Sunday, 31 March 2013

What the Ancients did for me

I remember very distinctly one school trip from my days at primary school. I remember weeks of preparation as I helped my mum to convert a white bedsheet into a tunic, mum doing the sewing whilst i gave artistic and historical guidance, and I recall spending many hours lovingly painting a design of snakes and hieroglyphs along the hem. I remember in-depth discussions about the issue of my hair: a light shade of ginger simply would not cut the mustard on this occasion, and a wig of black, glossy tresses was constructed using an old headband and a bin bag. This was also the day that my lifelong love-hate relationship with eyeliner began.

This wasn't just any old school trip. I was going to meet King Tutankhamen, and I needed to look the part of a genuine Egyptian to fit in, not to mention the fact that I had been practising for this moment for a while- I was known to have Ancient Egyptian days at home where I would wander around with an old gold necklace on my head declaring myself to be an Ancient Egyptian princess, whilst quietly cursing my more Celtic colouring and lack of servants, wealth, and ancient palace to live in.

I was-and still am- utterly enamoured by the Ancient Egyptians. Nothing quite adequately describes the thrill of being faced with a sarcophagus or two on a museum visit. My favourite things to pore over for an inordinate amount of time are the smallest things, the charms wrapped up with mummies. Small, shiny trinkets that were so highly revered they were thought to have magical properties; it perhaps explains why I am so easily distracted by glittery shiny things to this day.

My point is that this love of a culture so exotically distinct from my own was started in school. I have no recollection of history teaching in my primary school because memory is so bad, but I was left with a fascination of all things ancient and foreign, and that fascination still shapes my life today. Once I moved from primary school to middle school (do they even exist any more?), I can remember the thrill and excitement of starting a new subject in history, and all the possibilities it could bring. 'Ooh, the Romans!' I would think, 'there'll be people being eaten by tigers and stuff! Brilliant!' The Ancient Greeks, with their alarmingly modern gods arguing about the pettiest of things fascinated me back then and have continued to do so throughout my school and adult life. I remember a school librarian being somewhat alarmed by me dusting off and taking home the copies of The Iliad and The Odyssey to take home to read "just for fun" when obviously I should have been drinking cider on street corners instead.

Why am I wittering on about this on a blog supposed to be about healthcare? Well, because I just happen to have been listening to a podcast discussion about Gove's proposed new history syllabus. I am very demonstrably not a teacher of young people, nor do I require any history in my daily life (nor do I actually have any idea about the details or practicalities of Gove's syllabus), but I think this may make me weirdly qualified to actually comment on this subject. Gove wants a more Britain-centric teaching of history: well guess what Gove: British history is frankly boring. Its also not particularly British, given that we are a mish-mash of Angles and Saxons. Sure, Harold got an arrow in the eye, but in the face of all that exotic otherworldly-yet-just-within-our-grasp excitement of the Egyptians, Moors, Romans and Greeks, any child in their right mind would be bored of this country's history. Not every child is going to end up a history scholar: the majority of them will, like me, end up in a job where they don't *need* any history. But the key is surely to get them to engage enough with the subject when they're young that they end up *wanting* it in their lives and seeking it out.

So here's the thing: children at that age, before any prejudices of the state or the people surrounding them have properly kicked in, are open to and utterly interested by other cultures. When I think about it now, it would seem that my love for urbanity and multi-culturism has its roots in those days as a child learning about people different to myself. To instil some passion for history in children is to instil a thirst for looking deeper beyond surfaces and for searching for the hows and whys. It seems to me to be a real shame to politicise and manipulate this so it becomes focused on a narrower understanding of one country, and a series of dates.

There's quite a high likelihood that none of this makes sense, given that its very early in the morning and I'm typing this on my iPod. Apologies for all the errors and/or fallacies and oversharing of my childhood geekery


Oh, and FYI: Elgin Marbles tour guide available to hire, for the mere price of train fare, London-based accommodation and a pint in that pub i like round the corner from the British Museum. I'm often vague on the dates and things like that, but apparently quite entertaining on the important bits.

P.S. King Tutankhamen was very impressed with my outfit on that visit, and allowed me to do the demonstration of mummy-wrapping. I think it was the hair that did it. He was less impressed when one of the boys who had put decidedly less effort into his ancient styling kept demanding to know why King Tut had a Geordie accent and no sun tan if he was supposed to be Egyptian.

PPS. Clearly when I was writing this I had forgotten about The Tudors. They were quite cool, particularly Elizabeth I. I still stand by my point though that British history just doesn't have the panache or history from further afield.

Thursday, 28 March 2013

Homeopathic Harms Vol 5: Interactions

In February 2013, my friend Nancy and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we've decided to write a series of blog posts about a number of points we covered in the talk: 

In the next installment of our series on the harms of homeopathy, I want to talk about interactions. I've covered this a bit in the past, but let's have a look at this area in a bit more detail.

We all hopefully know by now that homeopathic medicines pretty much have no trace of active ingredient in them by now. Do we need to worry about drug interactions with homeopathic remedies?

Can homeopathic medicines interact with conventional medicines?
The obvious answer is no. Magic Sugar Water Pills are highly unlikely to affect any conventional medicines. There's a lack of actual evidence to prove this, but I think it's pretty safe to rely on a theoretical basis here. So that's great, right, blog post over and see you later. If only it were that simple.

Can homeopathic practitioners interact with conventional medicines?
Unfortunately, yes. very much so. It's pretty well known that homeopathic practitioners step over (and in some cases stomp over, then jump up and down repeatedly on) the boundaries between conventional and homeopathic medicines, just by the advice they give. One example would be vaccines- many homeopathic practitioners are against vaccines and therefore advise their patients to avoid them- Just look at the emails sent by pharmacist (and embarrassment to the profession) Tony Pinkus to an undercover BBC reporter. Little offhand remarks about the toxicity of conventional medicines, or big pharma conspiracies, or how conventional medicines might not work, all add up to the effect of harming the patient's relationship with their actual doctor. And how about the spectacular example of inappropriate advice in my previous post?

Can conventional medicines interact with homeopathic medicines?
I'd like to say no here, because of course homeopathic medicines are inert and don't actually contain any medicine. It is the case, however, that homeopathic practitioners unfortunately think otherwise, which can lead to a huge amount of harm as patients discontinue their conventional medicine in favour of homeopathy.

I have in front of me a book called "Homeopathic Pharmacy", by Stephen Kayne. This is a book aimed at healthcare professionals, and indeed is a  recommended resource for medicines information pharmacists in the UK. And yet, even this source, which we could consider to be one of the more balanced tomes (despite the ominous mention of Dana Ullman in the acknowledgments), contains a wealth of dangerous nonsense. This book tells me that, for example, "potent topical steroids are thought to negate the use of  homeopathy in the treatment of eczema and psoriasis" Now I know more than some that skin conditions such as this can be horrifically uncomfortable, not to mention their effects on your self-esteem. Stopping treatment that works in favour of a placebo is not, in my opinion, acceptable in any shape or form, especially given how vulnerable and desperate people can be because of skin conditions- don't forget that in some cases, dermatological conditions are terminal, as they can drive sufferers to suicide. 

