Salil B. Patel

Is dissection the only way to learn anatomy? Thoughts from students at a non-dissecting based medical school

Anatomical teaching has been centred around dissection for centuries. Generations of doctors have been initiated into the medical profession by cutting into their first cadavers. With the number of donor cadavers available decreasing and medical student numbers increasing, the emphasis placed on dissection has changed dramatically over the past 15 years. However, a solid appreciation of human anatomy is still a necessary part of understanding pathology and treatments. Therefore in light of these changes we ask, is dissection the only option? Or are there other options which students can undertake to develop anatomical knowledge?

The current state of the evidence for the use of drains in spinal surgery: systematic review

PurposeSearch for evidence pertaining to the effectiveness of drains used in spinal surgeries.MethodPubMed and EMBASE databases were searched for articles pertaining to the use of drains in all types of spinal surgery. The bibliographies of relevant studies were searched for additional papers that met the initial inclusion criteria. Level I and II studies were scored according to guidelines in the Cochrane Collaboration Back Review Group. We utilised the Population, Intervention, Comparison, Outcomes and Study design (PICOS) method to define our study eligibility criteria.ResultsNineteen papers were identified: four level I studies, eight level III studies and seven level IV studies. The four level I, involving the randomization of patients into ‘drain’ and ‘non-drain’ groups, identified a total of 363 patients. Seven of the eight level III retrospective studies concluded that the use of drains did not reduce complications. Two of the seven level IV studies agreed with this conclusion. The remaining five level IV studies reported the benefits of lumbar drainage following dural tears.ConclusionsThere is a paucity of published literature on the use of drains following spinal surgery. This is the first study to assess the evidence for the benefits of drains post-operatively in spinal surgery. The identified studies have shown that drains do not reduce the incidence of complications in anterior cervical discectomy and fusion, one and two level posterior cervical fusions, lumbar laminectomies, lumbar decompressions or discectomies and posterior spinal fusion for adolescent scoliosis. Further level I and II studies are needed.

Can the NHS learn from the rise and fall of ancient empires

The genetics of biology, quantum of physics and crux of consciousness are being unravelled by the eternal struggle against falsehoods we fancied calling Science. Such struggle does not exist naturally in the realm of politics. Truth-seekers battle against tides of misguided exaggeration and misplaced misguidance. British healthcare is in the throes of such misguidance. Consecutive governments nip and tuck at budgets, create taskforces and oversee new commissions while inevitably promising the public a loosely defined better NHS. Excellence, by its very nature, is contagious. The same is true for ignorance. When asked about the great cities of the past, public consensus would list the grandiosity of ancient Rome or London, bohemian Paris or revolutionary New York. Nevertheless, long before these western metropolises came to the fore, truly ancient cities were found in the Confucian swath of land we now call China. How, in a few centuries, did western empires – specifically Europe and North America – spring from nothingness to become the world’s superpowers? Niall Ferguson, an economic history professor at Harvard, argues that six factors alone are responsible for this tectonic switch from east to west. The scientific revolution, modern medicine, consumerism, capitalistic competition, the right to property and an unbridled work ethic are the cogs responsible for the creation of empires.

The difficulty in diagnosing X linked adrenoleucodystrophy and the importance of identifying cerebral involvement.

Two patients are described, a mother and son, who were initially clinically diagnosed with hereditary spastic paraparesis. This was rectified after very long chain fatty acid testing confirmed adrenomyeloneuropathy (AMN). The sons initial symptoms were characteristic of AMN (the commonest phenotype) but progressed to show symptoms of cerebral involvement. This evolution from non-cerebral to cerebral AMN is recognised in the medical literature and is increasingly important to consider in light of the availability of potential treatments such as haematopoietic stem cell transplantation.

Presentation of cauda equina syndrome during labour

Lumbar disc herniations are rare in pregnancy, with an incidence of 1:10 000. Less than 2% of these herniations result in cauda equina syndrome (CES). Diagnosing CES in pregnant patients can be difficult because changes in bladder and bowel habits are common in normal pregnancies. We present the case of a 29-year-old woman, with a history of lumbar radiculopathy, who presented at 39 weeks gestation with severe lower back and bilateral lower limb radiculopathy. Symptoms of CES began to develop only after the onset of labour. Diagnostic MRI was obtained following delivery and the patient was treated by microdiscectomy. Following surgery, bladder and bowel function began to normalise and at 3 months follow-up, she had made a full recovery. To the best of our knowledge, CES has never been reported to present during labour. This case highlights the diagnostic dilemma and need for a high index of suspicion.

