healthcare professionals

The beauty of disagreement

If this skepticism lark has taught me anything, its that disagreeing is a beautiful thing. Disagreeing with someone is a hard thing to do, in any context. Yet as humans, health care professionals, and as skeptics, its one of our keenest tools. Its only by being able to step into disagreement that we can understand our topic, our audience, and hopefully steer hearts and minds away from those willing to mislead.

I recently attended a panel about daring to disagree, which mainly focused on religious debates over Twitter and the like. I'm guilty of wiling away hours of my life arguing with homeopaths over twitter, and I'm often asked why, as I'm never going to change their minds. The short, and most noble answer is that someone undecided might spectate, and I might be able to make some impact into how they think about the subject. The more self-serving version is that its good practice to hone my skills in identifying fallacies and flaws, finding workarounds and ways of wording things, and to understand an argument in advance of the next time. In these types of arguments, the people who you are speaking to are removed from yourself, perhaps not anonymous as such but they tend to be used to arguing. Their position is usually on the defensive in the first place because their chosen subject has usually been the butt of skeptical inquiry for years.

But what of those closer to home? Sticking out heads up above the parapet in other situations is one of the hardest things in life to do. Most of us instinctively see disagreement as a threat and a personal attack, and we react accordingly. Even now, despite all I've learnt about constructing arguments and debates, with all of this practice, I certainly still get physical reactions when someone disagrees with me. My heart will pound, my mouth with become dry, and I'll want to curl up in fear because my body and brain immediately leap to the conclusion that no one likes me, that I'm so insignificant that I must automatically be wrong. I'm thankful to skepticism in that I'm able to take a deep breath and overcome those initial few moments, then can try to reassess my position. Am I actually right, but there are some good points to take away from the other stance? Or actually, is my reasoning flawed? In which case, why? Where could I have found more information, what is the other person bringing to it? Whichever way it goes, I, and the other person, end up learning more. Ultimately, we're not here to be right or wrong- we're hear to learn more, and that's the important bit.

Problems arise though because often our instincts take hold. I can't describe the number of times its all gone tits up. I can spend ages agonising over whether or not to disagree. Once I've decided to do so, I write and rewrite my argument so that it is as objective as possible, structured clearly, evidence based etc., only to have the response be “Eurgh why are you being so mean?! I thought we were friends!” or similar. I've tried all sorts of ways to word things, and I haven't quite come up with an answer on how best to avoid this response. Its not just Facebook etc. where this is a problem- we all hear in the news about irrevocable breakdowns in the doctor-patient relationship (Ashya King, as an example). We've all encountered the patient at the pharmacy counter who believes a random person waiting in the queue over our own expert advice. No one learns anything from these sort of exchanges, and that's a real missed opportunity.

So the question is, how do we go about promoting disagreement as a positive thing that we all need in our lives? How do we turn the tables on the thousands of years of evolution that make us shut down arguments as soon as they begin? Well I think the answer has to initially come from example. I believe the skeptical movement is extremely well placed to start this tidal change in thought, but we all have to practise the heck out of it every single day if we're ever going to get anywhere. We have to start being known synonymously as folk who are really, really good at disagreeing respectfully, and that has to start from within. Its clear that the skeptical community in the UK and beyond occasionally falls short in this regard, and that's a real shame as it appears to be driving good people away.

We need to recognise that we might agree with someone on one thing, but not the other. We can't see a person as synonymous with one of their opinions, and put people in good or bad boxes based on that. We shouldn't be labelling people as anti-this, or anti-that, and then refusing to engage further. We should be experts at digging deeper than that, looking behind the headlines to search for shared humanity underneath. We need to lead the way in disagreeing without bullying, and we should never, ever let up on that. We put ourselves in a position that could so easily be mashed up together with bullying by the general population when we dare to disagree, and we need to be relentlessly exemplary in our behaviour to prove that we aren't. We need to be the type of people who, even if faced with a mutant hybrid of Nigel Farage and Piers Morgan, would manage to keep their cool and be polite.

But then again, feel free to disagree ;)

Hxxx

 

Why I'm not currently a member of the RPS

Since there's a whole load of people tweeting their reasons for why they've renewed their membership, it seems like a really good time to discuss my reasons for not renewing.

Historically, membership of the Royal Pharmaceutical Society of Great Britain was mandatory, as they acted as both a professional body and a regulator. Their fees were huge- £400+, and they had a reputation for being very meek and for being a bit of an Old Boys Club. Then the split occurred, and now we pharmacists have to pay the regulator, the General Pharmaceutical Council, but we can choose whether or not we want to fork out for RPS membership. When I was working towards being a pharmacist, I was so excited and proud to be part of a professional body. I'd love to still feel that way today, but there are a few things standing in my way. Some of these reasons are very personal to me, whilst others I think may resonate with many. I can but hope that if they are read by anyone at the RPS, my comments are taken as they are meant- constructively, and with a hopeful heart that one day I will be convinced enough to renew my membership with them after a long hiatus.

