It is easy to forget…

It is 9am. The first patient comes through the theatre doors. A little 2-month old baby appears cradled in her mother’s arms, comfortable and at peace. After a quick confirmation of the procedure and the consent form, WHO regulations, the mother anxiously places her baby on the bed. With tears falling down her face she presses a kiss on her baby’s forehead and slowly begins to leave. As she leaves the anaesthetists begin their work.

The surgery was going well. The scrub nurses were ensuring the surgeons had their equipment at hand. The anaesthetists were carefully observing the patients’ stats. The surgeons were making their fine cuts and sutures hence swiftly conducting the procedure. Just as much as the team, I became so engrossed by the operation. I was thinking back to my lectures, trying to apply the medical knowledge I had gathered over the year to make sense of the procedure in front of me. I was listening out for key terms the team were throwing around and noted them to myself. And ultimately, I wanted to fulfil the point of the shadowing which was to try and figure out whether this was the medical specialty for me.

As the surgery came to a successful end and the final stitch had been tied, the team began to remove the blue sheets. At this point the reality of it all dawned on me. I realised something was wrong. During the procedure my perspective of the scenes that had unfolded before my eyes had altered. The amalgamation of the anatomy, the work and the medical terms had clouded my mind and as a result of gravitating towards the science, in the midst of it all, I had gradually lost touch with the patient. This tiny being in front of me, that had been draped in a sea of blue sheets had just become another surgical case to apply my knowledge too and to carefully observe the skills the surgeons were using in order to conduct such a procedure.  Yet this was the same baby that I had seen anaesthetised only a few hours ago. Guilt washed over me as the images of the crying mother flooded my mind as I realised there was so much more to this case than just the procedure. There was life.

In the moment of it all, I had become medically selfish, I had forgotten the baby’s worried mother and the family patiently waiting in hope that everything will be OK. There was not just a patient in front of me but in fact a human being.

I have always read and heard that in the process of trying to extract problems and focussing on finding solutions in the form of treatments, clinicians forget the patient. However, even though I was aware of all of that, I had fallen into a similar trap. But we must keep reminding ourselves: medicine is about the individual just as much as the conditions we aim to battle.

This epiphany put things into perspective for me and made me realise it is easy to forget.

The experience I have recalled and the lessons learnt, are things we all know and hence nothing new. But as a medical student, I want to take this memory with me for years to come. As I train, I want to try and not forget the person in front of me, as the famous Hippocrates once said “wherever the art of medicine is loved, there is also a love of humanity“, and I think it is a love we should hold onto.

AstraZeneca – ‘together we make a molecule a medicine’

AstraZeneca is a UK based pharmaceutical company aimed at using scientific research to offer patients life changing treatments. Yesterday, thanks to the SMF programme, I was able to attend an AstraZeneca masterclass at their HQ in Luton. The day involved a series of talks given by a range of AstraZeneca employees, explaining what their role involves and hence their contribution to AstraZeneca.

In the medical profession, although we make use of multiple drugs in order to treat patients, we rarely get a chance to understand the process of how drug gets ‘from bench to bedside’. However fortunately in attending this event I was able to get an idea of the bigger picture.

One of the activities yesterday involved working in teams to draw up the journey the drug takes to become a medicine. The process begins with the discovery of the molecule then it is followed by preclinical trials, early phase trials followed by phase 3 trials and then the need for regulation and funding by NICE. The activity taught me that at every aspect of the journey an obstacle presents itself which undoubtedly impedes the process of getting the drug to the patients. It explains the following statistics: only 1/100 drugs developed are taken to market and on average it takes 14 years with a cost of around £700 million to ensure that it does so successfully. However, whilst doing this activity I realised that when looking at the journey on a broad spectrum, it is so easy to forget the professionals at each stage of the pathway who make the whole process possible in the first place. From the researchers, to the manufacturers, the sale representatives all the way to the directors/leads, their input ensures the drug is able to make it to the next stage even if it is not guaranteed. As the AstraZeneca team very nicely put it ‘together we make a molecule a medicine’ – a great ethos to stand by, clearly emphasizing the need for teamwork and communication.

