Education: Medicine | theguardian.com

Forget funeral selfies. What are the ethics of tweeting a terminal illness? | Emma G Keller

Emma G Keller — Wed, 08 Jan 2014 18:40:03 GMT

Lisa Adams is dying of breast cancer. She has tweeted over 100,000 times about her journey. Is this educational or too much?

Lisa Bonchek Adams is dying. She has Stage IV breast cancer and now it's metastasized to her bones, joints, hips, spine, liver and lungs. She's in terrible pain. She knows there is no cure, and she wants you to know all about what she is going through. Adams is dying out loud. On her blog and, especially, on Twitter.

She has tweeted over 100,000 times about her health. Lately, she tweets dozens of times an hour. Her Twitter followers are a mixed bag. Some are also battling cancer or work in the medical field, others seem to follow Adams' life story like a Reality TV show. Here's a taste of what it's like:

Pain today is worst in days. Cannot get on top of it. I have 1)constant drip plus ability to do 2)on-demand drip, 3)emergency. All in use.
— Lisa Bonchek Adams (@AdamsLisa) January 8, 2014

But it radiates out to side of back ("radicular pain") and has nerve component of pain. Mixes with the lung pain/same side
— Lisa Bonchek Adams (@AdamsLisa) January 8, 2014

All morning docs and nurses go in and out so you may see answers to questions in spurts. I also sometimes nod off mid tweet...
— Lisa Bonchek Adams (@AdamsLisa) January 8, 2014

She has been scrupulous about keeping track of her seven year decline. Her journey began with six month routine postpartum checkup after the birth of her third child. You can read all about the details of her disease and treatment on her blog right up until about this morning, which is when she posted her latest entry, only a few hours after the previous one.

She begins each day with the same tweet:

Find a bit of beauty in the world today. Share it. If you can't find it, create it. Some days this may be hard to do. Persevere.
— Lisa Bonchek Adams (@AdamsLisa) December 27, 2013

Over the past few years she has tweeted more than 165,000 times (well over 200 tweets in the past 24 hours alone.) Her clear-eyed strategy of living with cancer for as long as she can has caught the attention of many women with breast cancer, several writers and thousands of fans from everyday lives all over the world. I heard about her in the process of organizing a Guardian US Living Hour chat on DNA and cancer tumors in early November. Before you knew it, she was in the chat having her tumor genome and her cancer trial discussed in detail. I never met her, but I swapped tweets and emails with her, and kept track of her health.

Which is why a few weeks ago I noticed she was tweeting a lot more and from a situation she described as agonizing. The clinical drug trial she was on wasn't working. Her disease seemed to be rampaging through her body. She could hardly breathe, her lungs were filled with copious amounts of fluid causing her to be bedridden over Christmas. As her condition declined, her tweets amped up both in frequency and intensity. I couldn't stop reading – I even set up a dedicated @adamslisa column in Tweetdeck – but I felt embarrassed at my voyeurism. Should there be boundaries in this kind of experience? Is there such a thing as TMI? Are her tweets a grim equivalent of deathbed selfies, one step further than funeral selfies? Why am I so obsessed?

Social media has definitely become a part of Adams' treatment (I wonder what her hospital, Memorial Sloan-Kettering Cancer Center, thinks about that.) Tweeting makes her less lonely, it gives her a purpose, it distracts her from her pain, and the contact it brings clearly comforts her. Adams has managed to keep her dignity and her deft sense of humor intact as she has charted her decline.

As she tweeted a few hours ago:

"Why is she tweeting if it hurts so much?" I am sure people ask. It helps to distract me especially when I am alone (it's 6 AM here)
— Lisa Bonchek Adams (@AdamsLisa) January 8, 2014

Adams is not alone in doing this. Journalist Xeni Jardin live tweeted her cancer diagnosis two years ago and the long treatment journey. Jardin told the Guardian last year that she wasn't sure if she would be quite as "sharey" if she could go back in time.

It's clear that tweeting as compulsively as Lisa Adams does is an attempt to exercise some kind of control over her experience. She doesn't deny that. She sees herself as an educator, giving voice to what so many people go through. And she is trying to create her own boundaries, flimsy as they might be. She'll tell you all about her pain, for example, but precious little about her children or husband and what they are going through. She describes a fantastic set up at Sloan-Kettering, where she can order what she wants to eat at any time of day or night and get as much pain medication as she needs from a dedicated and compassionate "team", but there is no mention of the cost. She was enraged a few days ago when a couple of people turned up to visit her unannounced. She's living out loud online, but she wants her privacy in real life.

In some ways she has invited us all in. She could argue that she is presenting a specific picture – the one she wants us to remember. "I do feel there will be lasting memories about me. That matters," she wrote to me in a direct message on Twitter.

The ethical questions abound. Make your own judgement.

Are those of us who've been drawn into her story going to remember a dying woman's courage, or are we hooked on a narrative where the stakes are the highest?

Will our memories be the ones she wants? What is the appeal of watching someone trying to stay alive? Is this the new way of death? You can put a "no visitors sign" on the door of your hospital room, but you welcome the world into your orbit and describe every last Fentanyl patch. Would we, the readers, be more dignified if we turned away? Or is this part of the human experience?

We've put together a condensed timeline of Lisa Adams' tweets. You can also read her entire feed.

