The Farmer, the Camel and the Cow with a Bad attitude.

farmer sickleFarmers in Ireland are bred tough. They don’t come in to see their Rheumatologist with a bit of muscular pain. They don’t come in with a few Heberden’s nodes. When they do arthritis, they do it properly.

The typical encounter with a farmer would be a chap who hobbles in ruefully, asking politely ‘Sorry to bother you doctor, but is there anything you can do for my knees?’. I usually rub my beard sagely and say –  ‘Hmm, let’s have a look at your hips, then’. Chances are that his knees are fine but his hips are shot to pieces. By the time they stumble into clinic you can guarantee that their hip joints are done for. It never ceases to amaze me that someone can develop severe osteoarthritis (OA) of the hips without ever having experienced pain in the hips or groin. And by the way, I still don’t know why OA of the hips is an occupational hazard for farmers. You see people from other heavy occupations who don’t seem to have the same problem. Perhaps it is something to do with the heavy work most of them did on the farm as young teenagers.

Another common example is the farmer with a seemingly straightforward shoulder capsulitis or tendon rupture. When you get down to the story, however, you find – for instance – that he has been dragged halfway up the field hanging on to the back of a tractor driven away by his 12 year old son who had found the accelerator instead of the brake. Perhaps the most memorable ‘rheumatological case’ was a farmer who hobbled painfully into clinic leaning precariously on two walking sticks with the worst knee joints I’ve ever seen. The valgus deformity on each side was at least 45 degrees and the knees had rubbed together with such violence that he had developed huge suppurating rheumatoid nodules.With each step he had to swing from one side to the other using his stick a bit like a pole vault. When I got him up onto the couch his legs seemed to be connected to the thigh by no more than half an ACL. How this man had continued working on the farm for the previous 5 years I will never know. To my amazement, he recovered well after his knees were replaced and he is probably still working on his farm to this day.

camelAnyway, I digress and really must return to the subject of my story. I could barely contain my excitement when a farmer come in to clinic and showed off his impressive knee swellings. I immediately recognised this as the little known ‘Bactrian camel’ sign. The ‘double hump’ is a dead giveaway. Given the usual yarns, I was not surprised when he told me the story of how this all started with being kicked on the shin by a mischievous young cow. It’s never something mundane like an ingrown toenail. For a farmer this is a regular hazard – but his story was tame compared to one of my patients recently who had barely escaped with his life after having been trampled over by half a dozen stampeding cows. Anyway, our farmer had developed a cellulitis in his ankle which was eventually treated in the local hospital. I say eventually because it is highly unlikely that a farmer would go to see the doctor when there was only a little redness around a scratch. He recounted how the swellings had started after the kick and now they were getting a bit painful. When he took his trousers off I was taken aback. The swelling on top of his right kneecap was like a six inch ‘bap’, and just below that he had a second fluctuant swelling above the tibial tuberosity. Both the pre-patellar and infra-patellar bursae were swollen and clearly displayed in all their glory. The profile was unmistakably that of a double hump-backed or Bantian camel. I wish I had taken a photograph for posterity. A large amount of clear fluid was aspirated from each swelling and steroid injected, to the patient’s evident relief.

As an educational aside, it is well known that infected bursitis often occurs in association with cellulitis, and a good long course of antibiotics is called for. However, this is not the first time I have seen ‘post-infective’ bursitis persisting long after the infection has cleared up. There isn’t a strong evidence base when treating bursitis, but in my experience a small dose of steroid can do the trick quite effectively. Some experts counsel weeks of inactivity, but in my experience if you tell a farmer to rest it is likely that you will be wasting your breath.

The old Irish farmer belongs to a stoical and dependable tradition, in touch with the land and in command of their over-worked but hardy frames. But are they a dying breed? I now see so many of them working on well into their 80s because their children have moved away seeking greener pastures and easier lifestyles. As a rheumatologist who sometimes tends to their ‘war wounds’, I salute them.

