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Bringing in doctors from abroad will incur other costs: are we sure that ‘we’re spending our money wisely? NO HOLDS BARRED Margaret McCartney Getting smart about GP retention
A hundred million pounds is a lot of And some GPs want to return to money. NHS England has pledged to practice. Huge e! orts have been made spend as much as this on recruitment to streamline this process, but is it agency fees to bring in GPs from abroad. working? Over the past couple of years The aim is for extra GPs. Overseas I’ve watched as an outstandingly sharp, recruitment will make up a large portion knowledgeable doctor I know wanted to of this new wave of doctors. return to general practice a er a few years In the s, general practice in the out of the country. She’s faced obstacles NHS was saved by Indian and Pakistani despite having worked as a GP for several doctors, at a time when a third to a half years before she le . of UK medical graduates were emigrating The costs are prohibitive: she had to themselves. But these doctors were not self fund a trip to the GMC in London for always well cared for. They o en found themselves an identi" cation check. She then had to study for and in the most deprived parts of the country, frequently pass a multiple choice exam followed by a simulated without much support, discriminated against, and in surgery (" rst attempt is free; resits cost # and #$, the least competitive posts (but o en the hardest). How refundable at the end of the scheme). A er passing the can we be sure that we’ll do better now? exams, a supervised placement must be found amid the We really need to spend money on retaining the GPs myriad forms. A bursary is payable for this, but doctors we already have, particularly if we’re losing them at such have found it slow to appear and not reliable for paying a rate (more than fewer GPs in England in March the bills. In the meantime, the GMC fees roll on, and than in March ). indemnity fees must be paid up front. And practices A large group of GPs are retiring early. Many do must apply to be accredited to supervise returning GPs— so because they hate the Quality and Outcomes limiting the doctors’ availability and o en making them Framework (QOF), the current GP contractual hard to " nd. framework, appraisal, or the pressure of being on call More than a year a er trying to start back, the doctor while also consulting. Indemnity fees are soaring and I mentioned still isn’t working as a GP. Couldn’t some have been cited by GPs as a major reason for early of NHS England’s money be spent on sorting out the retirement. Surely, the money allocated to overseas numerous small bureaucracies that add up to an recruitment could be used to employ people who have insurmountable barrier? pledged to retire in the next decade. Some crises are unavoidable; some have been We could o! er moderated, abbreviated appraisal created through an obsession with process above and a fresh approach to QOF (we’ve abandoned it reasonable judgment. Expecting doctors to come from in Scotland, and the sky hasn’t fallen in). We could abroad and sort out our mess, while doctors go to waste o! er protected sessions to make working in later life here, is senseless. a realistic—even popular—option. Bringing in doctors Margaret McCartney is a general practitioner , Glasgow from abroad will incur other costs including training [email protected] and orientation: are we sure that we’re spending our Follow Margaret on Twitter, @mgtmccartney money wisely? Cite this as: BMJ !"#$;%&':j($(& the bmj | 28 October 2017 147 PERSONAL VIEW Kate Womersley , Katherine Ripullone Medicalschoolsshould prioritisenutrition andlifestyleeducation Students need to understand the role of their patients' diet in health promotion and disease prevention
ould you expect General Medical Council requires Dietary UK, where nutrition education has a junior doctor qualifying medical students to interventions been notably lacking. It is not that to be con dent understand the role of diet in health are considered students don’t want to learn this giving basic advice promotion and disease prevention, to be outside material. If individual universities W and care for the which includes being nutritionally of the had the courage to lead the way in most common and fatal diseases? Of competent. Internationally, this preventive nutrition, the majority evidence base, course you would. NICE guidelines knowledge is lacking in medical unscientifically of medical students would be only state that a rst line intervention for training. Just % of US medical too keen to learn more about the “fluffy,” and diabetes, obesity, and high cholesterol schools provided the agreed subject. is to give “lifestyle advice”—but this minimum of hours of nutrition the domain of phrase is so vague that it is le up to education in . A recent study dietitians Image problem doctors and patients to de ne it and, of European medical schools was Nutrition science su# ers from an potentially, ignore it. slightly more optimistic, suggesting image problem in medical practice. In and , more than that nutrition education was a This starts with its subordination in % of American junior physicians requirement in !.% of institutions curriculums and qualifying exams. felt inadequately trained to counsel surveyed, with an average of ".! Dietary interventions are patients on diet and physical activity. hours of teaching. considered to be outside of the The picture is reportedly similar in This, however, has not been our evidence base, unscienti cally the UK. In Tomorrow’s Doctors, the experience at medical school in the “$ u# y,” and the domain of dietitians
ACUTE PERSPECTIVE David Oliver Binarytruthsdon’thelphealthpolicydebate