There can, apparently, be interactions between oral steroids and homeopathy too. "the patient's symptoms tend to be masked, however, making an accurate choice of remedy much more difficult", we are told on page 205 of Homeopathic Pharmacy. Well, you could call it a masking of symptoms, or you could- as I prefer, refer to it as "working". So what is the average homeopath to do then, when presented with a patient who is taking steroids but seeking their help? It would seem that the obvious (but sadly not the ethical) solution would be to ask them to discontinue their steroids so that that the symptoms are "unmasked". This will obviously lead to an increase in symptoms for the patient, and lead to unnecessary suffering, but it can also precipitate acute adrenocortical insufficiency, which can in the worst case scenario be fatal. Patients should "ideally" discontinue their steroids for 6 weeks prior to initiating a homeopathic remedy- this is more than enough time to result in loss of control in their condition. 

It's not just drugs themselves that can be a problem, but the excipients (inactive ingredients used in the formulation of a medicine) too. Strong flavours used in syrups, for example. This could potentially discourage patients to take- or to give their child- antibiotic syrups, with the potential to worsen or prolong a patient's condition.

Can foodstuffs interact with homeopathic medicines? 
Yes, apparently so, though again there is no hard study evidence for this- why would there be, when there's no good hard study evidence that homeopathy works in the first place? Coffee, tea, cocoa, chocolate, and spicy foods are all to be avoided. Aside from being unnecessarily restrictive, and potentially causing a patient anxiety, this idea fills me with horror. Imagine a life without tea, chocolate, or spicy foods. I rely on all of these three things to get me through my daily life, and would inevitably become depressed if I had to avoid any of them.

Can homeopathy interact with homeopathy?
I know, right? What a bizarre question, given that homeopathic remedies are sugar with specially shaken water sprinkled on. Can sugar interact with sugar? Well it seems that someone has decided that they can, based on a grand total of no evidence. Aromatic preparations, such as camphor, menthol, and peppermint, are supposed to inactivate other homeopathic medicines. Remember, though, that homeopathic camphor, menthol  or peppermint is highly unlikely to actually contain any molecules of camphor, menthol or peppermint, and we're left in a bit of a ridiculous situation based on nothing at all.

It would seem that homeopaths utilize certain foods or remedies as "antidotes". Apparently, if a remedy isn't working, and they want to try something else, they might ask a patient to drink a cup of coffee, or take a remedy like camphor to "wash out" the previous remedy so that they can start again. I'll refer you again to "Homopathic Pharmacy"- with a reminder that this is one of the more reasonable texts:

"It is certainly not dangerous in life-threatening terms, but used injudiciously will interfere with the vibrational pattern of the vital force.
Vital force, vibrational energy, sugar as an antidote to sugar, and none of it- not a scrap- based on science, evidence, or even basic logic.

See you again soon for the next episode :)


Homeopathic Harms Vol 4: OK, there's SOME evidence

This post is a taster of the the next in our series of blogposts following on from our SITP talk about the harms of homeopathy It's written by the marvellous @Skanky_fish

You can find the full blog post over at her blog, Evidence-Based Skepticism

Last time I discussed the problem of missing evidence of harm in homeopathy trials and consequently in systematic reviews.  This time, I’m going to discuss some evidence of harm that we DO have. Sadly, it’s not comforting.
In December 2012, a systematic review of the adverse effects of homeopathy was published in the International Journal of Clinical Practice (aside: for a quick explanation of systematic reviews and adverse effects, take a look at volume 2 in this blog series).  The authors of this review searched five databases of medical literature totalling nearly 50 million published trials (though likely with considerable overlap), and found just 38 articles that discussed case reports and case series of adverse events with homeopathy.

Wednesday, 27 March 2013

Homeopathic Harms Vol 3: Poor Advice

And so begins the third installment in our Homeopathic Harms series, a collaboration between myself and @Skanky_Fish of the Evidence Based Skepticism blog. For this post, I have my lovely, wonderful friend @shandymarbles to thank for the idea and the action. 

Indirect harms due to homeopathy can, as we're trying to cover in these posts, come in various different guises. In my opinion, there is none more dangerous than this: poor advice from homeopathic practitioners. 

To set yourself up as a homeopath in the UK, you don't need any medical background. You also don't need to register with any regulatory bodies or undergo any standardized training. Medical homeopaths, i.e. doctors who practice it on the side, are of course regulated by the GMC, but your common or garden variety homeopaths could basically be anyone.

And yet, they claim to practice medicine and give advice on your health. Scary stuff, in my eyes. And I can give you a specific example of how harmful this can be, because one of my good friends contacted a UK homeopath recently. This homeopath is, as is proudly declared on his website, an engineer by trade.

Under the pseudonym Stacey Slater (which apparently didn't appear to ring any alarm bells with the homeopath in question), my friend asked for help in treating bipolar disorder. She said she had stopped taking the medication prescribed for it because she was getting horrible side effects, and asked if there was anyway that homeopathic treatments could help her stay stable and avoid psychosis. There are a few things to note here: the question was very specifically asking if homeopathy could be used instead of conventional medicines, and was asking about avoiding psychosis- we're talking about serious symptoms here, not a vague sort of "could it help with me feeling a bit down" sort of question. The description of "horrible side effects" would immediately ring alarm bells to me- what sort of side effects, and how is she feeling at that time.

Here's the response I would have liked to have seen in a dream world filled with responsible homeopaths (actually, in my dream world there would be no homeopaths at all, but you know what I mean):

"Dear Stacey,
Thank you for your enquiry. I'm sorry that you've stopped talking your medication for bipolar disorder, and would like to advise you in the first place to speak to your GP first of all about the side effects you have been experiencing. You should also discuss with them your decision to discontinue your medicines, as stopping them suddenly may cause your symptoms to worsen.
Homeopathy may be a useful option to help treat some of your symptoms. However, I wouldn't recommend that it is used instead of your usual medicines, unless this is done with the agreement of your medical team. Once you have spoken to them, please do contact me again and I will be happy to discuss any homeopathic treatment with you then."

This response covers all bases. It makes sure that the primary outcome of patient safety is covered by referring them to their own healthcare provider, however its also helpful and leaves open the possibility of some homeopathic treatment as an adjunctive, complementary treatment. It does not suggest that homeopathy can be used instead of her usual medication.

Here, however, is the real-life response:

Dear Stacey Slater,
Yes I am happy to help you for your Bipolar Disorder and will try to restore your previous health. 
Recently, my grandmother has been treated for her 15 years long Bipolar disorder with only two weeks of homeopathic treatment. Now, my father-in law (Himself Medical Practishner) says she is 100% okay with homeopathic remedy and need not take any other medications.
To help you, I need some more information, like; your physical, mental and spiritual condition.
1. Any skin diseases are you suffering from?
2. Do you have problem of thyroid dysfunction? hyper or hypo?
3. Diabetes?
4.High or low blood pressure?
5. Since how long are you suffering from Bipolar disorder?
6. Your family history, if any one in your blood relation have tuberculosis, diabetes, cancer or high blood pressure?
7. Your liking and disliking? Food,Drink, time and weather
8. Your family life, etc..
Your detail will help me to prescribe best remedy.
Looking forward to your reply,"
There are a few things to note here, as I'm sure you can tell. This homeopath claims that they will "try to restore to previous health"- in other words, he is offering a cure to bipolar disorder. We've got some anecdotes in there, in lieu of actual clinical evidence, and an extraordinary claim that longstanding bipolar disorder can be cured with only two weeks of magic woo water therapy. Now, given that bipolar is, by its very nature (and name!) a relapsing-remitting disease of two extremes, there is no way that an anecdote could be used as evidence of successful treatment. Who’s to say his grandmother wasn't just going through a good period that just happened to coincide with taking a couple of week’s worth of homeopathic medicines. How do we know she wasn't using effective conventional medicines at the same time? Who's to say she even exists? I can't help but wonder about his grandmother's right to confidentiality as well- has she given consent to be used as an anecdote in his consultations with other patients?

