What are we scared of?

Scare-devil figure to ward off evil spirits, India

Scare-devil figure to ward off evil spirits, India

By and large, those of us in the west live in the least dangerous conditions in human history. Most of us have the basics: food, shelter, safety. We’re unlikely to be killed by wild animals (even other humans) and fatal infectious disease is rare. Life expectancy is long and few of us die in childbirth.

So why are rates of anxiety disorder high and rising? There’s probably a whole book to be written in answer to that question. But having less to fear doesn’t seem to have made us less fearful. Perhaps our evolutionary responses haven’t caught up with our changing circumstances. Perhaps we don’t quite believe our luck. Perhaps the rate of change itself makes us fearful.

I’m not seeking to make light of anxiety disorder. I know from experience how crippling and exhausting it is. But I am interested in what lies beneath these fears. What is it we’re all so frightened of?

The Wellcome Collection had a go at finding out in a recent interactive exhibition. People were asked to write down their greatest fears on a piece of paper, which they then crumpled and put in a bin, in a symbolic act of letting go. The curators then rooted around among the hundreds of responses to find out the most commonly-cited fears.

I don’t think the top five will surprise anyone. People fear death, being alone, losing someone, failure. And spiders, the only fear I don’t share. What strikes me is that they’re not irrational fears (except maybe the spiders). All of these experiences are inevitable. No-one can avoid confronting them at some point in their lives, or at the end of them. Perhaps our longer, safer lives even make some of these things seem more frightening, because we have less experience of them.

The Wellcome team did find some surprising fears. Vaginas, for example, and automatic doors (not together). Writing in public, which I think I can cope with. A sudden wine shortage, though. That’s a new fear to keep me await in the early hours.

Image: Wellcome Images, with CCL.

From antidepressant prescription to tight glucose control: seven clinical controversies that keep on going

mental_health_in_the_media.jpg338x219.2775Some clinical stories become perennials – issues that never seem to get completely resolved and pop up year after year. What’s the betting we can see the end of any of these seven controversies in 2015?

1: Are antidepressants over-prescribed? To some, depression is under-diagnosed and under-treated. Others think we’re medicalising ordinary sadness.

2: Bariatric surgery for weight loss. A sensible approach to disease prevention, or a cop-out that means people don’t take responsibility for their own health?

3: Statins for over-50s. A worthwhile investment in preventing heart disease, or under-researched mass-medicalisation?

4: HRT for menopausal symptoms. Out of fashion since the shock research of 2003, but do too few women now benefit from their beneficial effects?

5: Should we stockpile Tamiflu against a flu pandemic? Or does the evidence now point to it being too little use, for too much cost?

6: Dementia diagnosis. Is there a good reason to increase early diagnosis of this devastating condition?

7: Tight glucose control for type 2 diabetes. The best way to avoid complications, or a short route to hypoglycemia?

I took a closer look at these questions in my January feature for Student BMJ, here.

Five top medical stories of 2014

The helplessness of modern medicine in the face of a deadly virus was the over-riding image of the year. It was a forceful reminder that we don’t have all the answers – especially not in countries where the medical service is degraded by years of civil war and poverty. At home, non-communicable diseases of lifestyle and ageing made the headlines.

Ebola: The WHO first warned of its concerns about the outbreak back in March. By the autumn the disease had rampaged through three West African states, with no sign of being brought under control. The international response was ramped up in October, although Medecins Sans Frontieres warn that facilities are still inadequate. Trials of new drugs started in December. While they come too late for the more than 6000 people who have died in this outbreak, they may prevent the disease from becoming endemic.

Fat and heart disease: Researchers writing in the Annals of Internal Medicine wrote that dietary guidelines urging people to eat less saturated fat to lower their risk of heart disease were not based on sound evidence. Their systematic review and meta-analysis looked at data from 18 countries. They found no clear link between saturated fat consumption and heart disease risk. But the battle isn’t over. Nutritionists claim the research was flawed and current dietary guidelines should not be abandoned.

Statin wars: NICE, the government’s health watchdog, recommended that people with a 10% or greater risk of getting heart disease in the next 10 years should be offered statins – a jump from its previous recommendations that statins should be offered to those with a 20% or greater risk. A group of influential doctors protested that this could mean 5 million more people taking the cholesterol-modifying drugs, with their potential side effects. In tandem, research published in the BMJ (and highly-publicised complaints about it) made it clear that no-one can say for sure how common these side effects actually are.