Emma G Keller

How to treat a medical intern | Ranjana Srivastava

Ranjana Srivastava — Wed, 08 Jan 2014 01:02:06 GMT

Ranjana Srivastava: We may teach 'patient-centred care', but interns would also benefit from a more considered and considerate engagement with the patients they treat

Ranjana Srivastava

From the archive, 30 December 1846: Important discovery in surgery

Mon, 30 Dec 2013 00:05:00 GMT

Operations have been performed upon 'patients in a state of insensibility from the inhalation of the vapour of sulphuric ether'

Dr. Bigelow, of Boston, some few weeks since sent to this country an account of surgical operations having been performed upon patients, while they were in a state of insensibility from the inhalation of the vapour of sulphuric ether. This account describes the process and its effects:—

"A boy of 16 was seated in the chair. The first few inhalations occasioned a quick cough; at the end of eight minutes the head fell back and the arms dropped, but owing to some resistance in opening the mouth, the tooth could not be reached before he awoke. He again inhaled and slept three minutes, during which time the tooth was extracted. Upon coming to he said he had had 'a first-rate dream – very quiet – and had dreamed of Napoleon; had not the slightest consciousness of pain;' and he left the chair feeling no uneasiness of any kind, and evidently in a high state of admiration.

"A young man was made to inhale the vapour while an operation was performed upon the tissues near the eye. After a good deal of coughing, the patient succeeded in inhaling the vapour, and fell asleep. During the succeeding two minutes, the first incision was made, and the patient awoke, but unconscious of pain. Desirous to be again inebriated, the tube was placed in his mouth, and retained there about 25 minutes, the patient being apparently half affected, but, as he subsequently stated, unconscious.

"35 minutes had elapsed, when I found the pulse suddenly diminishing in force. The respiration was slow, the hands cold, and the patient insensible. Attention was now directed to the return of respiration and circulation. Cold effusions, as directed for poisoning with alcohol, were applied to the head, the ears were syringed, and ammonia presented to the nostrils and administered internally. It was only after being compelled to walk during half an hour that the patient was able to lift his head."

In a letter to the Morning Chronicle Dr. Boott, of Bedford Square, says that the inhalation has been tried in London with the most perfect success in the extraction of teeth; and that two surgical operations have been performed by Mr. Liston, without the patients having been in the least conscious of what had been done.

Dr. Forbes, the editor of the British and Foreign Medical Review, says:—

"Yesterday we had the satisfaction of seeing this new mode of cheating pain put in practice by a master of chiurgery on our own side of the Atlantic. In the theatre of University College Hospital, Mr. Liston amputated the thigh of a man previously narcotised by inhalation of the ether vapour. Shortly after being placed on the operating table, the patient began to inhale, and became apparently insensible in the course of two or three minutes. The operation was then commenced, and the limb was removed in what seemed to us a marvellously short space of time – certainly less than a minute; the patient remaining perfectly still and motionless.

"While the vessels were being secured, on being spoken to he roused partially up (still showing no signs of pain) and answered questions put to him, in a slow, drowsy manner. He declared to us that at no part of the operation had he felt pain, though he seemed to be partially conscious; he had heard some words, and felt that something was being done to his limb. He was not aware till told that the limb was off, and, when he knew it, expressed great gratification at having been saved from pain."

Refugee health matters – adequate screenings should be implemented now | Nicholas Talley

Nicholas Talley — Fri, 20 Dec 2013 05:11:52 GMT

Nicholas Talley: Processing asylum seekers is an immigration decision, but ensuring the health of these vulnerable people is a human rights issue

Nicholas Talley

John Paul obituary

Joe Barbenel — Sun, 08 Dec 2013 13:42:51 GMT

Bioengineer whose meticulous experimental work improved the reliability and strength of hip replacement joints

The biomedical engineer John Paul, who has died aged 86, played a crucial role in the development of reliable total hip replacement implants, which have improved the lives of great numbers of people. John produced the first realistic estimate of the forces that act on the hip joint during function; this information was essential for the design of safe implants and of machines to test them in the laboratory.

In the early 1960s John Charnley, an orthopaedic surgeon, introduced a metal and plastic artificial hip joint with an unnaturally small femoral head to reduce the effect of friction, ideas incorporated into the successful joints in current use. The first joints had a metal femoral component and a polytetrafluoroethylene (PTFE) socket fixed to the pelvis. Unfortunately the PTFE was unsatisfactory and wore out rapidly. Using ultra-high molecular weight polyethylene produced much less wear, but many of the joints broke, because they had been designed using unrealistic estimates of the forces that would act on them during function.

John set out to provide more reliable estimates of these forces and was able to do so because of his deep insight into the engineering principles needed to solve the problem and his meticulous experimental work.

The forces transmitted across the hip joint are produced by the weight of the body, the accelerations of the body and the power in the muscles that produce movement or stability. John designed and built an instrument to measure the forces produced by the body weight. He obtained the accelerations from recording moving volunteers using two cine cameras at right angles. These were digitised and then analysed.

John found it more difficult to determine the force in each muscle that affected the joint, which remains a problem, but was able to estimate the forces by grouping together muscles that had a similar effect. He showed that the forces on the hip were many times greater than the weight of the body. The magnitude of the joint forces and their variation during walking is known as the Paul Cycle, which was, and is, used in the design of hip implants.