The Robber of Memories: Memory loss in Art and Medicine

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…and he recalled that the Magdelena, father of waters, one of the great rivers of the world, was only an illusion of memory’
Gabriel Garcia Marquez ‘Love in a time of cholera’

Probably the most embarrassing experience I will never remember
My first personal experience of a significant memory lapse took place when as a medical student I took part in a study of oral Midazolam. I didn’t feel any different for a few hours after taking the drug and decided that I would make my own way home. An hour later I started to feel very sleepy, and everything for a few hours after that became a blur, a black hole in my memory. I was later told that I had walked into a packed meeting 20 minutes late, sat down in the front row beside the speaker’s wife and had promptly fallen asleep for the rest of the meeting! No matter how hard I tried, I could not piece together one thing the speaker had said or indeed how I had made my way home. Even though this was a trivial event, it was strangely frustrating and my mind kept churning the events over and over for weeks to try and get it back. I felt as if I had been robbed of something precious. It made me wonder what it must be like for people who begin to lose their memory, especially the most treasured memories of their loved ones.

A memorable Film informs an improbable clinical encounter

One of the most striking descriptions of memory loss in art has to be Christopher Nolan’s Memento. In the film the main character tries to compensate for his dramatic and specific deficit in short term memory by tattooing all over his body aide-memoire notes to himself as part of an obsessive and desperate search for the truth. I have encountered many patients with general memory loss in clinical practice but I did wonder if this dramatic failure of short term memory was just a fictional construct or if it could really happen. My question was recently answered when I came across someone with exactly the same deficit, brought on by a bout of encephalitis. She had suddenly become unable to form new memories whilst her past memories remained unaffected and her higher mental function was mostly intact. She continued to work out her puzzles but she  could not retain any new information for more than a couple of minutes. She just could not understand why she couldn’t go home or why people weren’t telling her what was going on. The frustration and anger that this caused was already beginning to distort her normally placid and cheerful character. Apart from ‘locked in syndrome’, I can’t imagine too many conditions more terrible to develop. The ability to remember (and forget) is definitely something we take for granted.

Probably the most memorable book I will always struggle to remember clearly
This leads me in a roundabout way to some of the books I have read this summer. The first was the Gabriel Garcia Marquez classic ‘100 years of Solitude’ which begins with the memorable line “Many years later, as he faced the firing squad, Colonel Aureliano Buendía was to remember that distant afternoon when his father took him to discover ice.” The novel revolves around the Buendia family and the people of Macondo, who have been afflicted by a plague of insomnia whose side effect is a loss of  memory.  We read how the people in this imaginary village had to resort to labelling everyday objects and even write instructions on how to use them.  In the words of Jacob Silverman, “Garci­a Marquez, who has described himself as a professional of the memory, that awareness (i.e. of slippage of memory) must be especially piquant, both because his work is so predicated on notions of memory, history, and ancestry, and because neurological conditions run in his family.” There are many references to memory in his works, and when reading ‘100 years of Solitude’ I almost felt as if I was being transported into a world where I myself was losing my grip on reality and getting lost in an impossible jumble of characters. The thread of history gets tied into so many knots that it takes an effort to unravel it (including regular reference to the family tree, for instance). In spite of the use of magical realism, some of the insights from these books are now being reflected or confirmed by research. For instance, we now know how important sleep is in developing and shaping our memories. Garcia Marquez’ books are also strongly influenced by the author’s experiences and travels in the area of Columbia near the Magdelena river.

Probably the least likely but most memorable travel itinerary in the world

This novel was the inspiration for another book I read this summer: ‘The Robber of Memories’ by Michael Jacobs. Jacobs is another writer with a life long obsession with memory, not to mention his childhood interest in tales of the Spanish exploration of South America. In his own words “The older I got the more I appreciated the role of travel as a stimulus to memories, and the way in which journeys even to new places were somehow always awakening memories of places seen in an ever-receding past”. This book is an intensely personal travelogue/meditation but should be of interest to those of us who want to gain an insight into the experiences of patients or relatives with memory loss or dementia.  ‘Escaping’ for some respite from his role of carer for his elderly mother with dementia, Jacobs embarked on a mission fraught with danger, following in the literary footsteps of his hero Garcia Marquez. Unusually, his journey was a quest to retrace his hero’s love affair with the Magdalena river, ignoring the threat of FARC guerilla attacks to make his way to the source of the river. The story begins with a meeting with the aged author, now himself in the lonely hinterland of early dementia. Garcia Marquez himself has had to let go of so many precious memories, but images of his beloved river had remained. His 81 year-old literary agent Balcells was quoted as saying of him:  ‘Gabo carries a constant glare of nostalgia in his eyes’. That description would have fitted my patient to a tee.