Who is this father-in-law mentioned? If he is so happy with the treatment, why isn't he happy to be named, and why is he even commenting on the grandmother's treatment? What relevance does this have to this homeopath's practice? The advice given that she "need not take any other medications" is a clear indication that this homeopath thinks that the homeopathy he advises can be used to "cure" bipolar disorder on its own, as an alternative to conventional medicine. By trying to make it seem like the advice has come from an actual medical practitioner, the homeopath is clearly trying to give this advice more credibility.

Lets have a think about the consequences of this advice: Our Stacey Slater is reassured that she doesn't have to continue on with her conventional medicines. She responds to the email above, goes on to have a consultation with the homeopath online (which costs £50 by the way- we're not talking pennies here. £50 for an email exchange!) She slips into psychosis, or mania, or a deep, deep depression. Eventually, she can't take anymore and she commits suicide. This homeopath has directly contributed to her death by not advising that she sees her medical team before discontinuing her medicines, and by claiming that she can be cured by inert sugar pills instead of continuing on with effective, evidence-based medication

The problem is, we can't gather robust evidence on this sort of thing, as it would be too unethical to do good, clinical studies. Maybe Stacey hasn't mentioned to anyone that she stopped taking her medicines and she was under the "care" of a homeopath- how would anyone know that the death was caused by him? And even if they did know, they're probably too upset and shocked at that point in time to think about raising a complaint. Who would write up a case report to publish in the medical literature? Certainly not the homeopath in question, he's not going to incriminate himself, and her medical team have probably had little contact with her since she's been advised not to bother with them anymore. And so homeopaths can continue to claim that their treatment is "safe", because we just don't know the scale of these sorts of cases. 

The only bright side here is that, of course, my friend will most definitely not be taking this shoddy advice. She's well aware that homeopathy is a whole load of nonsense and just contacted this guy to see what the response would be. However, we have to wonder how many other emails he's getting, from people who are genuinely seeking help. And we have to wonder what's happening to them, and whether they are safe.As an interesting, and rather creepy, aside the homeopath started following my friend on Google plus and Twitter a couple of hours after responding to her. This is at best weird and unprofessional, and at worst, really quite frightening. I can't think of any healthcare professionals who would do such a thing, just randomly looking up a patient on social media and then following them after one consultation- what about confidentiality? 

Tuesday, 26 March 2013

Homeopathic Harms Vol 2: Where's The Evidence?

Here's the next in our series of blogposts following on from our SITP talk about the harms of homeopathy. This is a guest post written by the marvellous @Skanky_fish of Evidence-Based Skepticism fame. Now, I'm going to be a bit bossy here and insist that, if you haven't already bookmarked her blog, you do so right this minute. Future blogposts in this series will just be posted on our respective blogs, but we'll be sure to post links to all of them so you don't miss any installments. so, without further ado, I shall hand you over to Nancy:
We often harp on about the evidence for homeopathy working or otherwise, and I’m not going to touch on that here, because it’s been covered beautifully by many more eloquent writers than me.  What you don’t often see though, is comment on the evidence for homeopathy doing harm.  In the last post in this series the lovely @SparkleWildfire touched on medicalisation, an indirect harm that’s very real but tough to quantify; but what about direct harms?  I’m glad you asked…

In conventional medicine, randomised controlled trials are the best kind of study we can do of a drug to see if it works and if it it’s safe.  What maybe doesn’t mentioned quite so often is that there’s an even *better* form of evidence – the systematic review.  These are produced when someone sits down to do the very tough but remarkably important job of finding every single scrap of evidence they can on a given topic, and pooling it all together to try and get closer to the definitive answer.  The result is a document that represents the best evidence possible for how well a drug (or anything else, for that matter) works, and how safe it is.

One of the biggest and most respected sources of these systematic reviews is the Cochrane Collaboration, who cover all areas of medicine.  Happily, they also have a few reviews related to homeopathy, and that seems as good a place to start as any.  The most recently published is:

Homeopathic Oscillococcinum® for preventing and treating influenza and influenza-like illness

The authors searched multiple databases of medical literature, covering a time period dating back to the mid-60s and all the way up until August 2012.  That’s a lot of literature.  Out of all the results they found six randomised, placebo-controlled trials of Oscillococcinum that were similar enough to be directly compared.  Since we’re not really interested in efficacy in this review, I’ll skip straight to the safety part: out of these six trials, including a total 1,523 people, there was one reported adverse event.  One. It happened to be a headache. Let’s stop and think about that for a moment.

A good quality randomised controlled trial collects every single adverse event that happens to every single patient.  And the use of the term “adverse event” is very deliberate, because it includes absolutely everything unexpected and unwelcome that happens (and here’s the key part) whether or not it’s likely to be related to taking the drug.  That might sound counter-intuitive, but the reason is simple – we want to pick up every possible side effect of drugs, and sometimes side effects are…weird.  So it might sound odd to include as an adverse event that someone got hit by a bus, but what if the drug they were taking made them dizzy, or confused, or clumsy?  It’s not unreasonable to suggest that any one of those things could end up in getting you involved in a traffic accident.  So every single little thing is recorded, and once the trials is over you do some sums to work out the key question – are these things *more likely to happen in the people who took the drug*? If 20 people broke a leg but they were equally spread out among the trial groups then nothing further needs to be said; if 19 of them were on the drug being studied then there might be something to worry about.  The flip side of that of course is that if 19 were in the placebo group, you might want to wonder if the drug is (perhaps unintentionally) promoting better balance and co-ordination, for example (or if everyone in the placebo group was a keen but inept snowboarder).

Is that one single adverse event out of over 1,500 people taking Oscillococcinum starting to look fishy yet?  What about if I drop in the snippet that some of the people involved (327, to be precise) took the remedy every day for four weeks, to see if it stopped them from getting flu in the first place?  How many times in four weeks would an average, healthy person experience something that you could call an adverse event – a headache, a tummy upset, indigestion, a strained ankle, a touch of insomnia?  I’ve had three of those things in the last 24 hours, and I wouldn’t say I’m a particularly remarkable individual.
So hopefully you can see from this that there’s simply a huge, yawning hole in the evidence about safety in homeopathy.  There are ways and means to address this (though they’re far from perfect), and I’ll address one of those in my next post in this series.

Wednesday, 20 March 2013

Vicks, feet, and a whole load of nonsense.

And so it was that I ventured onto Facebook last night, for the first time in a while. And what I discovered there was an intriguing post about putting Vicks Vaporub on your feet to cure a cough.

