Thalidomide: Nine things you didn’t know about the ‘poisonous pill’

Thalidomide was marketed to pregnant women as an antidote for morning sickness in the late 1950s, but the results were calamitous. An epidemic of babies born with various disabilities including limb, organ and neural damage led to its withdrawal from sale in November 1961. There were over 5000 known thalidomide survivors living worldwide in 2003, including 500 in the UK.

As a healthcare researcher, I had come to understand the thalidomide catastrophe as a systems failure: the disastrous outcome of an inadequate medications approval process. My dad, Dr Martin Johnson, was Director of the UK Thalidomide Trust between 2000 and 2014, and through him I had come to learn about its terrible impacts upon individuals and their families. I also understood that many survivors were still awaiting justice. However, in 2018, together with his co-authors Professor Ray Stokes and Tobias Arndt, dad published ‘The Thalidomide Catastrophe’, the first and only comprehensive history of thalidomide. Reading it led me to realise I had been seeing through a glass darkly. When laid bare, the thalidomide story is stunning, shocking and almost unbelievable. Here I share with you nine things I learned from the book:

Ed, aged 3

Ed, aged 3

  1. The full number of people affected by the drug reached tens of thousands. It is well known that thalidomide caused babies to be born with disabilities. However, it is highly likely that many other children died in the days and months after birth and that even more were miscarried or stillborn because of thalidomide. Johnson, Stokes and Arndt estimate that altogether, between 87,600 and 275,500 babies were affected.
  2. A single tablet had disastrous effects. Researchers have been able to link the days on which tablets were taken with specific forms of damage. For example, a tablet on days 21-22 after conception could cause damage to, or loss of the eyes. A tablet on day 24 could cause loss of the arms and a tablet on day 29 could cause loss of the legs. The key message from this is that the babies who survived thalidomide were those whose mothers took a tiny amount of the ‘poisonous pill’.
  3. Key players in the development of thalidomide are linked with the Nazi regime. The book explores this issue in meticulous depth and it is hard to summarise the evidence briefly. However, two things are clear. The first is that the Chief Scientist of Chemie Grunenthal, the Germany company who patented the drug, was Dr Heinrich Muckter. Muckter spent World War 2 (WW2) at an institution which tested drugs on Buchenwald concentration camp prisoners. The second is that Otto Ambros was a consultant for the Distillers Company, the British organisation which distributed Thalidomide in the UK. Ambros was sentenced to 8 years for his war crimes during WW2, which included using slave labour from the Auschwitz III-Monowitz concentration camp.
  4. Thalidomide seriously harmed adults too. When taken for more than 2 weeks, thalidomide could cause adults to contract ‘polyneuritis’, nerve damage involving symptoms such as tingling, numbness, excruciating muscle cramping and even partial paralysis. It could affect coordination, balance and the ability to walk. Altogether, around half a million adults were probably affected. “The Thalidomide Catatrophe” provides the response from Chemie Grunenthal to one affected surgeon who used the drug. “Thank you for your letter of 8th March 1960 in which you tell us you are increasingly suffering from paraesthesia and… probable polyneuritis… We wish to advise you that we have received no such reports to date” (p110). This letter was a lie: the company had received several reports and their false reassurance may have caused the surgeon to keep taking the harmful drug. As Johnson, Arndt and Stokes comment, these effects probably cost this surgeon his career.
    TIna Gallagher