Diagnosing dementia: NHS England offered GPs a cash bonus for diagnosing elderly patients with dementia. The move raised plenty of eyebrows, not least because services for people diagnosed with signs of early cognitive decline are lacking and existing treatments are limited in effect. But the potentially deleterious effect on trust between GPs and their patients caused the greatest unease among the doctors who called for the payment to be withdrawn.

Spinal cord re-growth: In a year when good news was hard to find, the story of how Polish surgeons used a British-pioneered technique to regrow nerve cells from a paralysed man’s olfactory bulb to ‘re-grow’ his severed spinal cord was heartening. If the team-work, technical know-how and resources brought to bear in this case could be replicated around the world, who knows what triumphs 2015 might bring?

Why the outrage over gastric bands?

Adjustable Gastric BandThe tabloid press was outrage by the possibility that ‘TWO MILLION obese Brits‘ could be offered bariatric surgery, after NICE guidelines recommended that weight loss procedures should be offered to people with diabetes and a BMI of over 35. The story was front-page news, with lurid estimates of the potential cost.

But why the outrage? Leaving aside the dubious figures (NICE estimates an additional 5000 surgical procedures a year if their advice is implemented), bariatric surgery is an effective treatment for a condition, type 2 diabetes, that causes serious disability and suffering. Dr Rachel Batterham, head of obesity and bariatric services at UCL, who developed the NICE guidance, says: ‘The health benefits of weight loss surgery are so great that it should be considered as part of the treatment for obese diabetics.’  She said people should be offered surgery as soon as possible after their diagnosis, for best results.

Persuasive evidence suggests that bariatric surgery not only cuts the chances of people with obesity getting type 2 diabetes, but that it can reverse the condition. NICE says that 65% of people with diabetes who had bariatric surgery last year are no longer in need of diabetes medication. That’s fantastic news, surely?

The outrage, of course, is not because of diabetes, but obesity. A caller to this week’s Any Answers programme on Radio 4 briskly asserted that anyone who needed healthcare because of ‘self-inflicted’ problems such as smoking or obesity did not deserve NHS treatment. They were, she said in a jaw-dropping display of judgementalism, lazy and lacking in self-control.

And that’s the heart of the argument against bariatric surgery. Never mind that NICE makes it a pre-condition that people should try to lose weight by other means before being considered for surgery, or that it’s a major operation which can have serious consequences. Never mind that we live in an obesogenic society, and that most people having surgery have spent years miserably trying and failing to lose weight. Forget that reversing the tide of diabetes could save the NHS money in the long term. People don’t like to see others getting something they don’t think they deserve – even if that something is a gastric band.

Image: Xopusmagnumx at en.wikipedi

Keep it simple when writing for publication

I spend a lot of time editing articles written for professional magazines, often not by professional writers. The topics are  fascinating and can be complicated, with lots of explanation needed. Simple explanation is hard to do, which means I do a fair bit of re-writing.

For anyone planning to submit a piece to a journal or magazine, especially if you’re not a professional writer, can I suggest some basic rules? Whoever edits your piece will love you for following these:

  1. Ask what word count is expected, and try to keep within spitting distance of it. The chances of you being allocated additional space if you write double the length are slim.
  2. Check the journal’s usual style and try to emulate that. Ask for the style guide if you’re unsure.
  3. Write in the active tense, unless you have been specifically asked to use passive tense. This is active tense: ‘The cat sat on the mat’. This is passive tense: ‘The mat was sat upon.’ Passive tense loses information (by whom?) and can sound pompous.
  4. Use simple words, and as few as you need. Do you need to say ‘people from the higher echelons of the socio-economic spectrum’, or could you say ‘rich people’?
  5. Shorter sentences are kinder to the reader than complex sentences. Try reading aloud. If you run out of puff mid-sentence, it’s probably too long. Cut it into digestible chunks – one idea, one sentence.
  6. To denote a quote, use this format. ‘He said: ‘That’s fine’.’ Said is good. Don’t waste your time thinking up alternatives like commented, advised, noted, explained, revealed.
  7. Before you submit the piece, re-read the brief from the editor. Have you actually covered what you were asked to write about? Or did you get side-tracked by a fascinating thought that occurred to you half-way through? The closer that your article is to the brief, the better the chances it will be published.
  8. Remember the aim of the piece is to inform and entertain the reader, not to impress them with your erudition.

Follow these rules and the editor will bite your arm off for more articles.

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