Ten years ago today (eleven by the time this is published), I learned that I had passed my medical school finals and became a doctor. It doesn’t feel like it was a decade ago.

At work, I recently happened to have a meeting with someone I worked with as an F1 doctor but haven’t seen since. It felt like we worked together a month ago rather than a decade. I still occasionally say “hi” in the street to the porter who used to comment on my “Bird’s Custard” colour tie as an F1. And yes, somehow my F1 year was long enough ago that ties weren’t yet banned in hospitals.

I think the Simon of ten years ago would be amazed to find that I’m now working in public health. I didn’t enjoy the occasional public health bits at medical school, and I wasn’t even really aware that it was it’s own specialty until I came to pick a career path. Public health always struck me as worthy, dull, and far removed from anything that actually had any measurable impact on patients.

It was only after a serendipitous run of F1 hospital rotations that I started to see the point. My first job was in upper gastrointestinal surgery, a subspecialty involving seriously brutal surgical interventions to treat cancers with very poor prognoses. My second job was in stroke medicine. My third was in gastrointestinal medicine, a speciality in which a large proportion of the patients had end-stage liver disease as a result of alcoholism.

I think it’s impossible to go through that sequence and not feel slightly despairing: hospital medicine comes too late for most of these patients. Their lives very often cannot be pieced back together: as one particularly insensitive consultant used to regularly say, for those patients “the party’s over”.

The most effective treatment for these patients would be to rewind time and tackle their problems before they were ill. This initially pushed me towards General Practice, until I realised (late) that this was the point of Public Health. My realisation of this came so late that I didn’t really know what public health doctors did all day, but stuck in an application to the specialty anyway… as well as general practice.

After long essay-style application forms, written exams and half-day intensive interviews known as “selection centres”, it somehow came to pass that I was offered places on both the GP and public health training schemes. I had 48 hours to decide between a familiar career path and one which sounded fascinating but that I barely understood. In truth, I hedged: I went with public health because general practice always under-recruits, and I was pretty confident that a re-application to GP would be successful in 12 month’s time if public health turned out to be awful.

I was also put off by the obsession with portfolios in General Practice. My experience of clinical portfolios was that doctors were judged too much on their ability to write and present evidence rather than on their practice of medicine. I was, even if I say so myself, great at presenting portfolios of glowing assessments as a Foundation Doctor, but this felt a bit flat. It seemed to me that people in public health were known by results and reputation, and I liked that idea. I’m not so sure that was an accurate assessment of either speciality, but it certainly played a part in my decision-making at the time.

Leaping into public health felt brave at the time, even if it seems like hedging in retrospect: no end of people were telling me that I’d be “wasted” in public health and that my skills with patients meant that I’d be a fantastic GP. Some of this was subfusc whispers in my ear, some was formal written feedback, some was mildly paternalistic advice. Only a minority were enthusiastic. Luckily, once I set my mind on something, I’m pretty strong-willed.

Public health wasn’t awful. I mean, it had its moments: within weeks of me accepting a place, the coalition Government announced an intention to move public health outside of the NHS. This may have been the right decision, but it was terrifying for me as an NHS doctor to know that my NHS career path had been cut off just as it was beginning.

As I progressed through my training, I came to really enjoy health protection, the part of public health which deals with outbreaks and other biological, chemical and radiological threats to the population. I liked the combination of clinical-style short-term pressure, thoughtful balancing of risks, and the close association with clinical colleagues (and occasionally patients). I wrangled the system to spend almost half of my training in health protection placements, and since 2016 I’ve been a consultant in health protection. It is—by far—the most enjoyable and rewarding job I’ve ever done, in which I’m surrounded by a brilliant team who never give anything less than their best.

So, in career terms, I could not be further from where I thought I’d be ten years ago. But I also couldn’t be happier with the choices I’ve made. I don’t really know that there’s a lesson in that.

Someone once told me that the most important thing in career planning is to do what you enjoy and collect certificates along the way. Delayed gratification is rarely worth it in career terms: the gratification might never come. But its hard to ever regret doing something you enjoy, and collecting certificates provides tools to make a “leap” to something else when the first thing stops being fun.

I don’t know whether that’s good advice or not, but it roughly correlates with my experience over the last ten years. Let’s hope that I’m still enjoying things as much ten years hence – whatever I’m doing then!

The picture at the top is obviously my own. It was from my graduation which was, of course, a little later than the day I found out I’d passed.

In this morning’s Monocle Minute, there was a fascinating bit about a public health measure in Pakistan which had completely passed me by:

Pakistan’s Punjab province has taken an intriguing step to discourage its citizens from chugging too many cans, demanding that brands such as Red Bull and Monster remove the word “energy” from their packaging and replace it with “stimulant”. The move comes from the scientific advisory panel of the Punjab Food Authority (PFA), who ruled that the word was misleading. The PFA decided that the drinks do not provide people with nutritional energy per se, rather that the caffeine, taurine and guarana merely stimulate drinkers.