    Tina Gallagher in 2002

  5. Warnings the drug was dangerous were ignored. To this date, Chemie Grunenthal claim that they could not have known about the harmful potential of Thalidomide. The evidence presented by Johnson, Stokes and Arndt makes this almost impossible to believe. For example, there is clear evidence Grunenthal’s Chief Scientist, Heinrich Muckter, received warnings a year before thalidomide even went to market from Dr Piacenza, an Italian doctor who undertook trials of the drug. Writing in 1956, Piacenza reported that the drug was unsuitable due to its toxicity. He described side effects in adult patients which included a whole-body rash and peripheral nerve damage. Reports from concerned physicians continued to be sent to Grunenthal, but the drug was not removed from market. Concerns were also raised about the potential harmful effects of thalidomide on unborn babies. For example, in 1959, scientist Dr Randolph Riemschneider raised concerns that thalidomide was causing birth defects in tadpoles he was experimenting with. As he later recorded, “we sent this information with photos to Chemie Grunenthal… Unfortunately, no answer was forthcoming” (p115).
  6. Even when its impact was known, Chemie Grunenthal continued to sell thalidomide. There were warnings that thalidomide was harmful before it even went to market. However, Chemie Grunenthal did not publicly acknowledge its harmful potential until 1961. In a speech on 14th July that year, Heinrich Muckter, Grunenthal’s Chief Scientist told his staff, “if I were a doctor, I would not prescribe Contergan [trade name for thalidomide] any more. Gentleman, I warn you… I see great dangers” (p41). Yet he didn’t withdraw the drug from sale until November that year. If he had pulled it immediately after his speech, more than 25% of the babies who were affected would have been saved.
  7. The impacts of thalidomide are sometimes invisible. Not all survivors were affected by the limb damage which is characteristic of thalidomide. As a toxic nerve agent, it also caused devastating hidden damage. Johnson, Stokes and Arndt report the situation of Julie Lane, whose mother had been supplied with the drug. Outwardly, Julie only had minor hand damage. However, at a young age, she developed epileptic fits. In her teens, she lost the use of her legs and later on, her arms. She also gradually lost her hearing and her sight. As her epileptic brain activity was not typical, her symptoms were misdiagnosed as being psychosomatic, and not of physical origin. This caused her problems to be stigmatised. However, a post-mortem conducted after she died aged 44 showed evidence of major internal damage which had been there since birth.
  8. Survivors still wait for justice. Chemie Grunenthal, the company which patented thalidomide, has never been held to account. A trial was called in 1968 but later suspended, apparently on the basis that “public interest in a continuation of the criminal prosecution no longer exists” (p.131). In the UK, Distillers, the company which distributed the drug paid out some compensation following a lengthy legal battle. However, survivors in some other countries have never received compensation, and all survivors are still waiting for an apology from Chemie Grunenthal.
  9. Some countries protected their populations from thalidomide. Several countries which considered licensing thalidomide denied or significantly restricted the sale of the drug. These included Turkey, East Germany, the USA and France. In Turkey, Dr Aygun undertook tests involving tissue cultures and concluded the drug was unsafe in 1960. In East Germany, the relevant officials had concerns based simply on the information supplied in the patent. They noted that due to the structure of the molecule, an “embryo-toxic effect” (p124) was possible. They refused a licence. In the USA, Dr Frances Kelsey resisted significant pressure from the prospective American licensee company (Richardson Merrell) and managed to delay the approval of the drug until it was removed from sale in 1961. Her delay meant that only around 160 babies are estimated to have been affected by thalidomide in the USA. What these countries show is that the toxic properties of thalidomide were possible to identify using the technologies and processes of the time. Those governments which failed to prevent the distribution of thalidomide are partly to blame for the disaster, and should also be held to account.

 

In 2019, the generation of thalidomide survivors is turning 60. What “The Thalidomide Catastrophe” makes clear is this: the international sale of the drug was preventable. Its risks should have been identified by the company which patented the drug, those which distributed it and by the governments which allowed its sale. The damage which was initially caused has been extended over six decades by a failure to acknowledge and apologise for the harm that was caused. The need for an apology remains.

How to start a journal and beat the academic publishing racket

Academic publishing is a multi-billion pound industry, with profit margins reportedly higher than those of Apple, Google and Amazon. It has always struck me as a racket: academics sign over their work to private businesses for free, and then their universities pay the same businesses hefty fees in order to read what they publish. Academics are also responsible for editing these journals and providing the peer-reviews, usually for free.

It hasn’t always been this way. In a remarkable brief history of the academic publishing industry, Stephen Buranyi highlights the key role of Robert Maxwell, a brash business tycoon whose greatest desire was to “be a millionaire”. Maxwell arrived on the scene just after the Second World War, which was a key turning point in academic history. The post-war years saw a huge growth in the number of people attending higher education and also in the academic publishing trade. In 1950, there were 10,000 journals published worldwide, but by 1980, this was had reached 62,000. Robert Maxwell and other businessmen capitalised on this growth and took the opportunity to privatise what had previously been a largely non-profit sector. There is now growing awareness that this industry is both ludicrous and detrimental, unwieldily costly and harmful to the progression of science. However, solutions are slow in coming. While open-access journals are growing, the majority of these charge fees for publication that far outstrip real costs. For these reasons, I have been intrigued and encouraged to see the development of peer-reviewed open access journals which do not charge authors to publish with them. These include Musicology Research Journal (MRJ), whose Chief Editor is Dr James Williams, Senior Lecturer at the University of Derby, and Psychreg Journal of Psychology (PJP), whose Chief Editor is Dennis Relojo-Howell, founder of leading psychology blog Psychreg. These journals offer a solution that previously would have been regarded as impossible: they are both free to the authors and free to readers. I spoke to Williams and Relojo-Howell to understand more about their journals.

