Amongst the species new to the red list is a suite of birds visiting the UK in summer, notably the cuckoo, wood warbler, and tree pipit. These birds, are widespread, but rapidly-declining, summer visitors to the UK.”
“Their addition to the red list is highlighting the concern that many long-distance migratory birds nesting in Europe and wintering in Africa are increasingly in trouble. Currently 21 of the birds on the red list are summer visitors to the UK, with the majority of these spending the winter in sub-Saharan Africa.”
I mentioned in passing in my book “The Cockroach Catcher” Jenner’s observation and the stir it caused. When I visited his home in Glouscestershire, the curator of the small museum, who was extremely knowledgeable, took pride in telling us how Jenner’s great work on Cowpox vaccination upset the medical establishment on the one hand, and how his observation on the murderous ways of the Cuckoo newborns upset the gentlemanly world of the Ornithologists on the other. It was the Royal Society that awarded him a Fellowship for his keen observation.

His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.

It is worth having another look at Brian Martin’s view on:
Dissent and heresy in medicine.

Social Science and Medicine, vol. 58, 2004, pp. 713-725.
Brian Martin is Professor of Social Sciences in the School of Social Sciences, Media and Communication at the University of Wollongong, Australia.

Brian uses models on politics and religion to illustrate the model of orthodoxy versus dissent/heresy. You can read his views here.

He noted that challenges from the inside - heresy and dissent - are far more threatening to an establishment than outside challenges. This is true of all establishments, not least medicine.

But why should it be? In a more co-operative environment, these differences become opportunities for learning. Medicine in particular will not progress if all dissenting views are suppressed and smallpox may have indeed killed for another 20 or 30 years or more.

After the discussion on politics and religion he turned his focus medicine.
He then analysed some methods of domination in medical research:
• State power
• Training
• Restriction on entry
• Career opportunities
• Research resources
• Editorial control
• Incentives
• Belief system
• Peer pressure

“Training to become a doctor is a process of enculturation and indoctrination. The heavy work-load of memorisation and intensive practical work discourages independent thinking.”

“Examinations provide a screening process that encourages orthodoxy. For those who pursue a research path through the PhD, the process of writing a thesis or dissertation further weeds out those who might challenge orthodoxy. Some dissidents and even fewer heretics may slip through the training and credentialing system, but then there are few desirable career paths.”

“In order to have a chance, dissidents and heretics need to understand that science and medicine are systems of knowledge intertwined with power, and that if their alternative relies entirely on knowledge, without a power base, it is destined for oblivion.”

Related Posts:
Orthodoxy and Knowledge
Picasso and Tradition