Stephen Hawking and Jeremy Hunt’s and sustaining services, we should Scotland and Sweden plan change for public argument in August over the sometimes focus on pragmatic populations of similar sizes to those future of the NHS and use of data solutions, whether or not they accord in STPs. led to some hard hitting claims and with our political ideology. On Black’s point about false strong accusations on both sides. For instance, England’s dichotomies, I would say that in In the a ermath of the spat the sustainability and transformation many areas of health policy two management consultant Stephen partnerships (STPs) could in theory apparently contradictory views Black wrote a provocative piece on deliver win-win bene ts by giving can each be partly true. The two the state of debate about the NHS. Two views more control and autonomy to views may be valid and perfectly Black’s thesis was that we can’t move may be local clinical teams and also more reconcilable if we are prepared to forward with constructive solutions equally valid permission for collaboration in consider both viewpoints when to the problems facing our health and and perfectly the interests of a population. They deciding how to proceed. care system if the debate is reduced reconcilable have been rightly criticised for The NHS is facing a major funding to falsely polarised, oversimpli ed being rushed, for overpromising gap long warned of by expert health arguments that are based on ideology savings, and for lacking clinical economists. It needs cash. But there rather than on pragmatism. engagement. It is not helpful to are further possible e& ciencies from I don’t always agree with Black’s discuss such localism only in tackling unwarranted variation, managerialist approach, but his terms of covert privatisation and fragmentation, and unproductive or argument deserves consideration. central government’s abdication of unevidenced areas of spending. And, If we are sincere about protecting accountability. Countries such as as with every system, we do need
148 28 October 2017 | the bmj Ongoing learning This undervaluation of nutritional BMJ OPINION Ara Darzi knowledge continues when it comes to professional expectations. It is Thereishugepotential rightly required that doctors stay toapplybehavioural up to date with the continuously economicsinhealth revised NICE guidelines in specialties Barely hours before Richard Thaler, the US such as oncology. This ongoing economist, was named as the winner of the learning is seen as a mark of Nobel prize for economics, Theresa May medicine’s progress. But changes in was announcing an opt out policy for nutritional guidance are considered organ donation taken directly from symptomatic of instability and lack of his writings. Such is the influence of scienti c certainty. Why in the case of the man credited as a founding father nutrition science is amendment not of behavioural economics, or “nudge expected, but rather belittled? theory,” now used by governments in rather than doctors. Medical Knowing exactly what we mean the UK and around the world. students rst hear about nutrition in by “improving patients’ diet and “My mantra is if you want to get biochemistry lectures about speci c lifestyle” would enable doctors to people to do something, make it easy,” Thaler told the Washington Post . metabolic pathways, abstracted focus on how they counsel patients, Whether donating organs or joining from disease mechanisms or patient personalised to comorbidities, pension schemes, making it easy means experiences. In later clinical years, individual cultures, and characters. making it the default decision. the details of healthy diets, ways to While the central aim should not The obverse is to make it difficult for assess malnutrition, or speci c food be to save money, if NHS doctors people to do the things you don’t want requirements for particular diseases become more e! ective and e" cient them to do. Restricting the pack size of in hospital and community settings at giving lifestyle advice, the paracetamol tablets cut suicides by !% in the are glossed over. opportunity to prevent disease on years after it was introduced in the UK in "". Medical students are routinely an impressive scale would free up Behavioural economics is being widely applied in the presented with evidence for resources. field of public health—and there is huge potential for the future, if we are prepared to grasp it. pharmaceutical decision making, Kate Womersley is a final year graduate Two of our greatest health challenges are that we eat but rarely with empirical data medical student , University of Cambridge too much and exercise too little. Evidence shows that about the impact of nutrition or kw!@cam.ac.uk overeating is not conscious, but heavily influenced exercise (of course, there is also the Katherine Ripullone is a final year graduate by cues such as the availability of take away outlets problem that less evidence in this medical student , University of Cambridge and the size of portions. Using smaller plates and eld is available). Cite this as: BMJ !"#$;%&':j()*# restricting the spread of fast food outlets helps people eat less. Whether donating organs or joining a pension, to make it easy make it the default decision to discuss long term, sustainable levels of e" ciency and equity in a On exercise, a recent US study showed that people who participated in a game with other family members solutions to funding and delivery. service that is free at the point of in which they were awarded points based on the We do have a major problem with delivery. But systems elsewhere number of steps taken increased the distance walked workforce planning, retention, and also deliver universal public health by almost a mile per person per day. recruitment. Yet, as Black argued, we services, with equal or better Similar efforts to use gamification and social could do far more to support, value, outcomes, sometimes at similar incentives to change health behaviour have had and retain existing sta! , and much of expenditure levels or with the ability mixed results. The authors suggest this is because this sits with local service leaders; we to spend more per capita. researchers have failed to follow the insights can’t blame only the government and I don’t subscribe to the dogma from behavioural economics. In the latest study, its arm’s length bodies. trotted out by right wing think for example, families were awarded points at the We do have among the fewest tanks that such health systems are beginning of each week which they lost if any family member failed to meet their target, drawing on the beds, and highest occupancy rates, inherently superior and show that the principle that individuals are more motivated by losses per head of population in the OECD, NHS model is broken. But, equally, than gains. with acute admissions and delayed we should not let the fear of being If we are to have success against the crippling transfers still rising. Yet many people shouted down stop us learning from diseases caused by poor lifestyles we must use every in hospital could be supported other health systems as we debate the weapon at our disposal. Harnessing the insights from outside hospital, and we could do NHS’s future. behavioural science could yield major gains. more to improve patient # ow, get David Oliver is a consultant in geriatrics and Ara Darzi is a surgeon and director of the Institute of Global more patients home sooner, and use acute general medicine , Berkshire Health Innovation, established to improve healthcare scarce beds wisely. davidoliver!