Cold, Hard Cash

Membership of the Society costs £192. That's a lot of money. Surprisingly, that's not a popular opinion- whenever I say so on Twitter I am hounded by comments like "It's only the price of a pint of beer per week" or "just give up your morning coffee!". The inference is that my priorities are all wrong, and I must be mad to not join for such a reasonable price.

A few years ago, I really was in financial trouble. It was a combination of things, including a divorce, that got me to that point. Some of those things were my fault, some weren't, but none of that mattered when I had ran out of my overdraft and an enormous bill was overdue. I'm now at a much more stable point in life, but that time is still fresh enough in my memory that £192 is still a lot of money for something non-essential. 

Attitude towards poverty and Other Snark

There have been a few occasions when I have mentioned that I can't justify the cost on Twitter, and as mentioned above the response has been rather eye opening, sometimes from RPS staff. It would appear that there is a complete lack of understanding of financial difficulties from some quarters. You try to explain that yes, it might just be the price of a pint per week, but if you haven't got the price of a pint in the first place it makes no difference, but that concept just does not appear to compute. Some of these conversations got so bad that I had people DMing me to check that I was okay.

I've been made to feel ashamed and belittled. This may not have been intended, but this general conception that pharmacists- presumably because they get paid fairly well- must never have real money worries is really concerning to me. A good wage is brilliant, but it doesnt 100% guarantee such financial security that £192 seems like a throwaway amount. Sometimes life just steps in and mucks everything up. As health care professionals, empathy is an extremely important skill, and there have been a few occasions were that seems to have been lacking. If folk can be so dismissive of financial hardships, what else could they be similarly judgemental about?

Additionally, I did see another, unrelated snarky tweet by a very prominent member of RPS staff to a tweeter who had dared to ask for evidence. This may be a very minor thing, but to me its a big no-no, since I'm so passionate about evidence based medicine. 

I wish I had screenshots of all of these conversations, but they happened a long time ago and I'm too tired to try to hunt them out. I know this might all sound super petty, but for an organisation with professionalism at its very heart, I think such seemingly small things add up.

 Evidence of Value for Money.

The RPS certainly does some very good work. And I can honestly say that I hugely admire their improvement over the years that I've been a pharmacist. They're a lot more visible these days, a lot more proactive. I've admired their stance on things like social media, homeopathy, and e-cigarettes. I love that they've collaborated with Sense About Science. But, despite all of these advances, I'm still not entirely convinced that membership would make enough difference to my daily life to justify a cost of £192. How do I know, if I'm not a member? well, I know this isn't particularly robust, but from my own n=1 experience of previously being a member compared to now, I see no difference.

I've never had a patient look at my credentials and say "Here, you're missing an R and an S from your MPharm, you must be a rubbish pharmacist.

Money=Professionalism

This is a concept which I simply cannot abide, but which is creeping more and more into the forefront. It seems that organisations are starting to equate RPS membership with professionalism, and this is very simply not the case. Throwing money about does not, under any costs, make someone more professional. I know some really terrible, unethical pharmacists who are members. Homeopathic pharmacists who repeatedly endanger peoples' lives, in spite of the RPS stance on homeopathy, appear to be members. Then there's me, who works bloody hard to be a good pharmacist, to promote safe and effective healthcare, and who spends sleepless nights worrying about my patients.

What of those of us who work our asses off, day by day, to help our customers, pay our bills and maybe, if we're lucky go on a little holiday? The implication that people who cannot afford membership are somehow less professional really, really drives me mad, and far from making me rush to hand over my cash, it instead distances me further.

Previous personal letdowns

I've written previously about a complaint against me when I was newly qualified, which was handled by the  RPSGB. Although they no longer deal with complaints, I was left with a lasting sour taste in my mouth following that experience. I spent a lot of time with the inspector, talking about the substandard working conditions I was being forced to work in at the time. I was assured that the RPS would fight to improve those standards, and that they would be taken into account. Of course there was no mention of that conversation in the report i later received.

I know this is anecdotal, and I know its unfair to tar the current RPS with the same brush as I did their predecessors. But it does mean that to me personally, they need to work a little harder than usual to win back my trust.

My Joining Threshold

I'm not entirely sure of what would convince me to join as of yet. This is still, despite all of these years, pretty nebulous and shifts occasionally. Some of my admittedly vague suggestions where there is room for improvement are:

  • Guiding a sea-change in the profession to embrace evidence-based medicine. 

  • Speaking up about the amount of unprofessional quackery for sale over pharmacy counters. 

  • Truly standing up for everyman: acknowledging the importance of every pharmacist out there with aching feet and a headache who hasn't had a proper lunch break in years. 

  • Shaking off the traditional top-down culture of the profession and finding creative new ways to really listen to those of us working at the front line- those of us who can't get the time off work to attend meetings in London and who are too exhausted at the end of our 16 hour shifts to spend hours reading consultations .

  • Making some really meaningful steps towards changing poor workplace conditions for pharmacists.

