Is Medical Professionalism a Thing of the Past? Medical virtues and the modern world. Dr Julian Sheather. March 4th 2015

An ordinary meeting of the Society was held on Wednesday 4th March. The President was in the chair. A minutes silence was held in the memory of Dr Peter Horsey. The President introduced the speaker Dr Julian Sheather who spoke to the title: ‘Is medical professionalism a thing of the past? medical virtues and the modern world’. Dr Sheather said that he had a philosophical background and that the language of ethics had something to say to the medical profession now it is under such pressure. Professionalism is difficult to define – you know when it is not there but it is at the heart of the doctor patient relationship. Modern managerial methods of guidelines and the like cannot take it into account. The RCP definition includes ‘vocation’ which is something that cannot be judged by external rewards. There is something within a vocation that draws those involved into it. Dr Sheather said that he often hears it is dying and that people are no longer going into medicine with a sense of vocation. However, medicine is more than a technical knowledge of disease, it involves human suffering and fear; there should be a desire to ameliorate this suffering. This involves judgement. Prostate cancer is full of uncertainty around diagnosis and treatment and rules cannot guide us. Patients need help to face these uncertainties. Medical paternalism is much talked about, and by inference disapproved of, and patient autonomy is the current mode. But do patients want to make decisions themselves? They want, and need, guidance and good sense. If doctors hide behind guidelines they cannot give it. Dr Sheather discussed Virtue Ethics – a contemporary moral reflection that focuses on action-orientated questions. It involves ‘good things’, defined either as the ‘external goods’, such as status and income which are competitive or the ‘internal goods’, such as those found within medical practice – for instance a satisfied feeling of a job well done -  which are not competitive. Professionalism is the exercise of those virtues necessary to the realisation of the ‘internal goods’ within it. Modern institutions undermine the independence of medical practitioners, the biggest threats being political interference and the cultural environment of health. For example, he said, guidance on management, and even financial incentives [such as the financial rewards for a diagnosis of Alzheimer’s Disease], coming onto the doctor’s computer screen cause a conflict of interest. NHS doctors have been immune to financial pressures in the past but these incentives will be a threat in the future. The internal goods are being exchanged for the external goods [money]. The growth of consumer culture in medicine involves the idea that ill health is unnatural and it is a problem for doctors as illness and death are seen as failures. Health is seen as an entitlement – a right. If you have this right then who has the duty of overseeing it? Doctors. Medicine is becoming responsible for all the ills of the world. Doctors are being asked to take on the social health problems they can do little about. The pressures on professionalism are enormous: if we cannot trust our doctors what can we do?

The President thanked the speaker for such a stimulating lecture. There being no other business the meeting was closed at 9.55pm

The Sinister Shepherd: Myths and Conspiracy Theories. The influence of syphilis on art, literature and music. Dr David Rowen. April 1st 2015

The AGM of the Society was held on Wednesday 1st April 2015. The President was in the chair. The minutes of the last ordinary meeting were read and approved. The President then introduced the speaker Dr David Rowen who spoke to the title ‘The Sinister Shepherd: Myths and conspiracy theories – the influence of syphilis on art, literature, and music’. He said the name comes from a Latin poem about a shepherd called Syphilis whom Apollo punished with the disease. It even has its patron saints - St Denis and St George. The tradition is that syphilis was brought into Europe by Christopher Columbus’ sailors but the evidence is poor. Columbus only had 120 sailors so they must have worked very hard to spread it so widely and quickly. However, there is no evidence of syphilis in older bones. In literature references to it only occur after Columbus’ return. There was leprosy in Europe pre 1500 and some of the leprosy skin lesions and nerve damage could have been due to syphilis. Dr Rowen did wonder if there had been a change in virulence about that time which changed everything. It was not realised that syphilis was a sexually transmitted disease until the late 17th century. At that time it took 3 years to suffer from tertiary syphilis. Today it might take 30–40 years. Syphilis appears in the arts. Durer made an illustration in 1496 of an astrologer with syphilis, possibly a reference to a theory that syphilis came from the stars. High-risk groups and activities were depicted in art – soldiers, sailors, vagabonds, prostitutes, courtiers, and students from Oxford and Cambridge. Etchings of bathhouses were not uncommon and depicted graphically. There is a woodcut showing secondary syphilis being treated by the clergy. The Catholics treated it with lignum sanctum crucis and the Protestants used mercury. Dr Rowen then discussed a number of composers and writers who were or might have been infected and how the disease or its treatment may have influenced their work.