Is the role of instinct important in medicine

‘I decided that it was not wisdom that enabled poets to write their poetry, but a kind of instinct’, wrote Socrates about this universally animalistic innate behaviour. However, does the instinct shown by artists during the process of creation transcend to the medical realm? Clinicians are practitioners of science, operating as a direct consequence of peer-reviewed data. If this is the case, how can we apply an attribute that does not take into account previous training or education? Instincts must be separated from reflexes, the later being defined as responses to stimuli without conscious thought. On the other hand, Darwin defined an instinct as being independent of experience, inherited and hence, unmalleable. Modern neuroscientists, such as Jean-Pierre Changeux, disagree and claim that our instincts are constantly being honed. The cerebral cortex is home to millions of uncommitted neurons that fuse when new memories are formed. However, the extent of fusion is not permanent but dependent on subsequent use and resultant reinforcement. If this is true, instinct is not based upon innate behavioural patterns but on previous experiences, which have been reinforced to such an extent that assumptions are made despite a lack of apparent logic. A similar school of thought is that proposed by Donald Hebb in 1949, whereby Hebb claimed that ‘neurons which fire together wire together’. Thus, instincts based on previous experiences would have the luxury of already being fused. This ‘Hebbian’ learning would in turn explain the choice of instinctive actions being favoured in high pressure situations. Additionally, multiple activations of neuron pairs would induce synaptic strength, arguably increasing the prevalence of that particular instinct. Atul Gawande, in his book Complications, writes about the role of instinct being essential when, as a surgical resident, he managed to differentiate between cellulitis and necrotising fasciitis. He admitted that as the symptoms of both inflammatory conditions looked identical at early stages, his instinct to pick the successful diagnosis ‘was not for logical reasons’. Instincts by definition are not inter-personal and thus, making the conscious decision to act upon or ignore one’s instinct must be done when taking into account the specific circumstances. No absolute rule can be applied to such unique scenarios. As a surgeon, for example, the decision tends to be more immediate due to the small window of opportunity available when operating. Nurses are asked to check patients’ routine observations at regular intervals. However, should they wake up patients in order to carry out tests? The two schools of thought argue about the benefits of sleep versus the importance of regular quantitative data showing progress (or a lack thereof). David Jones, an acute care nurse, argues that the role of instinct is integral when deciding whether to check often or to delay in favour of respite. Instincts are now moving from neuroscience textbooks to courtrooms in our increasingly compensatory culture. Legal cases such as Mueller v. Auker in the US show that instinctive decisions are not discriminated in court. In this case, a medical test was undertaken to aid diagnosis of a child. The parents were against the notion of the test and subsequently a detective, stationed at the hospital, temporarily removed the child from their custody. The court ruled that despite the parent’s trepidations, the doctors ‘clinical instinct’ to undertake the test, was of a higher priority due the instinct being a ‘wellrecognized and accepted feature of medical emergency practice’. The judge went on to say that due to the time pressure, the doctor’s decision need not have been a ‘perfect judgment’. Reference was made to Primiano v. Cook, a previous trial whereby similarly, doctoral instinct had been claimed by the defense. The judge quoted directly from a medical textbook and stated ‘despite the importance of evidence based medicine, much of medical decisionmaking relies on judgment—a process that is difficult to quantify or even to assess qualitatively’. A 2004 study tested the clinical instincts of staff at two children’s’ intensive care units in Boston, Massachusetts and Zurich, Switzerland. Clinicians were asked to predict the likelihood of bacterial infections occurring in each of the 347 patients. Predictions were updated daily until either the

Reason knows nothing: how biases infect medicine:

