‘The Emperor of all Maladies’ by Siddhartha Mukherjee

With cases of cancer rising due to various factors such as increased life expectancy and better detection techniques, it has become a major concern in today’s medical practice and for the public. As a highly recommended book, due to the extra time on my hands and because of my genuine interest in wanting to understand the origin of cancer and its progress through time, this book was an ideal read.

It was so useful to have picked up a book and fulfill my understanding of cancer through a piece whereby the author had amalgamated all the research for you; tracking the history of cancer from its humble beginnings to its recognized ‘potential’ today. Admittedly, it was avery long read, however I was able to genuinely appreciate the work of our predecessors as I gradually neared the end of the book; reading my way through the history of cancer, the research and the patients it had and still is affecting. The questions asked and the solutions found over time were certainly intriguing, however personally, the most enthralling bit for me are the questions and answers still yet to come.

Scientific advancements usually occur due to a trial and error approach, which was evident through this book. Within the chapter ‘VAMP’ Mukherjee discusses the new discovery of administering multiple drugs at once in different doses to target the cancer once and strongly. To the reader this comes across as a very invasive and insensitive approach, as what will happen to the patient who must suffer the consequences of all the treatments’ side effects? However, I guess we have to understand that, at the time, this was the only method which gave doctors/scientists an idea as to what the right dose to target cancer is. As Mukherjee highlights through the use of Voltaire’s quote – ‘Doctors are men (and women) who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing’

At the beginning of the book, you could see the approach researchers took, which usually involved trying to target the issue directly without any background to the mechanism of the problem. However, during the progression of the book you could see that this approach altered and in fact if was Sidney Farber, a paediatric pathologist, when trying to figure out how red blood cells were formed before figuring out how to block their abnormal growth in leukemia, who wanted to ‘…approach the disease from normal to abnormal – to confront cancer in reverse’. Personally, this is a technique that I believe would fare well if implemented in every situation that we handle. Through retracking the routes of the issue, you not only find answers which would help address the dilemma at hand but it may also present an opportunity to find other solutions which may just as beneficial.

‘A patient, long before he becomes the subject of medical scrutiny, is, at first, simply a storyteller, a narrator of suffering – a traveller who has visited the kingdom of ill’ – I personally love this quote, as it is a very accurate description of the position a patient is in, vulnerable and lost in unfamiliar territory, especially when confronting a life-changing disease. It conveys that it is up to us, the wisdom of the ill, that can guide them through different treatment options and experiences to make them feel safe. The metaphor certainly encapsulates what it means to be a patient and it helps define the core of the doctor-patient relationship.

After reading this book, it has definitely made me realize how sceptical many of us can be of change and new ideas. With every discovery made there was always considerable backlash from others in the same profession, the government or the media. However, I learnt that it was those that stood by their revelations, backed with adequate evidence, that created history and somewhat brought us one step closer to finding ‘cures’.

‘Call The Doctor’ by Dr Ronald White-Cooper

A memoir put together by his grandson and similar to ‘The Way of a Surgeon’, this book by Dr White-Cooper also recounts on medicine in the 20th century, thus allowing me to, once again, draw comparisons and see the stark contrast between healthcare before/during the war compared to healthcare in the post-war period.

‘Call The Doctor’ was a very refreshing read in the sense that it offered a doctor’s perspective at a time when the NHS did not exist and at the time of the war. Dr White-Cooper recounts his experiences and presents anecdotes of most patients he has met through each chapter. From an experienced surgeon to a GP in a small town, his years of work have enabled him to amalgamate a range of experiences and stories.

The title ‘call the doctor’ refers to how patients would previously get hold of their doctors, be it via letters or through using the local post office telephone. As one of the few doctors in town, Dr White-Cooper had a variety of roles, from treating patients in his clinic which was on the second floor of his home, prescribing treatment and then proceeding to dispense them himself (as there were no designated pharmacists at the time) and even attending patients in their own homes. Clearly, you can see how much the doctor’s role today has altered as it is mostly clinic based unless you work in much more remote areas.

The healthcare culture back then is truly a shock to us now, but I find it so fascinating that this is the system people would go by and were content with. Today, there are still places around the world that still follow a similar culture, naturally this is due to being a third world country and therefore not having the means to develop further which unfortunately means these individuals must travel endless miles unsure and only hopeful to get some form of medical treatment. But hopefully this too shall one day change.