@googlemail.com through evidence based innovation. He was a Labour health Finally, the NHS is widely Follow David on Twitter, @mancunianmedic minister from to acknowledged as delivering high Cite this as: BMJ !"#$;%&':j(&#) the bmj | 28 October 2017 149 ANALYSIS Solitary!confinement!in!prison"! we!need!to!change!the!clinicians’!role Cyrus!Ahalt!and!colleagues explore the con! icting responsibilities of healthcare professionals in a correctional practice that persists in prisons around the world despite evidence of its harmful e" ects
rison healthcare longer than #$ days as torture, a Conflicts or access to appeal. Mounting professionals work ! nding subsequently incorporated arise between evidence of serious mental health in a unique clinical into the UN’s minimum rules for obligations e& ects associated with prolonged environment designed the treatment of prisoners, also to patients solitary con! nement, however, has P to punish rather than referred to as the Mandela rules. and deference led many jurisdictions to limit its use to heal. Amid global calls for penal These rules require that solitary to the for people with pre-existing mental reform, healthcare professionals con! nement be used only in illness and for those who develop correctional have an ethical responsibility exceptional circumstances, as a last mental illness while in isolation. to speak out about correctional resort, and for the shortest amount of institution The principles of medical ethics, practices that endanger health time possible. Yet prolonged solitary the Hippocratic oath to “abstain and human rights. We examine con! nement remains in widespread from all intentional wrongdoing this responsibility in relation to use around the world, including and harm,” and the physician’s prolonged solitary con! nement, in Scandinavian nations o% en oath of the Geneva Convention all a practice that persists in prisons described as paragons of progressive prohibit healthcare providers from around the world. penal reform and even for prisoners participating in treatment that who are on remand. amounts to torture. The Mandela A widespread practice Reform of solitary con! nement rules further require that providers Juan Méndez, the United Nations is complicated by it typically being pay particular attention to prisoners special rapporteur on torture, has applied at the discretion of prison held in isolation. But many prison de! ned solitary con! nement lasting administrators without due process healthcare professionals encounter
THE CASE OF ARTHUR JOHNSON : KEPT IN ISOLATION FOR 36 YEARS
In September !"#$, a US court Johnson filed a lawsuit contesting his resulting “mental health file” comprised ordered Arthur Johnson be removed isolation shortly after. short reports that sometimes repeated from solitary confinement, where the Craig Haney, a psychologist and expert the same language verbatim and, on prisoner had been living for %$ years. witness testifying on Johnson’s behalf, the whole, were more correctional Despite only one minor behavioural reviewed his treatment files from !""% than health oriented. Mental health infraction since #&'(, Johnson, who through to !"#%. He described the care assessments outside the cell took was sentenced for life without parole that Johnson received over those years as place “sporadically and infrequently, for murder when he was #', had been “superficial psychological monitoring. . . at several year intervals.” These, by “STRUGGLING kept in indefinite isolation since #&(&. despite clear, substantiated risks to his Haney’s estimation, did not “remotely TO MAINTAIN HIS SANITY! ! ! In !"#), Johnson’s prison system psychological wellbeing” and criticised represent in-depth psychological APPROACHING mental health provider was asked numerous “mental health entries and evaluations, assessments, or analyses” LOSING THE to conduct a psychological review observations [that] reflect little more and “concluded with a correctional—not WILL TO LIVE” of him. Court documents show that than endorsements of corrections-based psychological—opinion.” the provider “had not developed a (rather than psychologically informed) Haney held extensive interviews communicative relationship with judgments and recommendations.” with Johnson and found he was [Johnson] at the time” but was asked to “struggling to maintain his sanity” and “vote” on whether he should remain in Assessments by non-health staff “approaching losing the will to live.” solitary confinement. Haney said the mental healthcare The court, siding with Haney, found The provider’s vote to keep him in that Johnson received consisted that Johnson’s decades in isolation isolation, she later acknowledged, was predominantly of brief “cell front” had caused “escalating symptoms of “based entirely on decades old escape checks for suicidal or homicidal ideation mental degradation” and probably attempts.” Prison officials decided conducted by non-health staff. Less inflicted “irreparable harm.” The court to keep Johnson, then $+ years old, frequent assessments by mental health ordered his prompt release from solitary in indefinite isolation based “in large professionals were also primarily confinement to the prison’s general part” on the provider’s assessment. brief, cell front interviews. Johnson’s population, where he currently resides.
150 28 October 2017 | the bmj a fundamental tension: the expectation that they assess the health of patients in solitary con! nement while knowing that such assessments might be used to extend patients’ exposure to a practice that is known to harm health.