A very quick google search suggests this is a long-standing bit of nonsense that's been doing the rounds with pretty much exactly the same wording for years. I thought it might be worth revisiting. so, here it is in its entirety, with my skeptical, critical thinking thoughts inserted in blue. I guess its a bit of an example about how to think about claims that appear at first glance to be too good to be true:

"Some of us have used Vicks Vaporub for years for everything from chapped lips to sore toes and many body parts in between. <Wait, What? Who uses Vicks Vaporub for chapped lips? I've never heard of anyone do this, ever. Firstly, it would sting lots, and secondly it could potentially be highly toxic, given its essential oil content, and aspiration risk when swallowed due to petroleum. I wouldn't put the stuff anywhere near my mouth.> But I’ve never heard of this. And don’t laugh, it works 100% of the time <100% of the time? Nothing in medicine works 100% of the time, so alarm bells are ringing loudly, unless this is the single most important medical discovery that's ever happenee, ever.>, although the scientists who discovered it aren’t sure why. <what scientists?>

To stop night time coughing in a child (or adult as we found out personally), put Vicks Vaporub generously on the bottom of the feet at bedtime, then cover with socks. <Feet seem to be a favourite of the quackery world, what with detox patches, reflexology and all that sort of thing. Alarm bells are a lot louder already. Why would Vicks be particularly effective on your feet? Is this as compared to any other parts of your body, or compared to nothing at all? Wouldn't it sting, and could it have potential to cause sensitisation in the area? Where is the prior plausibility here?>  Even persistent, heavy, deep coughing will stop in about 5 minutes and stay stopped for many, many hours of relief. <A coughing fit usually does stop after a few minutes of its own accord regardless of treatment. If it doesn't, and you're coughing constantly for more than 5 minutes, you probably need to be checked out by a doctor.> Works 100% of the time and is more effective in children than even very strong prescription cough medicines. <There are very few prescription cough medicines, on account of the fact that most preparations for cough don't really work anyway.Again, this 100% of the time claim is quite extraordinary and would require major clinical evidence to back it up.> In addition it is extremely soothing and comforting and they will sleep soundly. <Is the stinging, cold sensation you get with menthol really soothing?>

Just happened to tune in A.M. Radio and picked up this guy talking about why cough medicines in kids often do more harm than good, due to the chemical makeup of these strong drugs so, I listened. <What guy? What radio station? What are you on about? The only medicines now available for coughs in children OTC in the UK are glycerol and simple linctus paed- basically, sugary water. No "strong drugs here".> It was a surprise finding and found to be more effective than prescribed medicines for children at bedtime, in addition to have a soothing and calming effect on sick children who then went on to sleep soundly. <Where is this finding published? What sort of a study was it and how was it designed? How many participants were there? Was there a control group, or a comparator group and if so, what was the comparator? As it happens, none of these questions really matter given the studies themselves don't actually exist>

My wife tried it on herself when she had a very deep constant and persistent cough a few weeks ago and it worked 100%! <anecdote. It worked 100%, but in one person? This doesn't even make sense.> She said that it felt like a warm blanket had enveloped her, coughing stopped in a few minutes and believe me, this was a deep, (incredibly annoying!) every few seconds uncontrollable cough, and she slept cough-free for hours every night that she used it. <I'd imagine it would actually just feel like you had some oily gunk on your feet that would sting a little bit and feel cold. Who is this wife, and why should we believe this anecdote from an anonymous person? There's no way to remove regression to the mean as an explanation to this, but by now I'm suspecting this wife with a cough is mainly mythical>

If you have grandchildren, pass this on. <so presumably you don't need to bother if you're simply a parent, only if you're a grandparent?> If you end up sick, try it yourself and you will be absolutely amazed at how it works! <Actually, I suspect I'll just feel a bit silly. And will have minty-smelling feet>"

So of course I have done a search for the evidence and claims included in the post and have found a grand total of Nothing At All. I will say this though: If I was the manufacturer of Vicks, and someone had done some studies which found my product to be 100% effective, I would sing it loudly from every rooftop I could find. I would be the manufacturer of The Number One Most Effective Medical Product In The World Ever, and I would make sure that I made my millions on the back of that fact, as well as collecting my Nobel prize for Medicine and probably world peace as well. What I probably wouldn't do is ignore the claims, and continue on selling my product and advising that its used in a way which has a less than 100% chance of it working.

Direct harms from following this advice could include dermatitis and skin reactions. Indirect harms? Well, you've slathered some slippery, oily unguent onto the bottom of your feet. When you take your socks off, you may be slip-sliding all over the place.

The moral of the story is:Very rarely should you believe anything posted on Facebook. Unless its me, posting a link to my blog, of course.


UPDATE: I get a LOT of hits on this blog because of this post. If you've stumbled across it, i would love to know whether it has had any impact on what you thought about whether putting Vicks on your Feet would work, so please do leave a comment or drop me an e-mail.

Monday, 18 March 2013

The troubled life of a community pharmacist: Emergency Supplies

I've spoken a little bit about the sort of conditions I've come across in the community pharmacy setting. Today I want to talk about one specific issue which affects community pharmacists time and time again: the emergency supply.

Having worked for many years in community, I have definitely experienced a large amount of anti-pharmacist opinion. I can understand where it comes from: it's a very weird setting for a professional service, in a shop. Patients tend to build up a relationship with their GP, and the very setting of a surgery, with its closed-off rooms and offices free from distractions lends itself more to a professional image. There's a public perception that because pharmacist work in a shop, they're less important, less professional. This is a real shame, and often not the case. I suspect that many members of the public don't even realize that pharmacy is considered a profession: anecdotally I know of occasions where people with no qualifications have applied for pharmacist jobs and have been surprised to learn that you actually need a 4 year masters degree plus one year pre-registration training. It's a great shame that, in the eyes of many members of the public, we are nothing but glorified checkout operators. People are used to a "The Customer Is Always Right" attitude, but unfortunately in pharmacy, which is governed by specific laws that make it different from other retail situations, this isn't always the case.

It seems to me that this often leads to an assumption that where things go wrong with medicines supply, it's always the pharmacist's fault. We are the faces across the counter from you telling you that for whatever reason, you can't have your medicines. We are therefore the obvious target for the complaints, the "well if I die its all your fault!" statements which we hear regularly. But is this fair?

Let's imagine its a Saturday morning. You go to your local pharmacy to pick up your repeat prescription which the pharmacy picks up from your surgery for you, and its not there. Lets consider what might have gone wrong here:

1. The pharmacy has picked up the prescription and lost it. Rare, but it does happen. Most pharmacies/ surgeries will have records of what's been picked up though so its usually easy to find out if it is in the pharmacy or not. In this case, its fairly obvious that the pharmacy is at fault. The solution to this is also pretty obvious: you hunt high and low around the pharmacy until you find it.

2. The prescription is still at the surgery. Either it's been put in the wrong box for collection (a really easy mistake to make, used to happen at the surgery local to my pharmacy loads) or it hasn't been issued in time for the weekend. It might be that there is a query on the prescription or similar, so it hasn't been issued for a reason. However, its Saturday morning and the surgery is closed, so there is no way for the pharmacist to know why the prescription hasn't arrived in the pharmacy, only that it isn't there. In this case, it would be the surgery who is at fault as they've failed to ensure the patient's prescription arrives at the pharmacy ready for them to pick up.

3. The patient hasn't ordered the prescription in time for it to be ready for the Friday evening collection. Most surgeries will take 48 hours or so to process a prescription, and depending on the pharmacy you might have to add another 24 hours on to make sure it's dispensed. If the patient hasn't ordered their prescription on time, there's a good likelihood that it wont be ready at the surgery for the pharmacy to pick up.