When studying A-Level History, one of the factors I learnt that really pushed and revolutionized medical provision were in fact the Great Wars. At such a dire time where individuals were really vulnerable and also suffering multiple conditions from infections to mental instability, there was a gap in the market for much needed interventions to address the needs of these individuals. Hence the adoption of a National Health Service and the reason healthcare/science has excelled ever since.

At the time I am sure Dr White-Cooper never considered how insightful his accounts of his everyday practice and experiences would be, however they have certainly proven to be a positive contribution to the history of medicine.

‘The Way of a Surgeon’ by Dr George Sava

As I was roaming the White Cliffs of Dover, I came along a marquee which had a wide array of second-hand books that the locals were giving away for a small donation. When browsing through the wide selection of books I coincidentally came across the following. As the only medical related book I could take away from the White Cliffs and due to such an intriguing cover, I decided I would make this my souvenir from the trip.

The book was published in 1959. A Russian born British surgeon, Dr Sava has written a number of books ranging from his medical autobiographies to history and politics. However, in this post I shall be reflecting on his medical autobiography ‘The Way of a Surgeon’.

Within the first chapter, Dr Sava discusses neurosurgical procedures all of which seemed pretty similar to the types of surgeries we have today which deal with brain haemorrhage and oedema. However, it was interesting to read that at the time there was still no scientific explanation behind convulsions, a stroppy face due to stroke and depression, hence treatment for these conditions would be limited. In fact, it was shocking to read that the doctors at the time would refer to mental health as as ‘the most pathetic and terrible of all the ills to which the flesh is heir’ and depending on the severity of the depression they would invasively operate on the individual through a procedure called a leucotomy, i.e. the removal of the front part of the brain. Although this was deemed successful in ‘curing’ the depression, this then had major side effects of causing the individual to present childish traits. But unsurprisingly, at the time, this behaviour was considered to be much less of a problem compared to someone who always talks of suicide.

Understandably, we have to remind ourselves that this book was written at a time where medicine was just beginning to take off and the search to find a scientific explanation backed through statistical evidence was just developing. It was still to early for them to know how best to treat these patients and in fact what exactly they were treating. But as a 2017 reader, where it is common knowledge that those with mental health issues can be dealt with through counselling and drug treatment, it definitely makes you appreciate that such drastic actions are no longer taken today.

In the book, Dr Sava is reviewing and comparing the progress of surgery from the 1920s to the 1940s, i.e. from the time he is a medical student to a specialist, and hence proceeds to discuss how much the medical field has advanced. For a reader at the time the practices and interventions Dr Sava discusses would seem like a medical revolution but when comparing it to medicine today, we would perceive them as traditional and flawed practices. Over the last century, the research we have conducted and the data we have accumulated have enabled a wide range of new interventions and treatments to be discovered, hence our pool of knowledge has expanded. However, it is so interesting to see how stark the differences between practice then and now are. A random book which I lay my hands upon has become a real eye opener and has made me realize that although we have so much faith in our current practice and believe it to be the best as Dr Sava so confidently believes the same in his book, medicine is still growing and changing, to the point that in a coupe of decades’ time we will look back to the practice we conducted in 2017 and possibly cringe at how invasive some surgeries were and the mortality rates they carried with it. What would be even more amusing is if the future generations read about our common surgical practice and I would like to think, they would wonder why humans performed operations when there are perfectly capable robots. Ultimately, the point I am trying to get across and the reality of the situation is that we should never proceed to settle with the idea that what we have now is what will stay as nothing is written in stone, and as it has been said so many times before, as long as this world’s technology develops then it is not long before our profession taps into these advances, taking advantage of their presence and hence they begin to manifest themselves into medical practice and treatment. In fact, even Dr Sava at the time acknowledges how much further medicine has to go through the following statements: ‘the future may see the surgeon perhaps even grafting new valves into the heart’ or ‘the use of artificial radioactive elements’. As Sava realises, ‘Medical science marches fast, and the near-incurable of yesterday is so often the curable of today’

