All that training suggests doctors should know best | Letters

As a team of physicians and social scientists studying how choices are made during consultations, we were disturbed to read that the Royal College of Surgeons agrees with Lady Hale that doctors should not be making treatment recommendations (Report, 27 October). While a “paternalistic” approach is clearly inappropriate for the 21st century, decades of health communication research point to shared decision-making as the best alternative. This is categorically not the same as the “information-only” approach advocated in the new guidance, which requires doctors to withhold their views even when they have good grounds for making a recommendation, and even when the patient asks for one.

In our research, we found numerous problems with the enactment of patient choice, including patients not knowing how to decide, patients seeking the neurologist’s recommendation when it was not offered, and the near impossibility of providing information in a fully neutral fashion. Moreover, we found that there was no evidence that being offered choice was associated with higher levels of patient satisfaction.

Patients vary widely in their knowledge, preferences and decision-making capacity. Part of enacting shared decision-making is to work sensitively with the patient to establish what role they wish to play at that particular time. Certainly, patients should be given clear, balanced information about the range of available options, and the potential risks and benefits of each. But imposing choice on patients who do not want it is just as paternalistic as insisting that they follow doctors’ orders.
Dr Paul Chappell Department of sociology, University of York
Professor Roderick Duncan Associate professor of neurology, University of Otago, New Zealand
Dr Clare Jackson Department of sociology, University of York, UK
Professor Markus Reuber Professor of clinical neurology, University of Sheffield
Dr Merran Toerien Department of sociology, University of York

• It is clearly right that patients are given all the information they need to make a decision concerning their treatment options, but could I have the temerity to suggest that, quite often, doctor does know best? It would be a matter for concern were it not so – we are trained for 12 or more years at taxpayers’ (and, increasingly, our own) expense, and if we didn’t know more about illness and its treatment than the patient, all that money would have been wasted.

Some decisions are so complex that it is not possible to give the patient sufficient insight and knowledge to be able to choose between two courses of action. To fail to take a decision on their behalf in that situation would be an abdication of responsibility, and a betrayal of their trust.
Dr Bob Bury
Leeds

• Re your article (Leading doctors list dozens of procedures that ‘give no benefit’, 24 October), the Academy of Medical Royal Colleges research is a welcome contribution to the debate about the pressures faced by doctors daily. The headlines, however, focus predominantly on the 40 specific treatments and procedures the AMRC consider should no longer be in routine use, when perhaps we should be looking at what underlies GPs’ decisions on their use.

In the study, about 60% of doctors said their decisions were driven by a fear of litigation. A similar proportion said interventions were a result of increasing pressure and expectations from patients. I would argue that these statistics are in fact the most striking and concerning, and they concur with our own research. A survey of 600 GP members showed 67% are fearful of being sued – and of those, 85% say this fear impacts negatively on the way they practise. Furthermore, 86% of our members said they sometimes, most of the time or always encounter challenging experiences with patients when they do not provide the prescription, treatment or referral to a specialist they request.

This paints a clear picture of the increasingly challenging environment in which doctors are working, and highlights the need for doctors to understand and be supported on how to manage patients’ expectations. When expectations are not met, it can lead to dissatisfaction, a breakdown in trust and a greater risk of the patient pursuing a complaint or claim. This is an important debate for all in healthcare today, and for society as a whole.
Dr Pallavi Bradshaw
Senior medicolegal adviser, Medical Protection

• Polly Toynbee (Our nurses are being cast into a perfect Brexit storm, 25 October) suggests cuts were made to the trainee nursing workforce by Health Education England. In fact HEE has increased adult nurse commissions significantly in the past three years. Since our establishment, we have grown adult nurse training places by almost 15%.

Decisions were made in the system prior to HEE’s creation to reduce nurse commissions. Our priority has been to grow this vital workforce and can been seen in our published Workforce Plan for England.

Although our remit is primarily for the future workforce, we have also taken decisive short-term action to help the service. Our return-to-practice campaign has already secured on programmes a further 1,900 nurses. The new nursing associate role and more flexible training pathways into nursing will help to support the service. We are also working with NHS partners to reduce turnover and improve retention in the existing nurse workforce.

