UKCAT For Dummies - available now!

Reblogged from Get into Medicine UK:

UKCAT For Dummies is written by the founders of GeMS – Get into Medical School, building on the success of their popular UKCAT preparation course.

The UK Clinical Aptitude Test (UKCAT) is a standardized test used as an entrance examination for the majority of medical and dental schools in the UK. Its purpose is to test the likely aptitude of a candidate for a clinical career.

Read more… 87 more words

Regular readers will forgive me a brief moment of self-indulgence by reblogging this announcement. Written by my GeMS co-founder and I, I hope UKCAT For Dummies helps many prospective medical students get into the university of their choice!

Placebo Effects and Paradigm Shifts

It’s rare to find an article in the traditional medical literature that I feel readers here may be interested in, so I hope you will forgive my extensive quoting of McQueen & St John Smith’s Guest Editorial in the February 2012 issue of International Psychiatry which arrived through my letterbox this morning:

Placebo effects may be simplistically defined as those accruing from taking dummy pills or inactive treatments. In placebo-controlled randomised controlled trials (PCRCTs) placebo is defined negatively, as those non-specific (typically nonpharmacological) effects to be subtracted from the treatment arm, to reveal the specific (typically pharmacological) effect. Here, placebo is “noise” obscuring the “signal” of “real” treatment. Recently, placebo effects have been defined positively as the specific effects arising from caregiving.

Systematic evaluations reveal that placebo treatments can have large effects, sometimes larger than the effects of properly evaluated “evidence-based treatments”. This is the “efficacy paradox”. The neurobiology of placebo effects (nuclei, pathways, neurotransmitters, peptides and hormones) is being mapped out. There is evidence for various psychological  mechanisms, including classical conditioning, evaluative conditioning, expectation (including the expectations of professionals), the quantity of care and attention received from professionals, and the quality of the therapeutic relationship or alliance.

Placebo effects are no less real or, in some illnesses, clinically important than the effects of direct biomechanical or pharmacological interventions.

Healing rituals occur in all human societies… The investigation of placebo effects and mechanisms has emerged as a way of studying the “healing situation”. The technological model of medicine seeks impersonal means of cure that can be applied independently of context and person. The PCRCT is a central tool of technological medicine. It developed precisely to control for interpersonal healing effects and individual and contextual factors. This approach has had spectacular success in the treatment of disease (the objective anatomicopathophysiology).

However, meaning, cultural context, interpersonal effects, personal preferences and values are enormously important in the treatment of illness (the phenomenological
subjective experience), particularly psychiatric conditions (Miller et al, 2009)…

Prescribing evidence-based treatments and simply expecting the technology to work while failing to establish therapeutic relationships profoundly limits clinical effectiveness.

As the guest editors go on to point out, the real challenge is therefore to encourage the development of positive therapeutic relationships. After all, the non-placebo, technological side of the equation is comparitively conceptually straightforward, if admittedly time-consuming and expensive to develop.

They suggest improvements in the training of psychiatrists. This is an important issue, but perhaps it is also worth highlighting that therapeutic relationships are hardly encouraged by the way modern medicine (including psychiatry) is structured and delivered, and there is also a limit to the efficacy of training for the subset of practitioners whose natural talents do not lean this way. There is a strong focus on “evidence-based” practice – possibly because it is very measurable and audit-able – with relatively little regard to the art of being able to talk to someone in a pleasant and productive manner, and think about what the conversation might mean.

The guest editors suggest that this positive way of considering the placebo effect means that we are approaching a paradigm shift in how we treat people. I hope so, but paradigm shifts require a critical mass of people to think differently, and I’m not convinced we have that yet.

The full issue of International Psychiatry from which I have quoted can be downloaded in PDF format from The Royal College of Psychiatrists

Get into Medicine UK – Newly Launched

Get into Medicine UK

After more than a year of enjoyable personal blogging on WordPress, I’m proud to announce a new blog: Get into Medicine UK.