Mingled through the narrative Jacobs reminisces about his parents’ loss of memory and frets with anxiety and guilt about having left his mother. A dread of what might happen to him if he was to follow his parents into the fog of dementia seems to be an undercurrent throughout. He re-reads ‘100 years of Solitude’ and finds evidence that the author may have had a premonition of what was going to happen to him. He meets Marcela, whose mother has Alzheimer’s disease. She tells him about the tales of the disappeared, about the days when two or three unidentified bodies floated down the river every day. In itself, this is a powerful metaphor for the brutal ravages of dementia, separating sufferers from their loved ones in a way that reopens old wounds and prevents them from getting closure for their grief. She said that her mother could still recall some of the trauma but she couldn’t recall where or when they had happened. Jacobs quizzes the locals about the local myth about a ‘robber of memories’ who would visit you in your sleep. It is almost as if he was challenging the robber in his own backyard!

As we are led slowly up the river Jacobs reveals his plan to visit the village of Yarumal, where so many of its inhabitants are struck down early in life with Alzheimer’s disease. The seemingly fanciful idea of a whole community being struck by a ‘plague’ of memory loss is actually based in the strange but real world of the Magdalena. He meets and talks to Fransciso Lopero, a leading researcher who has made the sudy of this unique tribe his life work. Genetic discoveries here have allowed susceptible people in this town to be identified so that in future  potential treatments or vaccines can be tested in this group before they develop clinical symptoms of Alzheimer’s disease.

Many seek for hope at the end of the rainbow: Jacobs sought hope at the source of the Magdelena. And after all, the best research is essentially an adventure into the unknown inspired by a passionate hope and anticipation of discovery. Sadly, Jacobs died from cancer earlier this year. At least he was spared a house call by the ‘robber of memories’.

Further reading
The town of Yarumal and Alzheimer’s disease: Telegraph article by Michael Jacobs
Telegraph Obituary for Michael Jacobs
BBC Article (2011) about Francisco Lopera and his research in Yarumal
Selected quotes and memories of ‘Gabo’ – Huffington Post

More about Alzheimer’s disease from the Alzheimer’s Society

Bean-counters, Lamp-posts and Rheumatologists

bean counterI was talking to some medical students recently about the use of outcome measures in rheumatology. I happened to mention that ‘big data’ was the next ‘big thing’ in medicine. Cue blank faces. Followed by quizzical looks and a sly smile. I suddenly realised to my chagrin that not everyone has read Topol’s ‘Creative Destruction of Medicine’ and that my students are beginning to doubt my sanity. I rapidly tried to regain some semblance of dignity by explaining that outcome measures are all the rage in rheumatology right now.

Readers of my blog may have not be surprised to hear that at times I can get a little obsessive about the science of measurement in medicine. So as a form of necessary self-therapy and reflection I am going to explore the darker side of measurement science using a couple of well-known quotations.

einsteinblackboard03The first quote, usually attributed to Albert Einstein (but possibly more accurately credited to a Professor of Sociology, William Bruce Cameron), is as follows:

“Not everything that can be counted counts, and not everything that counts can be counted.”

So not everything we measure or count actually matters. We need to be very selective before we decide that some measurement is essential or routine. There seems to be an assumption that the more we measure the more scientific our care will be and therefore the outcomes will improve. In the case of rheumatology there is now an assumption that if we have a patient with rheumatoid arthritis and we do not complete a ‘disease activity score’ and a disability assessment in every patient we are in some way negligent as doctors. Now I would be the first to argue that early arthritis trials have demonstrated the need to adopt a ‘treat to target’ approach using objective and quantifiable measures to gauge response – but to extrapolate this to patients with 30 years of arthritis may not be either scientific or kind to the person in front of us, particularly when they mention that they have had a recent bereavement. In times like these, ‘feeling the pain’ will often trump feeling the joints. Some measurements may be eminently ‘scientific’ but completely worthless, particularly in managing the individual.

The second part of this elegant chiasmus claims that not everything that counts can be counted. I hope that every health care worker is acutely aware of this fact, but it is at the core of an empathic approach to medicine. How the patient feels cannot easily be reduced to a score on a questionnaire. How well does the doctor understand the narrative from the patient’s perspective? Can we really quantify how well or badly the doctor or nurse empathises with their patient?  There is a feeling that recent changes in the organisation of medical work have disrupted the continuity of care and the integrity of the ‘team’ looking after the patient. Medical ‘clerk-ins’ are reduced to ticking boxes in lengthy proformas and medical handovers are reduced to a rapid fire exchange of facts and figures. Increasingly, doctors complain of being tied to the computer screen completing page after page of data, and having no time to have a proper talk with the patient.  maninfogIn the midst of this swirling fog of data, have we lost sight of the patient? When we teach our students the importance of rigorous data collection and outcome measurement, will we remember to refocus their attention back on the importance of empathy and the art of medicine?