Doctors are not creatures of fact. Despite the medical profession striving for logical progression, a limiting factor is the orchestration by humans. We, as a species, are tainted by cognitive errors. Our decisions are influenced by a myriad of biases – both consciously and subconsciously tweaking everything we do. The names Amos Tversky and Daniel Kahneman may not be familiar to readers of the Journal of the Royal Society of Medicine. When asked to name medical pioneers – a modern day Osler, Jenner or Blackwell – the names of two Israeli-American psychologists do not immediately jump to mind. Tversky and Kahneman spent three decades focusing on judgement and decision-making under conditions of uncertainty. This started with simple, psychology experiments at Hebrew University in Jerusalem, cleverly cracking shells in our societal mirage of rationality. A culmination of this work resulted in the Nobel Prize for Economics, awarded to Kahneman in 2002. Medics make a constant stream of decisions tempered by uncertainty. Heuristics – the strategies by which we all form decisions – are fallible. One such example is the representative heuristic, whereby judgement is predicated on how much a novel situation/patient fits a known situation/patient. Physical representations of patients had a greater effect, when sorting patients into groups, compared with other factors such as known probabilities. For example, a study asked nurses to differentiate between scenarios suggesting a patient had a cardiac arrest or stroke. Additional situational information was given in some scenarios – whereby those in the cardiac attack group had been fired from their job and those in the stroke group had alcohol-smelling breath. The study found that nurses who had been given situational backgrounds were more likely to use this information to choose a less serious diagnosis – a highly significant effect reducing the accuracy of diagnosis. When probabilities were given (for example, 30% of patients were in the stroke group), the use of situational information superseded that of probabilistic objectivity. It is important to note that the process of diagnosis is complex, relying on a variety of factors including medical history, background, epidemiology and social factors. However, the paper reasoned that situational information, an example of the representative heuristic, bypassed more relevant factors in the decision-making process. These findings were remarkably similar regardless of training status implying such a bias was more deeply rooted than mere experiential naivety. Cognitive errors in medicine are in the process of being identified with no indication of exhaustion – the bandwagon effect, default bias, anchoring bias, decoy effect, ambiguity aversion, etc., the list is long. A study by Tversky investigating one such error, the cognitive framing allusion, appeared in the New England Journal of Medicine in 1982. A theoretical patient was given lung cancer with a short life expectancy. However, an experimental surgery, with the potential of a cure, was offered. One group of doctors was told the patient had a 90% chance of surviving the surgery. The other group was told the patient had a 10% chance of dying. Those in the first group were nearly twice as likely to recommend surgery despite the given percentages resulting in identical outcome (mortality vs. survival rates). The ethical implications behind this cognitive error are important to consider. Doctors financially incentivised to operate can use similar distortion techniques to influence the decision of patients. ‘This is a nudge in the medical world’ states Michael Lewis, author of The Undoing Project, a book centred around Tversky and Kahneman’s friendship. Nudges are subtle changes which have the potential to significantly influence choice architecture and resultant behaviour. Examples include an opt-out organ donation registry (generally considered good) and the creation of unnecessary additional paperwork needed to vote in the US (generally considered bad). We are complex. Our brains are a hodgepodge of functionally distinct areas. The motor cortex allows us to battle against Newton’s gravity and stretch Journal of the Royal Society of Medicine; 2018, Vol. 111(6) 214–215

Reflecting on medical student surgical conferences

We believe that as the focus of undergraduate conferences varies, so too will the motivations of the students attracted to them. Evaluation surveys indicated that students attended the neuroscience event because of specifi c career or research interests, whereas the opportunity to learn practical skills and an interest in surgery more generally seemed to be more infl uential factors in attending the orthopaedic conference.

The Case for Oxygen in Global Surgical Care.