Eagle-eyed readers will have noted the appearance of its link in my blogroll here this week, but I’d like to take a moment of your time to introduce it properly. As some of you know, I run a course helping prospective applicants Get into Medical School, explaining the complexities of the application process and the exams & interviews they face.

A key thing that students need to be able to demonstrate, both in their personal statements and interviews, is enthusiasm for the subject and an awareness of ongoing ethical & controversial issues in the field. Of course, you’d hope they’d be interested in keeping up to date for their own interest too, but it’s sometimes difficult to find time for this in addition to all the other work they’re doing.

Get into Medicine UK aims to help students maintain this awareness and enthusiasm by collecting some of the more interesting health & medicine stories from around the web into one easy-to-follow place. It also includes prompts for some of the ideas and questions the stories raise, which students might want to think about before their interviews. And best of all, the site is entirely free, with no restricted/pay content.

Of course, a lot of health news has relevance to a wider audience too, so even if you’re not in the health profession or trying to get into it, you should find something interesting to read there too.

Never fear, Beyond Anomie will remain my personal blog, but the great thing about WordPress is the flexibility of its platform and I’m excited about using it for Get into Medicine UK.

Thanks for your ongoing support, and do please spread the word to anyone you know who might be thinking about a career in Medicine!

Painfully Obvious

Image via Wikipedia

If we believe that painkillers work, they do; if we don’t, they don’t.

Dazzling new research worthy of being considered a “phenomenal”  finding?

Sometimes I wonder how trapped within a biological model one has to be to be surprised by such intuitively self-evident findings. Is it really so astonishing that our expectations influence the efficacy of medication? The placebo effect is not a new concept but is too often considered something to compare drug efficacy against, rather than having an inherent utility and biological basis.

But any clinician worth their salt already knows that using the right language to frame the discussion around a clinical intervention with a patient makes a vast difference to the outcome. Good communication skills improve the chances of the patient accepting the intervention, reduce the risk of poor concordance with the plan over time, and improve satisfaction with the results of the treatment.

Nowhere is this more likely to be true than when mental processes are themselves the target of the intervention. To return to the subject of this new research – the efficacy of analgesics – pain is essentially a perception. We only feel pain because we interpret certain peripheral stimuli in a particular way. Analgesics pharmacologically interfere with this process, but it can hardly be surprising that our perceptual set (the prevailing way we interpret all the incoming stimuli at any given time) will influence both the experience of pain and the efficacy of analgesics.

Communication skills and theory of mind are vital to good clinical practice (and life in general). Understand where the person across the table is coming from, and you can influence their outlook, improving the impact of any intervention. Careful “framing” of the problems and solutions acts as a force multiplier of the intervention if done well… and can cancel it out completely if done poorly.

This awareness of the importance of language and emotional connection applies just as much to everyday problems and situations as it does to clinical situations.

Related Articles

• Expectations can cancel out benefit of pain drugs (reuters.com)
• Injections are less painful if you don’t look away, scientists claim (telegraph.co.uk)
• Would a placebo work for you? (newscientist.com)

What are you worth?

Image via Wikipedia

How do we define value? What makes one thing more valuable than another? And does that logic apply to human beings?

These questions hinge on a deeper question about reality. If reality is just a sum of human constructs – an agreed consensus framework – then value itself must also be subjective and ultimately a question of mutual consent. If reality is objectively true – if it exists independent of human perception – then it should be possible to use the framework of that higher reality to determine what is valuable and what is not.

Fundamentally, this is an unanswerable question, so I prefer to short-circuit it. There may or may not be a higher reality, but because I am human all I can know about reality is limited by my own perceptions, and the same is true for each living being on this planet. Therefore, even if there is a higher truth, humans have no objective way of assessing whether they recognise it correctly, so it is better and more practical for all concerned to be operate within the lower, subjective, consensus model of reality.