  • Constructively engaging with non-members in order to raise the profile of the profession cohesively, rather than creating a false, unhelpful two tier system

  • Working towards breaking through mental health stigmatism both for patients and within the profession. 

The other important factor for myself is of course financial stability. I'm getting there. I'm not ashamed to say that at the moment, though, I'd rather prioritise that pint per week over membership. My social life is extremely important to me- its what has gotten me through the hard times, and I can see a clear benefit to my life from it. At the moment, sadly, I can't quite say the same about RPS membership, though hopefully in time I will be persuaded otherwise.

Hxxx

Special Investigation: Is Santa really a pharmacist?

Despite him being one of the most famous people on the planet, we know a suspiciously small amount about Santa Claus's background. I've had the suspicion for some time that he may in fact be a pharmacist throughout the rest of the year. 

A quick check of the GPhC register brings up no S. Claus’s, though of course that only rules out pharmacy practice in theUK. Unfortunately it would seem thatLapland does not have a similarly searchable pharmacist register, so we are unable to confirm his registration status in his home country. However, if Santa were to be working overseas, it would seem that Your Family Pharmacy, 15 N Kringle Place, Santa Claus, Indiana would be his first choice, especially given its prime location near to Lake RudolphCamping Park. (honestly, this place exists)

Santa is, of course, most famous for operating a highly efficient free delivery service. No doubt these skills have been honed throughout the rest of the year, as he organises a prescription collection and free delivery service to his patients.

As the song goes: “He’s making a list, he’s checking it twice”, demonstrating that Santa is following robust self-checking procedures. It is clear that he has the sort of attention to detail that is required by pharmacists. It’s also clear from this song that he is aware of NICE guidelines.

It seems clear that Santa’s system of working, is synonymous of that in a community pharmacy. He works alongside a team of highly skilled and well trained elves, though retaining legal responsibility for all that goes on in his workshop. One assumes that, on visiting the workshop, his Responsible Father Christmas sign is clearly displayed.

Perhaps the most convincing evidence is that of his links with the Coca Cola company. Santa has a long history of advertising the product, adding a splash of red and a liberal helping of fur to his usual pharmacy white coat. Its good to see that Santa is so devoted to advertising the invention of  fellow pharmacist John Pemberton, who originally invented the drink as a cure for his own morphine addiction. Santa is clearly interested in harm reduction and no doubt works closely with local drug and alcohol teams during the rest of the year to dispense opioid replacement therapies for patients.

Santa Claus, however, does have some flaws as a pharmacist. As discussed in the BMJ, he appears to pose a number of public health risks, including as a vector for infectious diseases, and in the promotion of drink-driving. It would seem that he would benefit from a visit to his nearest Healthy Living Pharmacy, where he can access advice on reducing his weight and brandy intake. It is good to note that he successfully quite smoking and seems to have remained abstinent.

Hxxx

Is pharmacy a good career choice right now?

I always wanted to be an archaeologist, growing up. I knew, however, that this was probably a pipedream- partly because I dislike creepy crawlies, but mostly because I was pretty sure in my childhood brain that everything interesting would have been dug up already by the time I was old enough to work.

Turns out I was wrong about that, but I’m still really proud of the profession I ended up in. I remember wandering up to the local shops with my Mum when I was little. We were talking vaguely about the future, when we had a little nose around the local chemist’s shop, cooing at the colourful bubblebaths and hairgrips that they had in stock.

“I know”, Mum said. “Why don’t you become a pharmacist?”

“What’s one of those?”, I asked. As far as I was concerned, the chemist’s shop was a place to buy cheap make-up and bath salts.

“Well, they stand in the back and mix up the medicines”. That’s it, I was hooked. I had images of brewing potions, mixing up gloopy ointments, and all sorts of stuff that, it turns out, in real life you only actually get to do for a couple of hours as an undergraduate. But my decision was made, and all the rest of my life I knew I was going to be a pharmacist.

As I got older, and I started telling people what I wanted to do, I used to hear nothing but positive things. I worked as a counter assistant in my local super market, and locums always used to tell me “You’ll never be out of work. Everyone is always desperate for pharmacists.”

At the time I graduated (2006), it still hadn’t been that long since the Great Pharmacist Shortage. This happened because the old style three year degree now became a four year Masters degree- so there was one year where no newly qualified pharmacists came on the scene. Everywhere you looked, people were crying out for a full time pharmacist to work for them. Whatever happened, you always knew that you could locum as a back up, and earn a good wage doing so.

As university went on, and I started applying for pre-reg places, I got worried. Not because I didn’t think I would get a place- in actual fact I was being courted by several companies, all of whom were clamouring to fill their pre-reg spots. I think I did maybe 10 interviews, and I got job offers from every one of them (and believe me, some of those interviews I was really quite atrocious in). No, I was worried, because I wanted to do my pre-reg in hospital, and I knew that pre-reg places really were limited in my local area- only 7 for the whole city.

