Although it has been slow to pick up on the maggot therapy story, the New York Times has produced what is likely the best article on it:

The analysis, published online March 19 in BMJ, found no difference between the two treatments in time to healing, although the larval treatment was somewhat more expensive and associated with slightly more pain. On the whole, the researchers concluded, there is little difference between the two treatments, and the choice should be left up to the patient.

NY Times

They even link to the original study! The Times of London could learn a thing or two from these guys.

Charles, Prince of Wales (Wikimedia Commons)

In the Daily Mail today, a report on Prince Charle’s Duchy Originals alternative medicines, which has already been blogged about by DC at Improbable Science. In today’s article

Prof Ernst, director of complementary medicine at the University of Exeter’s Peninsula Medical School, even accused Prince Charles of peddling ‘quackery’ and ignoring science to ‘rely on make-believe and superstition’.

He is right in a way – new medicines have to undergo rigorous clinical trials before going on the market. There have been no such trials on these tinctures and reports of their success are anecdotal.

Mail

I love how the author says he’s right ‘in a way’. As if being rational and scientific was a rather odd way of going about things. The author effectively treats anecdotal evidence almost on a par with randomised, controlled empirical evidence. 3 products are then discussed:

1. Detox preparation. The concept of ‘detox’ is accepted uncritically here. Ben at Bad Science will not be pleased. Notice the mysterious omission of the Cochrane review on artichoke leaf extract which no benefit in hypercholesterolaemia (which involves liver metabolism which is supposedly improved by this product), even though reviews are mentioned for the other two products.

2. A St John’s Wort preparation – this Cochrane review suggests some preparations may be better than placebo for major depression. Dr Nyokabi, mysteriously, recommends it for minor depression on this basis.

3. Echinacea – Dr Nyokabi mentions this Cochrane review saying it found Echinacea to be “beneficial”. It actually found some inconsistent evidence that some preparations “might” work. Hardly a resounding endorsement.

A mongolian horse - Wikimedia Commons

A very unusual article in the Daily Telegraph entitled ‘How the Horse Boy Conquered Autism’ advertising a book and documentary film called The Horse Boy about two parents and their child with pervasive development disorder not otherwise specified (PDD-NOS), also called ‘atypical autism’. They claim that their child ‘recovered’ with the help of horse-riding and Mongolian traditional healers (shamans).

“The other therapies we had tried – biological and behavioural – hadn’t had such swift and radical effects. Kristin is a good scientist and good scientists have open minds. Also it helps that I don’t have a New Age bone in my body – I was never interested in any of it growing up, but got gradually drawn in through working with indigenous tribes who don’t do anything without going through a shamanistic consultation process first. They are very practical people who live in some of the most hostile environments on the planet. They can’t afford to indulge in ideas that aren’t effective for them.”

Telegraph

I am very happy for these parents that their child’s neurological development has been so successful, and that they are enjoying their family life.

See this excellent post from 2006 over at LeftBrainRightBrain called Recovery Stories And A Dash Of Reality, discussing the lack of evidence for children being ‘cured’ of autism. It is however quite clear that even autistic children experience some neurological and cognitive development as they grow. Here is a recent review of the topic in Neuropsychology Review, in which it is suggested a diagnosis of PDD-NOS is a favourable sign; here is a case study from 1995. Note that rather than ‘curing’ autism, it is instead better to think of it as improving neurological function. The child in the story, Rowan, is still autistic.

The fact that Rowan, the child from the Telegraph story, enjoys riding, is not evidence of its curative ability. Similarly, the fact that the shamans were present at a particular point in time does not imply that their presence improved Rowan’s neurological development. Maybe if they had gone to Disneyland for a holiday instead he would still have improved at that same time. Correlation is not causation. I also object to the idea that the shamanic treatments are more likely to work because nomadic steppe people ‘don’t have time’ for ineffective treatments.

You also have to wonder about the presence of camera crews throughout the family’s journey. Surely setting out with the intention to make a documentary about this results in confirmation bias? And read this passage:

Back in Texas, Rupert and Kristin have used the unanticipated windfall from worldwide sales of the book and film to found an equine therapy centre. There is a new book in the pipeline called The Gifts of Autism, which treats its subject as a set of opportunities to be worked with rather than a problem to be fixed.

This is all very entrepreneurial. I just hope this article does not give people false hope that a cure for autism is just a horse-ride away.

Images from Wikimedia Commons.