One thing that did not fail to surprise me when reading this book is the behaviour and tone at which Dr Sava would consult his patients with. In chapter four, a patient came in with a diagnosis of TB and therefore believed his chances of survival had dropped rapidly to the point where he isolated himself and broke ties with his fiancée. The doctor, very uncharacteristic of a modern day physician, told him he was being a ‘spoiled child’ and his decisions were too erratic for a condition that could be treated. Although I can understand that Sava had faith in the treatment options available and its success rates, it is still quite interesting to read about the way he handled the situation. Today, we are taught to always respect a patient’s decision and if we can, render the situation right, in a manner of kindness and co-operation. Yet the contrast shows how much not only our medical techniques have advanced but also our conduct as a profession. In one of my clinical and professional practice lectures this year, I learnt that the scale of control between the doctor and patient has begun to level, we have moved away from the paternalist approach that Dr Sava clearly took, and have landed ourselves in a position of mutuality i.e. both the doctor and patient work together to reach a final decision. (Ezekiel J. Emanuel and Linda L. Emanuel.  “Four Models of the Physician-Patient Relationship.” JAMA 267:2221-6, 1992). Naturally, this is more empowering for a patient and also helpful for a doctor to understand what clearly matters mostly to a patient. However, once again, we have to remind ourselves that Dr Sava was practicing at a time doctors were seen as the elitists in society and therefore they held quite a lot of power and were respected tremendously, resulting in Dr Sava’s approach to the situation at hand.

Surgery is truly an exceptional specialty. As a practice that has been occurring since the beginning of time, from meagre amputations to today’s complex transplantations, it is a branch of medicine that is truly fascinating. It comprises of a range of knowledge, from understanding every detail of the human anatomy, the complex physiology and the need to be able to make fine cuts and sutures, it is an art in itself. However, as Dr Sava states after removing the uterus of a young female patient in order to reduce her pain, ‘Does the surgeons knife still cure one tragedy by creating the seeds of another?’. The operation resulted in her not being able to have children which was a major concern for the lady and her partner. He realises the limitations of surgery. Although it can be a major solution to a range of diagnosis’, it can be the cause of future complications. Indeed, this is something to expect when knife is put to skin and this delicate vessel is opened, nonetheless it means there is always more room for improvement.

Overall, it was a truly fascinating read. The comparisons I have been able to draw through being able to step back in time through Dr Sava’s words, has been remarkable. It is refreshing to read and acknowledge where we were a century ago relative to now. It makes you realise that we have come far and we have still yet to go even further.

#TalkNHS – the past, present and future of the NHS

A few years back, I attended a very similar structured talk at the Battle of Ideas in the Barbican. The issues raised then were similar to the ones raised now, just in a different environment and upon a different climate. Hosted by a range of educated and passionate professionals, the programme today was well worth attending and truly topped off with a keynote finale held by Professor Stephen Hawking himself.

As the title suggests, the talks were all based around our National Health Service, what its current state is, how we got here and what the next steps are; a very neat way of structuring a debate concerning the past, present and future of the NHS. With a variety of speakers from multiple backgrounds alongside a very passionate audience, naturally it quickly became a very heated yet informative day.

The first group of panellists held the discussions in response to the question ‘What is the state of the NHS?’. They raised a few very interesting points. The first being the division of health care and social care. Ms Liz McAnulty, chair of Patient’s Association, stated ‘care is care’ as regardless of what type they both address an individual’s needs. The fact that they have been classed as two different brands of care, which is understandable since they both address two entirely different perspectives, in the era we currently live in whereby the two are so intertwined, maybe it is time we see both as one in order to reduce this belief that one is more important than the other when we are increasingly starting to see the need for both to work together. Secondly, there has been a reduction in patient and public engagement. As Professor Richard Murphy goes onto say later, it is the people that pay for the NHS and are also the users of the NHS, hence covering both ends, but nowhere do they get a say or some form of engagement from their local commissioning groups which is supposed to be tailoring care for them. As a result, decisions are made that do not accommodate the public. Thirdly, as Ms Liz McAnulty stated ‘the same problems are happening time and time again’ due to the failure of the system to listen and learn from complaints. The same mistakes being made are costly and ineffective. Finally, there is the issue of a constant service transformation. The speakers clearly highlight that due to the above factors and many more, the NHS has reached a point whereby it is not able to deliver the care it aspires too, and as Dr Rachel Clarke put it, it is the ‘human cost of those statistics that are horrifying’.