I was lucky, and I got in. My year was really lucky, as it turns out there were enough jobs going for each of us pre-regs- though I actually went elsewhere. Whilst community pharmacy jobs were plentiful, hospital pharmacy was a lot more difficult to get a job in.

Nowadays, it has changed so much. I don’t think I can ever really hear myself saying the sort of things I was told to an enthusiastic school child now. “You’ll never be out of a job” would just simply be a massive lie.

When I was choosing universities, there were only a handful that actually offered pharmacy as a degree. In recent years there has been a proliferation of universities offering it now though, and as a result, the number of graduates is increasing year on year. I’m sure this isn’t the whole reason, but we have now reached a point where pre-registration places are becoming really hard to come by. There is a group of potential pharmacists, year on year, who will simply never be able to get a place anywhere.

So what does that mean? Well, you can’t register as a pharmacist, so you can’t work in your chosen profession. You’ve still got a Masters degree- but you’re actually pretty limited as to what you can do with it. Sure, its equivalent or better than a pharmacology degree, but you’ll always have a question hanging over your career, whatever you choose to do: “If you’ve got a pharmacy degree, why aren’t you a pharmacist?”. There’ll always be a slight, unfair, cloud of suspicion there. It means, even for those lucky enough to get pre-reg places, that jobs are more and ore difficult to come by, wages are being lowered despite responsibilities and workloads being higher, and locum shifts are both hard to get and pay an awful lot less.

Several places that I do locum shifts for have an email alert system for new shifts. On several occasions, I have received an email, checked my diary for my availability, then rang back immediately only to be told that all the shifts have gone already. The good thing that comes out of this is that, once you get your foot in the door, there is an incentive to work hard and become known as one of the best, most hardworking locums, because then you will get offered shifts first. The bad thing is that its now really hard to get that first step on the ladder.

How do we fix it? I have no idea, as it’s a multifactorial problem. A cap on the number of students studying pharmacy does seem logical, but that’s already been stamped upon by the Minister for Universities, science and cities Greg Clark MP, who has said:

Having considered the evidence I have decided that it is not necessary to introduce a specific student number control for pharmacy. The government's objectives for pharmacy can best be achieved outside of a number control system. It is the government's policy to remove student number controls wherever possible to enable students to have greater choice and to encourage universities to offer better quality courses to attract students. I believe pharmacy students can and should benefit from this reform and not be restricted. Therefore there is no need to consider further options for a pharmacy number control.”

It seems to me that the one thing that Mr Clark isn’t considering is those students. Yes, they might have greater choice, but I wonder, if asked, where their priorities lie- would they rather have more choice, or would they rather have some security in their future. I wonder if it has occurred to him to ask them directly.

So it is that I, and a number of other pharmacists, are sadly starting to discourage students from looking at pharmacy as a profession. Its through no fault of their own, and its brilliant that so many young people want to be pharmacists- but its hard out there, and its only going to get harder. Our bright young potential pharmacists might be better off opting for a less focused, vocational degree.

Hxxx

 

When real science gets left out in the Coldzyme

There’s no getting away from it, folks. Its sniffle season. For the next 6 months or so, the sounds of sneezes, coughs, and millions of noses being blown will echo throughout the nation.

We all know by now that the common cold is a virus. We all know that there is no cure. We also all know that, although you feel like crawling into a small dark warm cave and dying at the time, its usually much better after a few days, and it goes away of its own accord. Cold and flu remedies do nothing to actually get rid of your cold- they are there to make you feel better during it, although many of them are actually irrational combinations of products in shiny boxes with a redonkulously high price.

It is often said that if someone did come up with a cure for the common cold, they would be millionaires. I was, therefore, surprised to read this week in Chemist + Druggist magazine that indeed, the first ever product to not only treat the symptoms but to act on the virus itself was winging its way to pharmacy shelves as we speak. Really? Because blimey charlie, if that's the case, then this product should be Big News. 

The product is ColdZyme, a mouth spray that costs £8.99 for 20mLs. Seems a pretty fair price to pay for a product which claims to cure the most prominent infectious disease in the western hemisphere. It seems odd, though, that instead of this marvellous scientific breakthrough being plastered all over the media and medical literature, the article announcing it is tucked away quietly in a barely read corner of a trade journal.

What is this breakthrough, miracle product that will powerfully break down viruses? Well, an enzyme called trypsin. An enzyme that already merrily and plentifully kicks about in your digestive system, breaking down proteins. An enzyme which, for the purposes of this product, is inexplicable being derived from cod (which has meant that I have had to resist the urge to refer to it as somewhat fishy.) An enzyme which should be stored at temperatures of between -20 and -80 degrees Celsius, to prevent autolysis. Now, I've seen some fancy medicine packaging in my time, but never a simple mouth spray bottle that can manage such cold chain storage feats. So, if trypsin really is present in this product, then it seems fairly likely that its going to be inactive, unless the manufacturers have found a way of warping room temperature. Or you happen to be in Winnipeg in the middle of winter.