Monday 16 March 2009 – Student Fitness to Practice

The General Medical Council publishes new guidance for students. An article in the Telegraph about student Fitness to Practice (sFTP). We at the BMA are worried that it is ‘a sledgehammer to crack a nut’ and that sFTP will be invoked not only for breaches of professional behaviour but also for more minor incidents. I would encourage students to carefully read it. Note for example under ‘areas of concern’

Persistent inappropriate attitude
or behaviour

• Uncommitted to work
• Neglect of administrative tasks
• Poor time management
• Non-attendance
• Poor communication skills
• Failure to accept and follow educational advice

Tuesday 17 March 2009 – Minimum Alcohol Plan Proposal

The proposal from Chief Medical Officer Sir Liam Donaldson to put a 50p minimum price on a unit of alcohol to discourage binge drinking on cheap booze is met with a mixed reaction, mostly negative: see comments in the Guardian, Telegraph and a cynical analysis from Pulse. Reaction from NHS Blog Doctor.

Wednesday 18 March 2009 – Mid Staffordshire Hospital Scandal Update

Alan Johnson apologised for excess deaths at Stafford Hospital – see Guardian. The BBC asks what lessons are to be learnt from this incident. An extensive reaciton from NHS Blog Doctor. The Hospital is declared not fit for purpose – Times ;see also this commentary.

Thursday 19 March 2009 – Death of Natasha Richardson

The untimely death of actress Natasha Richardson sparks a blogosphere debate about the merits of the Canadian socialised health system. KevinMD asks whether she was failed by the system. NHS Blog Doctor argues in defence of socialised medicine these two posts and concludes that if a doctor had been brave or stupid enough to drill burr holes in her skull without an MRI he might have saved her but the legal liability environment discouraged anyone from doing so.

Friday 20 March 2009 – Hewitt seeks assisted suicide law change

Patricia Hewitt discusses setting into stone the non-prosecution of people for assisted suicide abroad. Many Britons travel to Switzerland to seek assistance from the NGO Dignitas; the current practice in case law is not to seek to prosecute these people.

Saturday 21 – Evidence base of PSA prostate cancer screening shattered but still widely practiced in US

Two new papers in the New England Journal of Medicine (one and two) were misleadingly reported by the British press. See Ben Goldacre at Bad Science:

Why would the American and the Australian journalists say something completely different to the British ones, about the very same evidence?

Bad Science

Sunday 22 March 2009 – Jade Goody dies

Jade Goody, the popular but controversial reality TV star, died at home in her sleep this weekend. Many people including the Prime Minister and Leader of the Opposition led tributes to her (BBC). See also articles on the effect of her highly publicised illness on cervical cancer screening rates and her obituary. Again, her death sparks a debate over whether she was failed by the health system: see US view on The Blog That Ate Manhattan and UK view on NHS Blog Doctor.

I would like to wish my condolences to the families of Natasha Richardson and Jade Goody.

Lucilia sericata larvae

***Edit 24/03/2009***

Effect measure has got a good post on this.

***Edit 23/03/2009***

The Guardian has now got a layman’s summary of the paper. It’s published in association with the BMJ but nonetheless seems a fairly balanced summary.

***Edit 21/03/2009 13:40***

Changes: 1. Image caption changed to describe species. 2. Quoted both BBC and Times more extensively, with headlines, for fairer comparion. 3. Added paragraph below:

Let me just clarify that I think that while nothing in either report is untrue, the fact that the two headlines seem to be suggesting very different things about the study suggests that one of them is more balanced. The Times story focuses on debridement, rather than time to healing or pain. In the words of the study authors:

the study raises uncertainty about the role of debridement in the care of leg ulcers. Although debridement is viewed as an important part of preparationof the wound bed, data describing the relation between debridement and healing are sparse. Research is required to explore the relation between debridement, healing, and microbiology as well to better understand the value of debridement as an outcome from the patient’s perspective.

******

A randomised controlled trial on maggot therapy was published in this week’s British Medical Journal. The researchers’ conclusion:

Larval therapy did not improve the rate of healing of sloughy or necrotic leg ulcers or reduce bacterial load compared with hydrogel but did significantly reduce the time to debridement and increase ulcer pain.

Seen in the BBC as this:

Maggot therapy hope ‘premature’

Maggots may not have the miracle healing properties that have been claimed, a UK study suggests. Researchers comparing maggots with a standard “hydrogel” in treating leg ulcers found little difference…

…There was no significant difference in the time it took the ulcer to heal between the two treatments or in quality of life.