The President then thanked Dr Rowen for such an interesting talk. The meeting then proceeded to the AGM of the Society which is recorded elsewhere.

Life in an Ugandan Mission Hospital. Dr Martin Radford. October 14th 2015

The first meeting of the new season was held at the Royal Southampton Yacht Club on October 14th 2015. Dr John Dracass, last season’s president ,was in the chair. He welcomed the members and proceeded with the inauguration of Dr Martin Radford, who was unavoidably absent at the AGM, as his successor. Dr Radford then took the chair. The members then stood for a minutes silence in memory of Mr Jason Brice and Mr Barry Evans. The president then introduced himself as speaker, his title being: Life in a Ugandan Mission Hospital. Dr Radford joined the staff of St Joseph’s Hospital, a Catholic Mission Hospital, in Masaka near Lake Victoria. It serves a population that is poor, but reasonably well nourished. It is a green and fertile area and the people live in huts made from clay bricks and have an acre of land to cultivate. There is no running water which has to be collected from the lake nearby. It is an easy trip often done by children with large containers. He graphically described the local village. St Joseph’s Hospital is relatively modern. A nurse, a very good nurse, sits on an elevated chair at the entrance and triages the arriving patients. The paediatric department is 3 years old and very nice on the outside. Inside are iron beds close together with 2-3 patients to a bed. General care is done by the family so the ward is very crowded with large families in attendance. The nurses are local, and locally trained, and the standards are excellent. There are not many doctors in Uganda due to the brain drain. However they have trained Clinical Medical Officers who do a 3 year course in which the clinical teaching is the same as for the medical students but basic medical sciences are minimal. They learn by algorithms. Many will later complete medical training. Dr Radford then considered some illnesses. Malaria is mainly the Plasmodium falciparum type which has a high childhood mortality. This affects the livelihoods of subsistence farmers who are dependent on children for help. Some children have an Hb of 1 or 2 on arrival and need urgent transfusion. The staff are very efficient in an emergency. There are good laboratory facilities with good technicians and the blood bank works well. There is a replacement blood policy and the family is expected to donate afterwards.

There is also a non-acute ward. Kwashiorkor is very common. There is little starvation but there is a lack of protein in the diet as they mainly eat bananas. There is a nutrition unit with a kitchen constructed like the family’s one at home and the sister runs sessions on preparing nourishing meals for the mothers of these patients. It is a rewarding illness to treat. HIV is treated elsewhere. Pregnant women are given ARVs after 12 weeks pregnancy. Avoiding breast feeding after delivery is difficult. Dr Radford also spoke about fistulas usually occurring after obstructed labour. The women smell and are stigmatised or even thrown out by the family and become destitute. He said that leaflets, supplied by the Addis Ababa Fistula Unit, were readily available in the ante-natal unit. These explain the causes and prevention in pictures and persuade mothers to come early to hospital if labour seems obstructed and explain how to get treatment. The surgical skills needed for treatment are not available in Uganda so the Catholic Church funds visits from surgeons from the UK and USA. The cases are collected and treated during these visits. Finally, he described Masaka, their district town, which is the fourth largest town in Uganda. He said the only building of note was the Catholic Church which is built in gentle catholic style. There were notices around the entrance saying that  women had the right to choose their contraception.

Dr Dracass gave the vote of thanks.

The Treasurer then gave her annual report. [Reported elsewhere] 
There being no other business the meeting closed at 10.00pm.