Medicine vs. Medical Device

The manufacturers make some really very extraordinary claims on their website, including one textbook example of special pleading. Their product, they state, isn’t a medicine. It’s a medical device, because it has no systemic effect. They then of course go on to helpfully tell us about the systemic effect it has:

“The medicines currently on the market only treat the various symptoms of a cold. ColdZyme treats the cause of the symptoms – the virus itself – and thus works both preventively against the common cold and shortens the duration of illness if you have already been infected.”

Right. So in the same breath, they are claiming that the product only forms a barrier, no more. But then they are also claiming that this barrier affects the ability of the virus to produce illness if you are already infected- viruses which are already through that barrier and inside your body. Come on, Enzymatica, you can’t have it both ways.

The Evidence

All these claims are backed up by evidence, right? Well, there is a tiny trial performed on only 46 people, which isn’t published anywhere. I can’t say whether or not it is a well designed trial, because I can’t see it in full, so to be honest, we pretty much have to just discount it. What we can do, however, if have a look to see if there is any other decent published information looking at the effect of trypsin on the cold virus. So I turned to the medical databases Medline and Embase, to trawl through the published medical literature. 

I did find one experiment which looked at the trypsin sensitivity of several human rhinovirus serotypes(1). And this appears to have found that viruses are only really susceptible to trypsin when there have been exposed to low pH, followed by neutralization- something which wont have happened to your common or garden cold viruses. I couldn’t find much else suggestive of a clinically significant antivirus action of trypsin.

The practicalities

This isn’t a simple, one-off- couple of sprays and away flies your cold sort of product. You have to use it every two hours, as well as after you brush your teeth and before you go to bed, and you have to continue this “until your symptoms are relieved”. That’s one hell of a regime. I have difficulty remembering to use medicines twice daily, never mind every two hours. I’ve never used this product, but I’d imagine that if it really does leave a “barrier” coating in your mouth, its a pretty unpleasant sensation. I can’t imagine many people sticking closely to these dosage instructions, and if the mechanism of action is as the manufacturer’s claim, skipping doses would cause the product to fail (if, indeed, it works in the first place)

We are also directed to “Start using ColdZyme® as soon as possible when you detect symptoms of a cold.”. Now, those of use who suffer with cold sores who have ever used aciclovir cream will know that this is often easier said than done- you probably haven’t got the stuff in the house, or at work, and by the time you’ve managed to get your hands on some, its already too late- your cold sore is out loud and proud, and using the drug will be pointless. Its likely that the very same thing will apply here. And remember that the incubation period for a cold is about 2 days- so the virus will already be cosily settled into your body before you even know about it. Its therefore completely ludicrous that this product claims to be able to reduce the length of a cold simply by forming a barrier.  

I know it can be used as a cold preventative, but how many people who feel completely fine are going to remember to use the product every two hours, every day, for the entirely of the cold season?

To Summarise

So, do I think there is scientific evidence to back up the extraordinary claims being made by ColdZyme? I might do when hell freezes over. Or at least when some decent trials are published, which might take just as long.  Do I think that this product should be sold through pharmacies? Absolutely not- this isn’t, if you ask me, real medicine. This is pure pseudoscience, trying its best to fool you into buying real medicine. Do I think lots of people will buy this, use it once or twice, then leave it to languish in their bathroom cabinet? Absolutely.

Here’s the problem though: this stuff will appear on the shelves of pharmacies all over. The pharmacists wont have a clue what this stuff is, and because they are really busy and probably quite tired at the end of each day, they wont be able to do the sort of evidence review I have managed to squeeze into a quiet moment. So they’ll get asked about it, and they’ll sell it. Some people will buy it and will feel better after a few days, and will think that the spray has made them better, forgetting that colds are self-limiting anyway. A customer might come back in the pharmacy one day, and say something like “hey, that new-fangled spray got rid of my cold!”, and the pharmacy staff will end up making recommendations on the basis of customer feedback and anecdotes, rather than on the basis of rational, scientific evidence. In my eyes, this really is a shame, and by selling this sort of nonsense, we really are cheapening our profession, and we're causing our customers to waste their money. 

If patients ask me about it, when I’m working behind the counter, I’ll tell them something along the lines of: “there’s no evidence or logical way that it works. It seems to be a bit of an expensive gimmick, with no decent basis to it. You’ll feel horrible with your cold, but it will start to go away of its own accord, I promise. In the meantime, you’d be much better off looking after yourself, having plenty of fluids and rest, and taking paracetamol according to the packet.”

Hxxx


It's time to reclaim holism

Holistic. It's one of those words that's sure to set any skeptic’s teeth on edge. It's basically a codename for woo, bandied about by supporters and pushers of all sorts of magic, unicorn tears, and snake oil.

But should it be? Is it time for the medical profession to reclaim the label holistic as its own, and start shouting from the rooftops about how we are holistic practitioners? I think it is, and here’s why.

holistic

həʊˈlɪstɪk,hɒ-/

adjective

Philosophy

adjective: holistic

characterized by the belief that the parts of something are intimately interconnected and explicable only by reference to the whole.