Global problems The US case of Arthur Johnson (see box, below le% ) illustrates the global problems faced by health professionals who treat patients in solitary con! nement. Prison health professionals worldwide must provide patients with community standard (“equivalence of”) care in institutions designed to deprive liberty. This arrangement can result in “dual loyalty” challenges: con+ icts that arise between providers’ obligations to their patients and their deference, whether explicit or implied, to the correctional institution that bears punitive responsibility for their patients. Ethical practices termed “enhanced The exceptional case of the APA Several international organisations challenges interrogation” and was used by and Guantanamo Bay received prohibit prison healthcare providers related to the US Department of Defence and widespread coverage, but the from participating in punitive dual loyalty others to justify, expand, and prolong e& ects of dual loyalty on prisoners correctional practices. Such remain torture ostensibly approved by in solitary con! nement, like Arthur guidelines, including those of the unresolved for experts from healthcare professions. Johnson, are less well documented. UN’s Istanbul Protocol and the World many prison Such complicity represents a Johnson’s mental health providers Medical Association, require that healthcare profound breach of the physicians’ were directly accountable to prison correctional healthcare providers oath in the Declaration of Geneva, administrators and, if the court attend exclusively to the physical providers which states: “I will not use my testimony is accurate, adhered to and mental health of prisoners, medical knowledge to violate an arbitrary schedule of health which includes both the standard human rights and civil liberties, assessments determined by duty to care and the responsibility even under threat.” Johnson’s correctional status rather to safeguard prisoners from cruel, inhumane, or degrading treatment. SUPPORTING THE NEEDS OF PRISON HEALTHCARE PROVIDERS Despite this guidance, ethical Global bodies could link the Mandela rules to the principle of equivalence in care more explicitly by calling challenges related to dual loyalty for community hospital standards governing the use of mandatory psychiatric holds to be extended to remain unresolved for many prison solitary confinement. healthcare providers, o% en with dire Medical associations could issue guidance on minimum professional standards for health assessment consequences. in correctional settings—such as confidential, therapeutic environments and a required disclaimer on all The role of healthcare providers evaluations of isolated patients that such conditions pose health hazards. in torture at the Guantanamo Professional societies and academics could partner to develop and disseminate curriculums for Bay detention camp—and the correctional health providers covering human rights, the principles of medical ethics related to the protection of prisoners, the health risks associated with prolonged solitary confinement, and dual loyalty. related collaboration between the This information is currently available in the World Health Organization’s Prisons and Health . American Psychological Association As advocated by the UN Office on Drugs and Crime, WHO, and others, medical associations could (APA) and the CIA and the Bush support jurisdictions where correctional healthcare systems are under correctional authority (such as administration—brought renewed the Ministry of Justice) to transition to the responsibility of government run health agencies (such as the attention to dual loyalty concerns Ministry of Health) This has been successful in the UK, Norway, and elsewhere. in the prison context. The APA’s Expanding on the model of the European Committee for the Prevention of Torture and Inhuman or misplaced loyalty to the state directly Degrading Treatment or Punishment,+% medical associations and government health agencies could undermined the health and human implement a system of external oversight to prevent healthcare providers from participating in prolonged rights of patients at Guantanamo solitary confinement, to impose appropriate penalties, such as the loss of licensure, when such ++ Bay. APA policy at the time allowed participation occurs, and to advance whistleblower protections for prison staff who report violations of psychologists to participate in the code of medical ethics. the bmj | 28 October 2017 151 assessment, including of a patient’s situations. This places even greater immediate threat to their self and importance on the role of health others. Only a clear, documented providers to ensure that solitary risk of immediate physical harm can con! nement is used for the shortest result in the deprivation of liberty. amount of time possible, consistent The involuntary hold is then imposed with prisoners’ health and human only as long as the immediate risk to rights. health and safety persists. Statements by a growing number This community standard mirrors of international bodies have created standards for the ethical use of a foundation for physician led solitary con! nement advocated by reform of solitary con! nement. the UN special rapporteur on torture, The US National Commission on the Mandela rules, the American Correctional Healthcare states that Bar Association, and the Istanbul healthcare professionals “should Protocols : that it be used only in not condone or participate in exceptional circumstances, as a cruel, inhumane, or degrading last resort, and for as short a time treatment” /$ and the Council of as possible. But as Johnson’s case Europe requires that medical The UN than his health. They conducted shows, and others have described, practitioners inform the prison defines assessments designed to accomplish prison health providers need support director when a prisoner’s physical solitary a correctional goal (whether the beyond appropriate guidelines to or mental health is put at risk by confinement patient could withstand ongoing