Centenary Conference for the Fellowship of Postgraduate Medicine
7th December, 2018 at the Royal College of Physicians London
Updates on clinical practice from lung disease to stroke, hypertension, liver disease, functional neurological disorders, safer prescribing and personalised medicine.
Approved (code 121386) by the Royal Colleges of Physicians of the United Kingdom for 6 category 1 (external) CPD credits.
Registration: Standard £75 (£50 for trainees) PMJ or HPT authors £50 (£30 for trainees)
1. Marking the centenary of the Fellowship of Postgraduate Medicine
Professor Donald Singer1, Professor Bernard Cheung2,3 and Associate Professor Ken Redekop4,5
1President, Fellowship of Postgraduate Medicine, London, UK; 2Editor-in-Chief, Postgraduate Medical Journal and 3University of Hong Kong; 4Editor-in-Chief, Health Policy and Technology and 5Erasmus University, The Netherlands.
The Fellowship of Postgraduate Medicine (FPM) is a British non-profit organisation that was founded after the First World War, with as its first president pioneering clinician and medical educator Sir William Osler, the Oxford Regius Professor of Medicine. The FPM supported the development in London of postgraduate educational programmes in all branches of medicine. The FPM today continues its interest in supporting national and international postgraduate medical education through its two international journals the Postgraduate Medical Journal (founded in 1925) and Health Policy and Technology (founded in 2012) and by organizing conferences and workshops. Ways in which the FPM is marking its anniversary include hosting a session at the May 2018 Hong Kong Medical Forum, a Centenary Conference on the 7th December 2018 at the Royal College of Physicians in London, providing updates on excellence in clinical practice, introduction of a new Associate Member category for the FPM, and the launch of new international awards for excellence in medical writing by doctors in social media .
The Postgraduate Medical Journal (PMJ) is a monthly journal with a global reach and is widely read online, with nearly 2 million page views in 2017 from North America, Europe and Asia and the most frequent recent articles coming from the UK, USA, China and India. The PMJ aims to support junior doctors and their teachers and contribute to the continuing professional development of all doctors by publishing papers on a wide range of topics relevant to the practising clinician and teacher. In 2017, the journal received 666 manuscripts with an acceptance rate of 20%. With increasing readership and quality of its articles, the journal’s impact factor was 2.078 in 2017, exceeding 2 for the first time. The PMJ will be publishing articles on updates in clinical medicine from the December 2018 FPM centenary symposium at the Royal College of Physicians in London. The PMJ will also have a special issue in 2019 on Sir William Osler, founding President of the FPM. In addition the PMJ will publish papers from other FPM meetings, including the FPM-PMJ session and other sessions at the 2018 Hong Kong Medical Forum, which provides clinical updates for around 2,500 physicians in the South East Asia Region, and also publish papers from future FPM meetings, including 2019 conferences planned on neuropsychiatry and on vascular disease.
Health Policy and Technology (HPT) is a new quarterly journal, focusing on development and implementation of health policy and the role of technology in clinical and non-clinical national and international health environments. HPT aims to educate and inform all stakeholders in health policy and technology, from researchers to clinicians, health economists, health policy leaders and experts in the biotechnology and pharmaceutical sectors. There was a 34% increase to 117 manuscript submissions in 2017 over the previous year, with an acceptance rate of 38%. The journal’s impact factor was 1.013 in 2017. As expected for an international journal, articles published in HPT in 2017 came from a wide range of countries from around the world: Austria, Canada, China, Cyprus, Germany, Greece, India, Ireland, Israel, Italy, the Netherlands, Norway, the Republic of Korea, Pakistan, Slovenia, Spain, Sweden, Turkey, the United Kingdom, and the United States. Pending theme issues for HPT will consider the impact of Brexit on health care, progress on heart health policy, including papers from a recent FPM symposium on health policy for preventing heart disease, and special issues on Big Data for health and on interoperability.