Now don't get me wrong, option 1 definitely does happen, but in my experience the vast majority of cases are because of options 2 or 3. The pharmacy often doesn't know whether to expect a prescription for a particular person, so without telepathy is unable to do anything about it when the surgery is still open, on sometimes a prescription hasn't been issued because a patient is overdue a review, or there's been a change in their therapy, or just because of a genuine mistake.

With some patients none of this matters. It doesn't matter how much you explain to the patient that it still seems to be at the surgery, or that if they've ordered their prescription on Thursday and it takes 48 working hours for the surgery to process it, in their eyes you're still the one to blame. It's common to have patients shout at you that if they die because they haven't gotten their medicines, it'll still all be your fault. There are a combination of reasons for this: a mistrust of pharmacists, a belief that GPs can do no wrong so it *must* be your fault, distress that a patient will be without their medicines, and most of all the fact that you're there stood in front of them in a retail setting, so they vent. This might sound a bit over the top but it really does happen all the time. I've been shouted at, sworn at, and and had things thrown at me over the counter on an alarmingly regular basis in these kind of situations. And because I'm a professional, and I believe in good customer service, I stand there and respond politely, and do my best to try to resolve the situation, whilst all the time I'm thinking "hang on a second here, this isn't actually my fault, yet I'm the one getting shouted at."

So anyway, back to our Saturday morning situation. You've ran out of  your meds and the prescription isn't there for whatever reason. So what can the pharmacist do about it? Well, there is provision for pharmacists to provide an emergency supply of a prescription only medicine to cover just such scenarios. This involves us essentially selling a prescription only medicine without a prescription. It's legal, provided we are able to justify the sale in accordance with the law. It's worth remembering that the worst case scenario for a pharmacist is that you can be done for manslaughter, so every pharmacist sort of learns to constantly think to ourselves "will this harm the patient?" and "Could I justify this in court?" So there are a couple of things that the pharmacist will be considering in the case described:

1. It must be an emergency situation: so it needs to be a situation where harm would be caused if the drugs were missed. The definition of this might vary from pharmacist to pharmacist: some might not supply an emergency supply of the contraceptive pill for example, because there's a perfectly suitable alternative available in the guise of condoms. That's fine, and its at their discretion. I tend not to do emergency supplies for statins, because missing a couple of days of a statin is highly unlikely to cause such an enormous raise in cholesterol levels that the patient has a heart attack. However a patient missing a few days of an anti-epileptic medication can mean that they get rebound seizures, which could go on to have a huge impact on their lives.

2. The patient can't obtain a prescription within a reasonable time: If the surgery is open, then we really shouldn't be doing emergency supplies. It's worth noting that "reasonable" does not always mean convenient to the patient, but we would be unable to justify an emergency supply if a prescription can be obtained in a reasonable timeframe. If a surgery is closed for the weekend, this is exactly the sort of situation an emergency supply is handy for, but do remember that there is always out of hours doctors or hospitals that could potentially supply a prescription.

3. The pharmacist needs to be pretty sure that it is a patient's regular medication. This is fine if you're a regular at that pharmacy, but can be terrifying if you don't know what the patient is on. I've had patients asked for their "epilepsy tablets, you know the ones that are purple" or "the blue blood pressure tablets" or something suitably vague. If I gave the wrong thing, and the patient was harmed, it would be me in the dock and me who would never be able to live with the guilt.

4. How much should we supply? The guidance used to state a maximum of three days supply in most cases. That's usually more than enough to wait until the surgery reopens to sort out an emergency prescription. This has now been changed to a maximum of 30 days, but it is important to realize why this guidance was changed. It was increased pre-emptively a few years ago when we were waiting for the bird flu pandemic to hit. The theory was that surgeries might have been overwhelmed or closed (due to the fact that everyone was dead from the flu!) so this would allow pharmacists to have some more leeway to provide medicines in that very specialized scenario. It's therefore difficult to routinely justify giving out 30 days supply when in most cases a prescription could reasonably (even if not conveniently) be obtained within a few days.

5. Pharmacists are able to charge for emergency supplies. If nothing else, it's a right faff to do, and it can take a while to dispense. But from a business perspective, if we didn't charge we're giving  away medicines for free with no guarantee of reimbursement. Think about it: you wouldn't expect that from any other retail situation. You wouldn't expect Tesco to just give you your weekly shop for free if you offer to pay for it later on in the week. Most places will be happy to reimburse the charge on presentation of a prescription, so its usually not too onerous. Again, its at the discretion of the pharmacist whether or not to charge. I remember a particularly aggressive patient who was very upset about how urgently he needed his cream for his skin condition that he hadn't gotten round to ordering. "It'll be YOUR fault when my skin flares up!" he was saying. "YOUR FAULT! I need it URGENTLY!". I explained that I would do an emergency supply for him so he wouldn't be without his cream. For some reason I can't quite fathom, he decided his skin wasn't actually that bad when he found out it would cost him over £65 for the cream. "Oh, it doesn't matter, it ummm, it feels a bit better now" he said, and shambled off.  

There are other laws and considerations that also need to be taken into account. but here's my overall point: The next time something goes wrong with your medicine supply, consider the fact that your pharmacist will and should do everything they can to help you, but they are bound by law and guidance and they need to be able to justify their supply. Sometimes, just sometimes, its not all their fault, and whilst I understand that pharmacists are visible and at the end of the line, so they might seem like the appropriate people to shout at, that isn't always the case. Pharmacies should have robust measures in place to ensure continuity of supply: not feeding back to the surgery if there is a recurring issue with their measures means they don't know to strengthen them. It sounds petty, but having to constantly hear customers who you do your best for assuming that something is your fault is wearing. It chips away at your professional pride and I know there have been times when I think "seriously, why do I bother?".

Pharmacists have feelings too. Some of them, anyway. Something as small as just saying "I know its not your fault but..." can be enough to make your day. 


Update: I am sorry if this post sounds a bit whingy. However I do think that there is a tradition in pharmacy (and probably many other areas of health care) of just sucking it up, and keeping quiet.  I think its useful to explain the kind of thought processes we go through so people can understand the often difficult position we are in.

And Another Update: Guys, I'm bowled over by you lot. This post has started a bit of a discussion on twitter which shows just how proactive we pharmacists can be once we start talking. There is talk of organising a pilot to see about reporting emergency supplies as systems failures to highlight where the problems lie and attempt to resolve them. This just proves to me that there are some really brilliant pharmacists out there, and that given the time, resources, and opportunities to be proactive, we can really make a difference. Do get in touch if you have any ideas or thoughts- leave a comment, email me, or tweet me @SparkleWildfire

Thursday, 14 March 2013

Homeopathic Harms Vol 1: Medicalisation

In February 2013, my friend Nancy and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we've decided to write a series of blog posts about a number of points we covered in the talk. Here is the first:  

Doctor's appointments: often you feel like you're in and out before you know it, and they can't get you out the door quick enough. They have a target number of minutes to spend with each patient, and sometimes you can feel like they don't have as much time as you'd like to discuss all the things you want to with them.

There is, then, one aspect of homeopathic practice which can be superior to that of conventional medicine: the consultation. A homeopath might spend an hour or more assessing each individual, not just asking about particular symptoms but about their personality as well, how they think and feel about the world. I've never been to see a homeopath, but I'd imagine this is really valuable to a patient, particularly those with minor mental health complaints. I know myself that when I've been to see a good GP who I feel has really listened to me, I leave feeling a bit better already.