Our aim is to make sure that future patient needs are met and that we have enough people with the right skills, values and behaviours available.
Professor Ian Cumming
Chief executive, Health Education England

• Join the debate – email guardian.letters@theguardian.com

All that training suggests doctors should know best | Letters

Brain training technique offers new possibilities for paraplegic people – video report

Dr Miguel Nicolelis explains the findings of the Walk Again Project, the collaborative project aimed at helping paraplegic people regain control of their lives using robotics. The project published its findings after ten months’ research into the use of virtual reality and exoskeleton technology with paraplegic people. However, it was found that the pairing of technologies lead to unexpected positive results for patients, all of whom reported increased movement on command and greater sensation after 2000 hours of training with the systems

Brain training technique offers new possibilities for paraplegic people – video report

"Brain training" technique restores feeling and movement to paraplegics

Eight paraplegics – some of them paralysed for more than a decade by severe spinal cord injury – have been able to move their legs and feel sensation, after help from an artificial exoskeleton, sessions using virtual reality (VR) technology and a non-invasive system that links the brain with a computer.

In effect, after just 10 months of what their Brazilian medical team call “brain training” they have been able to make a conscious decision to move and then get a response from muscles that that have not been used for a decade.

Of the octet, one has been able to leave her own house and drive a car. Another has conceived and delivered a child, feeling the contractions as she did so.

The extent of the improvements was unexpected. The scientists – part of the Walk Again Project that unites 100 scientists from 25 countries – had intended to exploit advanced computing and robotic technology to help paraplegics recover a sense of control in their lives. But their patients recovered some feeling and direct command as well.

The implication is that even apparently complete spinal cord injury might leave some connected nerve tissue that could be reawakened after years of inaction.

VR technology is combined with harnesses and other walking aids to get the patients accustomed to making a link between movement, and thinking about movement. Photograph: AASDAP

The patients responded unevenly, but all have reported partial restoration of muscle movement or skin sensation. Some have even recovered visceral function and are now able to tell when they need the lavatory. And although none of them can walk unaided, one woman has been able to make walking movements with her legs, while suspended in a harness, and generate enough force to make a robot exoskeleton move.

“Some of our patients, for the first time, were able to get out of their houses and go back to work,” said Miguel Nicolelis, co-director of the Duke University Centre for Neuroengineering, and based at the Alberto Santos Dumont Association neurorehabilitation laboratory in Sao Paulo.

The study parallels other approaches to spinal cord injury: there are hopes of stem cell therapy that could make possible natural repairs to the nervous system, and of electronic implants that might bypass a spinal cord injury to transmit the brain’s message to the muscles.

The Brazilian trial was originally intended as a test of the third approach: robotic aids driven by brainpower. The scientists gave an example of what they thought possible in 2014 when Juan Pinto, a 25-year-old paraplegic, used a brain-controlled robotic exoskeleton to kick a football during the opening ceremony of the World Cup in Sao Paulo.

The exoskeleton technology existed. Scientists had already demonstrated in a number of ways the capacity of a computer to “read” the electrical signals from a conscious command in the brain, and perform a correct action.

But after the eight patients had performed more than 2,000 sessions of brain training, for a collective total of almost 2,000 hours, the Brazilian team began to see entirely unexpected results.

“We stumbled into this clinical recovery, which is something that is almost like a dream, because it took the approach to a whole new level,” said Dr Nicolelis.

[embedded content]

Dr Miguel Nicolelis describes the research
Credit: AASDAP and Lente Viva Filmes, São Paulo, Brazil

“They have seen on their own terms a very significant improvement in their lives, in terms of mobility, of being able to feel their legs, to feel their skin; improvements in sexual performance for the men for instance. One of the ladies basically decided to deliver a baby because she now had visceral sensation,”

The scientists – 20 in all from Brazil, Switzerland, Germany and the US – describe their approach in the journal Scientific Reports. They fitted patients with electrodes that could register electroencephalogram signals from the brain. Then they asked the patients to “think” about moving their legs. None of them could do so: the motor cortex of the brain has a pronounced apparatus for representing movement, and the patients could “think” hand movements, but the leg connection had been wiped clean.