Maggots were not more effective than hydrogel treatment at reducing the amount of bacteria present or in getting rid of MRSA and were, on average, associated with more pain.

BBC

Compare with this:

When it comes to wound healing, the maggot cleans up

A study by a team of British scientists, published today, lends support to the use of the maggot in high-tech healthcare. They found that, left to graze on the skin, maggots can clean wounds that fail to heal five times faster than conventional treatments…

…Professor Nicky Cullum, a specialist in wound care, who led the maggot therapy study published in today’s British Medical Journal, said that maggots had cleaned wounds in 14 days — compared with 72 days with gel treatment. She said there was anecdotal evidence of increasing maggot use in the NHS.

The Times of London

It is a classic mistake in science reporting to fail to distinguish the subtleties in phrasing of positive vs. negative outcomes. While debridement was indeed faster the primary outcome – the wound’s actual healing – was no faster. And to top it off, the levels of pain reported were increased. This is certainly no miracle cure. If you read Nicky Cullum’s letter to the BMJ from 2006 entitled Not so fast with vacuums and maggots as firstline treatment you might also infer that the Times selectively quoted Prof. Cullum, who does not appear to be a maggot therapy enthusiast, to make it sound like she was supporting maggot use as first-line treatment.

I suspect that this story was intentionally misreported, in order to appeal to those readers who like the sound of maggots because they are ‘natural’. It is worth bearing in mind that maggots also ‘naturally’ cause disease by feeding on necrotic tissue – this is called fly strike or myiasis (warning: nasty pictures).

I have e-mailed this to Ben Goldacre at Bad Science.

The A* grade will be introduced to the A-level in 2010

School-leavers will need to get at least an A* and two A grades in their A-levels from next year if they want to study at Cambridge University.

BBC

This is particularly interesting for medicine, where AAA offers and the occasional AAB are the norm. Are we going to see A*A*A* offers a few years from now?

The person contacted for interview in the article is Richard Partington, Senior Tutor of my College, Churchill. I had the privilege of sitting across from him at the Master’s dinner last week, and we discussed the relative merits of A-level, Scottish Highers, IB, Pre-U and EB qualifications. Contrary to popular belief, he did not hold the IB in higher esteem than A-levels. He is, however, quite interested in the new Pre-U developed by Cambridge which will hit the UCAS application cycle next year, and which he helped develop. Faced with this new rival qualification, the A* grade may be a way for state schools to remain competitive.

He says in the article:

“The effect of A*AA “looks neutral”, he said.

“If we were to move perhaps in the sciences to using more than one A* there might be a widening participation benefit: there may be more state school students.”

As for widening participation, Cambridge has had an upward trend in acceptance of students from state school for many years now. Last year was 59%, the highest ever. It could be better, but generally Cambridge is doing okay on gradually increasing this figure.

However, even if we assume that A*AA offers won’t affect state school intake, this is a rather narrow definition of widening participation; it neglects the diversity of schools within the state sector and ethnic diversity. Cambridge remains very middle class and white. It may that Cambridge can continue to increase its state school uptake while taking people mostly from better-off socio-economic backgrounds.

11.33 am

I am at BMA House, the national headquarters, today. I have Hamish Meldrum, Chair of BMA Council, sitting directly facing me at the moment – I am at the heart of the action.

I have just finished my meeting on the Welfare Subcommittee – we discussed student Mental Heatlh, Exam Timetables, the Medical Schools Charter, Student Fitness to Practice and the BMA Welfare website.

1.46 pm

This morning the Chair of MSC, Tim Crocker-Buque, and chairs of the Education, Finance, Welfare and devolved nation committees gave us reports on their work since the last meeting. We also discussed Widening Participation. After a brief lunch break we are about to start the afternoon chunk of the agenda.

5.00 pm

Long afternoon. We discussed the Foundation Program, Tomorrow’s Doctors, Communicating with student BMA members,  and BMA-wide projects (Junior Doctors Contract, Workforce Planning, Revalidation, EWTD)

I wrote about the confusion and complexity of prescription charges across the UK last month. Since then, the BMA has issued a press release stating its position that it would be much simpler to scrap them entirely in England like everywhere else. Hamish Meldrum:

“Making the list of exemptions longer will not make it fairer. Ultimately, we could end up with a situation where only a tiny proportion of prescriptions attract a charge, which would be nonsensical.

Abolishing prescription charges altogether is the fairest and the simplest option.”