Medicine

characterized by the treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease.

There is a general perception, gleefully pushed by proponents of alternative healthcare,  that somehow conventional healthcare and holism are at odds with each other. The image of an uncaring, white-coated medical professionals hell-bent on simply treating that one particular symptom, with no regard for the fact that a patient is attached to that symptom seems pervasive.

We don’t help ourselves, I suppose. With a limited time on GP appointments, for example, its easy to feel like you’re being rushed through the system. Some surgeries ask that you book one appointment per ailment. Our health care professionals tend to specialise in one particular type of illness, and you can start to get the impression that they only care about that particular bit of your life, despite the fact that it’s very often all interconnected. You can feel passed from pillar to post, one day an appointment with a diabetes nurse, the next day an appointment with someone else for your arthritis, and two days later an appointment with a mental health specialist. So I do understand that it can seem like, as healthcare professional, we only care about your symptoms. 

But, even at the most basic level, it is impossible and really quite dangerous  to practice healthcare without looking at the patient as a whole. We’re all trained to do it, and its become so second nature to us that we have all sort of forgotten to be proud of it. As a result, we've lost control of the word holistic and we’re allowing unscrupulous charlatans to creep in to the public’s consciousness on the back of it. Of course, there are improvements to be made, but I think on the whole we do bloody well in the NHS, given the knowledge, funding and time constraints we’re lumbered with.

Now, in my day job as a medicines information pharmacist, I actually have no direct contact with patients. But I still, fundamentally, operate as a holistic practitioner. Here’s a basic example of what I mean:

GP: “Ah, hi there, I’m just wondering if there are any interactions between Champix and CellCept?”

In this sort of seemingly simple interaction enquiry, it is imperative that I look at the patient as a whole, rather than simply as two drugs out there on their own. 

  • Champix®▼(varenicline) is a drug used to help patients stop smoking
  • CellCept® (mycophenolate mofetil) is an immunosuppressive drug used to stop organ rejection in transplant patients. 

If I were to look at interactions of these two drugs,  I wouldn't find any,So fine, we’re good to go, right? I mean, I’ve answered the question, done my job, and all is well, yes? 

No, not at all. If I’m going to safely answer this question, I need to look at the patient as a whole. I need to acknowledge that they’re not simply a smoking machine that needs to stop but they’re a living, breathing complicated human.  I need to look at the patient holistically, not just as some isolated drugs.

So our patient is in his mid-forties, using the mycophenolate mofetil because he has previously had a heart transplant. He has a history of depression (understandable really, given how ill he has been in the past), and takes a couple of other medicines too (no major interactions on checking). He wants to stop smoking, which is great, a really positive step for him, but he’s failed a few attempts already whilst using nicotine replacement therapies. He's found these failed attempts frustrating in the past,which has then triggered bouts of depression. His liver and kidneys are working just fine.

So, looking at the patient as a whole, I need to think about how using varenicline will impact him as a person. Some of my thoughts go thus:

  • Stopping smoking itself might affect some drugs, as there are chemicals in cigarette smoke which can affect the enzymes that metabolise some drugs. Is this the case with any of these drugs?

  • Quitting smoking itself can be a trigger for depression or suicidal ideation. 

  • There is also an association between varenicline and changes in behaviour and thinking, including depression and suicidal ideation. Given this patient’s history, this will need to be discussed with him and he’ll need to be monitored carefully.

  • Certain cardiovascular events were reported more frequently with varenicline than placebo in trials: we need to bear that in mind and monitor him for any adverse reactions, especially given his heart transplant

  • Not succeeding in giving up smoking has made him depressed in the past. Continuing to smoke increases his cardiovascular risks. A good old risk vs benefit decision needs to be made.

So I discuss all this with the Dr, and her response is:

“Ah that's great. Yep, I knew about the depression stuff but to be honest I hadn't really thought about the cardiovascular risks. I'll discuss it all with him, and I think we'll go ahead and prescribe it but I'll make sure to keep him closely monitored”

By looking at the patient holistically, his Dr and I have made sure that he will know to look out for any cardiac effects and to report it as soon as possible if he does experience any side effects. We can make sure that he's also prepared for the fact that his mood might change, and knows to report any of that too. He’s willing to take these risks for the sake of stopping smoking, so we’re helping him to take a really positive step in his life, aimed with all the information he needs to do it safely.

That’s just a small example of how I practice holistic medicine in my daily life. All over the NHS, at every level, other healthcare professionals are doing the same thing in their practice. We don’t declare ourselves to be holistic, because its such second nature that we don’t even realise we’re doing it. Maybe its time to start reminding people-and ourselves- that conventional medicine does, fundamentally, mean holistic medicine. 

Hxxx

 

The importance of a fluffy pen

Many years ago, in my pre-reg year, I was pulled into an office by my tutor and told that I needed to sober up. She didn't mean that in an alcohol sense, but instead that I needed to start being more serious, dour, and less quirky. She told me that my personality, as it was, wasn't right to be a professional.