I suspect that the consultation itself may be part of what provides benefit to patients, rather than the sugar pills that are given out at the end of it. I'm not aware of any evidence that compared individualised homeopathic treatment to the OTC stuff though, which would be the only way to tease out and quantify any benefit from the consultation.

So what's the problem here? If a consultation with someone who appears to listen to you and care makes you feel better, where's the harm in that? The sort of subtle, indirect harms that we'll be discussing in this series of posts are often theoretical and would be very, very difficult to assess via hard, clinical evidence, so you'll have to bear with me while I discuss them with you and see if they make sense at the end of it. Consider the following story:

Imagine I'm quite an anxious person (in actual fact I am, so it doesn't take that much imagining to those who know me). Imagine I'm particularly anxious at the moment because I maybe have a public speaking event (something like Skeptics In The Pub, say!) to deliver in a few week's time. I might be finding it hard to sleep, I find I'm worrying about it quite often, and getting some physical symptoms- my heart is beating quite fast at times, say, and my stomach hurts at times, but it's nothing too serious.

I go to visit a homeopath (admittedly, this would be an unlikely thing to do if I was actually talking about myself) who takes time to discuss with me my problems. I get on well with them, and feel like they are really listening to me. During the discussion, I find that vocalising my anxieties helps me to rationalise them and my fears are allayed somewhat. Just the act of talking about it makes me feel better- in other words, the homeopath is delivering a talking therapy service to me. By the end of the consultation, I'm already feeling more in control of my anxieties, yet I'm still given some tablets to take home, and I dutifully follow the instructions I'm given.

As I've discussed elsewhere, there is a stigma about mental health issues. This also, unfortunately, extends to talking therapies too. Its quite likely that some people would be happier to declare "I'm seeing a homeopath" than "I'm seeing a counsellor" in front of their friends or acquaintances. The handing over of the sugar pills at the end of the consultation will no doubt suggest the talking bit is more "justified", and they can convince themselves that they're not mad, or the sort of weak person who would have to resort to a talking therapy. And thus, the stigma is reinforced. Talking therapies shouldn't be something to be ashamed of. You don't need some inert sugar pills to justify and hide the fact that, now and then, you just need to be able to talk to someone about your problems or feelings.

There are wider issues with this kind of thing too. The visit to the homeopath has made me feel better. I've been to see someone, left with some pills in my hand, and I've improved, reinforcing the fact that I feel better when given something to take. Let's say that in the next few months, I feel a bit rubbish because I've had a bit of a cold and I'm left with a cough that's been there for a couple of weeks. I go to see my Dr, who tells me that my chest is clear, and the cough should clear up of its own accord. However, I've expected to get something out of the visit- I don't want to leave the surgery with no pills in my hand, as I know that last time I left a consultation about my health I was given pills at the end of it and I felt better. It's left to the Dr to explain to me that I don't need antibiotics, and this can be a notoriously difficult thing to do. Some Drs might relent and give me a prescription for an antibiotic, contributing to the catastrophic situation we're in now with antibiotic resistance. If the Dr doesn't give me a prescription, I'm left with a bad taste in my mouth and a bit of mistrust in the conventional health care system. 'Next time I'm feeling ill', I think, 'I'll go back to that homeopath. They take me seriously because they gave me pills'.

And so the cycle goes on.... 

H Jo

Monday, 11 March 2013

Firewalk With Me: Science, Religion, and some very, very hot coals.

Firewalking is, to be honest, great fun. I did it last year and I shall again be strutting over burning embers in a few week's time, to raise money for The Stroke Association, for which I would be very, very grateful if you were to throw your spare pennies in my direction.
The sight that greeted me on arrival at last year's Firewalk. Gulp.
I also find it really, really interesting as its a ritual in which science and religion jostle with each other for attention and its easy to forget your rationality as you hope for something to protect your tootsies from becoming mere charred stumps.

Yours truly shambles along on coals which were 540 degrees Celsius.
I remember from last time that we were told in the pre-firewalk training that you needed the following three things to be able to firewalk successfully:

1. Fire connection- you have to know that it is a real-life fire, not a trick, and that it is going to be really, very hot. We were encouraged to go and hold our hands above the coals so that we knew that it was hot before walking. Apparently, if you tell yourself it's not hot, it just doesn't work.

2. A belief in a theory. You need to have some faith that it works, and that you're not going to end up as barbecue fodder. 

3. Intention to walk. You need to stand at the start of the walk, and know and want to walk across the fire. Supposedly there have been studies done where they blindfolded experienced firewalkers and they were unable to do it unless they knew when they were stepping onto the fire.

Some people believe they're able to firewalk because of their aura and golden light coming from their heart chakras and that sort of thing. The evidence for this appears to be a couple of photos which I'd imagine could easily be explained by the fact that a) you're moving and b) you're walking on fire, usually in the dark so its pretty likely that there's going to be a bit of a glow on photos. 

Other people believe that it's God who allows them to firewalk, and indeed firewalking is an integral part of some religious rituals and is generally considered to be a very spiritual experience.
"They believe that the power of Saint Constantine—the religious power—allows them to do it and that that is a miracle," Source: National Geographic
 You'll hopefully know me well enough by now to know that I'm unlikely to go in for this as an explanation. Indeed I'd suspect that if there was a God in control of such matters there'd be even more likelihood of me getting toasted feet, and he's probably see to it that I got hit by lightning or something at the same time, just for good measure, to prove a point and to punish me for all my years of non-belief. Is there any evidence that this option is the truth? In short, no. 

So that leaves us with physics then. Now, it's been many years since I actually did any physics, and admittedly my physics teacher spent more time attempting to give electric shocks to a boy called Alistair than anything else, but I know enough to be pretty damn confident that out of all the options, this is the one that makes sense. It's all about conductivity- because coal and wood are pretty feeble conductors of heat, and because you're walking, there isn't enough time for the heat to transfer to your feet to cause any burning. The evidence for this? Well, lots. Sticking your hand in an oven is an oft-quoted example, and few people declare that to be a spiritual experience overseen by a God, do they? 

Here's the thing: does any of this actually matter? According to the guy who did our training last time, apparently not, as long as you believe that something will get you across safely, it doesn't really matter. If only such attitudes were employed in other aspects of life, one can't help but wonder how many lives would have been saved/made better. 

So does believing in science make firewalking a less impressive experience? Surely if you take out the belief in a protective spiritual presence it would lose its appeal, right? In truth, this couldn't be more wrong. It feels magical, and every bit as much like you are conquering the impossible as it must do for spiritual types. The fact that its caused by the physical characteristics of different types of matter doesn't make it any less transcendent, scary, or beautiful. 

Of course, having said all this it'll be just my luck that I'll end up in a burns unit after my next one. I hereby give you permission to laugh heartily if this is the case. 

I'll just leave this here again, just in case you want to lighten your wallets.... 


Sunday, 10 March 2013

The Young Atheist's Mixtape

Firstly, apologies to Alom Shaha for the title of this post. It was either that or "NOW! That's what I call Atheism Vol 1", which I couldn't quite bring myself to use. I will also always cling onto any opportunity to pretend to still be young.