See it in the Telegraph, Mirror, Guardian & BBC.

Note also that the charges are set to increase by 10p to £7.20 in April: Mail, Telegraph, Mirror, BBC.

Now here is where it gets really interesting: although I agree that scrapping the charges entirely would make the system more consistent and fair, take a look at this article from GP Magazine Pulse. It suggests that prescription rates in Wales have significantly increased since the scrapping of prescription charges, particularly for NSAIDs. Now this is the crux of the matter: resource allocation. Prescription charges are among the NHS only co-payments, along with dentistry charges. Do we really want to be paying for people’s aspirin when they have a hangover, or making it even easier for people to have amoxicillin dished out to them in flu season? Or do co-payments, on the contrary, discourage people from taking drugs they need?

The wikipedia article linked references a meta-analysis that show co-payments may also discourage necessary use of medication, by the same token as they discourage unnecessary use. So perhaps scrapping is the most ethical solution. Let us hope the government are wise enough to increase NHS funding appropriately if that is their intention.
P.S. Co-payments should not be confused with top-up payments.

Like our medicine, our curricula should be evidence based. I believe that the balance of evidence favours early patient contact. Just search PubMed for ‘early patient contact’ and ‘medical students’ and you will find a wealth of evidence.

First, to give you an idea of exactly how much patient contact we get in our pre-clinical Preparing for Patients course, let’s ‘do the math’ as our transatlantic cousins say:

Year 1: Module A – GP 1 afternoon in surgery 1 home visit. 4h, 4 patients.
Year 2: Module B – Hospital 1 visit each in 2 Cambridgeshire hospitals. 4h, 2 patients. Done over 1 week outside of term (i.e. holiday/revision time)
Summer between Years 2-3: Module C – self-organised attachment to social care, voluntary organisation (e.g. bereavement charity, Alzheimer’s society), or alternative medicine clinic. Length variable: 4h, 4 patients.
Year 3 (intercalated year): Module D – 3 home visits to a women during pregnancy and 1 after birth. 4h, 1 patient.

Note that each has briefing/debriefing session on top; the hours mentioned refer only to actual patient contact. Each Module is assessed based on a piece of coursework.

So that’s a total of 11 patients over 16h of contact. That’s very close to 0.01 patients per day. There is also the fact that several of friends did about 35h over five working days for Module C in an alternative medicine clinic. This actually means their ratio of exposure to alternative versus conventional medicine is roughly 3:1 (35/12), which I find quite alarming.

I do think that our strong scientific teaching is an excellent feature or our respective courses and would not want it to be watered down in any way. I do think, however, it is strange that we don’t have just a little bit more. For example in Module B above we a take a week out of our holidays to do it, so why couldn’t we fit in 5 full working days of intensive teaching there, instead of 4h briefing/debriefing and 4h patient contact (a fivefold difference)? Why isn’t there a week of intensive Clinical Skills teaching after 3rd year exams? Oxford has something similar I believe, and Cambridge students who transfer to London school (e.g. Barts) which have more patient contact have to be given a few weeks of a special course to teach them which way round to hold the stethoscope. As one of his year’s top student, my supervisor (tutor) for molecular pharmacology remarked of his 4th year: “When I arrived for my first day at the clinical school, I realised that I knew nothing.”

I also think the argument that one requires a strong grounding in basic science before being able to learn communication skills, history taking, examination and use of procedures/instruments doesn’t hold up. Do all those incredibly skilled nurses have to know the intricacies of molecular pharmacology to understand drug regimens and their administration? They’ve managed so far.

So in summary, I vote yes to lots of basic science in my curriculum, but yes also to a reasonable amount of clinical exposure! Let me know what your views are.

The BMA issued a press release yesterday on the Coroners and Justice Bill which I discussed 2 weeks ago.

Despite vocal opposition from the other parties, clause 152 is still in the bill. From the press release:

Dr Hamish Meldrum, Chairman of Council at the BMA, says:

“The doctor-patient relationship is based on trust.  If patients cannot be 100% sure that their records are confidential, they will inevitably be reluctant to share vital information with their doctor.

“The Justice Secretary has indicated that he is willing to amend this legislation to protect a person’s right to confidentiality.  We welcome the fact that he is taking people’s concerns on board, and hope he will provide assurances that confidential health information will be exempt.”

This time, the press release has been successfully picked up by the Daily Telegraph, The Guardian, the Daily Mail and BBC Online.

Please write to your MP to state your position on WriteToThem.com