He was born in Sunderland, where his father, William, was working as an engineering draughtsman. John grew up in Old Kilpatrick, in the west of Scotland, near the shipyards where his father worked, except for the second world war years, which he spent in Aberdeen with two elderly aunts. He was educated at Allan Glen's school in Glasgow, excelling both academically and on the rugby field. He studied mechanical engineering at the Royal College of Science and Technology (now the University of Strathclyde). The Royal College was unable to award degrees as it was not a university, so John had to take his BEng finals at Glasgow University. A query came back to the college from the examiners, who asked if there was a possibility of his having cheated, because they could not believe that an undergraduate could know so much.

In 1962 he was a founding member of the bioengineering unit at the University of Strathclyde with Robert Kenedi and Tom Gibson. I met John in 1966 when I studied for an MSc at the unit; he was one of the supervisors of my research thesis. In 1970 I joined the staff. John was head of the unit from 1977 until he retired from the university in 1992. His published research on hip joint forces, including his PhD thesis, are classic reference works. With colleagues at the unit he extended his work to the knee, ankle and elbow joints.

The bioengineering unit rapidly became an internationally famous centre of excellence and John began to travel the world to present his research and encourage the development of fledgling bioengineering centres. John was chairman of the international standard organisation committee on bone and joint replacement and the equivalent committees of the European and British standard organisations. He was president of the International Society of Biomechanics (1987-90) and a fellow of the Royal Academy of Engineering and the Royal Society of Edinburgh. He continued these activities until just before his death.

John's reputation is based on work that he initiated 50 years ago, but which remains relevant today. The Paul Cycle is the canonical data used for designing implants. These days implants very seldom break, but fail due to particles produced by wear, which can be investigated using joint simulators based on his work.

John's wife, Bette, whom he married in 1956, died in 2004. He is survived by his children, Gillian, Graham and Fiona, and five grandchildren.

• John Poskitt Paul, bioengineer, born 26 June 1927; died 13 November 2013

Joe Barbenel

Piers Morgan: a psychiatric assessment

Dean Burnett — Tue, 26 Nov 2013 15:22:20 GMT

Piers Morgan’s recent Twitter comments suggest he thinks people with mental health issues shouldn’t be allowed to perform meaningful jobs. However, given his history, does this mean he himself shouldn’t be employed?

Dean Burnett

Art and literature could make doctors more competent and humane | Rachel Pugh

Rachel Pugh — Tue, 19 Nov 2013 15:00:00 GMT

Could studying the arts provide the cultural shift medics need to deal better with patients and to avoid scandals such as the one at Mid Staffs?

In the chaotic aftermath of the Kenyan Westgate shopping mall siege in September, the doctor leading the medical response at Nairobi's top hospital, Innocent Orora Maranga, found himself clinging, not to his medical studies, but to the leadership course he had done to supplement them.

As he reflects on the worst moments in the days following the attack, in which 67 people died, when as many as 10 ambulances bearing seriously injured victims were arriving together at Kenyatta hospital, and queues of people were turning up to give blood, Maranga says: "I was grateful for the invaluable 'non-medical' training I received at Manchester University."

A specialist in gynaecological cancers, he took a one-year leadership programme, following his PhD studies in oncology at the university. Here he learned about communicating with the public, mobilisation skills and dealing with leadership vacuums – of particular relevance at the height of the Westgate crisis.

Traditional medical training, focused on bioscience, is in Maranga's view failing to provide the human, emotional and practical skills doctors need to deal with everyday tragedy, let alone disasters such as Westgate. He says: "One comes out not knowing how to deal with real-life situations that don't necessarily require a written prescription. I believe a number of medical schools around the world might be churning out 'robots' with few other human skills."

His opinion reflects a growing view in the medical profession that to prevent hospital failures and scandals, medical schools need to change so that they equip clever young people to become confident but, above all, humane doctors.

Surprisingly, given the growth in medical technology, many believe the key is to integrate arts subjects into medical and healthcare studies. At a conference this weekend, Medicine Unboxed, eminent artists, musicians and poets are in open "conversations" with NHS leaders, politicians and doctors, about the role of the arts in achieving the cultural shift needed to avoid another Mid Staffs hospital scandal.

Dr Sam Guglani, an oncologist and organiser of Medicine Unboxed says: "Doctors should learn in a culture that teaches them to recognise and acknowledge human fear, rage, hope, ambivalence, finitude and courage, to be open rather than closed and to flourish in uncertainty rather than the illusion of facts. The arts illuminate this view, not science."

Some UK medical schools are already convinced. One of the leaders in medical humanities is Imperial College London. It introduces poetry, music and art to medical students in the second and fourth years, with an option of studying, as part of a BSc, medical humanities – which looks at medicine as an art, rather than a science and incorportes visits to galleries, film viewings and allows students to create their own piece of performance or artwork.

Course director, Giskin Day, says she sees highly intelligent but very young students hiding behind a screen of professionalism, medical language, tests and scientific concepts, and afraid to address patients as individuals in case they are drawn into their lives, families and emotions.

"The medical curriculum is so focused on safety and protocols," she says. "When things go wrong, the students are not used to being creative. They struggle with uncertainty, although ambiguity is part and parcel of medicine. Where the arts are so valuable is in honing students' abilities to make decisions based on interpretation of facts."