In this model, each of us brings to the table a unique perspective on the world. Reality is the net sum of all those perspective, weighted by our relative abilities to influence other people’s perspectives. The value of something is determined by the sum total of the world’s opinion on its value. This is a very circular proposition, as if something has traditionally been highly valued, it will tend to remain so. If it has traditionally been valued lowly, it would take a paradigm shift (e.g. a revolution) for its higher value to be recognised by a critical mass of humanity.

Thus, gold is valuable because it has been traditionally used as a valuable material. Proxy reasons include its relative durability, its scarcity, and its difficulty of extraction, but the same is true of any number of different commodities, metal or otherwise. Gold is pre-eminent in the human psyche as a marker of value because it has culturally cemented its position over millenia of use.

Over more recent centuries, certain currencies like the US Dollar, the Japanese Yen, and the British Pound Sterling have also been highly valued as so-called “reserve currencies“, held in relative esteem over others not because of the intrinsic worth of the paper – or electrons – underlying their value, but because of faith in those countries’ ability to repay their debts consistently. Whether they all hold their positions into the future remains to be seen, given Moody’s downbeat assessment of the USA’s credit-worthiness and the general concerns over sovereign debt levels.

But ultimately, whether these currencies retain their value or not will be down to the same reason why gold retains its value or not: faith in the mutually agreed consensus on reality and the worth of objects within it. It sometimes scares people to think of our entire financial system being built upon pure faith, but it should not be a frightening proposition once you consider that our entire reality is also built upon pure faith in much the same way. Of course, some have gone insane pondering that latter issue…

If the mutual consent of a large enough group of people can determine value, that means that ideas, and not just commodities and currencies, can be differentially valued. One aspect of this is politics. Over the long-term, countries get the governments the majority of their populations want. That applies just as much to tyrannies as to democracies; it’s merely the way that governments change that varies. Democracies are more sensitive to changes in large-scale public opinion, but it really is only a matter of degree.

If commodities, currencies and ideas can be valued in this way, it is not a significant stretch to realise that humans can also be compared, both as individuals and as groups. Some readers will be appalled by this, and point out that this line of thinking led to atrocities like the Holocaust and similar episodes of genocide and ethnic cleansing. They are right, of course. But the process of considering one person as more valuable than another still happens. For instance, on a small scale, family members and mutual friends generally value each others’ happiness higher than they do a stranger’s. If all humans were equally worthy in their eyes, this would not happen.

What then is the counterweight to prevent genocide?

Merely that a large mass of humanity also consensually agrees that despite our implicit measuring of value of one person versus another, we also choose as a population to limit the impact of that value judgement on smaller groups in society. This is a paper-thin protection against abuse, but all our societies can ultimately do.

On a less dramatic, but perhaps even more meaningful, scale, these relative valuations of one human’s life against another underpin the field of cost-utility analysis, which is increasingly used by governments, agencies and companies worldwide, to determine how best to spend money in order to maximise value. It’s all about getting the biggest bang for your buck for the most people for the greatest amount of time… and if you think about that carefully, you’ll realise that will always persistently work to the advantage of some groups relative to others. For instance, in healthcare, such QALY assessments will consistently benefit younger people relative to the elderly.

So, value is both mutable and dependent on mutual consent. Reality is as thin and fragile as a pane of glass, and it is only because we add our panes together that a viable edifice can be constructed. Our societies implictly use this model of value to determine the relative worth of ideas, objects, people and even money itself. And they will only value us as individuals or groups if we can convince a sufficient mass of others that we are indeed worthwhile.

If that sounds too tiring a task, the only alternative is limiting contact with society to necessity and protecting one’s isolated position by accumulating sufficient quantities of things that society already finds valuable.

The themes of this post are explored further in the next two entries:

• Risk and Reward
• Wandering the Desert

Interviews and Life: finding your own path

Our recent ferociously cold snap paused for breath today, allowing for a Sunday stroll through Oxford on a sunny and bright afternoon. After the persistent subzero temperatures of the past week or so, today’s several degrees above freezing seemed balmy by comparison. It was also a window of opportunity to relieve a mild case of cabin fever since the forecast is for temperatures to plummet again tonight. On the walk home, I was struck by just how many young people were roaming around town, clutching holdalls and consulting maps.