None of the patients in the experiment had benefited from any traditional rehabilitation before they joined the project. And none of the eight could control any movement below the level of the spinal cord injury.

The next stage was to introduce VR, and off-the-shelf walking devices now used in physical therapy centres for the injured, as well as overhead harnesses to get the patients accustomed to making a link between movement and thinking about movement. The experimenters fed back the sensation of walking to a pressure pad on the patient’s forearm, and used a VR avatar, to help give the patient the illusion of walking, and then the distinctive sensations of walking over grass or sand.

Gradually, and at different rates, they began to experience voluntary muscle function below the injury. They went from a total absence of touch sensation to the capacity to sense pain, pressure and vibration, though not temperature. Gastrointestinal function improved, and those who spent most time upright and walking saw the most improvement in bowel control. Men reported experiencing erections. All had been diagnosed as cases of complete paralysis. Since the training, some of them have now been reclassified as partially paralysed.

None yet can walk unaided, but one has progressed to walking – without any help from a therapist – with crutches and braces from hip to ankle to support the legs. The research paper describes results after the first 10 months of the study. But the training continues, and there is more yet to be published.

“We are already thinking about ways of disseminating this protocol with more affordable technology,” Nicolelis said.

“If you remember your first cellphone, it looked like a brick, and now I am talking to you from a tiny little cellphone in Brazil, so things have evolved very quickly. I think that at the moment we can show clinical benefits. There are about 25 million people in the world paralysed just with spinal cord injuries and when you receive a diagnosis of being a complete paraplegic people usually don’t do anything anymore to you. They just try to get you adapted to life in a wheelchair.”

"Brain training" technique restores feeling and movement to paraplegics

I am 16 and the training technique is destroying my well being

Breathe in. Breathe out.

The strings that hold you collectively are loosening. You feel what’s going on in your physique without currently being ready to management it. Your breathing speeds up. Each sense heightened, your total body shakes. Pins and needles are operating marathons up and down your limbs. It hurts. Everything is as well near. Also loud. And then you shut down.

You’re having a panic assault.

This isn’t an post about why far more awareness is needed about mental wellness troubles or how an remarkable method waved my anxiety away. Individuals articles and books exist, and they express individuals topics much better than I ever could.

This is an post about how our training system is ruining younger people’s lives. No person is listening to the teachers who say it, so possibly somebody will listen to me.

My name is Orli and I’m almost sixteen. When I was younger and I loved to play grown-ups, I dreamed of being 16 – of going to bed when I wished and having my very own money to devote on fairy wings (it hit me tough when I realised that no person dressed up as princess fairies when they received older).

I in no way dreamed I would be like this. It was a shock when I got to secondary college and realized the implications of the marking scheme: you succeed – and you fit in – or you fail. Out of the blue, the creativity I’d brought to all my school projects wasn’t accepted anymore. Rather I had to memorise information and statistics. That was when I realised that my long term would be primarily based on a set of criteria designed by examination boards – and that was when I started having panic attacks. The terror brought on by the thought of failing left me unable to sit virtually all of my GCSE mock exams.

Our training program is flawed. It is creating younger folks to come to feel the sort of strain that shouldn’t be imposed on anyone, of any age. In a 2007 Unicef review rating children’s wellbeing in 21 created countries, Britain came out last.

The system is teaching people that your greatest is not very good sufficient, that you must continually consider tougher and that 1 poor consequence makes you a failure. Achievement is measured by how properly you bear in mind the criteria on a provided day. How can we justify placing the health of young children on the line for an examination board’s definition of achievement? The most essential achievement a man or woman must aim for is getting comfortable in their skin, protected in the knowledge they can live their lifestyle and define achievement on their very own terms.

Associated: How pupil electrical power makes colleges a lot more open about psychological well being issues

Next yr the government’s new GCSEs and A-levels get impact and the grading switch from letters to numbers is not the only thing that will alter. The introduction of a single last exam in area of a number of modules implies college students will now only have 1 likelihood. One particular set of answers will mark the variation between accomplishment and failure.

How can it make sense for us to be deemed responsible sufficient, at sixteen, to make choices that form the rest of our lives when we’re not responsible sufficient to vote for the men and women making these selections?