The new Associate Member category for the FPM will be open to doctors in established postgraduate training posts, to senior doctors in established posts and to other experts who are interested in postgraduate medicine. The FPM will shortly launch new international awards to recognise best social media writing on medical themes. Articles should aim to increase understanding by the public and health professionals of important health-related issues. Up to 5 awards will initially be made – one for each major geographical region: the Americas; Europe; Africa; South Asia; South East Asia and Australia/New Zealand. Winning writers will have the opportunity to publish their award-winning article in HPT or the PMJ. The FPM has in recent years been a major supporter of the the medical humanities initiative, the Hippocrates Prize for Poetry and Medicine , which has attracted interest from over 70 countries, with recent awards presented in the UK, at Harvard Medical School and in Chicago, and the 10th annual awards due to be presented at the Centre for Life in Newcastle-upon-Tyne.
- Singer DR Marking the centenary of the Fellowship of Postgraduate Medicine. Postgraduate Medical Journal. 2018; doi: 10.1136/postgradmedj-2018-136150
- Website for the Hippocrates Initiative: hippocrates-poetry.org
2. Prescribing Challenges in Modern Practice
Jamie J Coleman MBChB, MD, MA (Med Ed), FRCP, FBPhS, FFPM(Hon)
Professor of Clinical Pharmacology and Medical Education
University of Birmingham, UK.
Prescribing is the most common patient-level intervention within healthcare. The growth in number of licensed medicinal products over the last century through an “age of excitement” in clinical pharmacological and pharmaceutical research means that prescribing is an increasingly complex task. The complexity is increased further by increasing multimorbidity in an ageing population, which can lead to potentially inappropriate polypharmacy.
Providing medication without harm is a challenge to modern society and the World Health Organisation has set a challenge to reduce medication-related harm by 50% globally by 2022 . A key aim in the UK is to provide support to all prescribers to reduce prescribing errors through a variety of interventions including education and training, interprofessional communication and support, and digital technologies (incorporating clinical decision support).
Comprehensive therapeutic care involves the assessment of the utilization, quality, clinical appropriateness and ongoing cost of prescribed medications. An important skill of the modern prescriber is knowing when not to prescribe or indeed withdrawing inappropriate medication under supervision, with the goal of managing inappropriate polypharmacy and improving outcomes: the process of ‘Deprescribing’ .
Modern practice requires prescribers to be able to provide holistic therapeutic care in a patient-centred approach. This can be challenging when patients are receiving care from a variety of specialists. The prescribing itself may be devolved to other colleagues (junior doctors or family practitioners) from the original decision maker. Communication and collaboration between healthcare practitioners and patients is essential if important pharmaceutical care guidance is followed according to best practice.
- World Health Organisation (2017). Medication Without Harm: WHO’s Third Global Patient Safety Challenge Available at: http://www.who.int/patientsafety/medication-safety/en/ (accessed 20/05/2018).
- Reeve E, Thompson W, Farrell B. Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017 Mar;38:3-11.
3. What to do about difficult hypertension?
Professor Una Martin
University of Birmingham, UK
Hypertension is one of the most important risk factors for cardiovascular disease, which is a significant cause of morbidity and mortality worldwide. Resistant (or difficult) hypertension is thought to affect 1 in 6 patients with treated hypertension and carries an increased risk of death and cardiovascular disease. It is generally defined as uncontrolled clinic blood pressure (>140/90 mmHg) after treatment with three or more antihypertensives to include optimal doses of an ACE inhibitor (or an angiotensin receptor blocker), a calcium channel blocker and a diuretic. There are some factors that must be taken into account before a diagnosis of resistant hypertension can be made. “Pseudo-resistant” hypertension can be caused by poor clinic blood pressure measurement technique, patient non-adherence to prescribed medication, patient intolerance to certain anti-hypertensive medications and white coat hypertension (where blood pressure appears high in the clinic but is controlled out-of-the-office on home or ambulatory measurements).
Pharmacological treatment of resistant hypertension is focused on the addition of fourth-line therapy and recent evidence supports the use of spironolactone. Lifestyle should be reviewed and patients encouraged to exercise regularly and lose weight, reduce their alcohol and sodium consumption and stop smoking. In patients who remain uncontrolled on optimal treatment, there are a number of alternative treatment options and surgical procedures which can be considered. However, the evidence supporting each of these is limited and in some cases, conflicting and therefore more prospective randomised controlled trials are required before any can be adopted into routine clinical practice.