Unfortunately, as the system is being drained of funding and resources, we know that this has also meant morale amongst staff is low. As a result, it has led to ‘burnout’ and a huge portion of valuable NHS staff leaving the profession hence causing further damage to the service. The government and many believe the solution to this issue is to just recruit more individuals but as Dr Sarah Wollaston, MP for Totnes and Chair, mentioned, ‘it is not just about recruitment but also retention’. The pressures and the challenges in the NHS have created a very unattractive environment for current and future healthcare employees to want to work in. The individual drive due to the core principle of compassion and the staff wanting to be there for their patients, is the reason why the NHS still stands today. But as Dr Clarke wrote in her book, which I recalled in my last blog post, there is only so much one can give without becoming exhausted. Personally, as a medical student, I am scared for the future. I know the reasons as to why I came into Medicine and I hope these reasons stay with me for the years to come. However, considering what is going on, I fear that this constant battle between healthcare professionals and politicians, with one party trying to explain the situation and the other not wanting to listen, may create an environment that will inevitably mass produce a future workforce that may not retain the same compassion the NHS staff now hold. Why would the future workforce try to give it 110% when inevitably their efforts will not have an impact? Would it not be easier for them to come in, do their job and then just leave? That is what low morale will lead to, a drain in determination and passion to genuinely want what is best for the patient, because it is this cohort which will be tired of fighting against an unresponsive system.

One member in the audience posed the question “Should we dissuade individuals from the NHS?”. A great question which encompasses what many would think considering the state the NHS is currently in. Dr Clarke made a valuable point: we cannot proceed to stigmatise individuals especially when they need the care. I completely agree with her. In a system which is being let down due to the government’s decision to poorly fund a complex service and hence not provide patients with community alternatives, we cannot place the fault of the government upon the patients. The public have a right to healthcare and hence the government have a duty to provide this healthcare. Through trying to dissuade people to balance the numbers, we risk pushing away those that may need vital and immediate intervention.

Time and time again, as is the case with any complex situation, when it comes to finding solutions to the problems the NHS faces, they are never clear-cut. When organisations, politicians or even individuals have their eureka moment and think they have sorted the issue out, they find they have just scratched the surface. It is like cutting garden weed off the surface but not pulling it out of its root, it will always grow and hence will always continue to be a problem. The NHS is facing a similar scenario. It is difficult to pinpoint where in the timeline things have gone awry and what needs to be done to undo the actions of previous individuals, hence in each attempt to fix the problem we can sometimes be doing the complete opposite. Naturally, this is expected of a service which is very complex and caters for the needs of millions. Over the years, like an old house, there has been renovations and decorations, but the foundations upon which it was built in 1948 were not accommodated for the society and the demands we have today. What would be great is to break the whole thing down and start again, however this is not possible. Therefore, our only course of action is to continue doing what we have done, which is to make gradual changes. Hopefully this is a with a much more evidence based approach and not like Ms Lara Carmona, Associate Director at the Royal College of Nursing put it, an ‘evidence informed’ approach which is usually adopted, i.e. the evidence is there but it is chosen not to be looked at.

Considering the fragmented service that exists today, where one service provides mental health support, another provides the physical support and so on, in an era whereby people are living with multi-morbidities, Anita Charlesworth, Chief Economist for Nuffield Trust, mentions the fact that inevitably this means individuals are being treated as body parts rather than holistically. As a result, in response to the question ‘what next?’, she suggested four things: funding needs to be increased on a sustainable level, the social care system must be secured, the workforce matters should be put first and inequalities must be addressed. Very broad but clear goals to achieve, which would hopefully begin to dig at the bigger issue.

‘Your voice is important’ – whether Stephen Hawking meant it in the literal sense as prior to this he was explaining how the weakening of his larynx led to a tracheostomy which meant he lost his voice hence realising the value of oral communication. Or if he meant it in the metaphorical sense, that our voices need to be heard in order to bring about change. Regardless, this short statement really stuck with me. He then went onto mention that there are multiple forces of different interests looming above the NHS and ultimately the future will be dictated by which force is the strongest. Hawking believes the balance of power currently lies with the profit making private companies but the power of the public and democracy exists too, therefore we need to take advantage of this. Which brings me back to why the four words Professor Stephen Hawking spoke, stuck with me. I did not realise how strong and how much of an impact simply speaking your mind and open communication can have, but after sitting in a room full of passionate professionals and campaigners and hearing how they have all made their mark through standing their ground and vocalising the values and belief they strongly hold onto, I think this is a great step forward in ensuring we protect the service we treasure the most. As Professor Richard Murphy responded to one of the audience members’ question ‘What can we do for the future of our NHS?’ – “Talk.”.