She adds that 80% of diagnoses depend on the patient's story, and studying poetry or literature can enhance students' narrative competence and improve their ability to relate to different cultures and groups .

Joel Katz, a Harvard professor of medicine, has taken this further by devising a course, Training the Eye, to teach medical students to interpret paintings in sessions at Boston's Museum of Fine Arts. His 2008 study showed that participants were able to make 38% more clinical observations than those who had not done the course.

He says: "Students who do this course have come back to us years later and said, 'I feel much more prepared and confident in my ability to do physical examination'. What one person sees in a painting may be very different to what another sees and through discussion, they can maybe get to a third view or see other truths that the painter intended or didn't intend. And that's our goal. That's what we want to see them do."

With an estimated 30% of the US health budget spent on unnecessary tests, a process to improve clinicians' observation skills could prove a financial winner.

At Manchester University medical school, medical humanities is now compulsory in all undergraduate years. Peninsula medical school, in Plymouth, which specialises in integrating a wide range of activity into all aspects of its undergraduate curriculum, is researching the impact as part of an overarching General Medical Council objective called Tomorrow's Doctors.

Yet not everyone is convinced. Sir David Weatherall, an Oxford haematology professor, wrote in an article in the journal Medical Education: "I realise that this trend carries the objective of producing more rounded, and hence caring, doctors and reflects a response to the unfortunate trend in British education to very early specialisation. However, I remain to be convinced that remedial courses of this type have a major role to play in producing more broadly based medical practitioners."

But Maranga says: "I think arts and humanities should be incorporated into the medical curriculum globally. Medicine is a hybrid of both arts and science – a science for the rigour of evidence to deal with illnesses, but an art for effective delivery of treatment. An art, to give the human touch to the healing process and treat patients holistically."

And, as Guglani points out: "The events of Mid Staffs are not unique, but the propensity for it to happen is based on a version of medicine that suggests that patients are not human beings."

Medicine Unboxed, Cheltenham, 23-24 Nov medicineunboxed.com/2013-voice/

Rachel Pugh

Keith Reed obituary

Mon, 18 Nov 2013 11:35:30 GMT

My friend Keith Reed, who has died of cancer aged 61, was an analytical psychologist whose work brought peace and tranquillity to many. His sensitivity, compassion and commitment made him much respected and highly valued.

We both grew up in North Cheam, Surrey. I recall playing football at the London Transport ground, despite being chased by the ground staff, and scrumping in the adjacent orchards. Our friendship persisted despite me being dragged off by him to watch his beloved Fulham football club.

After graduating from Warwick University with a degree in economics and economic history, in 1974 he became a social worker and obtained an MSc in applied social studies at Oxford University. He specialised in therapeutic work with children in long-term care and became a consultant for other multidisciplinary workers engaged with children at risk and their families. He undertook analytic training at the Tavistock Clinic and qualified as a Jungian analyst in 1989.

His overriding interest was the development of therapeutic skills for work with adults and children who had experienced childhood trauma. In 1986 he resigned from his social work post. He then worked primarily as an adult analyst. Keith considered a Jungian attitude helpful, and his more pragmatic approach allowed him to offer psychoanalytic psychotherapy to those not usually undertaking it. The therapy could be quite intense, consisting of several sessions a week, sometimes over many years.

He provided supervision and consultation services for the public sector and for more broader-based organisations and training bodies. The courses he helped run were regarded by many as the best in London.

When possible he swam every day, and he enjoyed walking; the Thames path, the North Yorkshire coast, the Pennine Way and the Coast to Coast walk were all favourites. He also loved dogs and cats – his cat Crosby only reached the Methuselan age of 19 because Keith rescued him from a well.

Keith's response to those who said life could be so very hard and unfair was "Yes, that's how it is." And, on his own death: "It can't be that hard, lots of people have done it."

He is survived by Rowena, to whom he was married for 24 years, and who lovingly nursed him in his last few weeks; and by Angela, his sister; five nephews and two nieces.

John Playfair obituary

Wed, 13 Nov 2013 17:18:09 GMT

My father, Professor John Playfair, who has died aged 82, spent most of his working life as a lecturer and professor of immunology at the Middlesex hospital (later University College hospital), where he researched the immunology of tropical diseases including malaria. His textbooks Immunology at a Glance (1979), Infection and Immunity (1994, with Greg Bancroft) and Living With Germs (2004) are still in use.

The son of Major General Ian Playfair and Jocelyn (nee Malan), a novelist, John was of Scottish and French Huguenot ancestry. He was educated at Cheltenham college and studied medicine at Pembroke College, Cambridge. After qualifying as a doctor at King's College hospital, London, in the 1950s, John worked briefly at the Marsden and Brompton hospitals and then branched out into research on cancer and tropical medicine. He married Line Mariani in 1959 and shared a lifelong love of her native Corsica, spending many happy holidays there.

He spent three years in the early 1960s at the University of California, Berkeley, and also travelled extensively with the World Health Organisation; he visited hospitals and laboratories, and was in great demand as a lecturer and external examiner.

He also wrote fiction, and his three early novels, Pursued by a Bear (1958), Andiamo! (1959) and The Dying Art (1960) were well received; he later wrote several crime novels, which will be published online. He was also a talented painter and draughtsman.