Today the NHS faces many challenges: an ageing population, high birth rates, increasing effect of lifestyle factors on diseases, change in public expectation and even a change in the healthcare structure, which has meant pharmaceutical companies have had to adapt their approach to marketing their drug in order to accommodate the current system. Previously, healthcare professionals would have more time to meet up with pharmaceutical sale representatives for face-to-face meetings about the new drugs on the market and hence then would proceed to decide whether they would want to invest or not. However due to the increasing challenges the NHS faces, today doctors do not have time and therefore companies have become heavily reliant on online media in order to to sell their product. This involves the use of email subscriptions, phone calls or webinars to ensure the clinicians are kept up to date with new treatment. As these pharmaceutical companies are continuously working on adapting their approach to accommodate a form of communication that is best for the medical field, it ensures that the NHS is always able to provide a range of treatments for their patients.

Regardless of the fact that the masterclass was solely based on the way a pharmaceutical company works and the different roles within it, it was still very useful to attend. From a medical perspective, it has made me appreciate how this strong network of committed and hard working individuals, who also have the patients’ best interest at heart, ensure there are new forms of life changing treatment available. Without the input of the pharmaceutical industry, my role as a future doctor would not be possible.

Innovation in Surgery – Proximie and UCLP

Continuing with the theme of my previous post, once again I will be discussing medical technology and how it is gradually being integrated into care.

On Tuesday evening, we were fortunate to have Dr Nadine Hachach-Haram, co-founder of Proximie, and Dr Charlie Davie, interim managing director at UCLP, give us insight to the type of the work they do and how their work has an impact on the way healthcare is delivered.

The first talk was given by Dr Charlie Davie. The organisation he works for, UCLP, serves as a platform which provides healthcare professionals the support they need in order to increase the speed at which they get their innovation/ideas into practice. Dr Davie nicely summed it up by stating that UCLP provides a “package” in the form of skill set, funding and the network in order to boost the rate at which these start-ups get going. He clearly highlighted that the NHS can be quite a complicated landscape to understand for a beginner, therefore UCLP offers the “ecosystem” that can provide innovators a clearer sense of direction.

However, the biggest challenge that he finds is common amongst the medical profession, is the need to overcome behavioural changes. As medical technology and innovation is such a new concept, most clinicians reject the idea of choosing to integrate it within their care. I found this very interesting and can somewhat understand as to why this would be the case. For example, at the recent MedTech conference, one of the innovative ideas involved the use of “StethoCloud” i.e. a stethoscope plugged into a phone and connected to an app. The app listens to the patient’s breathing and using its algorithm it determines the diagnosis and possible treatment options (at the moment it is strongly aimed at targeting pneumonia in children). It is an ingenious idea and once perfected it looks like a potential product that could diagnose very efficiently, however I must admit I was a little saddened. Just recently, during our clinical skills sessions, I learnt how to perform a respiratory examination and I really enjoyed being able to use the basic combination of observation, percussion and ausculatation to determine a possible diagnosis. As medical students, it gives you this great sense of achievement and appreciation as to what a doctor, with years of practice and refining of their skills, is able to do for their patient. Therefore, the fact that this new piece of technology is able master the art of diagnosing within months and take over, could be one of the reasons for hesitance to accept the idea. It sheds light upon the fact that many clinicians still perceive medicine as a very traditional profession, where they highly value being able to put their skills to the test and most importantly where they are still able to maintain the patient contact, which after all is what medicine is all about. Nonetheless, as Mr Davie pointed out, as the populations’ demographics and needs are constantly changing, the current healthcare system cannot keep up, therefore practice needs to change. Regardless of how much we value this traditional system that we have/are being trained in, we need to ensure that we can provide the best quality of care for our patients, and the only way this is possible is if we accept and adopt innovation. Naturally, innovation that can work alongside this traditional approach to medicine would be ideal.

After the first talk, we were then introduced to Proximie. I must admit, prior to this session, I had very little knowledge as to what Proximie involved. However, Dr Hachach’s talk left me both informed and inspired.

In summary, Proximie is an AR platform which allows specialist surgeons or clinicians who are unable to access remote areas to provide their knowledge and skill expertise through this secure cloud system. It aims to democratize access for patients globally, from the Royal Free to Gaza, Peru and Vietnam, so patients everywhere can receive the best care without the need to wait or the extra finances. Additionally, it also serves as a learning platform for students and trainee doctors alike. The live streams of the surgical procedures, which are recorded and stored in a library, allow medical students to gain insight to the surgical field whilst also learning their anatomy and it enables trainee surgeons all over the world to observe how procedures should be done. Furthermore, it enables specialists to provide feedback on each other’s work and hence allowing for improvements.