Spinal Surgery for Back Pain: a story of gain, disaster and industry led contagion. Mr Evan Davies April 6th 2016

The AGM of the Society was held on Wednesday 6th April 2016. The President was in the chair. He introduced the evenings speaker Mr Evan Davies FRCS consultant spinal surgeon at SGH. He spoke to the title “Spinal Surgery for Back Pain: a history of gain, disaster or industry-led contagion”. Mr Davies said he had been a medical student at SGH in 1984. He is mad about rugby and was captain of the Southampton University rugby team.
The Egyptians recommended physical therapy and activity for back pain, but of course had no idea of its causes. In mediaeval times it was considered not to emanate from the back but was punishment for sin. It was during the Renaissance that ideas about the causes of back pain were first discussed. In the late Georgian times it was observed that the first railways caused back pain due to spinal jarring from the uncomfortable ride of the first trains. Back pain was mainly treated with traction and bed rest and immobility. The first back operation was carried out  in 1911 but it was not until the1970s that operating on the back became routine. There was an interesting Oxford trial that compared aggressive physiotherapy including cognitive therapy with surgery for back pain. The physiotherapy cost £3000 and surgery £6000 but 2 years later the surgical treatment had better results. In Denmark a trial tried to estimate the cost to society of the standard treatment of rest and no work, compared with immediate surgery. By 2 years the surgical group were much more likely to be back at work and in all were costing a lot less to society. Mr Davies also spoke about scoliosis surgery. He said that modern techniques meant that children were now back at school in 4 weeks. He considered, though, that the School Scoliosis Screening programme had a poor pick-up rate.

The President thanked Mr Davies for an interesting talk and the meeting proceeded to the AGM of the Society. [The minutes of which are circulated before the next AGM].

Ordinary GP - Extraordinary Job. Dr Laurence Buckman Former Chair of the BMA. October 5th 2016

An ordinary meeting of the Society was held on Wednesday 5th October 2016. The President was in the chair. There were no reported deaths of members. In the Secretary’s absence, the minutes of the last meeting were read by Dr Dracass and were accepted as correct by a show of hands.

The President introduced the evening’s speaker, Dr Laurence Buckman, who spoke to the title “Ordinary GP; Extraordinary Job”. Dr Buckman considered himself to be an ordinary GP who, almost by accident, had had the opportunity to influence medical politics. He practiced in a six doctor partnership in North London and was also a GP tutor at UCL as well as an adviser to the RCGP, the BMA and the CQC. As a trainee to Dr Marks, a former Chairman of the BMA, he had become a member of his Local Medical Committee, on which he served for 30 years, and in 1997 had been elected a negotiator for the BMA. From 2007 to 2013 he had been Chair of the BMA’s General Practice Committee. In his time with the BMA he had dealt with 12 Secretaries of State for Health and had the opportunity to observe the inner workings of the civil service, especially the Department of Health. In his experience, popular TV programmes such as “Yes Minister” and “In The Thick Of It”, were more fact than fiction.
He described the history of the GPC, founded in 1911 to fight the health reforms of Lloyd George. Although long a part of the BMA, the GPC was answerable to the Conference of Local Medical Committees rather than the BMA Council and in this role it negotiated GPs pay with the DDRB, responded to government policy and looked at workforce issues, professional regulation, prescribing and education. 
While often frustrated by government policy and methods, he admired career civil servants who were usually highly intelligent and expert in their sphere. Ministers, by contrast, were often short-termist, populist and influenced more by election success than by the good of the NHS. Only a few of those he had worked with had gained his admiration. During his time as chair of the GPC he had acquired a reputation for not mincing his words and was once labelled by the Daily Mail as “Red Rob with a White Coat”. This, he explained, had been a misunderstanding by the civil servants who did not appreciate that the BMA covered a spectrum of views and was not party political. Representing such a broad church had proved difficult at times but, he felt, that while he been able to do some good for the profession, it had also been fun.
Although supported by the BMA Media Unit, and undergoing training in negotiating skills, he had lost his temper during a ministerial TV interview only once, but it had resulted in the DOH avoiding ever risking a Minister appearing with him on TV again. 
Dr Buckman described some of the complex issues he had had to deal with as well as more humorous ones. Negotiation, he said, was like a consultation and was about the art of the possible rather than victory and vanquished. It was important to be well prepared, know the facts and to have a firm bottom line position. A “wise agreement” was ideal but was not always the one that could be sold to the profession. Sometimes the best option was to do nothing. He also explained the role of Special Advisers and some of the more convoluted methods by which government policy is announced, floated and eventually visited upon the populace.  