The reason for all this activity is that tomorrow marks the start of the annual interview season, when over 10,000 nervous applicants descend on the University over the space of a fortnight, to be grilled by their potential colleges as to whether they will be offered a place to read the subject of their choice. Their odds are actually pretty good by the time they get to the interview stage (a lot of the whittling down having been done at the shortlisting stage) but the nervous expressions etched onto their faces are understandable as they feel their entire lives are dependent on how they perform over one or two 20 minute interviews.

It took me back to how I felt when I was in their shoes, which is now rather more years ago than I care to calculate. That year also had particularly bad weather, with snow falling heavily on the day I had to attend. Fortunately the car made it through the inclement conditions and I was able to settle in comfortably before interviews the following day. I was still rather tense but the interviews themselves were surprisingly enjoyable, believe it or not, and it was a relief to feel I’d done my best. A relief which turned to delight a couple of weeks later when I was offered a place.

Nowadays, I find myself in the position of helping young people learn the skills they need to get through the application process, and in fact next weekend I’ll be teaching an interview skills workshop as part of the Get into Medical School courses I run with a friend. It’s always an enjoyable course to teach, partly because we have time to offer each attendee a full-length mock interview, so we can give them feedback on what they do well and the areas they might want to consider improving. That lets us get to know them a bit better than on our regular one-day GeMS course which gives more of an overview of the entire application process. It’s a nice feeling to know that you’ve made a positive contribution towards helping someone talented achieve their potential.

As part of that plan to try to offer something a little extra, we’re also running a Summer School next year, so that international potential medical school applicants (and others who find it tricky to travel to our one-day courses) can also get the benefit. The Summer School will let them combine getting that advice and coaching with the chance to experience what it’s like living in an Oxford college for a week.

It’s not always possible to predict where life will take you. When I first came for interviews here, I had no idea I’d still be living in this city many years later, let alone that I would be helping others get in. The illustration to this post is taken from the much larger fresco of The School of Athens, by Raphael, which is one of four frescoes dominating the Stanze di Raffaello in the Apostolic Palace of the Vatican City. It is thought to feature every major Greek philosopher, though the identities of some remain uncertain. Plato points to Heaven, Aristotle to the Earth, reflecting their different philosophical priorities. Thus, not everyone will find the same path to wisdom, but that the life task facing us all remains the same: finding what is best in ourselves by developing insight, maximising that potential through thought and study, and growing from the experience.

Giving the finger

Image by Daniel Stark via Flickr

Add this story to the ever-growing list of human conditions now linked to the size of your finger.

It describes a correlation between the relative sizes of your index and ring fingers and your risk of developing prostate cancer. For the men in the audience who are now looking down, it’s your right hand you need to examine.

If your index finger is longer than your ring finger, that’s correlated with a lower than average risk of developing prostate cancer, and vice versa. As for causation, well, that bit isn’t entirely clear, but finger length is associated with in-utero exposure to testosterone, and testerone levels are thought to affect the risk of prostate cancer, so you can vaguely guess that there may be some form of causal relationship, even if the details aren’t worked out yet.

Whether there’s any realistic utility to this minor discovery is another matter entirely, but it’s the latest in a long line of attempts to link outer appearance to inner biology. Sticking just to fingers, we’ve also been informed that long ring fingers are associated with improved mathematical ability but worse literacy, with higher earning power, protection from heart disease, homosexuality, and depression.

In truth, most of these are just demonstrations of correlation rather than fully worked through causal pathways, though potential causal relationships again revolve around the relative levels of testosterone to oestrogen in the womb. And they all discuss relative risk, rather than an absolute/inviolate relationship between one factor and the other.

While there’s little doubt that the methodology used in these studies is somewhat better and more reliable than that used a century or two ago, I can’t help but be reminded of the science of phrenology, where it was thought that man’s personality could be determined by the bumps on his head.