The second quotation has been attributed to AE Houseman or Andrew Lang:

People Use Statistics as a Drunk Uses a Lamppost — For Support Rather Than Illumination

 

This is justifiably a popular quotation and any medical researcher worth his or her salt will doubtless be familiar with the dark arts of manipulating statistics to make the data seem to support your hypothesis. Reviewers of publications have become wise to this, and statistical scrutiny is a little more rigorous than it used to be. Even better, clinical trials registration requirements and ethics reviewers will insist on you defining the primary and secondary outcome measures before the study begins. This only goes to prove that nowadays you need a higher level of statistical jiggery-pokery’ to baffle your readers and ‘stay ahead of the game’.

 

dogLampost

Managers Use Statistics as a Dog Uses a Lamppost — For ‘Marking their territory’ Rather Than Illumination

 

The third quotation could be attributed to a certain PV Gardiner, the writer of this blog. He has clearly borrowed heavily from the afore-named Andrew Lang. He has also used polite and politically correct language within the quotes which readers may wish to replace with more descriptive and direct terminology.

I’ll tell you a story to illustrate the point. A few years ago we were told that we were obliged to carry out an ‘audit’ on our use of biologic drugs in the region. Nothing unusual with that, you may say – they are very expensive drugs, after all. However, we did detect quite a hostile and accusatory sub-text to the discussions. After a little ‘digging’ we discovered that somebody  in management ‘on-high’ had ‘discovered’ that we were using biologic drugs twice as much as the average in the UK. We thought we were using the same NICE guidelines to treat similar patients, so this seemed odd. Cue some anxious head-scratching and navel-gazing by the chastened rheumatologists. Strangely, our own figures hadn’t seemed to suggest any problem at all. Eventually, we discovered that someone in management had been using a single figure (the prevalence of RA in our region) that had changed everything. This figure suggested that RA was only half as common as in the rest of the UK. We were most intrigued. Could it be something in the pure Irish spring water? Could it be our fondness for Guinness or Bushmills whiskey? How had they arrived at such a figure, when there had never been a study of the epidemiology of RA in our region? We have never had a diagnostic database to record the prevalence of RA. In fact, they had obtained the figure from a reference found in none other than the official National Audit Office report into RA in England. That article had briefly referred to comparative data in other nations, and the quoted statistic actually came from a paragraph in a local newspaper where a journalist had mentioned in passing the estimated number of people with RA in our region. Well, it is just as well that we discovered the source of these scurrilous rumours. Otherwise the aforementioned honourable rheumatologists might well have wound up propping up the local lamp-posts (or was that the other way round?). We live to fight another day…

 

Blindspots and Reflections in Acute Medicine

20130901-172904.jpgHave you ever pulled out into the fast lane and narrowly missed a car coming from behind you? You think to yourself ‘How on earth did I not see that car?’. We all know that this wouldn’t happen if we always checked properly before we pulled out, but few of us can pay full attention all of the time. After decades of many such needless accidents (estimated 800,000 per year in the US), car manufacturers finally introduced the convex wing mirror. This may not have been the most exciting innovation, but it works and saves lives. This reminds me of some of the avoidable problems with medical errors. It is surely about time that we recognised common ‘blindspots‘ and did something to improve patient safety. If these situations are predictable, we should be discussing these issues frankly with each other and especially with our trainees. When we teach our students we need to admit that we have personally made mistakes, but show them how we are learning from them so that patients can be protected from these errors in the future.

Have you ever reflected on a acute medical ward round and realised that you have missed something that should have been obvious to you? After passing the ‘milestone’ of 20 years as a consultant physician I can see some recurring themes. You might think that we should have learnt from our mistakes, but some things seem to happen again and again. And when we get older we need to be even more aware of our limitations because other staff may not have the confidence to point out our mistakes.

A Typical ‘Blindspot’ in Medicine: The ‘alcoholic’
We call it the ‘revolving door’ syndrome. These patients often come in to hospital intoxicated with alcohol levels that would put the rest of us in intensive care or worse. After a day or two of confusion and aggression the medication helps them settle with and they leave, promising never to drink again. Sadly, many walk straight to the local off license and the whole process starts again. Eventually the well of empathy can run dry. Medical and nursing staff can be just a little less attentive, and this can lead them to make serious errors they would normally never make.