achieve an ethical standard of care solitary con! nement (rule 0/./). exceeding solitary con! nement) rather than a for their isolated patients. But a broader coalition of 15 days as health goal, under conditions (such medical leaders must provide Opportunity for leadership torture as brief, cell front interviews) that greater leadership to ensure that fall far short of equivalent standards Many of the reforms needed to correctional healthcare providers of community care. make criminal justice systems safer have the speci! c guidance, These providers witnessed and more e& ective, from improving training, supervision, and support conditions (such as lights that never police interactions with mentally they need to assess, treat, and turned o& ) and recorded outcomes ill people to optimising transitional advocate for their patients in of even brief assessments (such as healthcare to the community, solitary con! nement (box, p #$#). “non-communicative”) that should require leadership from the In Arthur Johnson’s case, and have triggered e& orts to remove healthcare professions. in countless other examples of Johnson from isolation but did not. Enhanced leadership and action prolonged solitary con! nement Ultimately, his healthcare providers is particularly critical in eliminating throughout the world, the medical gave a clinical endorsement prolonged solitary con! nement. profession has abdicated to their of Johnson’s mental ! tness for Unlike other pressing matters in legal and correctional colleagues inde! nite isolation, violating ethical penal reform at the intersection of the responsibility to ensure that proscriptions against participation human rights and medical ethics— incarcerated individuals are in punishment, particularly forms including capital punishment and protected from cruel, inhumane, amounting to torture. forced feeding —very few experts are and degrading treatment and Clinicians in community hospital calling for the absolute prohibition receive quality, community- settings, on the other hand, are of solitary con! nement. Rather, its standard healthcare. routinely asked to assess the use for short periods is generally It is time for the medical appropriateness of involuntary viewed as a necessary, temporary profession to claim a larger psychiatric holds. In such cases, correctional tool to de-escalate leadership role in criminal justice clinicians must undertake a robust dangerous or potentially dangerous and penal reform. We can start with an e& ort, beyond guidelines KEY MESSAGES and statements, to change the role that clinicians play in medically • The UN de" nes solitary con" nement exceeding $% days as torture' re( ecting mounting harmful correctional practices such evidence of psychological and physiological harms as solitary con! nement. • Healthcare professionals who work in prisons face unique challenges for which they often lack Cyrus Ahalt, co-director adequate guidance and support Alex Rothman, associate director of policy • Professional medical organisations and international bodies should lead reform of prison Brie A Williams, founding director, Criminal health systems and support healthcare providers practising in these settings Justice and Health Program, University of • Promoting the translation of standards from community care to prison health systems may California, San Francisco reduce dual loyalty concerns among healthcare providers Correspondence to : B Williams • Prison healthcare providers should be supported by training in medical ethics [email protected] Cite this as: BMJ !"#$;%&':j()&$
152 28 October 2017 | the bmj LETTERS Selected from rapid responses on bmj.com. See www.bmj.com/rapid-responses
RESPONSE!TO!TERRORISM state of observational research— LETTER!OF!THE!WEEK Triaging in the face of data sources worldwide are not a mass casualty event How much is too readily accessible, and data aren’t much medicine? shared after a study is completed. Gulland describes how doctors We must tackle the policy rose to the challenge of recent I welcome Pathirana et al’s account of and privacy issues to increase terror attacks in the UK (Medical how medicalisation might be limited sharing of real world data. Response to Terrorism, !" (Analysis, !" September). But the Better, responsible sharing of September). Before becoming conversation around diagnosis should data has considerable potential a junior doctor, I was deployed acknowledge that a doctor’s job is not for improving healthcare and to Afghanistan with the British to specify how much medicine is just enabling more effective use of army and witnessed the right. A growing body of evidence may limited resources. importance of rapid triage in the indicate that diagnosis and treatment can Laura McDonald, manager, Uxbridge first crucial moments after mass cause harm, but no amount of evidence can tell us how much is Anna Schultze, research associate, London casualty events. too much medicine. Evidence about the likelihood of harms and Alex Simpson, research associate, Accurate triaging of patients benefits is just the start; someone has to make a value judgment. London into categories T$-" (similar The challenge for clinicians is to help each patient make their own Sophie Graham, research associate, to the paramedic “priority” evidence informed judgment. London Radek Wasiak, vice president, London P$-" categories) enabled rapid Those who write about overdiagnosis or underdiagnosis need to Sreeram V Ramagopalan, director , assessment of injured personnel tell us both sides of the story: how many lives are lengthened for Uxbridge and prioritisation of often every $%% people who receive diagnoses and are treated, and how Cite this as: BMJ !"