I think there is much to be done around the regulation of food packaging, as it often seems pretty misleading. But most of what I’d thought about previously was around claims about the “healthiness” of foods and claims about calorific content. In fact, I’ve had previous publications ranting about both the food industry and the public health response on the latter point, but don’t have any clear answers of my own to offer. I’d never really thought about the connotations of “energy” drinks as a name, so I think the story above is a really interesting development and I’ll be intrigued to see whether it spreads more widely.

Sometimes, even those of us in public health miss public health developments in our own country. I only recently because aware of the fact that liquid laundry detergent capsules are now packaged in opaque containers not because of changing consumer preferences but because of very sensible European legislation, designed to reduce their attractiveness to children.

That’s a public health legislative win by anyone’s yardstick… and while most had realised the packaging had changed, no-one in my office was even aware that the legislation existed. It’s amazing how much public health measures can pass by even those of us working in the field – we perhaps don’t do enough to celebrate public health achievements that aren’t badged like that.

A year or so ago, my friend James O’Malley wrote a great article revealing that Fuller’s pubs had gone sugar-free on soft drinks – years before the Soft Drink Levy came into force. This was a voluntary public health measure by a private business. Wouldn’t it have been great if, say, Public Health England or the Faculty of Public Health had seized on this as an example of responsible action and praised the chain – rather than simply ignoring it? Just a thought.

The photo at the top is a cropped version of this photo posted to Flickr by Mike Mozart. I’ve edited and re-used it above under its Creative Commons licence.

In most of medicine, and in Health Protection in particular, one occasionally comes across people who have made questionable decisions which have had severe consequences. When people decline routine vaccinations or fail to use a condom for specious reasons, it can be both depressing and frustrating to be picking up the pieces.

It’s easy to rationalise that health is not at the top of everyone’s personal agenda and that sources of misinformation are common and commonly believed. At these times, it feels like the most productive outcome is to channel the frustration into improving the information on offer and trying to reach the people who have missed it.

A friend once told me to think of ‘health’, a topic which most of my life is dedicated to, in terms of ‘transport’, a topic with which I’m intimately engaged as a ‘user’ but in which I’m completely non-expert:

I might get frustrated that people don’t take obvious preventative health measures, but when was the last time I checked my tyre pressure, an obvious ‘preventative measure’ in the ‘transport’ world? (I’ve done it once in the nine years I’ve owned my car.)

I might get annoyed that people don’t have any idea of the true cost of their healthcare, but what’s the true cost of the public transport I take to work each day? (I’ve no idea.)

I might think that’s it’s patently obvious that homeopathic remedies contain no active ingredients and are a total waste of money, but what’s the evidence of benefit for the ‘premium’ grades of petrol? (I often buy them, even though there’s probably no benefit.)

And then, just occasionally, I come across something that seems so appalling unappealing that I’m baffled that anyone, medical knowledge or not, could possibly want to engage with it, let alone risk harm by doing so:

One type of apitherapy is live bee acupuncture, which involves applying the stinging bee directly to the relevant sites according to the specific disease.

Live bee acupuncture. Wowzers trousers. This paper by Vazquez-Revuelta and Madrigal-Burgaleta in the Journal of Investigational Allergology and Clinical Immunology, from which the above quote is taken, reports a terribly sad case of a 55-year-old woman who died from live bee acupuncture.

The paper reports that she’d been attending four-weekly for two years for the procedure, with the aim of treating

muscular contractures and stress.

As one might expect,

the risks of undergoing apitherapy may exceed the presumed benefits, leading us to conclude that this practice is both unsafe and unadvisable.

There is little about this paper which isn’t at least mildly astonishing. But then I wonder… I don’t know what the transport equivalent of intentional bee stings might be, but perhaps I engage in that too.

The alarmingly cute picture of a bee at the top of this post was posted on Flickr by Ozzy Delaney. I’m reusing it here under its Creative Commons licence.

A couple of news stories I’ve read lately have made me think about our approach to regulation of advertising.

First, there was this story by Travis M Andrews in The Washington Post about the portrayal of smoking in shows made for streaming services:

Among the vices often embraced by streaming services and avoided by broadcast television is tobacco in all in its forms … A study compared seven popular Netflix shows to seven popular broadcast shows. In this sample, it found Netflix’s shows featured characters smoking almost three times as often as those produced by broadcast networks like NBC, ABC and CBS.