Here are a couple of stories that I hope will help to illustrate how this can happen.

A man came in to a hospital agitated and confused with a very high alcohol level. He was an alcoholic who had been in many times before in a similar state. He usually woke up after a day or two and went through the detox process. The examination in the ED was a brief one, if the notes were anything to go by. On that occasion his confusion didn’t settle and he deteriorated. A CT scan was ordered – belatedly – and it turned out that he had an undiagnosed skull fracture with multiple contusions in his brain. If it wasn’t for the alcohol the scan would have been done on arrival into the ED. Head injury guidelines have since helped to make this sort of error less likely to happen, but sadly it is not an exceptional case.

Another man with chronic alcohol problems came in to a hospital in a similar intoxicated state. On recovery a couple of days later he complained of a pain in his shoulder. He had thrown things at the nursing staff the night before and there wasn’t a lot of sympathy around. After a brief examination his shoulder was X-rayed and to nobody’s surprise no fracture was seen. He was sent home. He was readmitted two days later and a fractured cervical spine was diagnosed. Would the assessment have been any more careful if he had not been an alcoholic? I am sure it would have been.

These stories are not particularly newsworthy and I’m sure you could easily have come up with similar reports. Judging from the headlines in the press, these incidents are not unique to the hospitals I have worked in.

There are a few lessons I am trying hard to put into practice:

  • Alcohol is a powerful analgesic, and serious injuries can easily be missed when an intoxicated patient is admitted.
  • Taking a clear history & performing a careful examination is often difficult or impossible when your patient is drowsy, confused or otherwise unco-operative. So don’t just rely on first impressions. Go back and re-examine. If in doubt, do the imaging.
  • Make sure that there is a good protocol in place for managing alcohol withdrawal including the use of scoring systems such as CIWA-Ar. This will help to prevent periods of agitation, confusion or drowsiness.
  • Set the example by always treating the alcoholic with respect, even if you are getting abuse.

Motor Vehicle Accidents can also be prevented by paying attention to the rear-view mirror: if you see a high powered motorbike approaching you might know from experience that it is likely to overtake you rather sooner than expected. An important skill in medicine is to develop the habit of honest reflection.

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What are we doing to make our service safer?

scaffold safetyI was speaking to a man recently who had worked all his life as a scaffolder. I asked him about advances in safety since the early days. He told me the story of when he worked on scaffolding 23 stories up on a building site in London many years ago. He seemed proud of the raw bravery you had to have in those days, but in hindsight he can’t believe the risks they took at work every single day. One day his foreman called him to join him on some work on the next floor. For some reason he didn’t go immediately and just a few minutes later his shocked workmate informed him that tragically the foreman had just walked over some loose boards and fallen 24 stories to his death. The scaffolder spoke about the incident as if it was yesterday and he still wonders why he hadn’t died that day. Safety regulations on building sites have dramatically reduced deaths and workmen these days wouldn’t dream of taking those risks. In the case of the health service, we as health professionals are not taking risks with our own safety but with that of our patients. So reducing risk – ‘first do no harm’ – should always be at the core of our professional integrity. In today’s uneasy climate it doesn’t take much to bring the great weight of ‘quality inspectors’ and intense media attention to bear on a hospital and its services. At the moment this level of scrutiny is still quite infrequent, and people may get the impression that patient safety is not embedded into routine practice. It is high time that we all started to reflect on what we are doing to improve patient safety and let people know what we’re doing. High risk specialties involving high risk surgery or obstetrics are well used to reporting deaths to confidential enquiry programmes such as ‘CEPOD’. In some cases, particularly in the U.S., these statistics are available to the public and not anonymised. In lower risk specialties such as Rheumatology the measures of safety and quality are harder to measure. The safety measures listed below are gradually being incorporated into routine practice. Here is a provisional list of some of the measures we currently use in our Rheumatology unit to promote patient safety:

  • We report serious drug adverse effects using the ‘Yellow card’ post marketing surveillance run by MRHA. This is a voluntary reporting scheme: some report more than others, but it can help to pick up problems that haven’t surfaced in the drug’s development. We also contribute to a national ‘risk registry’ for the newer biologic drugs (BSRBR).
  • Morbidity reporting for infusion reactions. In the past year we noticed quite a high incidence of allergic reactions in our unit to Iron Dextran infusions: following discussions with specialists and pharmacists we have changed to another preparation with a lower risk of reaction. None of the reactions were serious, but it is still a patient safety issue.
  • Clinical Incident reports – actual harm or near misses. Our hospital has a database for this and the risk management team rate incidents as green/yellow/red by risk level. We contribute to this, mainly for the more serious incidents. These incident reports are looked at centrally and there isn’t normally much discussion at a local level. It is therefore difficult sometimes to see whether anything changes when problems are identified.
  • In our unit, we have started holding regular ‘Mortality and Morbidity’ multidisciplinary meetings – using a clear unambiguous format. These meetings take place once a month and take a few hours to prepare and write up.
  • Multidisciplinary clinical discussions about unusual imaging reports or difficult diagnostic or treatment decisions. We have a good meeting with radiologists to discuss x-rays and scans, but we could probably do better in discussing difficult cases with our peers. It is very difficult to find a time when all clinicians are free.
  • We use (and helped to develop) agreed regional shared care guidelines for ‘disease modifying drugs’ which used to be thought of as drugs with a lot of side effects. We record in the notes that these have been issued with every prescription and we check that monitoring is carried out when patients attend clinics. In our system the General Practitioner or Family doctor has responsibility for monitoring blood tests. We try to record telephone calls for advice, but this is an area we can improve on, perhaps by using email more often. We also standardise patient information about these drugs – we give out booklets but make sure that the patient understands the most important issues.
  • We are responsible for monitoring blood tests for patients on biologics drugs – our pharmacist and specialist nurses take responsibility for this and use an agreed protocol.
  • When we conduct research, we adhere to ‘good clinical practice’ standards and the international statement of Helsinki. We are also regularly monitored by the Trust’s R&D department and have to provide annual reports. Each study has to have prior approval by a regional (and very detailed) ethics review body.
  • We have a discussion of major drug safety alerts or other safety alerts at our monthly multidisciplinary meeting.
  • We carry out regular audits – for instance, this year we looked at the accuracy of Methotrexate prescriptions in patients admitted to hospital. This has led to several proposals to help ensure that mistakes are reduced/identified before a patient can come to harm.
  • Each doctor who works in the unit has to undergo an annual appraisal. For consultants, this includes a review of statistics including mortality & a comparison with peers. There is also a discussion about any complaints, incidents or legal cases. Each doctor has to sign a probity and health statement. Every five years a doctor in the UK now has to undergo revalidation. This assessment has to include two confidential surveys about the performance of that particular doctor – one from patients  and the other from health professionals with whom they work.

This is not an exhaustive list, and it doesn’t mean that there aren’t areas in which we need to improve. For instance, we don’t yet use a clinical database, and we don’t have any link to the patient’s prescription list held by their GP. We don’t participate in a peer review programme – this doesn’t yet exist in our region. These are significant developments that may contribute to patient safety – but they have to be properly resourced and supported by our hospital’s management.

The mark of a good doctor: The Caring Quotient (CQ)

What is the essence of a good doctor and how can we choose the right applicants at medical school?

The traditional way to choose doctors was mostly based on knowledge/memory tests. Choose the brightest students and you will get the best doctors, or so the theory went. However, there is a problem. Some very clever people have ended up as very poor doctors. Whilst it is likely that it will always be necessary to have and maintain a high level of learning in order to be a competent doctor, this is clearly not the whole picture. The general theory that IQ is the key to success has been undermined in recent years, and it has been clearly shown that there are other important aspects of intelligence that are not measured by IQ tests or tests of memory recall. Some would argue that today’s easy availability of vast data banks of knowledge will further erode the preeminent position of the learned doctor.

One area of active development has been to look at ways of testing for ’emotional intelligence’ or EQ. These theories are based on the work of a several psychologists over the past 50 years or so, particularly that of Daniel Goleman’s 1995 Book called ‘Emotional Intelligence’. His domains of EQ may be summarized as follows:

  • Knowing your emotions.
  • Managing your own emotions.
  • Motivating yourself.
  • Recognizing and understanding other people’s emotions.
  • Managing relationships, i.e., managing the emotions of others.

This does seem to make a lot of sense, but some have expanded the concepts to encompass such a broad sweep of ’emotional competencies’ that the term seems to lose all validity. To my way of thinking, desirable characteristics such as fairness or trustworthiness cannot be considered as subtypes of intelligence. Studies have shown a poor correlation between the EQ scores of employers and their employees’ assessments of their employer. A person with a high EQ will not always act with empathy/respect/fairness to the people around them although they should be in a good position to understand and practice these positive behaviours.