Throughout his life he played and studied the clarinet, collecting and restoring antique French clarinets and designing improvements to the instrument, such as new keys and bore sizes. He loved playing every member of the clarinet family and arranged chamber music for various wind ensembles. He wrote regularly for the magazine of the Clarinet and Saxophone Society. Many of his rare clarinets have been donated to the Sir Nicholas Shackleton collection of historical instruments at Edinburgh University.

My father's great sense of humour and broad range of interests brought him a wide circle of friends. He loved to read, often with a glass of pastis in hand, and he was looking forward to the arrival of his first great-grandchild. We are planning a "clarinet fest" next year for all his friends to celebrate a life full of passion and harmony.

He is survived by Line, two children, Miranda and me, four grandchildren, Robert, Catherine, Sarah and Alice, and his brother, Guy. John donated his body to medical research and asked that his ashes be scattered near the Sanguinaires islands off Ajaccio, Corsica.

California was sterilizing its female prisoners as late as 2010 | Corey Johnson

Corey Johnson — Fri, 08 Nov 2013 15:15:00 GMT

California banned force sterilizations in 1979, but as recently as 2010, female inmates in the state were getting the procedure

On a lazy Sunday in March 2012, I was headed out to run errands when CNN's Anderson Cooper 360 turned to a broadcast called "Eugenics in America". The report recounted the sad history of minorities, prisoners, the poor and the disabled being forcibly sterilized during the early 20th century.

No news there, right? Yet, I was taken aback when the piece focused on California's role. I never knew the Golden State led the nation with nearly 20,000 sterilizations. Nor did I know that Nazi Germany consulted with California's eugenics leaders in the 1930s. I also was surprised that CNN's reporter was unable to get lawmakers in Sacramento to talk about this.

I set out to learn more. Were there any living victims? If so, how many and how could I find them?

Coincidentally, soon afterward, I received a tip that sterilizations may have occurred in California's women's prisons as recently as 2010. The assertion shocked me. It sounded outlandish.

By then, I knew that California lawmakers had banned forced sterilizations in 1979. Since 1994, elective sterilizations have required approval from top medical officials in Sacramento on a case-by-case basis. Had that happened in these cases?

I sought out the prisoner rights organization Justice Now and traveled to its Oakland office. Advocates showed me state spreadsheets indicating contract doctors were reimbursed for performing tubal ligations on inmates. The group's data was incomplete. It lacked the amounts paid. And there was no information on who was sterilized or whether the procedures were approved at headquarters. But at a minimum, the documents showed that the tip wasn't as off base as it first appeared.

The missing information foreshadowed the difficulties that would come in the months ahead as I sought to fill in the blanks. Intense secrecy governs these surgeries. Strict state and federal laws protect patient privacy. Prison attorneys fought to deny access to key documents and records, including those not medically related. Also, inmates who have been sterilized are reluctant to talk about it for many reasons – some of which stem from shame and trauma from the surgery.

Still, I crisscrossed the state seeking and meeting people who could help break the silence. Over time, I obtained a more complete spreadsheet of tubal ligation procedures and costs. Prison officials talked to me both on the record and off. So did former and current inmates. A few medical records trickled in as well.

Highlights from the first story that The Center for Investigative Reporting published 7 July (which I authored) show the results, including:

• Doctors under contract with the California Department of Corrections and Rehabilitation sterilized nearly 150 female inmates from 2006 to 2010 without required state approvals – and there were perhaps 100 more dating back to the late 1990s.

• Former inmates and prisoner advocates say prison medical staff coerced the women into agreeing to the surgeries, targeting those deemed likely to return to prison in the future.

• From 1997 to 2010, the state paid doctors $147,460 to perform tubal ligations, according to a database of contracted medical services for state prisoners.

• A prison administrator acknowledged that she tried to find workarounds, and the prison's ob-gyn defended the expenditure, saying:

Over a 10-year period, that isn't a huge amount of money compared to what you save in welfare paying for these unwanted children – as they procreated more.

• One former inmate, who gave birth to a son in October 2006, said she repeatedly was pressured to agree to a tubal ligation, including while at the hospital under sedation for her C-section. "He said, 'So we're going to be doing this tubal ligation, right?' " she said. "I'm like, 'Tubal ligation? What are you talking about? I don't want any procedure. I just want to have my baby.' I went into a straight panic."

The story went viral on social media. News organizations and bloggers nationally and internationally circulated the piece, prompting intense debate. Lawmakers immediately denounced the sterilizations, which appear to have ended in 2010, and demanded answers. So far, two hearings have been held. A state audit was ordered and fast-tracked to determine what happened and who knew what when. And, of course, our investigative journalism work continues.

Corey Johnson

Can a shot of humanities make doctors more humane? | Charlotte Blease

Mon, 04 Nov 2013 12:35:14 GMT

A course of 'medical humanities' is supposed to unlock the empathy so often missing in care, but evidence is lacking

A couple of years ago posters of a corpse started appearing on campus. The sight of a (seemingly) dead man with a tag on his toes certainly grabbed my attention.

Closer scrutiny revealed that the grim poster was an advertisement for a medical amateur dramatics production. Under the guidance of a theatre director, a choreographer and a medical ethicist, the production, involving third-year medical students, was an "experimental performance piece" designed to explore the topic of "body donation" to dramatic effect.

The director of the production – the fruits of a joint School of Medicine and Performing Arts venture – would later clarify the importance of the event to colleagues under the jaunty title "Doctors can dance too: using devised theatre to explore a topical issue in bioethics".

