Deep Breath In

Medicalising the mind with Suzanne O’Sullivan

Our environment moulds our brains, and alters development, and so there are culture-bound ways that our bodies express distress.
In this week’s episode, we discuss the mysterious phenomenon of Sweden’s ‘sleeping beauties’: asylum-seeking children who were affected by resignation syndrome, which led them to become completely inert.
We talk about the pros and cons of applying medical labels to people’s symptoms – are we applying labels too easily, and over-medicalising things which could be classed as normal? Being given a diagnosis may provide some relief to a person experiencing certain symptoms, but, in doing so, are GPs actually creating more patients?
Our guest:
Suzanne O’Sullivan is a consultant in clinical neurophysiology and neurology, based at the National Hospital for Neurology and Neurosurgery in London. Her specialist interests are in epilepsy and functional neurological disorders. She is also the author of ‘The Sleeping Beauties: And Other Stories of Mystery Illness’.

Burnout with Rachel Morris, Cat Chatfield and Abi Rimmer

Burnout has become something of a buzzword recently, but has now been officially classified as a syndrome caused by the workplace. Over the course of the pandemic, clinicians have been under more stress than ever, and evidence shows that burned out doctors are more likely to make medical errors.
As the pressure being piled onto GPs, and other medical professionals, is only increasing, the adage of ‘put your own oxygen mask on first’ has never been more apt, but many of us feel that we simply do not have the time or energy to devote to self-care. In this week’s episode, we discuss how to recognise the early signs of burnout, and how struggling with stress can feel like a personal failure.
We also talk about practical measures we can take to build resilience within teams, and to safeguard our own mental health, in order to help lessen the burden on individuals and on healthcare systems more widely.
Our guests:
Rachel Morris is a GP and educator, leading training courses in leadership and resilience, and she is also the host of the You Are Not a Frog podcast.
Cat Chatfield is the research integrity editor for The BMJ, and the wellbeing campaign lead, as well as being a ‘resting’ GP. She hosts the BMJ Wellbeing podcast.
Abi Rimmer is a reporter, and the editor for BMJ Careers. She co-hosts the BMJ Wellbeing podcast with Cat.

Health anxiety with Guy Edwards and Helen & Peter Tyrer

In general practice, doctors commonly see patients who are experiencing varying degrees of health anxiety, which can be difficult to navigate. GPs often want to offer reassurance, but reassurance can be like a drug to these patients: the more reassurance they receive, the more they need. In this week’s episode, we discuss how new technology which allows patients to check symptoms at home (such as pulse oximeters) may increase anxiety levels, and how our stock phrase “keep an eye on it” may be the worst thing we could say to patients with health anxiety. We also talk about the therapeutic value of a GP visit, and the importance of letting anxious patients know that all of their symptoms – physical and mental – will be taken seriously.
Our guests;
Guy Edwards is a patient who developed health anxiety around five years ago.
Helen Tyrer is a former GP, a senior research fellow at Imperial College London and is the author of ‘Tackling Health Anxiety: A CBT Handbook’.
Peter Tyrer is a professor of Community Psychiatry in the Centre for Mental Health in the Division of Experimental Medicine at Imperial College London.
Reading list;
https://www.bmj.com/content/364/bmj.l774

Long Breath - Whitney Robinson on getting out the vaccines

In this episode, we're bringing you the full interview, a deep breath, with Whitney Robinson, a social epidemiologist and associate professor at UNC Chapel Hill.
Whitney gives us her take on how we should be thinking about risk when it comes to covid-19 infection and vaccine rollout. This is a nuanced conversation about the health and economic disparities of covid-19 the consequences of failing to reach the most vulnerable groups, and the importance of tackling this from a community level.

GPs vs. surgeons with Clara Munro and Sarah Robinson

There is a common perception of surgery that it’s an old boys’ club, and that anyone joining the profession is expected to match the archetypal personality type in order to fit in. Whilst this is starting to change in some specialities, it does still present a challenge, especially to junior staff trying to establish themselves. The relationship between primary and secondary care can be quite remote, and approaches towards patient care can sometimes seem at odds with each other.
In this week’s episode, we discuss the paradigm shift that COVID-19 has caused in the management of specialist consultations, as well as the obstacles to having successful open conversations between GPs and specialists, and how we might overcome them in order to provide better care for patients. We also ask, should we refer a patient with a suspected hernia for an ultrasound?
Our guests:
Clara Munro is a general surgeon based in the North East of England and a clinical fellow at the Faculty of Medical Leadership and Management. She is also the editorial registrar at The BMJ.
Sarah Robinson is an upper GI surgeon at the Northumbria Healthcare NHS Foundation Trust. Her areas of interest include hernia surgery and upper GI cancers.