As I sit here, reflecting upon the fantastic day I have had, learning all about the NHS and its people, I am left wondering what I, as a medical student, can do for the future of our NHS. And I think I will simply start by talking. Talking about issues the NHS faces. Talking about the politics surrounding it. Talking about what the possible next steps are. The more knowledge I can gain on the topic, the more I can raise awareness amongst my peers too, and hopefully this will mean a greater interest is taken, across the board, to try and help save our NHS.

‘Your Life in My Hands’ by Rachel Clarke

In the wake of the junior doctor strikes last year, Dr Clarke recently published her book ‘Your Life in My Hands’. which is a memoir describing the work being done on the NHS frontline, on a general and personal level, in order to shed light upon the realities of the medical field and how it differs from what politicians and the media are portraying.

One of the main reasons I chose to pick up this book was so that I can gain a better understanding of the situation regarding the junior doctor contract and the strikes. Although every form of media had the issue covered, I felt that after reading so many different articles and posts about the strikes at the time, I was confused as to how I felt about the whole thing and what was really happening. Therefore, in making the decision to read this book, I can gladly say that I have been able to gain a much more rounded overview of the situation at hand. As a pivotal time in history, which will inevitably determine where medicine in the UK will be heading in the next couple of years, and as an individual who will soon be venturing into the field, I feel this was a necessary step in order to familiarise and guard myself with the facts.

Within the book, Dr Clarke has done a fantastic job of recounting her experiences in a very honest way. Through her style of writing, I felt that I could see that her only aim was to be truthful to her audience, and coming from someone who works in the forefront of the service, it only makes her memoir that much more meaningful. It definitely highlights, and has taught me, that you have to work in the NHS to really understand what needs to be done to improve it. This enhances the complexity of the service and its finances. Therefore, although the government insists that they are doing all they can, personally I feel that if Dr Clarke, along with many other doctors out there, are all publishing entire books stressing that the service and its resources are really being stretched, then this is a cause for concern that really needs addressing.

The humanity of a conversation has become a luxury your conditions of work deny

I think this quote perfectly sums up the climate of the situation with the NHS. When I first came across this statement, it made me realise how accurate Dr Clarke is. It made me think about every volunteering or shadowing hospital experience I have had and in the process it made me realise that not once could I recall ever seeing a doctor having a conversation with a patient about anything else but their diagnosis and treatment. I can understand that ultimately this is the role of the doctor, to be able to treat the ill, but this is not the only thing I aspire to do. In the process of treating my patient, I want to actually get to know my patient. I do not want to be a part of a service which treats individuals mechanically, as though they are items on a conveyor belt, that need to be kept moving in order to avoid a systemic failure. But unfortunately, in light of the current events, this is where medicine is at today.

Just recently I came across a BMA article with the following title “First-rate health service, third-rate funding” (https://www.bma.org.uk/connecting-doctors/b/the-bma-blog/posts/first-rate-health-service-third-rate-funding) In summary, as the name suggests, the article talks about how the UK is the first in the world to be able to deliver a safe, affordable and fair service to its population however in terms of funding it ranks as one of the lowest in the world. Understandably as we live in a world whereby an individual’s personal opinion is always approached with scepticism, I can see why a doctor’s cry for help may not be taken too seriously. However, when the statistics are published through an independent organisation, and it correlates with what a whole body of professionals are fighting so strongly for, then surely alarm bells need to go off at this point. Yet regardless of the numbers and the facts provided which justify the need for more funds, we still find that we ask ourselves, why is nothing being done?

From the moment I set foot inside my medical school, I was overawed by the potential of medicine – the extraordinary capacity of the human body to endure and survive serious illnesses, of doctors and scientists to discover new cures and above all of the human spirit to rise above adversity with the kind of dignity and strength at which so often I could only marvel’

This is definitely the stage at which I am at now. Before starting medical school, I was aware of what medicine had to offer but truthfully I did not realise its full potential until upon the completion of my first year. When reflecting on how much I had learnt and how much I have still yet to learn about the human body, the treatments and my role as a doctor in all of it too, it is mind-blowing. Now that I think about it, the above quote would have been a fantastic response to a medical school interviewer’s favourite question “Why Medicine?’.

Above all, it certainly encapsulates the beauty of medicine and some of the reasons as to why so many individuals choose to become doctors. The role of a doctor is all about giving to your patients, whether that is in the form of your knowledge, time or care. But in the system that our doctors are having to work in today, as Dr Clarke puts it, after providing solace of this kind, how much can it end up taking from a person? There is only so much we can all give without the exhaustion hitting us and before our morale runs low. Something needs to be done.