Performances such as these might be medical fringe but the medical humanities are burgeoning. On both sides of the pond, medical school curricula are increasingly taking seriously the role of the creative arts, English, history, anthropology, sociology and philosophy in broadening medical students' education. And the injection of "culture" is not just being prescribed to students: qualified doctors are also encouraged to dose up on the arts and gain continuing medical accreditation as a result.

Last year, I attended a medical humanities conference in the US. This time the performers were humanities PhDs; the audience comprised the same but also included doctors on away days notching up some credit. The presentations were wide-ranging, from "Leonardo da Vinci's contribution to modern orthopaedics" and "Medicine as magic in Ancient Egypt" to "The creative inspiration of medicine in the writings of Arthur Conan Doyle" and the catchily titled, "A dermabiographical approach to Zelda Fitzgerald's figure paintings".

While some of the talks were insightful, stimulating, and perhaps even noteworthy, there was an underlying dogma running through the majority of the contributions. It found its proudest voice in an English professor who proclaimed that reading Tolstoy's The Death of Ivan Illyich had inspired her class of interns to improve their bedside manner. With literary guidance as her beacon, she had turned these naturally (and literally) clinical young medics into sensitive human beings. Under the pressure of ER, palliative care, or even in surgery, these doctors would be better able to respond to the needs and feelings of their patients.

The underlying dogma is that studying the humanities makes doctors humane. It sounds good. It might even sound intuitively right. But the "common" in common sense is often the unrefined variety. Lurking beneath the medical humanities' manifesto is a form of associative thinking – a sort of causal fallacy: it is the notion that literary or philosophical absorption, and compassion for one's fellow beings, follow a simple linear path. After a decade working in humanities faculties, my own experiences don't exactly corroborate the view.

And herein lies the problem. There is no reliable evidence that studying literature improves levels of compassion among medics. This is not to say the dogma won't yet be vindicated. And it is not to say teaching or improving levels of empathy among medical students and doctors is an unimportant task. In fact the very opposite is the case: compassion and empathy form a crucial part of the doctor-patient relationship. Doctors need to be aware of the range of experiences that illnesses and personal circumstances can bring. Empathy is also crucial in creating the kind of atmosphere where patients can communicate effectively – and when patients aren't forthcoming about symptoms, doctors miss a major piece of the puzzle.

The point is that nobody – least of all medical educationalists – can afford to be glib about how this facet of medical professionalism can best be found or achieved.

And what about other healthcare professionals? Exponents of the literary medical humanities appear less eager to ingratiate themselves among nurses, for example. Couldn't our nurses, home helps and other healthcare workers use some of this (purported) literary elixir? An academic Google search located one publication advocating the use of (specifically) "popular literature" among nursing students. According to this reasoning, we should prescribe Danielle Steel to our nurses, while administering Dostoyevsky to the medics.

Sound out of touch, condescending and (dare I say it) lacking in humanity? Perhaps the vanity of the humanities needs a dose of its own medicine.

Medicine Unboxed is a project that connects the public with healthcare professionals in a scientific, political and ethical conversation about medicine, illuminated through the arts. For more information on this year's event in Cheltenham, 23-24 November, visit our Facebook page, follow @medicineunboxed, or visit our Pinterest boards to learn about the conference programme

Should we fear DNA testing? | Emma G Keller

Emma G Keller — Sun, 03 Nov 2013 15:49:06 GMT

DNA sequencing is here to stay. The implications for global health are mind-blowing, yet many worry about privacy concerns

Imagine you had a tumor. Surgery removed most of it, then chemotherapy or radiation took care of the cells that lingered. You went through a harsh period where you felt exhausted and ill, but then you were OK. Cancer free. Until one of your tests showed some new shadows in a different part of your body. Your cancer was back and on the move.

But then your doctors told you that by sequencing the genome of your tumor and looking at it in the context of your overall DNA, they realized you could take a drug that would essentially block cancer's progress in your body. Would you take the drug? Would you be happy that your DNA had been sequenced?

Now imagine you've just had a baby. State or national law mandates that your baby's blood is drawn after birth and his or her genome is sequenced. A database houses the information anonymously, but the details of your child's gene structure are shared with research facilities and drugs companies. How would you feel about that?

Both of these hypothetical situations already happen. As we clamor about the loss of our privacy in the age of the internet and NSA eavesdropping, it's worth considering another aspect of public record keeping. Whose medical privacy is worth losing for your improved health or for the improved health of society?

Every baby born in the United States is currently screened for disease at birth. The range of testing varies from state to state and you can check the variety here.

Doctor Robert Darnell of the New York Genome Center wants to replace what he feels is an inefficient testing system in New York State with genomic sequencing performed on each newborn. He's not alone. Pilot schemes across the US have begun to screen newborns as doctors investigate the benefits of using genomic information as a healthcare resource throughout a child's early years.

At the same time researchers are trying to figure out how to protect and/or share that information. What are the rights of a child not to know his genetic heritage?

Meanwhile in the United Kingdom, the NHS hopes to have sequenced the genomes of 100,000 people by 2017 with the eventual aim of having everyone's DNA in their database.

With most of our medical records already online how much should we care about losing this level of privacy? Should you be scared that employers would be able to find out from your genome structure that you carry the Huntington's disease gene and fire you? Can your genetic predilection for Alzheimers or breast cancer be held against you?