#$;%&':j()** limited medical resources. Triage many people experience measurable harm. Those who promote systems can be used effectively screening should consider the unmeasurable but important harms PATIENT!AIDS by almost anyone, including caused by being labelled as “at risk,” and both sides should Improving attitudes soldiers injured yet conscious acknowledge and debate the tension between medical progress to hearing loss and awaiting support. and medicalisation. Many responses to mass Patients already negotiate this tension when making decisions Oliver writes, “We’re not always casualties use practices adapted about preventive medication. Healthy scepticism about early knowledgeable about using, from the battlefield. CitizenAID is diagnosis needs to begin at home in the biomedical community. checking, or adjusting hearing an app developed with military We don’t need reminding that screening labels many people with aids” (Acute Perspective, input that explains how to triage a disease that would never cause them harm; we just need to !" September). Improving an injured person through to remember the harm that such labelling can cause. the attitudes of clinical staff to managing amputation. Louisa Polak, GP and PhD student , Colchester hearing loss is important. Some We must look at ways to Cite this as: BMJ !"#$;%&':j()*% 0%% of people aged +%-+* improve pre-hospital triage and and *&% of those over 2% have public involvement in those first with youth groups in deprived DATA!SHARING substantial hearing problems. crucial moments to improve areas of Glasgow, teaching street Lack of data sharing in The figures are higher in those in overall survival outcomes. art techniques and the concepts observational studies hospital or care homes. Chris B Yates, FY! , Cramlington of health promotion. Action on Hearing Loss, the Cite this as: BMJ !"#$;%&':j()*& Participants worked with local Several articles call for the UK charity, is keen to improve street artists to develop murals. sharing of clinical trial data understanding and can provide LIFESAVING!GRAPHIC!DESIGN The health themes came from (Research, !* July), but sharing education sessions. Locally, Street art for promoting workshop participants, which of observational data receives we have given them to general public health messages helped give the local population little—and arguably insufficient— practices, postgraduate groups, ownership of the murals. We attention. This is despite these care homes, community teams, The Wellcome Collection’s found that the bottom-up data having important uses, and NHS referral centres. current exhibition explores approach of community for example, in assessing the Notably, we talked to the NHS the use of graphic design in involvement was integral. weekend effect in the UK and in complaints team, who changed health education (The Big This cost effective method national clinical guidelines. the way it works to make it easier Picture, "% September). In !%$&, of bringing health education A review of !"+ observational for members of the public with while a junior doctor in Glasgow, to local communities has been studies published in The BMJ hearing loss to contact them. I founded a programme called shown to be effective in the between January !%$/ and Telephones are especially difficult Heart: Health Education Art to developing world. We in the West August !%$+ found that 0"% of when your hearing is in trouble, so communicate public health could better use the creative studies had a statement implying NHS call centre users can benefit messages through creative industries at our disposal. that the data could not be shared. from such advice. mediums. Colin W Primrose, locum emergency Possible reasons for this include Ted Leverton, retired GP and volunteer Our pilot project focused on registrar, assistant lecturer , Melbourne patient confidentiality concerns, for Action on Hearing Loss, Bere Alston street art. We held workshops Cite this as: BMJ !"#$;%&':j())( but the result reflects the current Cite this as: BMJ !"#$;%&':j()*' the bmj | 28 October 2017 153 Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]
OBITUARIES John B Nichols Devadas Ganesh Pillay Ralph Josiah Patrick General practitioner Consultant medical Wedgwood Fakenham, Norfolk microbiologist Public Professor of immunology (b !"&!; q St Health Laboratory University of Washington Bartholomew’s Hospital, Birmingham, National Medical School, Seattle, London, !"*+), died Infection Service, Public USA (b !"#$; q Harvard after complications Health England (b !"++; University Medical School of rheumatoid arthritis q !""'; FRCPath), !"$%), died from heart and heart problems on died from suspected failure on #& July #'!% " May #'!% myocardial infarction on #$ September #'!% Ralph Josiah Patrick Wedgwood was born John B Nichols came to Fakenham as a Devadas Ganesh Pillay (“Das”) started in London. He moved to the US when his young doctor. He became senior partner in as a consultant medical microbiologist in education at Bedales School was interrupted the local group practice and developed it Birmingham in 1''0. He previously worked by the second world war, and he was evacuated along modern lines. His particular interest at Good Hope and Heartlands hospitals and to New England. After internship and was in cardiology. He took part in many local for Public Health England. He was passionate paediatric residency at New York University, activities. One that was dearest to him was about medical microbiology and was widely Bellevue Hospital, he returned to Harvard the Old Manse, a halfway house for patients acknowledged as an expert, particularly in the Medical School as a research fellow and was with mental health problems, which he area of antibiotics and antibiotic resistance. introduced to immunodeficiency disorders and brought into being: he arranged its financing, He was an excellent teacher, which is borne autoimmunity. He moved to Western Reserve chaired its management committee, and out by the regard with which undergraduate University School of Medicine in !"