The media coverage of medicine in the UK over the past decade has been coloured by the dark shadow of Harold Shipman. A clever doctor who knew how to get patients to trust him (high IQ and EQ) but one who fundamentally lacked compassion for his patients. There has been a growing recognition that we need to take more care to recognize and weed out doctors like this but nobody seems to have any clear idea as to how this could be achieved. Appraisal, revalidation and multi-source feedback have been introduced but many feel that as currently set up it is not able to identify the next ‘Shipman’. Reflective practice is a good thing to encourage, but for many doctors their reflection relates mainly to their professional educational activities.

How can we encourage doctors to reflect more on the things that influence their quality of caring? I propose that it would help if we introduced the concept of a ‘caring quotient‘ to complement the IQ/EQ domains. We all recognize that doctors should be caring, but how much and in which situations? This could be tested by proposing challenging clinical situations and getting the opinions of a number of physicians as to what they would do in the same situation.

Is it possible to be TOO caring so that professional boundaries are crossed to the detriment of the patient or other patients under our care? Is it possible for a doctor to be very caring 90% of the time but ‘lose it’ from time to time? If this behavior is not a fixed characteristic it may be useful to consider it as a continuum that can vary, perhaps in predictable ways. Research has shown that, in general, doctors and healthcare workers tend to be biased against patients with alcoholism, dementia or the ‘heart-sink’ patient with the thickest file but the lowest rate of serious pathology. I have seen a number of medical errors over the years that have arisen because an alcoholic has not been accorded the same level of care and attention as others. Difficult behaviour by patients often provokes a negative reaction in us and if we don’t learn to recognize and compensate for this we will make mistakes. Some of our individual biases are so deeply ingrained that we will transgress again and again. I try and teach medical trainees to actively watch out for these biases – as I try to do – and change their behavior to compensate.

So, can a doctor actually learn to recognize situations or patients that ‘make their blood run cold’ and change their behavior accordingly? Doctors would benefit from building up a self-reflective narrative portfolio to include their reflections on difficult or challenging interactions with patients. We could hope that this would encourage more insight into where we are going wrong, where our ‘CQ’ was inappropriate for the particular situation we were faced with at the time. I have put together a mind map to begin to tease out some of the positive and negative factors that could affect a doctor’s ‘CQ’. This is a work in progress!

Meddling with the mind and mining the memories

How do memories form and why do some memories become extraordinarily painful? We have all heard about conditions like post-traumatic stress syndrome, where traumatic memories linked with painful and distressing emotions cause real and disabling distress every time they are recalled. Have you ever been tempted to banish some of your memories into oblivion? The film ‘Eternal Sunshine of the Spotless Mind’ explored what might happen if we were able to selectively erase some of our painful memories. The consequences were not always as positive as expected.

But what about musculoskeletal pain? Does memory play a part in establishing chronicity in chronic pain? Some of the recent research on Fibromyalgia Syndrome (FMS) using fMRI seems to support the theory that painful stimuli can become ‘amplified’ in the brain and form inappropriate linkages with fear and emotion centers in the brain. These are the sort of links that would normally only be made with really severe painful stimuli such as a life threatening injury. Now, it has to be admitted that brain imaging studies in FMS are small and the findings can easily be disputed – but what if they were correct and point to a serious distortion of the interpretative neural matrix in the brain? We all have an ‘interpretative filter’ for sensory signals in the brain – the mechanisms by which the brain ‘triages’ the incoming signals into normal everyday stuff we can safely ignore and the sort of warnings that we really need to worry about.

So – what if part of the problem with FMS was that exercise has become inextricably linked with negative memories? We know that the opposite can occur: healthy people who exercise may get an ‘endorphin buzz’ that gives them a natural ‘high’ after exercise that makes them want to do it again. People who enjoy competing get a competition ‘high’ that makes them want to have another go. Are we prepared to put up with more pain if we have a strong memory of the ‘gain’? Can there be a polar opposite to ‘psychological dependence’?

Some of my patients with FMS previously enjoyed exercise and had been very fit before something happened to them. FMS patients will often recall having gone out for a walk and becoming so disabled by pain that they couldn’t get home again – this sort of negative memory seems to set up a fear of exercise and a conviction that exercise is unhelpful.