In a perfect world, the answer to these questions would be no. And, in fact, Americans – dependent on insurance in a country where the cost of care is sky high – are more at risk than Brits to abuse. Which makes it unsurprising that most of the worst case scenarios put forward by privacy experts revolve around insurance companies denying coverage.

But to focus solely on the privacy concerns of individual genome sequencing is to miss the point. DNA sequencing is here to stay. For the first time ever, we are looking at the chance to cure major diseases, possibly before they take hold. The implications for global health are mind-blowing. What if your baby girl could avoid developing the diabetes that has run through your family for generations? If Schizophrenia could be halted in its tracks?

We are living on the edge of a brave new world where the possibility of living without the health problems that have plagued us for generations is within sight. It says something about human nature that we can't imagine this happening without sabotage.

I recently worked on a special DNA report for WNYC, which you can listen to here.

I'll be conducting a live chat with Dr Darnell on Monday, 4 November at 1pm EST (5pm BST). Leave your comments below and I will raise some of them with him.

Emma G Keller

Hugh de Wardener obituary

Caroline Richmond — Tue, 29 Oct 2013 14:55:40 GMT

Pioneering doctor in the treatment of kidney disease who, as a PoW, cared for allied soldiers forced to build the Burma railway

Hugh de Wardener, who has died aged 97, pioneered kidney dialysis in Britain, performed the UK's first renal biopsies, enabling accurate diagnosis, and wrote the definitive textbook on the kidney, first published in 1958. He showed that salt raises blood pressure, that long-term antibiotics prevent urinary infections in susceptible adults and that Wernicke's encephalopathy, a neurological condition usually seen in alcoholics, was caused not by drink but by vitamin B1 deficiency.

De Wardener came from an aristocratic French family who had fled to Austria during the revolution. A later generation migrated to America. His parents met when his US-born father, a commodity broker, was living in Paris, and his mother, also an American, was taking singing lessons there.

He was born in Paris. After his parents divorced, he was sent to boarding school in Sussex not speaking a word of English. He went on to Malvern college, Worcestershire, and to St Thomas' hospital medical school. He qualified in 1939 and took a house physician post in Scunthorpe. Within a week his consultant died in a road accident, leaving De Wardener to cope single-handed with 100 medical and paediatric patients.

Six months later De Wardener joined the army. After service in Britain he was drafted to Singapore in 1942, a month before it fell to the Japanese, and became a prisoner of war. He spent the remaining three war years looking after soldiers who were forced to build the Burma-Siam railway, as fictionalised in the film The Bridge on the River Kwai (1957). A fellow prisoner, John Coast, published a novel, Railroad of Death (1946), describing the camp's caring and brilliant "Dr Ginger de Hugenot [sic]". De Wardener successfully treated diphtheria in allied PoWs by using an antiserum he made from the blood of other patients.

When running a cholera ward in the PoW camp he recognised that some malnourished patients had Wernicke's encephalopathy. He confirmed this by autopsy and recognised that it was dietary. He treated it by getting the Japanese to supply Marmite. After the autopsies he preserved the prisoners' brains in formalin, and when the camp was abandoned and the Japanese were destroying evidence of their maltreatment, he buried them with notes in a sealed drum in a prisoner's grave. This was later excavated and his research was published in a classic 1947 Lancet paper.

De Wardener was repatriated in 1945, having suffered jaundice, diphtheria, cholera, malaria and malnutrition, to find he had tuberculosis. After a brief convalescence he became registrar at St Thomas' hospital. He immediately started researching kidney function, doing many uncomfortable experiments on himself and colleagues. In 1960 he was appointed professor of medicine at Charing Cross hospital medical school. At that time, kidney failure was considered a death sentence. Having heard the US physician Belding Scribner describe the first patients on dialysis, De Wardener introduced it at Charing Cross in 1964.

After "retiring" in 1981 he continued working, collaborating on kidney function with Graham MacGregor of St George's hospital, Tooting. In 2004, he gave the first of the annual De Wardener lectures at Charing Cross hospital, which was received with acclaim. In 1961 he founded what is now Kidney Research UK. Realising how hard it is to be on thrice-weekly dialysis, he established a holiday fund for patients and a seaside dialysis "hotel" in Emsworth, Hampshire.

De Wardener was appointed CBE in 1982 and was president of the International Society of Nephrology from 1969 to 1972 and of the Renal Association from 1973 to 1976. The US National Library of Medicine lists 223 papers by him, the last published in 2012.

In 1969 he married his fourth wife, Josephine Storey, the nurse who established Charing Cross's dialysis unit with him. He is survived by Josephine and their two sons, and by a son and daughter from his previous marriages all of which ended in divorce. In his last months he suffered from peripheral neuropathy, a legacy of the prison camps. He died in the De Wardener ward, the intensive care renal unit at Hammersmith hospital.

• Hugh Edward de Wardener, physician, born 8 October 1915; died 29 September 2013

• This article was amended on 30 October. Hugh de Wardener's father was not serving in the US army at the time he met Hugh's mother, and she was not of French descent. These points have been corrected.