#$ and generally oversaw everything throughout his students continue to hold him, and the success nine years later joined the new medical school career. Despite the early onset of rheumatoid in national examinations of registrars he had at the University of Washington in Seattle. arthritis he continued his activities (including trained in microbiology. He was on a # km fun Ralph loved to travel to his native England to golf). Eventually he became confined to his run walk in Walsall when he collapsed and see family, as well as journeying through Italy, own house, where he was cared for by his wife died. Das showed a deep commitment to the France, or Germany. Predeceased by two sons, and son for the last few months of his life. He care of patients and the improvement of the Ralph leaves his wife, Virginia; two sons; and leaves his wife, Margaret, and two children. healthcare system and the lives of people. four grandchildren. Christopher Hawke Abid Hussain Helen Chapel Cite this as: BMJ #'!%;&*":j$+&- Cite this as: BMJ #'!%;&*":j$%&" Cite this as: BMJ #'!%;&*":j$+-" Audrey Couch Christopher Paul Lindsay Gwladys Eira Pennant James Consultant radiologist Freeman General practitioner Royal Liverpool Hospital Consultant psychiatrist (b !"#-; q Liverpool and Royal Liverpool and psychotherapist; University !"*&; DPH), Children’s Hospital regional consultant for died from vascular (b !"#%; q Liverpool eating disorders Royal dementia on #" July #'!% University !"*&; DMRD Edinburgh Hospital After qualifying Gwladys Liverp, FRCR), died on #' (b !"$%; q Edinburgh Eira Pennant James (née September #'!% !"%!; MPhil, FRCPE, Williams), known as Eira, After house officer posts at the United FRCPsych), died from metastatic carcinoma of worked at Morriston Hospital, Swansea, south Liverpool Hospitals, Audrey Couch trained the prostate on #' August #'!% Wales. She spent three years in Singapore, in radiology. She joined the radiology Christopher Paul Lindsay Freeman (“Chris”) returned to England in the early !"&'s, and department of the Royal Liverpool Hospital in became a senior lecturer at Edinburgh worked as a general practitioner in Chepstow !"*+ and worked there until her retirement. University in !"+' and an honorary and then in the south east of England. In Her interest was in vascular radiology, consultant at the Royal Edinburgh Hospital. !"&& she gained a diploma in public health. before subspecialisation was introduced. Initially a general psychiatrist, he developed In the !"*'s she served as medical health Her interests included sports cars and the an interest in eating disorders, and in !"+0 officer for Boots the pharmacists in London Mersey pilot service. With her husband, took up a consultant psychotherapy post to and subsequently at County Hall, London. she ran the Gerrard and Audrey Couch pursue this. He published around !#' papers She practised as a GP throughout the !"+'s. Charitable Trust, providing assistance and and several books, but his main focus was The last positions she held were as medical support for charities connected to animals, his patients. His principal contributions officer for the Royal Air Force at stations rescuers at sea, and seafarers, cultivation were at opposite poles of the therapeutic based at Biggin Hill and Hereford. Eira’s of medicine and surgery, and churches in spectrum—namely, electroconvulsive interests outside medicine included theatre, Merseyside. Predeceased by Gerrard, Audrey therapy (ECT) and the application of evidence classical music, art, literature, and travel. She was supported by carers and friends in her based psychotherapies. He leaves his wife, leaves three children, seven grandchildren, final years. Katherine; two sons; and five grandchildren. and two great grandchildren. R W Galloway Tom Brown, Derek Chiswick , James Hendry Mandy Syrat Cite this as: BMJ #'!%;&*":j$%!- Cite this as: BMJ #'!%;&*":j$%$' Cite this as: BMJ #'!%;&*":j$%!"
154 28 October 2017 | the bmj Richard!Gordon Anaesthetist who swapped medicine for a career as a writer
Richard Gordon (b !"#!; recounting the response of his q Barts !"$*; FRCA), died after then boss, Robert Macintosh, head a stroke on !! August #'!% of anaesthetics at the Radcli$ e In# rmary. “My boy, I think you’ve Richard Gordon, the highly made the right decision.” successful author of the Doctor Doctor at Sea , which appeared in the House novels who has died soon a% erwards, was made into a aged !", once said that he learnt to # lm starring the -2 year old Brigitte write as an assistant editor on The Bardot, alongside Bogarde and BMJ , where he was put in charge Robertson Justice. of obituaries. “It taught me how to The () Doctor books and # lms, write convincing # ction, and all which made Gordon a household went well until one day I killed o$ a name in the (!"2s and (!+2s doctor of divinity, so shortly a% er I and led to a television series, were found myself going to sea,” he told followed by many other novels BBC Radio &’s Desert Island Discs and non-# ction books, including in (!)(. The Facts of Life , a (!+! novel In an interview with LBC radio in featuring a woman doctor’s concerns (!*+ he joked about the conventions about a new oral contraceptive; of obituary writing at the time. “We The Facemaker , on pioneering had a sort of code—if we put ‘he reconstructive surgery; The Sleep su$ ered fools badly’ he was the of Life , a novel on the development rudest man in miles. Hibernian of anaesthesia; and The Secret MIKESLAUGHTER/GETTY IMAGES temperament—he drank a lot. Man Life of Jack the Ripper (to whom Gordon once Good Neighbours—Suburbia with problems—he drank alone.” Gordon attributed a surgical training said that he Observed ((!)+) and Happy Families because of his skill in removing learnt to write ((!)*). A member of the Garrick and Bestselling novelist victims’ wombs). He also wrote as an assistant Beefsteak clubs, and the Marylebone Doctor in the House , his # rst novel, the (!*+ BBC TV play The Good editor on The Cricket Club, Gordon enjoyed Doctor Bodkin Adams which was published in (!"