4. Diagnosis and management of non-alcoholic fatty liver disease (NAFLD)
Professor CD Byrne
University of Southampton, UK
Non-alcoholic fatty liver disease (NAFLD) is a metabolic liver disease that includes a spectrum of liver disease extending from simple steatosis or non-alcoholic fatty liver (NAFL) to steatohepatitis (NASH), liver fibrosis and cirrhosis. NAFLD is also a risk factor for developing type 2 diabetes (T2DM) and cardiovascular disease. Patients with NASH may or may not have liver fibrosis, but the presence of advanced liver fibrosis not only increases the risk of cirrhosis and end stage liver disease but also markedly increases the risk of hepatocellular carcinoma.
The ‘gold standard’ diagnostic test for NAFLD is the liver biopsy but there are now a variety of non-invasive tests that can be used to diagnose and monitor the various stages of NAFLD and whilst none of these tests are perfect, each have their strengths and limitations that influences how they should be used in clinical practice.
The early stages of NAFLD, i.e. liver fat and inflammation (steatohepatitis) respond to lifestyle changes such as weight loss and increases in physical activity that are also important components of T2DM management; and the available evidence supports the importance of lifestyle change in people with NAFLD. However, such change is notoriously difficult to achieve, so safe and effective treatments are also required to prevent and treat NAFLD. The presentation will discuss the diagnosis and management of NAFLD, including key points of management from the recent UK NICE NAFLD Guidelines (ng49), Joint Societies European Guidelines and US Guidelines.
5. Therapy for asthma and COPD
Professor Peter J Barnes FRS FMedSci
National Heart & Lung Institute, Imperial College London, UK
A hundred years ago the main treatments for obstructive lung disease were adrenal gland extracts, herbally-derived sympathomimetic ephedrine and anticholinergics, such as atropine. There have been extraordinary advancers in the pharmacological therapy of asthma and COPD, yet the major classes of therapy we use today are based on these original therapies – long-acting β2-agonists (LABA) derived from adrenaline and muscarinic receptor antagonists (LAMA) and inhaled corticosteroids (ICS) developed from the adrenal cortex hormone cortisol. Triple fixed-dose inhalers containing all 3 drugs have now been developed and are convenient for some patients. In asthma, by far the greatest advance has been the introduction of ICS for control of the underlying eosinophilic inflammation of the airways. Although ICS are effective in most patients, there is often very poor adherence as symptoms are intermittent. In a new strategy, instead of a short-acting β2-agonist, such as salbutamol, patients use a reliever inhaler containing a rapidly-acting LABA formoterol combined with an ICS. This provides much better control of asthma and is a simple strategy for most patients. At the other end of the spectrum, patients with eosinophilic severe asthma not controlled on conventional therapies may now be controlled with biologics, which include antibodies against immunoglobulin-E, interleukin-5 and interleukin-4 receptor. In COPD the mainstay of treatment is LABA and LAMA, often as a combination inhaler, whereas ICS are only effective in a proportion of patients that also have eosinophilic inflammation. New safe anti-inflammatory treatments are needed to prevent the progression and exacerbations of COPD.
6. Poetry, medicine and the Hippocrates Prize
Professor Michael Hulse1 and Professor Donald Singer2
Department of English and Comparative Literary Studies, University of Warwick, Coventry, UK; 2Fellowship of Postgraduate Medicine, London, UK.
Why should health professionals be interested in poetry? Patients and their families and carers are accustomed to the use of music and painting in therapy and recent years have seen remarkable growth in the use of poetry for therapeutic purposes. Poetry now features in the curriculum for training health professionals, including doctors, nurses and midwives, in many academic centres in Europe, North America and other continents.
The concept is not new. Poetry was used to treat abnormal mood by the Greek doctor Soranus two thousand years ago . Renewed interest in poetry as therapy during the 20th-century has inspired a growing body of poetry written about serious medical disorders, including psychiatric problems, HIV/AIDS and cancers .
For almost a decade the Hippocrates Initiative has been exploring the relations between the disciplines of poetry and medicine, both through scholarly inquiry at its annual international symposium and creatively through the Hippocrates Prize for Poetry and Medicine, which over the years has attracted entries from some seventy countries worldwide. During this session on poetry and medicine, we shall hear readings from the Hippcrates Prize by previous winners Jane Draycott and Wendy French.