The way to make positive the following generation is educated as ideal it can be is not to shove exam papers in their faces, it is to allow them breathe, to create a relaxed and enriching surroundings for understanding. Our training technique is producing a generation of broken younger grownups, wound up by a crucial in the back and dropped when they are deemed unfit. It is creating a generation of fearful young individuals who will by no means be daring adequate to consider initiative and find out new issues simply because they’ve been taught that good results is a location that only has one route.

When I appear back on my panic attacks, I want to shake myself – I’ve let a group of politicians with a rigid definition of achievement do this to me. Practically nothing is so essential that it is really worth risking your overall health more than, not even the piece of paper you get, age sixteen, to inform you regardless of whether or not you are very good enough.

Relevant: Secret pupil: 6 factors I’d by no means dare inform my instructor

If you’re a younger particular person who can empathise with this report, I want to tell you that there are a wonderful a lot of of us, and it will get far better. To the politicians, my message is simply this: if you want the nation’s long term generations to be totally free of the crippling anxieties and worry of failure entrenched by the present technique, you have the electrical power to adjust it.

Ultimately I have 3 phrases that’ll make me sound like the whiny 5-yr-outdated I wish I even now was: this is not fair.

I am 16 and the training technique is destroying my well being

Last but not least, training to create United kingdom care workers" capabilities, but no income to spend for it | Justine Cawley

The professional knowledge, behaviours and capabilities essential in social care continue to be significantly underdeveloped. Photograph: Rex Features

Tomorrow sees the Kingsmill review publish its report into working conditions in the care sector. Like final month’s Panorama investigation of abuse of older men and women in care properties, it will highlight the urgent require for nicely-trained, skilled and compassionate social care personnel. Older people’s care wants are diverse and increasingly complicated, ranging from acute and continual sickness to dementia and palliative care, in addition to mobility concerns and psychological wellness troubles.

But the professional understanding, behaviours and skills essential in social care continue to be significantly underdeveloped. Care-property staff are the forgotten workforce and are typically regarded as to be the lowest of the reduced by their counterparts in the NHS. As today’s residential houses have replaced NHS lengthy-remain hospitals, it is essential that personnel have the range of expertise, abilities and practice to cope.

Most care residences never have medical doctors on phone so are dependent on out-of-hours services and GP locums. Extended waits for a go to suggest that personnel need to have to know what they are performing, as there is typically just a registered nurse in a care property and not even that in a residential home. To make matters worse, there are not adequate people doing work in social care: our ageing population needs this workforce to increase by one million folks.

In purchase to provide much more specialist education and training, we have developed a perform-based mostly degree program called Elizabeth Care, specialising in the care of older folks in all care settings. The initial program commences at the end of Might at the University of Surrey, for men and women previously operating in social care. This is the first program created for nurses and care residence employees searching following older folks.

The curriculum is based mostly on a framework that measures the patient, family-member and workers encounter, with modules in man or woman-centred care, compassion in care and individual and professional growth.

Recruitment for a foundation degree will commence in January. A professional pathway will for that reason become a actuality, guaranteeing that anybody coming into the social care sector can have a genuine career, with promotions and spend rises as they complete their coaching. It signifies that a younger particular person coming into at apprenticeship degree can rise by means of the ranks from an enriched care practitioner to fully qualified nurse specialising in the care of older folks, rather than getting poached by the neighborhood supermarket for increased pay out.

Although all three principal political parties endorsed this initiative, the lack of funding is jeopardising its existence. Even though NHS trusts have typical access to income for instruction and improvement of their staff, individuals in smaller sized nursing and care residences are finding it difficult to afford our program, even even though they are seeking right after NHS individuals.

Health Education England has an annual earnings of £5bn and £95,000 is invested on education and training in the NHS each minute, but next to nothing at all is offered for employees in social care. An example of how minor is invested on nurses in nursing properties and other neighborhood settings is illustrated by a local university that was allotted just £5,000 a 12 months in government funding to spend on education care-home staff. Even though some courses cost as little as £570, it would not pay out for any person wishing to complete a longer program or our degree, which expenses £7,790.