After answering several questions from the audience, Dr Buckman was congratulated by the President on such an interesting talk and the meeting ended at 10.15pm.

The Story of HIV: Paradise Lost, Paradise Regained. Dr Liz Foley. November 2nd 2016

An ordinary meeting of the Society took place at the Royal Southampton Yacht Cub on 2nd November 2016. The President was in the chair. Dr Keightley introduced the speaker Dr Liz Foley who spoke to the title: ‘The Story of HIV: Paradise lost; Paradise Regained. Dr Foley said that it is now 35 years since 5 young gay men were diagnosed with Pneumocystis pneumonia, a rare disease rarely seen in young people. There followed  many reports of Kaposi’s sarcoma and a new condition named AIDS was described. Three years later the HTLV3 virus was isolated from from a lymph node.
In 1985 the famous film star Rock Hudson died of AIDS and there were cases of it being spread by human blood and tissue products. Mass hysteria was the consequence with it being imagined generally that the virus could be caught by just being near someone who was possibly HIV positive. Ryan White, a 15year old haemophiliac, was excluded from school and gays were unable to rent property. The hysteria was only quelled when the late Princess Diana was televised shaking the hand of an HIV patient with AIDS. This was a turning point. 
Dr Foley described the natural history of the illness. By 1989 it was known that the CD4 count dropped and the virus replicated in the blood stream. It would then take up to 8 years before the onset of AIDS. It takes about 4 weeks for seroconversion to take place. The first drug, AZT, became available in 1987. By1996 a highly active anti-retroviral therapy scheme was introduced using 3 drugs synergistically, each working on a different part of the HIV life cycle. As a result the incidence of AIDS has dropped significantly. Guidelines suggest starting therapy at diagnosis but this is not funded by the NHS. Treatment will be required for the rest of the patient’s life. The situation is now that treated HIV patients now live longer than non HIV patients Dr Foley said. However 17% of patients with HIV are not diagnosed and are unaware of it. 
In pregnancy 98% of mothers opt for an HIV test.  AZT is given to mothers at any stage of pregnancy with the result that the transmission rate is now down to less than half a per cent, where it was formerly 34 per cent. As HIV is also transmitted in mother’s milk breast feeding is not recommended. In Africa the solution is to continue with AZT until weaning.
Treatment as prevention is also effective and protects others from being infected. Pre-exposure treatment is now being promoted. Risk factors and counselling were also discussed.

The President thanked Dr Foley for a most interesting presentation and the meeting proceeded to the Treasurer’s annual report. The details are reported elsewhere. Dr Phillip Carter, seconded by Dr John Dracass, proposed the accounts be accepted which was carried unanimously

A Scientist in Wonderland:searching for truth and finding trouble. Prof. Edzard Ernst December 7th 2016