On a more sinister note, the idea of linking internal qualities to external physical attributes has been, and is, commonly used by propagandists and political cartoonists. In the past, this has included exaggerated racial caricatures, emphasising certian features such as long noses or large lips. More recently, we’ve seen cartoons and photo-manipulations such as the Bush-Chimp and Obama-Chimp which show that this remains a potent technique of reinforcing differentiation between a self group vs another group.

One can argue that there’s a difference between using scientifically-validated relationships to make a point and using arbitrary similarities, and I agree that there is. But the world is rarely so sensible as to actually make note of the difference.

Related Articles

• Is finger length a clue to increased risk of getting prostate cancer? (dailymail.co.uk)
• Study links finger length to prostate cancer risk (reuters.com)
• Finger length is a marker for risk of prostate cancer (telegraph.co.uk)

The Higher Path

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Psychoanalysis is a technique to cure excessively suffering individuals of the unconsciously misdirected desires and hostilities that weave around them their private webs of unreal terrors and ambivalent attractions. The patient released from these finds himself able to participate with comparative satisfaction in the more realistic fears, hostilities, erotic and religious practices, business enterprises, wars, pastimes and household tasks offered to him by his particular culture.

But for the one who has deliberately undertaken the difficult and dangerous journey beyond the village compound, these interests too are to be regarded as based on error.

With these words in The Hero with a Thousand Faces, Joseph Campbell describes the two types of journey most humans travel on through their lives, and the different ways they can react to therapy.

One group – the majority – seek out only a return to a shared delusion of normality: “the last projected fantasies of primitive physical will to live like other human beings; the will to live according to normal motives of desire and hostility, in a delusory ambient of phenomenal causes, ends and means”. This is nothing more than procrastination, but many people are not ready for something more, and at least it allows them to function within society.

Another group seek something higher. The subconscious conflict they feel between a yearning for life/flesh and a wish for death/peace is such that before they can return to the normal world, they must walk a different path. Many religions attempt to find a solution by theorising that the mortal life is fundamentally flawed (“sinful”), only to be redeemed after death; or that a true understanding of life can only come about through leaving behind physical limitations and accepting a transcendental unity (Buddhism). Clearly, these can be interpreted as two sides of the same coin.

Can this sense of tranquillity with existence be achieved during life itself? Again, I find myself returning to Epicurus for an answer:

• We must free ourselves from the prison of everyday affairs and politics
• The tranquil man is not troublesome to himself or to another
• There is also a limit to frugality. The man unable to consider this suffers a similar end as the man who indulges in excess
• The greatest fruit of self-sufficiency is freedom

All are taken from the Vatican Sayings, but I have taken the liberty of re-ordering them to make this point: the more the noble soul involves himself in the affairs of those trapped in unhappy states, the unhappier he will become. That does not mean he looks down on others, but simply recognises he operates differently. By limiting his exposure to the necessary minimum for his needs, he will be as free as possible.

And from freedom, comes tranquillity, or true happiness.

Sight beyond sight

It used to be said that the eyes were the window into the soul… even if no-one can quite remember who said it first, the quote being variously attributed to the usual suspects of the Bible, Shakespeare, and various other historical luminaries. What is certain is that the eyes remain an source of vital information for the astute observer of non-verbal body language: the so-called Pan-Am Smile where lack of emotion is revealed by lack of movement in the muscles around the eyes; the sideways or downwards involuntary glance of the nervous, distracted or dissembling; the glazed expression of the average student in a mid-afternoon class and bored beyond redemption.

The blind Ancient Greek Tiresias even has two separate myths to account for his loss of sight. In one he was said to have been blinded in retaliation for seeing the goddess Athena naked while she bathed. Later relenting, Athena, unable to reverse the loss of his vision, gave him sight beyond sight: the power of prophecy. Another tale suggests that he displeased the goddess Hera by taking Zeus’ side in an argument over sexual pleasure, resulting in Hera blinding him and Zeus making partial amends by bestowing him with precognitive ability.