Vaccines and headaches - with Heather Angus-Leppan and Whitney Robinson

Two topics currently being hotly discussed in the media and in clinical practice are headaches after the COVID vaccine, and the impact that structural racism is having on vaccine uptake.
Headache and fever are common symptoms after a vaccination, but there are concerns about the potential link between the AstraZeneca vaccine and blood clots, and these concerns, exacerbated by the recent frenzy of media coverage, may be damaging the general public’s faith in the vaccination programme, and impacting uptake.
In this week’s episode, we discuss how GPs may safely assess for cerebral venous sinus thrombosis (CSVT) in a patient presenting with a headache post vaccine, and the difficulty of gauging the scale of the risk of blood clots. We also talk about the controversial Sewell Report, which concluded that institutional racism is no longer a problem in the UK, and how, once we reach a post-COVID world, we need to focus more on wellbeing and work towards a fairer healthcare system for all.
Our guests:
Heather Angus-Leppan is a consultant neurologist, and epilepsy lead at the Royal Free London NHS Foundation Trust, as well as an honorary senior lecturer at UCL and Imperial College London.
Whitney Robinson is an associate professor of epidemiology in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. She is also the co-host of the Acadames podcast https://www.acadamespodcast.com/
Further reading:
- "Black people need better vaccine access, not better vaccine attitudes" by Rhea Boyd, https://www.nytimes.com/2021/03/05/opinion/us-covid-black-people.html
- "The health-care industry doesn't want to talk about this single word," by Ron Wyatt, https://www.washingtonpost.com/opinions/2021/04/05/health-care-racism-medicine/
- "The Sewell report cited my work - just not the parts highlighting structural racism," by Michael Marmot, https://www.theguardian.com/commentisfree/2021/apr/07/sewell-report-structural-racism-research
- "Black Memes Matter: #LivingWhileBlack With Becky and Karen," by Apryl Williams, https://journals.sagepub.com/doi/10.1177/2056305120981047

Remote prescribing with Geva Greenfield and Benedict Hayhoe

The past year has seen an increase in antibiotic prescriptions, especially for broad-spectrum antibiotics. This might be due to the rise in teleconsultations, which limit the ability to examine patients, causing GPs to experience higher levels of uncertainty in making diagnoses.
This week, we discuss the impact that COVID-19, and COVID tests, have had on access to healthcare, the risk of antimicrobial resistance, and how the pandemic has altered the presentation and case mix seen in GP surgeries. With teleconsulting likely here to stay, how do we adjust to the changes in primary care provision, in order to prescribe with confidence? And how do we become good antibiotic stewards?
Our guests:
Geva Greenfield is a research fellow in the Department of Primary Care & Public Health at Imperial College London’s School of Public Health. His research focuses on primary care and health policy, and big healthcare data analytics.
Benedict Hayhoe is a London-based GP, and a clinical lecturer in the Department of Primary Care & Public Health at Imperial College London’s School of Public Health. His research interests include digital health and antimicrobial resistance.
Further reading:
https://www.expmedndm.ox.ac.uk/step-up
Armitage A, Nellums L. Antibiotic prescribing in general practice during COVID-19. The Lancet Infectious Diseases 2020. https://doi.org/10.1016/S1473-3099(20)30917-8
de Lusignan S, Joy M, Sherlock J, Tripathy M, van Hecke O, Gbinigie O et al. PRINCIPLE trial demonstrates scope for in-pandemic improvement in primary care antibiotic stewardship. medRxiv. 2021. https://doi.org/10.1101/2021.02.02.21250902
Han SM, Greenfield G, Majeed A, Hayhoe B. Impact of Remote Consultations on Antibiotic Prescribing in Primary Health Care: Systematic Review. Journal of Medical Internet Research 2020; 22(11):e23482. https://doi.org/10.2196/23482
Hayhoe B, Butler C, Majeed A, Saxena S. Telling the truth about antibiotics: benefits, harms and moral duty in prescribing for children in primary care. Journal of Antimicrobial Chemotherapy 2018; 73(9):2298-2304. https://doi.org/10.1093/jac/dky223
Hayhoe B, Greenfield G, Majeed A. Is it getting easier to obtain antibiotics in the UK? British Journal of General Practice 2019; 69(679):54-55. https://doi.org/10.3399/bjgp19X700829
Morrell L, Buchanan J, Roope L, Pouwels K, Butler C, Hayhoe B et al.. Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study. Antibiotics 2020; 9(608). https://doi.org/10.3390/antibiotics9090608
Shah S, Wordley, Thompson W.. How did COVID-19 impact on antibiotic prescribing across England? British Dental Journal 2020; 229(9):601-604. https://doi.org/10.1038/s41415-020-2336-6
van de Pol A, Boeijen J, Venekamp R, Platteel T, Damoiseaux R, Kortekaas M et al.. Impact of the COVID-19 Pandemic on Antibiotic Prescribing for Common Infections in The Netherlands: A Primary Care-Based Observational Cohort Study. Antibiotics 2021; 10(196). https://doi.org/10.3390/antibiotics10020196
Zhu N, Aylin P, Rawson T, Gilchrist M, Majeed A, Holmes A.. Investigating the impact of COVID-19 on primary care antibiotic prescribing in North West London across two epidemic waves. Clinical Microbiology and Infection 2021. https://doi.org/10.1016/j.cmi.2021.02.007