An ordinary meeting of the Society took place at the Royal Southampton Yacht Cub on 7th December 2016. The President, Dr Keightley, was in the chair. She introduced the speaker Professor Edzard Ernst, Emeritus Professor of Complimentary Medicine at Exeter University. He spoke to the title ‘A Scientist in Wonderland: searching for truth and finding trouble’. Professor Ernst said that he grew up in Germany with homeopathy. His family didn’t consult doctors. He qualified in Munich. He came to St Georges Hospital in London to do research into blood flow and later was appointed to the Chair of Rehabilitation Medicine in Hannover University where a new 2000 bed hospital was about to be opened. Asked to to do the inaugural speech he recounted that when researching it he found that all the records pre-1938 had all been destroyed, other crucial documents were lost and he met with obstructions to his enquiries. He also found that three quarters of the medical school staff had disappeared during the war. In 1992 he was appointed to the first Chair of Complimentary Medicine in the UK in Exeter. His mission statement was to apply science to alternative medicine. At the opening of the Medical School, which the Queen opened, she requested to meet him. His team reviewed 38 different alternative treatments and initially looked at acupuncture, chiropractic, homeopathy and herbal medicine. He explained the principles of dilution of substances in homeopathy and that at C30 it was a molecule floating in the space between the sun and earth. There were also ridiculous potions like Berlin Wall C30 for feelings of oppression, dilutions of Bath Spa water for rheumatism, Oxpecker eggs, slug, alligator etc.
He said that the first proper trial of homeopathy was in 1835 - a double blind RCT, which concluded the results were indistinguishable from placebo. In 1937 at the World Congress of Homeopathic Medicine in Berlin the Nazi’s inaugurated a large research programme into it but the results were never published. Professor Ernst said he has reviewed some 500 controlled trials and had come to the conclusion that cherry picking is endemic. Trials need to be peer reviewed. Up to 2011 there were 164 peer reviewed trials but they were inconclusive. He performed a systematic review of systematic reviews of homeopathic trials in 2002, which was repeated by the NRC Australia some years later, with the conclusion that the evidence does not show homeopathy to be effective. He also conducted a survey of 9000 children and found that the uptake of childhood immunisations was lower in those who use homeopathy and as part of the research surveyed 104 homeopathists which revealed that 31 advised against childhood immunisations. This provoked a lot of protest and the ethics committee came under pressure to remove their approval and forbad him publishing the results - but he published anyway. There was a University enquiry into the incident which supported him. However the matter was leaked to the press. The Times called him Quackbuster for reviewing the evidence and informing the public. He also has ongoing battles with big homeopathic Pharma.  Professor Ernst was asked what Exeter University expected from him. He said it was to do the research he did - which was fine until the Smallwood report came out with unrealistic claims after which he was made persona non grata and funding for the department dried up . He was also asked about medical student teaching. He replied that students only started appearing after 2000 so he was well into his term by then. He finished by saying that homeopathy is popular because mainstream medicine is not providing the time or sympathy that patients want. It is a reflection on our system.
The President thanked Professor Ernst for his talk. There being no other business the meeting closed at 10.10pm.

The Foott Memorial Lecture: Dr Iain Simpson. Forty Years of Cardiology. March 1st 2017

An ordinary meeting of the Society took place at the Royal Southampton Yacht Cub on 1st March 2017. The President, Dr Keightley, was in the chair. The minutes of the previous meeting were read and approved. After a minutes silence was held in memory of Dr G H Foott the President introduced Dr Iain Simpson, Consultant Cardiologist at the Wessex Regional Cardiac Unit Southampton, who was to deliver the Foott Memorial Lecture. He spoke to the title “40 Years of Cardiology”.  He introduced his talk by saying that Dr Foott had a Scottish connection, as well as the speaker himself, as he had practised for a time in Helensborough after leaving the navy before coming to Southampton. Dr Simpson then reminded us of the important events of 1977, including that of a 3rd year medical student at The Royal Infirmary in Glasgow who became inspired by cardiology. Angina was then treated with nitrates, and surgery and coronary care units were only just being introduced. Dr Simpson said that the most important investigative tool at that time was the stethoscope - the art of listening to the heart was paramount. ECHO and simple imaging were just beginning. He became interested in imaging and started research into aortic stenosis so he arranged to go to San Diego to study under Dr David Sahn, a pioneer of cardiac imaging. Colour fluoroscopy was then being introduced in San Diego to assess the severity of valve disease and whilst he was there transoesophogeal ECHO also. On his return to the UK Dr Simpson was appointed in Southampton. He said that we were ‘incredibly blessed’ by the quality of the heart surgeons in Southampton and this had laid the foundation for the preeminence of our unit. He then discussed the progress of treatments over the last 40 years and how drugs came and went and came again. The change, in particular, in the management of MI from being given diamorphine and put to bed in the then new CCU with ECG monitoring, to the present treatment of primary angioplasty within 47 minutes of your entry into the hospital was remarkable. Ninety-five percent of patients in Southampton will be treated thus and now severe angina as well. In the last forty years the mortality from MI has fallen dramatically. He said he had now become especially interested in prevention. The smoking ban had resulted in a 10% reduction in CVD. Lifestyle, and diet in particular, with 150 minutes of exercise a week in 2 or 3 bouts were crucial. He also considered the case for primary prevention with statins was overwhelming. He also suggested everyone should check out their heart age on the internet at www.jbs3risk.com 
The President thanked the speaker for his excellent lecture and there followed a session of questions. The meeting was then closed at 10.10pm