Now, we could spend all day poking holes in this ‘study’, but the thought is still going to fester: it does seem like there might be more smoking in these shows than in those on broadcast TV.

Second, there was this BBC Trending story by Branwen Jeffreys and Edward Main about YouTube stars being paid to encourage kids to cheat on school assignments:

YouTube stars are being paid to sell academic cheating, a BBC investigation has found. The BBC Trending investigation uncovered more than 1,400 videos with a total of more than 700 million views containing EduBirdie adverts selling cheating to students and school pupils. In some of the videos YouTubers say if you cannot be bothered to do the work, EduBirdie has a “super smart nerd” who will do it for you.

This isn’t so obviously related to health but does highlight an issue with inappropriate advertising within online streams which are typically seen by children and young people.

Both of these stories made me reflect on the work that has gone into restricting advertising of harmful products such as cigarettes and energy dense foods, and how the fruit of that work might be lost if legislation doesn’t keep up with changing media consumption habits.

For example, there are no regulations around the portrayal of smokers on streaming shows, whereas broadcast shows must comply with Ofcom’s rules, including Rule 1.10:

Smoking must generally be avoided … unless there is editorial justification.

There seems to be non-stop debate in the media press about whether TV ads or online ads are more ‘impactful’, with the conclusion usually predictable according to who has funded or published the work. But it does seem increasingly clear that many people (including me) are now watching more streamed content than broadcast content, and that this is more common among younger people.

It’s hard not to worry that the slow pace of legislative change might cause us to unintentionally slide back to an era of lesser regulation of what is actually seen despite strong evidence of harm. We really mustn’t let that happen.

The photo at the top was posted on Unsplash by Tina Rataj-Berard and is used here under the Unsplash licence.

A couple of years ago, I wrote a post for the Fuse Open Science Blog about the system failures which lead to patients ‘inappropriately’ presenting at A&E, and how this is often blamed on patients who are expected to self-triage with a high degree of accuracy. I’ve thought of this today because it popped up in my Facebook ‘memories’.

This has prompted a couple of completely disconnected thoughts.

My first thought is that what I wrote then remains true today, and has become even more relevant with ever-increasing pressure on NHS Trusts. Effective triage of patients to the ‘correct’ NHS services is a nut that remains stubbornly uncracked.

More money has been ploughed into putting GPs in A&E departments, despite mixed evidence on cost and patient throughput. Some companies are experimenting with triage chatbots for the NHS which feels to me like an unlikely solution to the problem of sorting acutely unwell patients. The NHS Choose Well campaign keeps steaming ahead at various levels of the NHS as though doing more of the same will result in a completely different outcome.

Anecdotally, clinical colleagues tell me that last winter was ‘better’ than others in recent years, in as much as A&Es were over-filled with patients who should be there rather than patients who shouldn’t be there. Of course, that means departments are more pressured. Perhaps the fear of long waits and ‘chaos’ puts off ‘inappropriate’ attendees. I’m certain that it puts off some ‘appropriate’ attendees and that this will, at least in a very small way, have contributed to excess winter deaths for 2017/18.

My second—unrelated—thought is that I have absolutely no memory of writing or publishing that Fuse article. I mean, I know I wrote it, but I have no memory of constructing it, or of looking up the stuff about Joseph Hodgson and drawing a parallel between misuse of historical charitable hospitals and the modern NHS.

I’m always bad at remembering things I’ve worked on in the past, but to have such a complete absence of any memory for something I wrote (and clearly put thought into) only 24 months ago is remarkable even for me.

I can only assume I was knackered when I wrote it… which would also explain the slightly crap call-back pun in the last line. I can see what I was trying to do, but reading it now, I think it slightly missed the mark.

The picture at the top is a cropped and edited version of a photo published on Flickr by gwire. I’m using it under its Creative Commons licence.

Last week, I read this remarkable story about a new cruise ship by Oli Franklin-Wallis in Wired, and have been thinking about it ever since:

Symphony of the Seas – which, on its maiden voyage from Barcelona in March 2018 became the largest passenger ship ever built – is about five times the size of the Titanic. At 362 metres long, you could balance it on its stern and its bow would tower over all but two of Europe’s tallest skyscrapers. Owned and operated by Miami-based cruise line Royal Caribbean, it can carry nearly 9,000 people and contains more than 40 restaurants and bars; 23 pools, jacuzzis and water slides; two West End-sized theatres; an ice rink; a surf simulator; two climbing walls; a zip line; a fairground carousel; a mini-golf course; a ten-storey fun slide; laser tag; a spa; a gym; a casino; plus dozens more shopping and entertainment opportunities.

Cruise ships mean two things to me.