We take great pleasure in acknowledging the generous sponsorship of the UK’s Fellowship of Postgraduate Medicine (for the health professional and open categories of the Hippocrates Prize) and of UK healthy heart charity the Cardiovascular Research Trust (for the young poets’ award). Judges have included eminent poets such as Jorie Graham, Gwyneth Lewis, Philip Gross, Jo Shapcott and the late Dannie Abse, leading figures from the medical profession such as Professor Sir Bruce Keogh, Professor Steve Field, Dr. Owen Lewis and Professor Femi Oyebode, and prominent people from public life, among them James Naughtie, Robert Francis QC, Martha Kearney, Neal Baer and Mark Lawson.
There were entries from thirty-seven countries on five continents for this year’s prizes in the open category, the health professional category, and the young poets category. These awards were announced on 11 May at the Poetry Foundation in Chicago following the Hippocrates international symposium on poetry and medicine, hosted this year by the Center for Bioethics and Medical Humanities at Northwestern University’s Feinberg School of Medicine.
The 10th annual Hippocrates prizes will be awarded on 17th May 2019 at the Centre for Life in Newcastle, with American-Mexican poet and PEN international President Jennifer Clement judging the international Open and Health Professional awards (closing date 14th February 2019) and New Zealand poet Elizabeth Smither judging the young poet awards (closing date 1st March 2019). To find out more about the Hippocrates Prize, Hippocrates Press publications, and the Hippocrates Society, please visit www.hippocrates-poetry.org.
1. Singer DRJ, Hulse MW. Poetry, medicine, and the 2018 International Hippocrates Prize. Lancet. 2010 Mar 20;375(9719):976-7.
7. New approaches for old diseases: what to do about malaria?
Professor Sanjeev Krishna FMedSci
St George’s University of London, UK
Disease and deaths caused by malaria have fallen significantly in the past few years. These successes rely on many interventions such as better diagnosis, the use of insecticide impregnated bed nets and artemisinin combination therapies. There is also hope that vaccines can be improved to assist in elimination programmes that have been so successful in many countries.
Gains against malaria remain fragile because effective interventions can fail quickly. Mosquitoes can be selected for resistance to insecticides, and parasites escape from artemisinin combination treatments. Vulnerable populations such as pregnant women still only have a limited repertoire of preventative strategies available. Whilst malaria caused by conventional species is as old as the hills, zoonotic parasites that infect humans in particular geographic areas are emergent infections.
Some of these risks of increasing malaria burdens can be mitigated by recent advances. The need for more sensitive diagnostic tests in the era of elimination is being addressed, together with newer methods to monitor molecular markers for drug resistance. New drug classes are being discovered, and there are many vaccine candidates in different stages of clinical development. Together with these innovations and increasing resources to manage malaria, there is also greater scope for applying existing antimalarials more effectively.
8. Ageing and multi-morbidity
Professor Thomas B L Kirkwood
Newcastle University Institute for Ageing, UK
A growing fraction of the population is living to advanced old age, bringing increased prevalence of a wide range of age-related chronic diseases. Age is much the largest risk factor for a whole spectrum of different diseases, dwarfing the contributions from genetic, lifestyle and environmental risk factors. Furthermore, the fact that so many conditions share ageing as their dominant risk factor means that very old people commonly exhibit extensive multi-morbidity. In terms of underlying mechanisms, we now know that ageing itself is not programmed. On the contrary, our bodies are programmed for survival, but evolutionary considerations mean that there was never reason to invest in the potential for indefinite survival. Consequently, we now understand that ageing is driven by the lifelong accumulation of damage in our cells and organs, and the same is true of age-related, chronic diseases. Thus, there is a huge overlap. Recognition of this common ground between intrinsic ageing and the underlying causes of age-related multi-morbidity offers intriguing opportunities to improve the trajectories of health across our lengthening lifespans.