Although I have yet to try out Proximie, I think the programme is fantastic. It definitely works to create a community where every professional in the medical field can strongly benefit. As Dr Hachach mentioned, their aim is to hopefully get the platform to become a strong teaching material at medical schools. Currently, UCL funds for the platform however I was completely unaware. It is a shame such a great programme has not been promoted enough as I know lots of medical students would strongly appreciate and benefit from being able to observe surgery in real time as it would help put the medical degree into context and it would serve as a great reminder for the type of work that we are training towards.

I also posed a few questions to Dr Hachach – here are the summary answers:

1) When you started Proximie, did you consider/imagine it would become a solution to many problems?

Dr Hachach suggested always conducting “synergistic work”, i.e. when you set out with an innovation always work towards perfecting it towards one purpose and hopefully along the way you can accommodate many solutions. In Proximie’s case it started out as a platform where it can provide live streams of AR surgery but now it is used as: a teaching material in the NHS/medical schools, a platform to help those in remote areas access good care and it also allows for feedback and improvement. It has had a “snowball effect”.

2) Surgeons are usually known for not wanting to make their mistakes transparent due to wanting to maintain their reputation. How did you overcome this barrier and get surgeons to use Proximie?

Anyone applying to access Proximie must agree to the license agreement therefore it provides surgeons with a safe data stream. As well as that patients also consent for the procedure to be filmed.

3) Has there been evidence that through specialists being able to provide feedback to one another, Proximie has improved practice?

Proximie are currently in the process of collecting data on the patients’ outcomes and date of discharge. All of which will determine whether it has been able to help surgeons improve their skills and hence ensure better outcomes for the patient.

4) What was the biggest challenge you faced in the whole process of setting up Proximie?

Dr Hachach mentioned learning the system was her biggest obstacle as she did not understand the financial side or the agreements required. However, with the support of many accelerator programmes and her colleagues, who all retain a wide range of skills and come from different fields, she was able to combine their knowledge along with her clinical knowledge/perspective to create the final product.

Overall, it was really nice to hear more about the role of medical technology in care from two professionals who are currently working in the field. Although medical technology still needs time before it can become properly integrated into care, establishments like Proximie and UCLP are beginning to pave the way. One of the biggest lessons I learnt today (and one both Dr Hachach and Dr Davie mentioned) is that the best ideas usually come from the use of existing innovation/technology and being able to integrate them into different pathways to see where they best fit. Through this application you are able to become disruptive in a positive way.

MedTech Conference 2017

On Saturday I attended the MedTech Conference at the Royal Free. The conference was strongly aimed at equipping us with the skills, knowledge and the networking opportunity required in order to take ideas that have the potential to bring change to our healthcare system and get them into practice. Thanks to UCL’s Medical Society and to all the presenters that kindly gave up their time to speak to us, they were able to deliver an exceptionally inspirational event.

It was made evident through the multiple speakers and talks that healthcare is moving towards a digital era. The future for the NHS lies in the use of computers, sensors and smartphones when delivering care. In the Five Year Forward View, it states that one of the ways they will achieve their goals is through optimising the use of computers and smartphones (https://www.england.nhs.uk/ourwork/futurenhs/nhs-five-year-forward-view-web-version/5yfv-ch4/) This move will ensure the NHS is able to run more efficiently while providing care which is “tailored to the individual“.

Healthcare services such as the NHS continuously touch lives. It is a service we will all seek many times in our lives and even more so as we age and develop chronic diseases, due to the simple fact that we are living longer. However, because of this, the pressures on the NHS will inevitably increase and hence there is a growing need for ideas and solutions that can relieve this.

Your.MD is an example of one company who have developed a solution in the form of an app. The creators wanted to introduce this concept of “pre-primary care” through the promotion of self managed care in order to relieve the pressures on the primary sector. The app has been cleverly set up to allow patients to describe their symptoms to a Personal Health Assistant through a chat. Through the use of language processing, the system matches the symptoms the patient enters to possible conditions. All the information that the app provides has been regulated by the NHS, therefore it is medically accurate. Although the app currently only diagnoses around 300 conditions, the developers aim to reach 3000.

A few weeks ago, as I sat in on the consultations at my GP placement, it was clear the patients had done their research prior to their appointment. However, their knowledge had come from Google. Although Google is great at providing a phenomenal amount of information, for a patient that needs relevant information, Google’s algorithm of ordering the sites according to the ‘most visited’ may not be helpful. Therefore, the Your.MD team have aimed at dedicating their time to put together an easily accessible app to ensure patients can access the right information, so that they are properly educated about their condition and hence they can then proceed to make a well-informed decision as to whether they should seek further help from the primary care sector or not.