There must be other sources of funding, but Skills for Care, which administers its very own workforce advancement fund and is responsible for the grownup social-care workforce, is a “bad relation” and doesn’t fund increased-level qualifications, prioritising rather apprenticeship qualifications.

Professor Martin Green, chief executive of Care England, which represents independent care companies, says: “While the government spends billions on coaching and has publicly welcomed this new qualification, it seems unwilling to place its money in which its mouth is. This leaves nurses and care employees out on a limb, forcing committed men and women to fund any instruction from their personal sources. This is merely unacceptable. The government should allow the NHS and the training bodies to make income available to our forgotten workforce.”

Last but not least, training to create United kingdom care workers" capabilities, but no income to spend for it | Justine Cawley

Ban Ki-moon backs campaign to tackle FGM by means of training

UN secretary common Ban Ki-moon, stated: ‘It has been deeply inspiring for me to hear that a 17-yr-old has attracted effectively over 200,000 signatures to her petition demanding action to end FGM.’ Photograph: Lucas Jackson/Reuters

The UN secretary basic, Ban Ki-moon, has backed Fahma Mohamed’s campaign – which is supported by the Guardian and anti-FGM campaigners – to place education at the heart of tackling female genital mutilation. Ban praised the 17-yr-old’s campaign – which has now attracted a lot more than 212,000 signatures on adjust.org – calling it “deeply inspiring”, and applauded her call to enlist headteachers to assist reach every woman who is at chance of FGM.

As a consequence of the campaign – which calls on the training secretary, Michael Gove, to write to every headteacher in the country asking them to inform teachers and mothers and fathers about the horrors of FGM – the Scottish government has presently said that it will create to heads all through Scotland, and following sustained public stress Michael Gove agreed to meet with Mohamed to examine the problem.

Ban praised the move in Scotland, stepping up stress on Gove to adhere to that lead. “It has been deeply inspiring for me to hear that a 17-yr-previous, Fahma Mohamed, supported by the Guardian, has attracted nicely above 200,000 signatures to her petition demanding action to end female genital mutilation,” wrote Ban in a comment piece for the Guardian. “Headteachers – and governments – have a crucial role to play in assisting to persuade households not to send their daughters abroad and aid these girls, some 24,000 in the United kingdom alone – considered to be at danger. The selection of the Scottish government to write to every single headteacher asking them to train workers and educate dad and mom is a key stage forward.”

Mohamed, a pupil from Bristol and a trustee of the charity Integrate Bristol, stated she was honoured to acquire Ban’s support. “It truly is wonderful that our campaign has had this kind of a broad reaching influence and I’m truly honoured by Ban Ki-moon’s support and praise,” she mentioned. “If he can help us persuade Michael Gove and the Division for Education that they need to have to act, and now, then all of us in my Integrate Bristol group would be delighted.”

Ban explained Mohamed was a important part of a around the world campaign to bring an end to FGM, which is estimated to impact much more than 125 million girls and females across 29 nations in Africa and the Middle East, in which FGM is most prevalent. An estimated 60,000 women and women have been victims in the United kingdom alone.

He stressed that there was no developmental, religious or well being cause to minimize or mutilate ladies and females, creating: “Although some would argue that this is a ‘tradition’, we should recall that slavery, so-known as honour killings and other inhumane practices have been defended with the same weak argument. Just simply because a hazardous practice has extended existed does not justify its continuation […] FGM triggers grave harm. The wellness consequences include depression, insecurity, ache, infections, incontinence and at times deadly problems in pregnancy and childbirth. Mothers should not be terrified of giving birth to daughters.”

The UN secretary common pointed to progress being created in Uganda, Kenya and Guinea-Bissau, which have recently adopted laws to end FGM. Arrests have been produced in Ethiopia, in Sudan a campaign has been launched against FGM, even though in Kenya elders have imposed a fine on any person carrying out or abetting the practice.

Every single country in Africa had sponsored the UN’s global day of zero tolerance for FGM on 6 March, he stated. “The result on men and women will be profound, sparing them horrible suffering and discomfort. So, thank you Fahma for what you are doing to aid make this occur.”

Ban Ki-moon backs campaign to tackle FGM by means of training