A pill to erase your memory?There are two interesting lines of research that could spell hope for patients with FMS. One was highlighted in an article by Jonah Lehrer in Wired magazine called ‘The Forgetting Pill’. Now I hasten to add that the drug in question has so far only been trialled in mice and is a very long way from being used in humans – but it highlights an interesting direction of research that may eventually have major benefits. The basic idea is that deep-seated memories are constantly being remolded in a process that involves neurons creating new linkages through protein synthesis. A Neurologist David Sactor from Columbia University has discovered a form of Protein Kinase C called PKM zeta that is crucial to this process. He and colleagues have developed a PKM zeta inhibitor ‘ZIP’ which has been shown to cause selective erasure of unpleasant memories in rats. Yes, rats. And by the way, ZIP had to be injected into the rats’ brains. So at the moment the only people likely to be planning to use ZIP will be evil dictators. But it is an intriguing idea and the concept that you only have to recall a memory to raise the possibility of changing the nature of the memory is an important one. Professor Alain Brunet from McGill University has conducted successful trials using Propranolol (an established drug for high blood pressure) to suppress painful memories in PTSD sufferers. There’s also a good article on this at the Smithsonian website.

Transcranial direct current stimulationThe second area of research – more directly relevant to patients with FMS – is the recent use of Transcranial Magnetic Brain Stimulation or Transcranial Direct Current Stimulation (tDCS). Preliminary trials have been quite positive, although we cannot be certain how these low level and painless magnetic/electric fields can alter what is going on in the brain. One of the more plausible theories is that they may alter the neuronal excitation and thereby alter the abnormal levels of ‘amplification’ of signals in FMS. Is it possible that this works in a similar way to the memory modification techniques – splitting unhealthy links between sensory areas in the brain cortex from emotion/fear areas?

Some work that suggests a possible link was recently featured in a BBC Horizon programme on memory. In the programme a musician with ‘focal dystonia’ played the piece of music that he most associated with his early memories of the ‘twitch’ that had ruined his performing career. By recalling the memory whilst applying a low voltage current using tDCS the researchers felt that they could alter the excitation state of the neurons and dampen down the effect of the old memories. Old associations could potentially be ‘over-written’ by remembering a new performance with a more positive outcome.

If this early work with tDCS or Transcranial magnetic stimulation in FMS is replicated by independent researchers it will open up a whole new field of treatment. Our best proven interventions for treating FMS currently involve re-training the mind and body using graduated exercise programs or cognitive behavioral therapy. However, this is tough and some patients just can’t break out of the vicious cycle of pain, fatigue and insomnia.

A case for bringing back paternalism?

Paternalism has become a bad word in medicine. The physicians of old are caricatured as stern unapproachable male figures who commanded their patients to take the treatments they prescribed without any explanation. The patient’s own opinion didn’t seem to come into it at all. The term ‘paternalism’ also evokes the idea of a stern unloving father figure who rules the home with an iron rod and doesn’t hold back on punishment when his child misbehaves.

I’m not going to defend the old style of medicine  – nor would I want to defend the sort of strict uncaring style of parenting that gave no room for the child to develop.

Good parenting requires a progressive ‘evolution’ in parental behaviors and attitudes. The younger the child the more directive the parental advice and the briefer the discussion or explanation will be. The caring parent will provide a safe environment for the child by making decisions for them – with their best interest at heart. As the child grows and gains education and maturity they will be able to have an increasing role in decision-making until they are fully independent.

I would argue that doctors need to understand where their patients are on the continuum between the passive or less well informed patient and the patient who has a comprehensive knowledge of their disease and its treatment. In the case of rarer diseases the patient (perhaps with the help of online resources) may even build up a knowledge base that is superior to that of their specialist. The doctor should help the patient become better informed by guiding them to reliable sources of help and sometimes warning them where the sources are unscientific. Some would argue that a doctor’s job should be to dispassionately offer the information and leave the patient to make the choice (e.g. between two or three different Disease modifying drugs for arthritis). I think it is quite cruel to leave patients on their own to make these important decisions and not to use your skills of persuasion to help them to make the decision when they are afraid to do so, perhaps because of a particular side effect mentioned on the information leaflet.

I would argue that most patients want and expect expert help, guidance and advice from their doctor. Most patients expect us as specialists to have sifted the information and to speak from experience. It is not wrong to present them with a preferred choice and coax them into going along with our proposal – perhaps we should call this characteristic ‘benevolent paternalism‘.