There were many other examples too, such as IBM Watson Health which has been used for: drug discovery, improving patient experience, oncology, genomics and so much more (http://www.thememo.com/2016/11/29/ibm-watson-healthcare-app-ibm-watson-hospital-ibm-watson-cancer/). As well as that there were companies like Mercinia Technologies and Health-Tech Innovation LABS who bring innovators together and provide them with the finances and expert guidance to bring their ideas to life. All in all, there were multiple companies/organisations present who all work towards one aim, which is to ensure that they do their best to try and make our healthcare system better.

Although the event was mostly aimed at providing the attendees who had potential ideas/projects in mind with the tips and advice to get their projects going, I still found the event very useful. While I currently do not have any innovative ideas up my sleeves, the event has made me think about health technology and as a result I am now much more eager to keep my eyes open, as I progress through my medical training, for opportunities that have the potential need for innovation.

I thought the conference was great in enhancing our ability to think innovatively in order to bring about change or as one of the speakers put it “disrupt the status quo within the system” in order to improve outcomes and patient satisfaction. It was amazing to be amongst a crowd of immensely curious and inventive individuals. There was a real sense of unity to really want to bring about change for the NHS, a change that can not only empower patients but also help our healthcare system become more efficient and effective.

RNOH Trial

A few weeks back I saw an opportunity advertised by the medical school bulletin that allowed medical students to be a part of a simulator trial at the Royal National Orthopaedic Hospital. Although I have had previous experience of using simulator robots, I have never had the experience of being a part of a trial, therefore I decided to sign up.

The trial involved attending two, one hour sessions at the training centre in Stanmore and within each hour there were two tasks set to complete. Both tasks involved drilling a guide wire into the femur so that it ends up positioned in the middle of the apex of the femur. The aim of procedures like this are to stabilise fractures between the trochanters in the femur. The two tasks had the same principle but varied in method: i) done through a simulator robot ii) done through the use of a surgical drill and styrofoam model.

With no previous experience or insight into the orthopaedic field I was really nervous; especially considering the fact that I was being scored on my performance. Nonetheless, I took on the challenge and with hindsight I must say I thoroughly enjoyed it.

Robot SimulatorThe simulator robot arm used to navigate the drill on screen was very sensitive. In order to execute the angle at which I was going to insert the drill into the femur, I had to be very careful in the way I was moving the robot arm, hence requiring a very strong hand-eye co-ordination. The aim was to get the drill and the guide in a position which can ensure that within one drill, the hole is made directly to the middle of the apex of the femur. Ideally, the less holes in the patient’s femur the better as it avoids causing the patient pain. In order to aid the process of drilling, a lateral and anterior-posterior x-ray film could be taken. On my first attempt, it took me around 10 to 15 minutes of constant slight movements with a very stiff arm along with 150 x-rays to get the drill in what looked like the right position. Unfortunately, on my first go I had underestimated the angle which resulted in a score of 2/11. But on my second attempt I was much closer to the ideal position and managed to secure a score of 9.93/11.

In the second task, the same concept and features applied, however this time I was physically doing the procedure with an actual drill and polystyrene model (this was acting as the patient’s femur). On one hand I had the guide (metal piece) positioned along the model and on the other I had the drill with the wire inserted into it. I faced two challenges. One involved actually being able to hold the very heavy drill in a steady position so that I could ensure the wire was going in horizontally. And second, as it was just a polystyrene block and not a femur model, it was not easy to pinpoint the shaft of the femur in order to get a good sense of direction and indication of where to insert the drill therefore, just as with the simulator, I had to rely on the x-ray films. However, in terms of coordination it was much easier as I was physically in control of the drill therefore it was much easier to navigate.

AP and Lateral X-rays

In my opinion, I felt that if surgeons are able to practice their surgical skills both on simulation systems and models, it would aid their training. Also, considering the medical field is becoming much more modern and innovative in terms of technology, who knows, maybe one day all our surgeries will be done through robots, therefore it is great if surgeons are exposed to training which involves this simulation experience.

Overall, it was a fantastic experience. Considering it was both my first trial and first exposure to orthopaedics, I was somewhat pleased with my results. Although I do still need a lot of practice! Nonetheless, the opportunity to conduct an orthopaedic procedure but also to trial a new simulator robot was totally worth it.