At the time, I believed her. She told me that I would never make a good pharmacist if I carried on the way I was. I was terrified, as all I wanted to do with my life was to be a pharmacist. If I couldn't be a good one, then I would really need to change my personality.

All of this started because I had a Christmas pen. It played tinny music for an alarmingly long time when pressed, and it became a bit of a joke in the dispensary to sneak up behind me when I was working and set it off, making everyone dissolve into giggles. A dispensing assistant, who was wearing a Christmas tie, was also told off, and strongly advised to not wear it again.

But nowadays, I disagree heartily that you have to be serious to be professional. I think a little bit of well-placed silliness and a lot of humour can add to our professionalism.

We need to be approachable to patients. And what makes a person more approachable than a little bit of personality? Nothing, except perhaps a novelty pen. On a couple of occasions, women who have come to see me about the emergency hormonal contraception pill, and who have been very nervous, have ended up giggling at a ridiculously fluffy pink flamingo pen I used to have. It broke the ice, and they could see that I was a person just like them, and I wasn't going to sit there all business-suited and high and mighty at the other side of the table and judge them. They felt a lot more comfortable because of that pen, and I think I was able to help them a lot more as a result.

At the moment, I have a Special Pen in my desk drawer. It is comedically large, pink, and slightly phallic, with some floppy rubber spikes on the end. I like to take it out of my desk drawer and offer it up, straight-faced, when people ask to borrow a pen. 

my special comedy pen, with a banana for scale

my special comedy pen, with a banana for scale

We health care professionals deal with a lot of dark stuff on a daily basis: sickness, death, disability, anger, frustration etc. We need to balance that darkness out with something lighter. Whether its doing something daft in the dispensary to make your staff laugh for a few seconds when times are stressful, or donning a fox mask and writing silly things on the internet, it all counts. 

As long as we put the patient first, we treat others with respect, and we work within our limits, true professionalism doesn't have to mean that we all walk about with serious faces.


Hxxx  

A comparison between medical and homeopathic information sources

Recently, I’ve been delving back into the world of homeopathy, and all of the nonsense that it entails.

Part of my research and preparation has been consulting homeopathic texts- materia medica and repertories that are still in use by modern homeopaths.

One thing that I have been repeatedly struck by is the stark differences in the quality of these information sources compared to those used in modern medicine. Let’s take a look at some of those differences.

Up To Date?

Part of my day job’s role is resource management. This means that I need to make sure that all of the resources that we use and have access to are present and up to date. Whenever I use a book as part of my work, I document which edition I have used. If I use a website, I make sure to include when it was last updated. When we get a new book in the office, I find the old copy and cover it in stickers saying “Out of date- do not use”.

I don’t do these things because I am weird, or because I enjoy it. I do it to ensure that I give the most accurate, up to date information so that the patient gets the best care. What we know about medicines is constantly evolving- new medicines, new safety information, and new evidence is emerging daily. What might have been correct to the best of our knowledge last year may now have been subsumed by more recent experiments, and so the information sources I use change accordingly. So, for example, I can reach for a copy of the British National Formulary from 2005, and find information that recommends sibutramine as a weight loss aid in certain patients. However, if I look at the current version, I won’t see it in there, as it has since been withdrawn for safety reasons. If I were to have used the 2005 copy to advise a patient, I might have given them the wrong advice, in the context of what we know today.

How up to date is the information used by homeopaths? According to The Homeopathic Pharmacy (Kayne, S. 2nd Edition, published in 2006 by Elsevier Churchill Livingstone, page 192- I did warn you about the documentation): ‘The most well known are Boericke’s Materia Medica with repertory and Kent’s Repertory of the Homeopathic Materia Medica’. Sadly, the author of this book doesn’t see fit to bother telling us when these were published. Neither does the online version of it, although there is a bit of a hint in that the “Preface to the ninth edition” on there is signed off by William Boericke in 1927.

Nineteen Twenty Seven. Medicine and healthcare is a pretty fast-paced industry, with new innovations and information coming out at an overwhelming rate. So much has happened in medicine since 1927 that there is no way that anyone should accept health care advice based on something written from that time. I know I certainly wouldn’t be too happy if my GP gave me health advice from a dusty tome, or if I went to the dentist’s to find them using equipment from the 1920’s.

Maybe Kent’s Repertory will be more up to date? A Quick look at the website gives us no clues. This time, the preface contains no date at all. The closest thing that we have to a publishing date is the fact that the website is copyright 1998, and appears to have been formatted by a default-font loving child in the early nineties.

Political Correctness

Over the years, medical terminology has changed and evolved along with society and scientific discoveries, and rightly so. In some cases, words that used to be considered as perfectly legitimate scientific terminology (such as ‘Mongol’, or ‘Mongoloid Idiocy’, used to describe a person with Down syndrome) are now considered downright offensive. Even whole swathes of what is now considered normal society (such as gay people) were once declared as illnesses- and of course we know better by now, or at least we should do, and if you don’t- grow the hell up, will you. We generally don’t refer to people as “hysterical”, or “insane” anymore, as we know a lot more about such conditions, so are able to categorise people more helpfully and professionally.