It is interesting to note that both these Greek Myths feature a female causing a man to lose his ability to see the world due to being too interested in sex but I leave the sociocultural implications of this to the ethnologists, or possibly the modern therapist.

Another similar aside requiring a dedicated specialist to fully interpret the meaning behind the symbolism would be that (depending on context and part of speech) we use the same word – “vision” – for the ability to see, for having a strong sense of imagination and purpose, and for experiencing visual hallucinations whether of psychatric, religious or pharmacological origin.

More prosaically, sight remains the sense most of us fear to lose the most, due to its primacy in how way we acquire data from the world. Three separate news stories over the last couple of days show we remain fascinated by stories of restoring sight, enhancing it, or even finding ways to abolish it altogether.

The painting above depicts an event from Ovid’s Metamorphoses. The nymph Liriope brings her infant baby Narcissus to Tiresias, so that he may foretell the child’s fate. Tiresias gnomically pronounces that Narcissus would live a long life provided he did not come to know himself. Narcissus pined away to death after seeing his own reflection, perhaps demonstrating that vision and insight are not always the same thing.

Drugged-Out Science

There’s an interesting new study in the Lancet from Professor David Nutt (erstwhile chief UK drugs advisor prior to being sacked last year for disagreeing with the previous administration), which has been publicised as stating that “alcohol is more harmful than heroin”, as evidenced by the pretty-looking graph published across all the usual media outlets:

The detail behind the headline is rather more complex, and illustrates neatly how the general public and the mass media simply don’t understand how to interpret information.

The key thing to understand is how they got to the end point of this graph; what was the methodology used?

The study aims quantify the harm posed by various drug on both users and on wider society (eg through criminal behaviour to acquire funds to access the drugs), and so place each drug on the same unified scale. The methodology they used to do this is Multi-Criteria Decision Analysis, something I touched upon in a previous blog entry as being a very powerful method of problem-solving.

In order to perform MCDA, you need to have a panel of people making judgements on a series of pre-determined scenarios. The make-up of the panel therefore is the most important determinant of the results generated. In this case, the panel were the members of the government’s Independent Scientific Committee on Drugs, plus another 2 invited experts.

That makes a total of 25 culturally-homogenous scientists.

However expert these members are in the scientific literature, I would strongly question whether 25 people from a narrow professional group constitutes a broad enough panel to make decisions about overall harm of each drug on society as their definition of harm may not be that which a wider panel might use. Furthermore, since all the members of the panel work together regularly, they are likely to have all developed broadly consistent opinions with each other over time, something which will have been regularly reinforced through mutual agreement.

This “crowd convergence effect” or “groupthink” means that in effect, the panel contains far fewer than 25 different opinions, more likely only 2-3 mildly competing views at most. For all practical purposes, this study is therefore based on two or three people’s personal (if unusually well-informed) opinion. That strikes me as methodological thin ice on which to base public policy.

And that’s without the further problem of considering that the availability and stigma of each drug on the list varies wildly, which complicates ability to determine the actual underlying health and societal effects. For instance, because heroin is illegal, to acquire it automatically requires criminal activity. And because alcohol is legal, it is very easily available , multiplying its effect on society disproportionately. This means that making judgements around the harm is the very essence of a wicked problem, where cause and effect are intertwined to such as extent as to make disentanglement impossible.

In short, while the study has a useful role to play in terms of opening up the discussion for public, people should be very wary of assigning too much power to its findings.

Also in the News…

On a completely different note, below is a short collection of links to some other interesting news stories that grabbed my eye over the last few days, and that I haven’t had the time or inclination to make a full blog entry on:

• Enough changing clocks, let’s just keep BST all year round
• No national drug rationing, just local rationing instead. Better or not? You decide
• Pink is so not your colour, dahling. Only 12 points. Fuschia (16) would be so much better…