Why start a peer-reviewed academic journal?

As both Williams and Relojo-Howell attested, self-publishing an academic journal is a significant amount of work. So why do it? Williams said his motivation arose from his experience as a PhD Student and early career researcher. “Acceptance of manuscripts in current musicology-based journals can sometimes feel a little elitist. Editors and traditional publishers prefer to go with already-known academics, and are less likely to take on manuscripts from early-career scholars”. Williams also described his dissatisfaction with the traditional academic publishing industry, and its money-oriented focus. MRJ meets this gap by focusing on publishing the work of early career researchers, and by managing all copy-editing and manuscript management in-house. Relojo-Howell’s motivation was different. As a psychology blog editor, he had begun to receive blog post submissions that were overly long and technical. These posts weren’t suitable for publication as blog posts, but he could see their importance and academic merit. He created the journal to provide an outlet for these articles, and to broaden the overall scope of Psychreg. 

Ten steps for starting a journal

Whatever the focus of your journal, the steps for setting one up are similar.

  1. Identify the gap. What is the need your journal will meet? How will it improve information sharing in your field? Once you’ve identified this gap, you need to set the scope of your journal. Decide which types of articles you will include, and those you won’t.journal website
  2. Build a website that will home your journal. A full description of this process is beyond the capacity of this article (and my expertise!) but the key parts of this are to buy a domain name, find a web hosting company and then prepare the content within this. Popular web-creation platforms are wordpress.com, wix.com and weebly.com. Relojo-Howell suggested that it’s also worth looking into the Public Knowledge Project: this provides Open Journal Systems (OJS), federally funded software designed to support the set up and management of open access journals.
  3. Set up an editorial board. Both Williams and Relojo-Howell highlighted the importance of this. First, this group can provide the strategic direction and support that can get your journal started and help it grow. Second, this group can provide credibility to the project. As Relojo-Howell said, “When I started, potential contributors were only interested in who was on the editorial board. I have never been asked about the journal’s impact factor”.
  4. Involve associate editors who can provide support. Williams described the importance of including a multi-skilled team. “We have editors with different areas of expertise and varying skillsets, including people who are familiar with copy-editing and academic publishing”.
  5. Call for papers. You can spread the word about your new journal via social media, personal networks and by contacting other relevant university departments. Neither Williams nor Relojo-Howell had found this aspect challenging. As Williams said, “We have only ever advertised the journal in the UK, but we have received submissions from Australia, Canada, the USA and Asia”.academic publishing
  6. Manage your submissions. Traditional journals use manuscript-management software, but this comes with a steep price tag. “I contacted Emerald about their systems”, Relojo-Howell said, “but they asked for £38k”. Open Journal Systems (OJS) provides an alternative, free-to-use alternative, but this isn’t necessary. “I use a spread-sheet to keep on top of submissions”, Williams said. “It works fine”.
  7. Copy-edit and type-set your articles. While this may feel like a challenge, both Williams and Relojo-Howell said it was possible to do using widely available software. Williams said that he uses Word and Adobe programs to provide a professional-looking finish to his articles. Relojo-Howell commented on the fonts he uses: “I use a combination of paid-for fonts and some free Google fonts”.
  8. Apply for an International Standard Serial Number (ISSN). For us in the UK, this involves submitting an application to the British Library. Williams suggested that the British Library will expect to see evidence of around 3-4 previous publications and a commitment to continue publishing on a regular basis.
  9. Plan how to give your articles a Digital Object Identifier (DOI). DOIs are a string of numbers, letters and symbols used to permanently identify an article of document and link it to the web. Relojo-Howell recommends using Zenodo for this purpose. Initially funded by EU project funding, Zenodo is now open to all research outputs and offers its services free of charge for open access publishers.
  10. Wider registration. There are a variety of international platforms with which to register journals, including Web of Science, PubMed and SCOPUS. This type of registration seems to be a longer term process, however. Relojo-Howell said he had contacted both the Directory of Open Access Journals (DOAJ) and Thomson-Reuters, but they indicated that they would expect journals to be up and running for closer to five years before they would register them.