As a result, we healthcare professionals are very aware of how crucial the use of clear, concise, professional communication is, including the information in our resources. No self-respecting modern medical text would ever dream of using out-dated, offensive terms, and if it did, there would be an outcry.

Let’s have a look at the sort of thing that Boericke’s Repertory wants to help us to treat. There are things like “Brain-Fag”, “Cretinism”, “Masturbatic dementia”, “Fears of syphilis”, “hysteria”, “insanity”, “weak memory from sexual abuse”, “Haughty”, “Stupid”, and many others. These were just taken from the “Mind” section, but there are many other examples in the other sections too. These terms are just too outdated and are wholly inappropriate to be used in today’s society.

Having looked through various other Materia Medica entries too, I’ve found statements that are sexist, bigoted, and occasionally racist. Nice eh? You don’t find that sort of thing in an up-to-date copy of Martindale: The Complete Drug Reference.

Clarity

Good, modern medical resources are all about clarity. They need to be- after all if someone gives the wrong medical advice because they have interpreted something incorrectly, patients could be at risk.

Jargon is sometimes necessary, but nowadays medical jargon tends to use standardized, accepted terminology which keeps the risks of misinterpretation to a minimum.

Homeopathic repertories and material medica, on the other hand, are full of vague, odd terms which are massively open to interpretation. What, pray tell, is a “voluptuous, tingling female genitalia” when it is at home? (and I wonder whether Ann Summers offers free delivery on such a thing?). What does “expectoration, taste, herbaceous” mean clinically? How is one supposed to diagnose “Taedium vitae”? When would you class a person as “Obscene, amative”, and when would they be considered as merely “gay, frolicsome, hilarious”?

In Conclusion

Our health is arguably the most important asset that we have. Why would we entrust it to sources which are terribly out of date, inaccurate, and in some cases, offensive?

Homeopaths like to paint themselves as a caring, human alternative to the more business-like, clinical world of real health-care professionals. But when this alternative categorises people as being “stupid”, or “cretinous”, and is happy to use criminally out of date resources which can risk peoples’ health, I wonder just how caring and ethical it really can be.  

I've said this before, and I'll say it again: why would you continue to use an abacus when calculators exist, and are proven to have a better record at getting the right answer?

 

A tale of an excellent healthcare system

It seems that everywhere you turn these days there's another horror story about the NHS. In the wake of the Mid-Staffordshire report, press, patients and staff are reeling from what seems like a never- ending list of systematic failures. Some of us in the UK are no doubt left questioning the value of the NHS, wondering whether our taxes are being spent on nurses who are more about painting their nails and chatting than looking after patients and doctors who merrily stand by as scores of patients die while they discuss what they watched on TV last night. 

As with all things, the juicier media stories come out of negative experiences. There are major failings in the NHS for sure, and my goodness we need to address them. But we need to also realise that there are a huge amount of strengths associated with our healthcare system also. Alas, our current health secretary seems hellbent on destroying the good bits once and for all. Unless we start paying attention to the good, positive stories... Well, as the cliche goes, you don't know what you've got til it's gone.

So here is a little story of my recent experience with the NHS.

As you will no doubt know by now, given my incessant whinging on the subject, I currently have guttate psoriasis. You'll probably also know that it's completely freaked me out, and caused a bit of a flare up of anxiety. 

I registered with my local doctors, which I had been meaning to do for ages. I rang at 8am and had a registration appointment by 9:30am that day. The healthcare assistant i saw was warm, friendly, and very empathetic. By 10:15 I was seen by a doctor who was equally friendly, had a good proper look at my rash, and who explored my feelings about it and helped me rationalise my anxiety about it. By 10:30 I was out the door, prescription in hand, and feeling much better. 

Fast forward a few weeks and my rash is still getting worse. I pop back to the doctors and again am seen by a doctor who takes a lot of time and effort to find out how the rash is affecting me in myself. She made me feel totally justified in my feelings and went out of her way to arrange an urgent dermatology referral for me. I had a throat swab for residual strep with the same healthcare assistant who looked after me initially and she was brilliant, chatting with me about how often her mum had to scrub the bath when her sister had eczema as a child. We had a bit of a giggle, and that was exactly what I needed. I get the feeling that had I needed a good cry, she would have been equally happy to spend time listening. 

Some might say this is just them doing their job. Maybe it is, but I think in my case they've done their job brilliantly. I've felt like I've seen people whose primary aim is to help patients like me, and who genuinely care about my emotions and quality of life.

It's little stories like this that have kept the NHS going for all these years. They're also the kind of stories that are so easily forgotten. I know from experience that a little bit of positive feedback from someone you've made a difference to can really make your week, so if you've had a similarly positive experience, no matter how small, I urge you to share it. 

Hxxx