-, , starring BMJ, where # shing, gardening, and watching introduced the character of Sir Timothy West and based on the trial cricket. Many of his books were Lancelot Spratt, the irascible of an Eastbourne GP suspected of he was put composed while walking the family chief surgeon—“S for spleen, murdering several of his elderly in charge of dog in Petts Wood, near his home, P for prostate, R for rump, A for patients in the (!"2s. obituaries he said. apoplexy.” It became a bestseller Not all his work was greeted with and was made into a # lm two Early life popularity. In The Private Life of years later, starring Dirk Bogarde, Born in Paddington, London, Florence Nightingale , published in Kenneth More, and James Robertson Gordon Stanley Benton studied (!)*, he cast the nursing heroine as Justice. (John Osborne, who would medicine at Selwyn College, gay. A press conference scheduled later write Look Back in Anger , Cambridge, and then Barts, where for St Thomas’ Hospital had to be played “fourth intern.”) It sold () in (!&- he changed his name to held on the pavement a% er the million tickets in the year it came Ostlere. He would later adopt the hospital cancelled it. But the comic out and recouped its 1!) 222 pen name Richard Gordon. appeal of Sir Lancelot Spratt and budget within a couple of months, A% er qualifying in (!&" he took the # ctional St Swithin’s, deemed a winning Kenneth More a BAFTA the job with The BMJ and then sort of “Rabelaisian Arcadia” in the for best actor. Much of the comedy worked as an anaesthetist and had style of Evelyn Waugh by The BMJ was drawn from Gordon’s time as several spells as a ship’s doctor. His in (!"-, has endured. Doctor in the a medical student at Bart’s during # rst book, published in (!&!, was House was broadcast in (4 episodes the war. Anaesthetics for Medical Students . on BBC Radio & Extra last year. Its success, possibly allied to a In (!"( he met and married fellow Gordon, who died in hospital a% er childhood desire to be as funny as anaesthetist Mary Patten. In (!++ a stroke, leaves his wife, Mary; four PG Wodehouse, prompted Gordon they wrote A Baby in the House children; and nine grandchildren. to leave medicine only # ve years together—a guide to parenthood. Joanna Lyall , London a% er he quali# ed and become a They lived in Bromley, Kent, for joannalyall#'@gmail.com full time writer. He was fond of almost "2 years and this inspired Cite this as: BMJ #'!%;&*-:j&""% the bmj | 28 October 2017 155 BMJ.COM HIGHLIGHTS
longer concerned about life expectancy, it’s healthy life MOST READ ONLINE expectancy, so the big issue is A junior doctor by any can we compress morbidity at other name the end of life . . . BMJ !"#$%&'(j)#'# “You need a bit of luck to avoid the non-preventable diseases [like Parkinson’s and rheumatoid arthritis], but much of what happens to us is the environment in which we live. It’s like the #$th century when polluted water was a problem. In the %#st century PODCAST and the end of the %&th century, the equivalents were Focus on physical Exerciseinoldage the car, the computer screen, activity can help avoid and the desk job. unnecessary social care A new BMJ analysis says that as they get older, but they’re Scarlett: What we need to BMJ !"#$%&'(j)*!' encouraging exercise in older not the same thing at all. do, as Muir is saying, is people could save billions “There are some things change the environment so David Oliver: of pounds by keeping frailty about ageing that are that it’s easier for people to Challenging the at bay. Two of the authors, inevitable, like loss of skin " t the exercise in. It’s not victim narrative Scarlett McNally, a consultant elasticity, but a lack of " tness much that’s needed, it’s #(& about NHS doctors orthopaedic surgeon, and is not inevitable. It’s because minutes a week (that’s %& BMJ !"#$%&'(j)%!) Muir Gray, a public health people just aren’t doing minutes a day) of moderate doctor, discuss this argument enough exercise to maintain exercise to get you slightly Self harm among in a linked podcast: their " tness and this is out of breath, but we need children and Scarlett: People o! en confuse something that’s modi" able. everyone to do it. adolescents ageing with the lack of " tness Muir: What’s emerging Listentothepodcastat BMJ !"#$%&'(j)%&" that most people experience now is that people are no bit+ly/exercise_analysis
FROM THE ARCHIVE TWEET OF THE WEEK PassingprohibitionSaloons “Nearly #$ &&& cases of measles smugglingandtheevilofdrink were reported in the EU between On this day in , US had increased, but this was January %&#+ and October Congress passed the Volstead a small offset to the general %&#/, including 00 deaths.” Act—which enforced the result . . . Though alcoholism Last week this was The th Amendment’s ban of was often but one part of a mesh BMJ’s most popular tweet. the manufacture and sale of of evil circumstances, the short The above " gures were alcoholic drinks within the US. cut towards the removal of that recently released by the Two years later ( Br Med J evil which prohibition provided European Centre for Disease ;:), The BMJ covered promised to be successful in Prevention and Control, and a lecture about prohibition diminishing disease, poverty, were reported by The BMJ given before the Society for and crime.” in a news story about the the Study of Inebriety, in which A few years later, however, ongoing e1 orts to tackle the the speaker discussed how the journal printed a slightly measles outbreaks sweeping “the results of the first year less optimistic report ( Br Med J through Europe ( BMJ of national prohibition were !;:E"), which claimed %&#/;2($:j03&2). GP Nuala admittedly only partial . . . and that, “Owing to the intense O’Connor @DrNuala echoed partly because of the wide scale on which smuggling is the surprise of other readers Canadian and Mexican borders, carried out and the absence and fatal cases of poisoning, when she replied to say “I did over which smuggling at first of control, numerous forms which were very rare before the not realise the numbers were was easier even though it was of alcohol containing toxic passing of the Volstead law.” so high.” from overseas. The domestic substances . . . have given rise National prohibition in You can follow The BMJ on manufacture of alcoholic drinks to a large number of severe America ended in "". Twitter @bmj_latest
156 28 October 2017 | the bmj