Caroline Richmond

Doctors are more likely to be depressed? I'm not surprised | Ranjana Srivastava

Ranjana Srivastava — Wed, 09 Oct 2013 02:10:30 GMT

Ranjana Srivastava: A new survey found that one in 10 doctors entertained suicidal thoughts in the past year. Those are sobering numbers illustrating a problem I'm all too familiar with

Ranjana Srivastava

Applying for medicine? Get ready for the new-style interview

Abby Young-Powell — Mon, 07 Oct 2013 08:53:00 GMT

The latest interview system is designed to prevent people from over-preparing – so how can you make sure you do your best on the day?

Read more: how to write a personal statement for medicine

"Imagine that you're the headteacher of a school. You've got a limited budget and a choice of pupils to spend it on. There's Mary, whose parents have died, or John, who's been successful with his school work. To whom would you give the money, and why?"

Postgraduate student Allon Gould was presented with this scenario during an interview to get into medical school. It's the type of question that could be asked in one of a series of "multiple mini interviews" (MMIs) for medicine or dentistry, where students walk around a circuit with different scoring stations.

"During your interview, it's important to show that you can communicate," says Allon. "It's the explanation you give for your answer that's important." Allon told his interviewers that he'd give the money to Mary, because "she needs it more than John does".

As they work their way through their MMIs, candidates may be asked to interact with actors, who pretend to be an upset classmate, or a neighbour with a lost pet. Interviewers watch to see if students can make ethical judgements and solve problems.

"It's a practical assessment," Sara Doherty, director of student services at St Georges University, says. "Candidates have to show us what they're capable of doing, rather than tell us."

This makes an MMI difficult to prepare for – and that can be a scary prospect for high-achieving students accustomed to studying hard for success. How can you get ready for an interview that's designed to prevent you from getting a headstart?

One way is to do plenty of research before you get into the interview room. Look at the information universities put on their websites and make sure that you understand what interviewers are looking for in an MMI. "Students should get a feel for what an MMI is from the resources available online," says Dr Robert McAndrew, admissions tutor at Cardiff University.

Make notes during your work experience and go over them before your interview day, so that you've got examples to talk about when asked to discuss your answer. "Keep a diary, then you can talk about a patient or mention specific cases," says Becky Horton, who had an MMI interview at UEA. "Make sure you understand key concepts, such as patient confidentiality."

Keep up to date with current affairs, as interviewers may get ideas for tasks and questions from the news agenda. "Students should read the national newspapers, and watch the news on TV," Kim Piper, lecturer at Queen Mary University, says. "For example, last year there was a lot of talk about assisted suicide, so students needed to think about that."

Practise with someone you don't know, as that'll help you to get used to an interview situation and to role plays. "Any student who practices questions with an adult they don't know well will find it easier," says Piper. "Doing that can help to get rid of nerves."

On the day, don't panic if you fall down on one part of the interview. An MMI allows you to make up for it elsewhere. "If you feel you've done poorly at one station, don't worry," says Dr Robert McAndrew. "Most universities use 10 station MMIs, so there's plenty of opportunity to excel elsewhere."

Be yourself, says Micki Regan, from the admissions team at St Georges University. The point of an MMI is to show your personality and to discuss your views. "Some students are liberal with the truth when they talk about how much work experience they've done," says Regan. "We will find out, so be honest and don't embellish."

Make sure that you listen to the question properly and don't rush your response. "Take time to think about the scenario," says Regan. "Sometimes candidates over-rehearse and don't listen. They answer the question that they've prepared for, rather than responding to what we've said. Quite a few candidates fall down on that."

If you're unsure of what to do, ask us to clarify, says Pat Harkin, deputy director of admissions at Leeds University. "If someone says something that sounds odd, double check it. If you asked someone in the street for directions, they wouldn't have a problem with the fact that you didn't know something and that you asked. It's the same here, we don't mind, so ask."

If you keep calm, then you'll perform better at interview. "Relax, because nobody is trying to mislead you," Harkin says. "We want an insight into what you're like, and into how you work in a group. There are no trick questions, because that would be pointless for us."

Trying to figure out what the interviewer wants you to say is a waste of time. "There often isn't a right answer in an MMI," says Harkin. "That's a mindset you get from exams. Go with your gut instinct and gut feeling. Don't try and predict what we want you to say, because you don't have much time."

So if you're told to imagine that you're a headteacher with money to spend on either Mary or John, don't try and second guess which one the examiner wants you to choose. It doesn't matter which you opt to help, as long as you explain your reasons and show that you've thought about the question. Once you've done that, you can take a deep breath, relax, and move on to the next station.

The MMI was developed in Canada and piloted at St George's Medical School in 2009-10. Since then, a number of medical schools have converted from traditional interviews to the MMI, including Leeds, UEA and Birmingham university.

One of the main benefits of the "speed dating" style of the MMI is that it doesn't favour those from the best schools, but gives all candidates an equal opportunity to succeed on the day.

"My multiple mini interview wasn't anywhere near as hard as I expected it to be. In fact, I really enjoyed it. The things they ask you to talk about are interesting and I think they want to get the best from you," says Becky Horton, now in her first year at UEA.

"There were seven stations and I had to spend five minutes at each," she explains. She liked it because if you did poorly on one question, you could walk away from it and do well on the next. "I said something stupid but it didn't matter because the bell went and I moved on to the next station."

Is it very different from a traditional interview? "Some people prefer the MMI, because it's less daunting. Overall, I'd say that it's like a normal interview – but in little bits."

Abby Young-Powell