Earlier this year, I went on a ‘mini-cruise’ from Newcastle to Amsterdam aboard a DFDS ship. The journey was an overnight 15 hour or so thing, so certainly not equivalent in any way to spending weeks at sea on the world’s biggest cruise ship. The rationale for this was that I fancied a last-minute break and couldn’t find a cheap flight from Newcastle, so went on a cheap boat instead, spent a day in Amsterdam, and took a cheap flight from there. This worked remarkably well, and I’d do it again.

This was the first time I’d been on an overnight boat since our annual family camping trips to France when I was a child. Prior to going, I’d sort of thought in the back of my mind that I might be the sort of person who might one day enjoy a proper cruise. This experience put me off.

The ship was lovely, and I was particularly impressed by the cabin. I had expected a pokey bunk-bedded hovel but was actually rewarded with a fairly large space which looked not unlike a Travelodge room, with an en-suite bathroom. The food on board was also much higher quality than I would have expected. But I am somebody who likes to wander—and even with only 15 hours on the ship, I was itching to get off and explore. Exploring the ship felt a bit constrained.

It was silly of me not to realise this in the first place. Wendy and I ruled out going to an idyllic holiday resort last summer for the sole reason that it was located on a main road along which walking was not advised, so we couldn’t ‘go for a wander’ without catching a bus or taxi somewhere first. I hadn’t really clocked that ‘going for a wander’ wasn’t really a go-er on a ship.

While the Symphony of the Seas is ridiculously bigger than the ship I was on (it’s more than twice as long and can take four times as many passengers across twice as many decks), I still think I’d feel ‘cooped up’ pretty quickly. So I don’t think I’ll be going cruising anytime soon.

My other relationship with ships is professional. One of the more esoteric parts of my role as a Consultant in Health Protection is that I am the designated Medical Officer for a number of ports. This gives me certain legal responsibilities relating to ships and the health of their crew—most of which are thankfully delegated to people much more expert than me. But just imagine how complex an outbreak of norovirus or Legionnaire’s disease could get on a ship as huge as Symphony of the Seas. I was fascinated to read in Oli’s article about some of the steps taken to mitigate the risks:

“The level of hygiene is extreme,” Yrjovuori announced, as we passed a hand-washing station. Though ship-wide outbreaks of sickness make the news at least once a year, the total number of passengers who fall ill is a fraction of one per cent. But close quarters enable outbreaks, so sanitation regulations at sea are stringent. Every part of the ship, from lift buttons to the casino’s chips, are sanitised daily; interior materials have to stand up to the high level of chlorination from the constant cleaning. Rubbish is frozen in vast storage containers to slow bacteria growth and is only removed in port.

Fascinating stuff… perhaps we could even try and replicate some of it on land!

The pictures in this post are my own from the above-described ‘mini-cruise’ adventure. The pictures in the Wired article are a great advert for the power of print, looking far more arresting as double-page spreads than as on-screen images.

A few years ago, I did a stint in General Practice. One of the commoner things people would come and see me for was a sore throat, and as a good antimicrobial steward I tended to send them away with self-care advice.

One bit of advice I routinely gave to adult patients was to gargle with salt water: dissolve half a teaspoon of salt in half a cup of boiled water mixed with half a cup of cold water, gargle with it for a minute and spit it out. I think it may even have been written on the little self-care leaflets I used to dish out.

This has a surprising amount of evidence behind it for a home remedy, though largely in the context of postoperative throat pain. It is now the published NHS advice for sore throats—it may have been at the time too, I’ve no idea.

What sticks in my mind about this advice is the number of people who mentioned at unrelated later appointments what excellent advice it had been. I even remember a singer telling me the advice had rescued a performance she thought she may have to cancel. In my experience, patients aren’t especially forthcoming with positive feedback on self-care strategies, but I really seemed to get a lot about this advice. Despite that, and despite a vague awareness of the evidence base, I didn’t really believe it. I mean, it sounds like utter nonsense, like the sort of folk remedies you hear for all kinds of things that aren’t evidence-based (and can even be downright unhelpful).

And yet… over the last week or so, for the first time in as long as I can remember, I’ve been suffering from a really sore throat. I tried gargling salt water. And, blow me down with a feather, it really works. Certainly, I’ve found it far more effective than any throat sweets or sprays I’ve come across.

I think there’s probably a deep message in here somewhere about common sense being remarkably uncommon, or about doctors being the worst patients, or about a disconnect between academic evidence and belief systems. But really, I’m just trying to say if you have a sore throat, try gargling with saltwater. It worked for me.

I came across the advert at the top of the post via the Boston Public Library online. I wonder if there are any medications advertised today as for both “man and beast”? If you’re wondering, you didn’t have to get your “beast” to gargle it:
it could also be applied topically (hence ‘liniment’, which is a word we don’t use nearly enough these days).