High Fidelity by Nick Hornby is undoubtedly one of my favourite books. I have a very dog-eared copy which I have read many, many times, to the point where each time I re-read it I'm often surprised to find a line which I had assumed was actually my own thought, its so ingrained into my being. Yes, I'm the kind of person who cries at live and recorded music, and I'm one of the "people of a certain disposition (who) are frightened of being alone for the rest of their lives at twenty-six" (except for I had the same fear at much younger ages as well). Of course I've always wanted to be in a relationship with a musician so I can be mentioned in sleeve notes, and I have no idea what came first- the music or the misery, but I know that my love of music is probably responsible for my (now rather repressed) tendency to be hopelessly romantic.

So, when there was a bit of a conversation about atheist songs on Twitter this morning, it seemed the obvious thing to do to attempt a Barry-From-Championship-Vinyl-Style Desert-island, All-time Top five list of Songs for Atheists.

Of course I've failed miserably at this task: I've had so many suggestions that I can't bring myself to agonize over which should be cut, and in what order they should appear in. So instead, I give you a compilation, a mixtape of all your atheist suggestions.

"To me, making a tape is like writing a letter- there's a lot of erasing and rethinking and starting again... You've got ti kick off with a corker, to hold the attention... and then you've got to up it a notch, or cool it a notch, and you can't have white music and black music together, unless the white music sounds like black music, and you can't have two tracks by the same artist side by side, unless you've done the whole thing in pairs, and... oh there are loads of rules."

Argh, who am I kidding? If I were to be making a mixtape I'd also be here for days, also agonizing over what order it should go in. So Instead, I'm giving you a list in order of what tweeted suggestions were received when, and I will no doubt think of nothing else over the next few days when I can reshape it into a more acceptable mixtape format.  Alternatively, stick them on your generic fruit-based MP3 player device and press shuffle. That will save many hours of my life :) If  you've made any of the suggestions, do give me a shout with your reasons so I can add them in, and I'll obviously be happy to add anything else you lovely folk care to suggest too.

God's Song by John Martyn: It may be controversial, but I'm going for the John Martyn version, mainly because I love pretty much everything that he has done. He is indeed one of the artists who have made me cry seeing them live. I think his tone and voice are particularly suited to this song.

Don't Fear The Reaper: Any version really, I tend to lean towards the one by Caesars, just because.

This Must Be The Place by Talking Heads: I'm not entirely sure why, as its not particularly atheist-based, but it sprung into my head and I have found myself listening to it a lot. I guess I just think its about being grounded in this life, by love rather than any vague notion of an imaginary god. I could, of course, be completely wrong, but its probably a bit safer than trying to shoehorn Psycho Killer in somewhere instead, as that would really annoy the Christians ;) I guess I should throw Heaven in there somewhere too.

Churchhouse Blues by The Dodge Brothers: because why not throw in a bit of skiffle? And whilst I hate to see gin wasted, it would seem that burning church houses down with it could be seen as a worthy cause for many atheists.

God by John Lennon: as recommended by @deep_anchor

What If No-one's Watching? by Ani DiFranco: as recommended by Alom Shaha. It makes an appearance in his book and all, don't you know :)

I Don't Believe In You by Talk Talk: as suggested by @spiderkemp

Gone to Stay by Freakwater: as recommended by @kzelnio

Glory Hallelujah by Frank Turner: as recommended by @MarkRTurner and @jackpot73

Everything Alive Will Die Someday by George Hrab: as recommended by @RespectMyCrest

Intervention by Arcade Fire: as recommended by @RespectMyCrest

Blasphemous Rumours by Depeche Mode: as recommended by @RespectMyCrest

Eternal Life by Jeff Buckley: as recommended by @RespectMyCrest

Allow me to intervene again at this point to also put in Hallelujah, the Jeff Buckley version. And no, not just because I was-and probably am still- utterly in love with him, but that line:"And it's not a cry that you hear at night/ It's not somebody whose seen the light/ It's a cold and it's a broken hallelujah'... The way Jeff sings it has a devastating note of bitterness which...resonates. And yes, it is also about rude things which God would no doubt not approve of.

Wake Up by Arcade Fire: as recommended by @RespectMyCrest. by his own admission it may not be strictly atheist, but if I'm allowing myself This Must Be The Place, I'm allowing Joe his amazing songs also :)

No God, Only Religion by Spiritualized: as recommended by @astrotomato. Oh, and by the way, the pharmacy nerd in me loves Ladies And Gentlemen We Are Floating In Space. That album packaging was just fantastic.

On and On by Tom McRrae: as recommended by @RespectMyCrest

Imagine by John Lennon: as recommended by @helgestad, @kasilas and @deep_anchor. It's true, it needs to be in the list. But I can't help but hear our old friend Barry from Championship Vinyl scathingly declaring that it's simply too obvious. 

Thank God I'm An Atheist by Al Baker: as recommended by @jackpot73

I Will Follow You Into The Dark by Death Cab for Cutie: as recommended by @jackpot73

Enjoy Yourself by The Specials (or any other version you fancy): It occurs to me that this could be the quintessential atheist/humanist anthem.

Epitaph by King Crimson: as recommended by @rupagulab

I Could Build You a Tower by Get Cape, Wear Cape, Fly. People who know me well will know that I think GCWCF (is) are one of the most consistently perfect bands (person) around nowadays. I therefore nominate this song, which isn't entirely about atheism but does address the age old problem of evil, fundamentalism etc. It's also very beautiful, as is the whole of the album Searching For The Hows And Whys, which I think is as close to an entirely perfect album as I have found.

Dear God by XTC: as recommended by @PublicSerpentOz and @j2blather

God is a Spider by The Cherry Poppin Daddies: Not strictly an atheist song I guess, but one expressing a painful dissatisfaction with a god. Also: great band name for this sort of a list. And everyone needs more ska-swing-big band-punk in their lives.  

A Rational Response by Greydon Square: as recommended by Alom Shaha. Some welcome rap for our list. I must admit that despite a flirt with hip hop in my younger years I've never heard of Greydon Square, but a quick glance at his Wikipedia page suggests he's pretty interesting. And apparently he's also known as The Black Carl Sagan, so who could argue with that?

Had To Thank Someone For You by Nev Clay. Nev is a local folk singer who I first discovered when I was a teenager, and love his witty, beautiful music with a passion. I've just stumbled across this gorgeous little ditty and knew it was just perfect for this list- "but last night i knelt and prayed like a little kid again - i had to thank someone for you. and i don't know or care if anything was listening. i had to thank someone for you."

Atheist's Lament by Aidan Moffat  as recommended by @Jon Mendel. He's right, I'm not entirely sure how this has been left off the list for this long!

And clearly, no self-respecting atheist song list would be complete without a bit of Tim Minchin. As recommended by @obsolesence we're going with Ten Foot Cock and a Few Hundred Virgins and, of course The Pope Song.

So there we have it so far. Clearly, this is the sort of thing that I will lie awake at 3am thinking about ("OMG I need to put <insert obscure song> in, why didn't I think of that already, its so obvious. but not too obvious, obviously")

Saturday, 9 March 2013

The study of monsters: a perfect area for more critical thinking.

(Teratology: Noun: The scientific study of congenital abnormalities and abnormal formations. From the Greek teras [meaning monster or marvel] and logos [meaning study])

"Hands up, who is afraid of advising someone takes a medicine in pregnancy?"

In the couple of training sessions I've delivered, this has been my opening line. And many hands go up. I regularly give advice on medicines in pregnancy in my job, and it strikes me that it is an area which could hugely benefit from more critical thinking and a reliance on evidence in everyday medical practice. I'm thinking might do a little series of blog posts on this subject.