To the Editor, The recent article about a lack of available oxygen for surgery in lowand middle-income countries (LMICs) highlights an imperative public health concern [1]. As mentioned, oxygen is a paramount component of safe surgery. Sadly, it is not ubiquitous in many operating theatres in LMICs and this deficiency needs to be addressed quickly. Particularly surprising was the delayed addition of oxygen as an essential medicine by the World Health Organisation (WHO) in 2013. Amongst the plethora of techniques for which oxygen is key, pre-oxygenation is a good example of the necessity for a steady supply—helping lead to favourable operative outcomes in certain patient groups. The aim of pre-oxygenation is to replace bodily nitrogen stores with oxygen, hence prolonging the duration of apnoea before desaturation occurs. This can typically be achieved through 3 min of normal tidal breathing, or eight vital capacity breaths. As pulse oximetry tends to pick up signs of desaturation late, pre-oxygenation allows more time for any issues to be recognised and addressed, helping improve safety and outcomes. Whilst there are no clear indications for when pre-oxygenation must be utilised, strong supporting evidence emphasises its use in rapid sequence inductions, critical illness, obese patients, paediatric surgery and during pregnancy. The three key requisites for pre-oxygenation are (1) high inspired oxygen concentration, (2) a firm seal around the delivery device and (3) adequate alveolar ventilation. Lack or dysfunction in any one of these components will mean that pre-oxygenation is either inadequate or not possible; such is the case in many LMICs without adequate availability of oxygen [2]. A recent report in the Lancet, focusing on healthcare delivery in Sierra Leone, found that for a population of 6.1 million people, there were four practising anaesthesiologists in addition to 70 nurse anaesthesiologists [3]. Perhaps with this knowledge then it is not quite as surprising that another recent study analysing surgical capacity in the same country, which included ten of the countries seventeen government hospitals, found that 40 % of operations had no supply of oxygen, whilst the remaining 60 % only had an interrupted supply [4]. This is by no means isolated to Africa; a study which looked at 21 facilities in Papa New Guinea found that only 30 % of procedures had uninterrupted oxygen supply [5]. In addition to the deficiency of oxygen itself, monitoring was also an issue with a lack of pulse oximeters and oftentimes anaesthetic machines. Whether the absence of oxygen is due to a shortage of resources and equipment or due to shortfalls in broader infrastructure needs more investigation. Given the evidence behind the value of this precious surgical commodity and its severe paucity in many LMICs, it is vital that changes are made to correct this deficiency. A significant investment in time and money is essential to help raise awareness of this problem and fund the necessary changes and supplies. & Salil B. Patel salil.patel@students.pcmd.ac.uk

Global Surgery in the Elderly must Focus on Education.

To the Editor, I read with interest the recent article on the operative care of elderly patients in low-resource settings [1]. With over 2 billion people worldwide identified as not having adequate access to surgical care, an increasing number of these will be elderly patients. Hence, it is important to identify the specific differences in surgical needs and barriers accessing care compared to that of younger demographics. One major difference this study highlighted was the surprising lack of emergency operations performed on the elderly compared to younger age groups. One would logically assume the opposite would be the case, especially as research undertaken in higher-resource countries showed that the number of urgent operations performed was higher in older demographic groups [2]. However, as the article mentioned, a lack of infrastructure surrounding hospital care (such as established emergency vehicle services) often means that patients die before surgical care can be provided. Another reason for the lack of urgent procedures on the elderly may stem from families’ perceptions that surgical interventions are not as useful in older patients. Thus, these patients would be less likely to be taken to hospital and other interventions may be preferred regardless of medical precedent. Studies such as these provide evidence for public health professionals to instigate rational measures to counteract barriers in accessing surgery. Building infrastructures that allow for emergency services to transport patients, often without any other means of transportation, to hospital is integral to the care of the elderly; this is even more paramount in low-resource settings where other means of public transport may not exist. It is also important to note that education will play a big role in reducing pre-surgical mortality. Surgical care is often the only known source of curative interventions and making sure the public understand this is essential. A recent systematic review focusing on barriers to surgical care found that the biggest factor was a lack of knowledge about the care itself [3]. This would provide an explanation as to why many were not aware of the importance of surgical care—especially with regard to the elderly. Public health programs can be put in place to stop these negative perceptions and hopefully increase the urgency of transporting elderly patients to hospital. The newly emerged field of global surgery is rightly concentrating on educating more surgeons in low-resource settings while funding equipment and twinning programs. In addition, the public perception must also be changed in order to accommodate a society where surgical care is a right and not a luxurious intervention reserved for those with a higher income. Local campaigns advocating the essential nature of surgery and the importance of fast referral would help drastically. The elderly are often reliant on others and therefore, this education must be aimed at all age demographics.