Air accident investigation: the story of the 1710 Naval Air Squadron. Ms Cheryl Pitt: Head of Materials

An ordinary meeting of the Society took place at the Royal Southampton Yacht Cub on 1st February 2017. The President, Dr Keightley, was in the chair. The minutes of the previous meeting were taken as read. The Society’s new website was then demonstrated to the members present.The President introduced the evening’s speaker Ms Cheryl Pitt The Head of Materials in the Royal Naval 1710 Air Squadron who spoke to the title “Air Accident Investigation: The 1710 Naval Air Squadron  and how we assist with crash investigations”. She outlined the history of the squadron. It was only created in 2010, in order to bring together the specialist techniques involved in routine aircraft scrutiny, repair, and crash investigation, which previously were spread around a number of different departments which was inefficient. The MOD had been thinking about outsourcing the different activities. The squadron has teams world-wide in 15 different locations. The commonest task is repairing damaged aircraft which they try to do at once. They assess the damage and design any repairs needed. The damage may be anything from holes in the fuselage to corroded mechanical parts. Ms Pitt’s department monitors aircraft for cracks and fractures, corrosion, and performing structural investigation and testing. It is available 24 seven 365 days a year. It also involves analysing any damage and perhaps designing a completely new part to prevent a recurrence. They also have crash investigation teams. Assessors start onsite and meticulously make and record scene-of-crash data and collect evidence. This may involve bringing up an aircraft from the sea bed or transporting enormous fragments, such as the fuselage from the Lockerbie disaster, to base. The pieces are then reconstructed as far as is possible. She described the case of a twin engined Tornado that crashed after one engine failed and the other then caught fire. The pilot bailed out.The plane disintegrated on hitting the sea. All Tornados were then at risk of being grounded which would be a military emergency. The department brought up many sacks of pieces from the sea bed and urgently investigated. On reconstructing the engine bay they found that the firewall between the two engines had a design fault such that when the first engine overheated and exploded it allowed burning shrapnel to pass into the adjacent engine bay setting it alight. As a result the firewall was redesigned and the aircraft were modified. Ms Pitt brought with her several damaged items for our inspection
The President thanked Ms Pitt for her presentation and the meeting was closed at 9.50pm

Tristan da Cunha by Drs Iain and Pamela Levac. 6th December 2017

An ordinary meeting of the Society was held on Wednesday 6th December 2017. The President was in the chair. He introduced the speakers, Drs Pamela and Iain Levac who spoke to the title: Island Doctors on Tristan da Cunha - the worlds most remote inhabited island. It all started when they saw an advert for an MO on Tristan da Cunha which took their fancy. Tristan is part of an archipelago of  four volcanic islands of which only one is inhabited. It has a population of 293, who speak olde english. It is wet and windy and it rained for the first 46 days of their time there. It is  situated 1700 miles form South Africa and is 6 days by sea. There is a regular boat every few months to supply the island. The Leavacs travelled by cargo boat and she described the very complicated landing procedure due to the tiny port which large ships cannot use and the enormous ocean swell. The island is administered by the Island Council who control everything. The medical centre and hospital is new and staffed by nurses. It has treatment areas and an operating theatre and is generally well equipped - in particular an X-ray machine and ultrasound. Medical supplies have to be ordered 2 boats ahead. The population are farmers and fishermen. Accidents are common and are treated locally. If a patient requires a casevac if there is no regular boat nearby then a passing ship has to be persuaded to help. Our speakers phoned consultant colleagues in Dundee for advice when needed. There is also a  tele medical link with Pittsburg University Hospital which can be used for reviewing X-rays, ECGs and general advice. Medical work is mainly reviewing and treating the high incidence of obesity, diabetes, gout and asthma. She said that in-breeding disease was not very evident at present but in time might become a problem. Pregnancy is supervised until 34 weeks when the patient is sent to Cape Town. Pamela said that she was glad there were two of them. She considered life would be difficult for a single handed MO, which is usually the case. She said the population were extraordinary. They were caring and looked after each other. The community was very well organised.  Young people were tending to leave the island though. 
Her talk was followed by questions. The President then thanked them for their interesting talk and there being no there business the meeting was closed at 22.23.

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