So why are so many people afraid of giving advice? One word: thalidomide. You'll all probably know what went wrong in the thalidomide disaster- a drug that was commonly used for morning sickness which unfortunately causes limb malformations when used at the time of pregnancy when women get morning sickness. That, coupled with the lack of post-marketing regulation ad monitoring back in those days- led to a perfect teratogenic storm, with obvious impacts for those affected, but which also shook the medical profession to its core. The good thing is that it forced a rethink in medicines regulation and triggered interest in pharmacovigilance, with schemes like pregnancy registries, teratology information services, and the MHRA's Yellow Card scheme being introduced in its wake. It's also left a lasting, deep-rooted fear of the potential of medicines to cause harm in pregnancy in pharmaceutical companies, patients and medical professionals alike.

Why is this fear a problem? Well, primarily because some pregnant women do still get ill, and do still need medical treatment. I've lost count of the number of times I've heard a doctor say to me "my patient has (insert life threatening disease) and she's found out she's pregnant, so I've stopped all of her meds. What harm will that have caused?" And my first response is "how is your patient?", along with having to try very hard to stop myself saying "what do you think is going to be more of a teratogen, whatever the drug is, or having a patient who is dead?!" Such decisions to stop treatments are often done without consulting any evidence first, and there is a clear potential for harm to patients and their pregnancies in such situations.

Another harm is that, in the event of something going wrong in a pregnancy, there's a tendency to way something to blame. I think it must be truly awful to have to think that because you have taken medicines, it's all your fault, especially as in many, many cases there will be no clear causality.

I think we can pretty safely say that, because of the things that have been put in place since thalidomide, that another similar disaster won't happen again. There are drugs which can undoubtedly cause harm in pregnancies but as with all things in medicine, we have to consider a benefit vs risk balance. And we have to take into account what evidence we have access to, think about its limitations, and apply it to each individual situation. Just stopping all medicines because a patient is pregnant is not going to be the least risky option in most cases (and indeed in all those aforementioned cases that I've discussed, the drugs the patient has been on have turned out to have some pretty reassuring data sets). I even know of a dr who panicked so much when he found out his patient was pregnant that he put a note through her door telling her to have an abortion because he had prescribe her some drugs which turned out to have a pretty robust safety record in pregnancy. Imagine the emotional harm this sort of thing could cause.

I don't want to end up writing a hugely long blog post so I'm going to end this one here as I'll cover some more aspects in future posts.

Thursday, 7 March 2013

What are the GPhC for?

Many years ago, just after I qualified, I was working in a new 100 hour pharmacy in a very well known supermarket chain.

To be honest, the working conditions were pretty terrible in that store. I had brilliant staff, but not enough of them. At the time, the policy of the supermarket for 100 hour pharmacies was to have no support staff there for the first hour and a half of the day, and the last two hours of the day. I argued tooth an nail against this, as we all know that pharmacists should ideally not self-check a prescription, no matter how quiet the pharmacy was between those times. The attitude of the company was that I was in the minority, and that I was complaining unnecessarily.

At this time I was the only permanent pharmacist working there: the rest of the time we were running on locums. The company policy was to ideally use their locum booking system, but this was notoriously unreliable. I found myself setting my alarm for 6 am every morning, getting up and getting ready to wait for a phone call to tell me I would have to go in because the locum hadn't turned up, even on my days off. I found myself doing 16 hour shifts, occasionally one after the other, and with 3.5 hours of that spent on my own.

Even without the horrendous attitudes from other managers in-store (the daily battles, the snide comments about how much I was getting paid, the total lack of understanding about pharmacy law, and the outright sexism), these conditions were brewing for a dispensing error.

The day it happened, I was working a 14 hour shift the day after working after a 16 hour shift. I was having to check a prescription whilst also being on the phone, because of the lack of staff. I checked that the drug, strength, directions etc were correct, but I didn't spot that the wrong name was on the label.

The patient rang up to check that the cream was the right one for them. We apologised profusely, offered to redispense, offered to go through our complaints procedure etc. the patient was happy with the reassurance that it was the right cream and refused the other measures, stating that she was quite happy that the situation was rectified.

Next thing I know, I'm being investigated by the then-regulator, the Royal Pharmaceutical Society of Great Britain. You can't even imagine what this did to me. I was an absolute mess, convinced that I was going to lose the career I had worked so hard for. I co-operated entirely with the investigation, just as I had with the patient. I informed the inspector of the working conditions and my fears that it would lead to something more serious. None of this was taken into account in the final report, which gave me a warning, and the fright of my life.

All this for a minor dispensing error, which caused no harm to anyone.

You'd think, then, that the current regulator, the General Pharmaceutical Council, would come down hard on any pharmacist who actually endangered patients willingly. You'd think they would take decisive action, particularly where a pharmacist has had similar previous warnings which they have chosen to ignore. You'd think this would especially be the case where the pharmacist in question had been caught out by a BBC journalist posing as a concerned mother wondering about whether her child should be protected against whooping cough, a disease which can - and does- kill people.

See where I'm going with this? I'm hearing reports that the GPhC are suggesting that the Ainsworth's pharmacy case is nothing to do with them, and that as homeopathy is regulated by the MHRA it isnt their area. If that's the case, why is Mr Pinkus and the premises even registered with them?

I'm really hoping that this isn't the case, and that the GPhC are actually going to take decisive action. After all, what sort of a message does it give out to the public if they aren't being protected from harm? What sort of a message does it give out to the pharmacists that do their bet every day, trying their hardest to be as accurate as possible in working conditions that are ill-designed for such a purpose?

Come on GPhC, be fair to the majority of your pharmacists who work according to your standards and actually do put patients first, and who do ensure that their recommendations are evidence-based and made with the best interests of the patient at heart. .


P.S. bacon. (Ignore this unless you are @aptaim)

Monday, 4 March 2013

Lets talk about death, baby

Yep, settle in, dear friends, and lets have a think about death. Specifically, assisted suicide.

This subject has come up quite a bit recently in the field of pharmacy and medicine. The PJ online are asking me to vote on whether or not I would refuse to dispense a prescription as part of an assisted suicide. The GMC is revisiting guidance to Drs. It's time to have a bit of a think about how we as pharmacists feel about playing a part in death.

There's a word which I think should be associated with death, and that word is dignity. People on the brink of death are still people, and I think in such discussions that fact is often forgotten,. We talk about our professional ethics, our religious choices, the impact it would have on us and our consciences, but I think we should talk-and think- more about the thoughts and needs of each dying patient.

We're all frightened of death of course. I've been lucky enough that I haven't had much experience of it so far, but I've had enough to have experienced the lack of control one feels when faced with the death of a loved one. And all the bizarre rituals, funerals, cremations, all of these things that we do are desperate attempts to claw some control and dignity back from the situation.

And so it is that I personally don't really need to think that much about this decision. I wouldn't hesitate to dispense medicines for assisted suicide, if it is going to give someone the dignity that they so richly deserve.

People who believe in a god may think this is a typical example of an immoral atheist wanting to go on a legal murder rampage, playing god and interfering with when someone's "time" is. But in actual fact i think it's more about caring for the person involved, giving them respect for the person they are-and were. We need to remember that they remain a person to the end- and so should be allowed the right to choose, right up until the end.

Hopefully that makes sense.

A tale of an excellent healthcare system

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

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

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

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

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

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

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

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