Making the most of tele-dermatology with Lucy Thomas and Afzal Ansary

The use of telemedicine is on the rise, and the pandemic has led to an increased demand for this service, due to the availability of face-to-face appointments being severely limited.
In this week’s episode, we discuss the benefits and pitfalls of teledermatology. With long waits for secondary care referrals, teledermatology allows dermatologists to fast-track patients requiring urgent investigations, and to direct them to the most appropriate care, which helps to alleviate some of the pressure on GPs.
We talk about the common concerns around missing a skin cancer diagnosis, and the importance of empowering our patients to understand when to seek further help. How do we take good photos of skin lesions to aid diagnosis, and what is the vital information that dermatologists need from a GP referral?
Our guests;
Lucy Thomas is a consultant dermatologist at Chelsea & Westminster Hospital NHS Foundation Trust, she was also part of the Dermatology Team of the Year in the 2020 BMJ Awards, for the creation of a teledermatology service.
Afzal Ansari is chair of the Royal Photographic Society's medical committee, and a medical photographer with decades of experience.
For more on teledermatology
https://www.bad.org.uk/healthcare-professionals/teledermatology

Suddenly shielding and vaccination variation, with Kevin Fenton and Kamlesh Khunti

Suddenly 1.7m extra people have been told to shield from coronavirus, thanks to the QCovid algorithm, and that's causing confusion - ethnicity is one of the risk factors in QCovid, and yet there is a signal that there is lower update of the vaccine amongst ethnic minorities in the UK.
In this week’s episode, we discuss how particular factors, such as age, ethnicity, and comorbidities, affect your QCovid score, and why a GP can help people interpret that population level risk to themselves.
We also discuss how institutional barriers may be preventing people from accessing the vaccine, and the active role that GPs should play in engaging with their at-risk patients, and how they might best support the communities they serve in promoting vaccine uptake.
Our guests:
Kevin Fenton is the Regional Director of Public Health England for London, and Regional Director of Public Health NHS London.
Kamlesh Khunti is a professor of Primary Care Diabetes & Vascular Medicine at the University of Leicester. He is also the co-director of the Leicester Diabetes Centre, and co-developer of the QCovid algorithm.

Mental health toll of lockdown with Daisy Fancourt and Farhana Mann

In the UK, we are currently in the midst of our third lockdown since the pandemic began, and there has been a huge surge in people experiencing mental distress, anxiety and depression during the past year. The novelty of the first lockdown, in which people optimistically took up a variety of new activities, such as learning a language or baking endless loaves of banana bread, has long worn off, and many people now feel like they’ve used up their “coping resources”. Confusing public health messaging has led to great uncertainty, a feeling that we’re having to put our lives on hold, and dwindling hope. In this week’s episode, we discuss the difficulty of measuring the mental health impact of the pandemic, and how other issues (such as financial strain or bereavement) may cause long-term mental health problems. We also talk about loneliness: how to approach the subject with our patients, and the role that social prescribing may play in tackling it.
Our guests;
Daisy Fancourt is an associate professor of psychobiology and epidemiology at UCL. She is the lead researcher on the COVID-19 social study, (https://www.covidsocialstudy.org/) which looks at the psychological and societal impact of the pandemic, and she is also the director of the COVID-Minds Network (https://www.covidminds.org/).
Dr. Farhana Mann is a psychiatrist in London and Wellcome Clinical Research Fellow at the Division of Psychiatry, UCL. She has been on the government advisory group on tackling loneliness, and is part of the UKRI Loneliness and Social Isolation in Mental Health Network, led by UCL.
Additional resources/further reading:
'A life less lonely: the state of the art in interventions to reduce loneliness in people with mental health problems'
https://link.springer.com/article/10.1007/s00127-017-1392-y
'Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID-19 Psychological Wellbeing Study'
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7513993/
'Understanding loneliness in the twenty-first century: an update on correlates, risk factors, and potential solutions' Social Psychiatry and Psychiatric Epidemiology (2020) 55:793–810 https://doi.org/10.1007/s00127-020-01889-7
UCL Network is @ucl_loneliness on Twitter, and they are a good place to start if looking for updates on the field. People are very welcome to get in touch via the website too:
https://www.ucl.ac.uk/psychiatry/research/epidemiology-and-applied-clinical-research-department/loneliness-and-social-isolation