9. Applying Personalised Medicine in Clinical Practice
Wolfson Centre for Personalised Medicine, University of Liverpool, UK
Personalised or precision medicine represents the overall concept of how drugs can be better targeted to individuals or groups of individuals to improve efficacy of the treatment, and minimize any safety issues, thereby improving the benefit-risk profile of the therapy. In order to achieve this goal, many different technologies will need to be utilised which includes all the omics technologies, drug pharmacokinetics and pharmacodynamics, and the use of wearable sensors, to name a few. While there has been a lot of emphasis on all omics technologies, genomics has had the greatest impact. Personalised or precision medicine approaches can be applied to chemical entities, cell therapies and nucleic acid-based therapies. For example, with respect to the latter, advances in gene therapy are beginning to produce real benefits in inherited diseases such as haemophilia, while antisense therapies are being utilised in a number of CNS conditions including spinal muscular atrophy and Huntington’s disease. Targeted therapies developed on the basis of the identification of somatic driver mutations are now the norm rather than the exception in cancer medicine, with combinations of treatments including targeted and immune therapies promising tractable responses in previously untreatable malignancies. Pharmacogenomics is also gaining traction with different approaches being used including (a) developing or repurposing drugs on the basis of mutations in disease-causing genes; for example the use of ivacaftor in cystic fibrosis; (b) defining inter-individual variability in dose, for example with warfarin; and (c) in preventing serious adverse drug reactions; for example the use of HLA genotyping to prevent life-threatening adverse reactions such as toxic epidermal necrolysis. Pre-emptive genotyping approaches are also being used where genetic data is available at the point of prescribing, much like the availability of liver and renal function tests. It is important that future generations of healthcare professional are trained in the area of precision medicine, as the complexity of new drugs increases, the therapy choices available increase and our ability to delve deeper into making the right therapeutic choices for patients improves.
10. Functional neurological symptoms
Dr Tim Nicholson
Institute of Psychiatry, Psychology and Neuroscience, King’s Medical School, London, UK
Functional Neurological Disorder (FND) is at the complex interface of the body and mind and therefore also physical and mental health. It has been neglected by medicine so little is known about its mechanism or treatment. However, there have been recent critical developments, particularly establishing it is as common as Parkinson’s or multiple sclerosis and associated with poor outcomes and consequently associated with very high rates of disability and both health and social care costs.
There have also been critical changes in its diagnosis. The historical requirement of identifying causative stressors has been removed as it is now clear that these are not found in a significant proportion of patients. Instead, there has been increased emphasis on identifying ‘positive neurological signs’ which allow its reliable distinction from other disorders. Such signs can also be explained to patients to help them to understand the basis of the diagnosis and how it can be caused by dysfunction of cognitive processes such as attention and illness representations, thereby increasing acceptance of a complex and stigmatised diagnosis. The widespread adoption of the acronym FND and therefore the term ‘functional’, an aetiologically neutral term, has also facilitated critical steps in uniting patients and clinicians.
FND patients regularly have current and/or past comorbid symptoms presenting to other specialities such as fibromyalgia and Irritable Bowel Syndrome, which can be viewed as related disorders with overlapping mechanisms. Insights from FND research are therefore well positioned to inform the broader field of functional disorders which account for approximately 30% of morbidity and costs across medicine.
11. Reducing the Severity of Stroke
Professor Anthony Rudd
Stroke Consultant at St Thomas’ Hospital, London and Professor of Stroke Medicine, King’s College London, UK. National Clinical Director for Stroke with NHS England; London Stroke Clinical Director; Chair, Intercollegiate Stroke Working Party.
100,000 people in the UK have a stroke and worldwide it is responsible for 15 million deaths every year. With the ageing population, it is predicted that mortality will rise by 45% over the next 20 years in Europe and there will be over 4.5 million stroke survivors. Only 30 years ago it was considered to be a largely untreatable disease. There was no evidence for any acute intervention and rehabilitation was sporadic and rarely available at all in the community. In fact, little had changed over the previous century since Osler had written that ‘there was no possibility of a cure’. Huge advances have been made in reducing the severity of stroke. Being managed on a stroke unit compared to a general ward reduces the odds ratio of death or dependency by 21%. Intravenous thrombolysis does not save lives but overall greatly increases the chance of disability free survival. The last 3 years has seen publication of multiple trials of thrombectomy, all showing major benefits in reducing disability. Transferring patients from hospital to home early, continuing specialist rehabilitation and early supported discharge team are also more effective than conventional care at reducing the severity of stroke.
Delivering evidence based care to all patients regardless of where they live and when they have a stroke is challenging. Progress is being made with stroke being a priority area for the NHS, learning the lessons from the restructuring of stroke services in London and Manchester