Other considerations

  • Finding peer-reviewers. My colleagues who edit traditional journals have described to me the challenges of finding peer-reviewers. While Williams and Relojo-Howell suggested this could also be challenging with new, open access journals, Williams suggested a personal touch could help support a positive response rate. “We approach academics who are working closely in the field of the article, and send personal requests. 60 or 70 per cent of the time, they agree”.
  • Clarify that you are a genuine academic ground-roots initiative. Unfortunately, at the same time that the genuine open-access field is growing, the number of predatory journals is proliferating at great speed. In a previous post, I clarify the warning signs of academic spam emails. However, if your potential contributors are concerned, let them know that the first clear distinction is that predatory journals ask for large sums of money and usually offer to rush through submissions at great speed. The second clear distinction is your academic board. You can signpost potential contributors to contact your board members for reassurances, if they are concerned.

Is it worth it?

Both Williams and Relojo-Howell admitted that their journals were time consuming and offered no financial benefits. However, what is clear is that starting these journals offers significant job satisfaction. As Williams said, “I saw it as a real problem – I wanted to help other graduating PhD music students… I don’t think I have reaped any rewards for myself, but I do know a lot of people now. It’s great for networking”. Similarly, for Relojo-Howell, the reward lies in contributing towards open science: “I wanted to demonstrate that dissemination of science can be reconstructed to become more democratic – a science that is shared for wider consumption”.

Ten tips for aspiring Clinical Psychologists

The competition to become a Clinical Psychologist is fierce. In the UK, the constituent parts of the training are a three-year undergraduate degree which is accredited by the British Psychological Society (BPS), and a three-year taught Clinical Psychology doctorate. The doctorate is full-time; candidates are employed by the NHS and complete a series of six-month placements in addition to coursework and a research project.

Psychology undergraduate students self-fund their degrees and as such, courses have flexibility about the number of students they can enrol. Psychology is consistently the second most popular degree in the UK, with an estimated 13,000 graduating each year. However, until recently, the only places offered on the doctorate were NHS funded, and therefore carefully regulated. Between 2012 and 2018, doctorate courses enrolled around 590 students per year altogether; just 15% of the total number of applicants. While three courses now include self-funded places, these come with a price tag of £20k+ a year, putting them out of reach of most graduates. 

Here, I offer 10 tips for aspiring Clinical Psychologists:

1. Know the bottom-lineIf you are at the point of applying for the doctorate, look at the particular courses you are interested in on the Clearing House website. What are their non-negotiables? Many courses now stipulate that candidates must have a 2:1 or a score above 65% in their undergraduate degree. Others require that applicants have a year’s clinical experience supervised by a qualified psychological therapist. If you don’t meet their stipulations your application will be automatically excluded, even if it is otherwise strong.  It is therefore worth researching each course’s bottom-lines before you apply.

2. Look into placement-year degrees. Several universities including Aston, Bath and Leeds (where I am based) offer applicants the opportunity to undertake a placement year ‘in industry’ between the second and third year. This means that students can gain relevant clinical experiences which can help them to be competitive applicants for graduate jobs. These placements are overseen by the universities, helping to ensure that they provide students with more useful experiences than they may gain through general volunteering. Some placements also offer a contribution towards expenses or a stipend, which volunteer roles generally do not. 

3. Consider the ‘Increasing Access to Psychological Therapies’ (IAPT) initiative for an alternative career as a psychological therapist. IAPT was launched in 2007 to provide greater access to psychological interventions for people with mild-to-moderate anxiety and depression. It is now planned to expand in order to provide therapies to 1.5million adults per year by 2020/2021. There are two main types of psychological therapists working in IAPT: Psychological Wellbeing Practitioners (PWPs) and High-Intensity CBT Therapists (HITs). PWPs are recruited into training positions with IAPT services on an NHS band 4; once they are qualified, they are paid at band 5 and can progress to band 6 (for information on NHS pay bands, see here). Similarly, HITs apply to train with specific NHS services. They train on band 6 and are paid on band 7 once qualified. Sign up to NHS jobs for alerts about these roles. A follow-up of HITs suggested that 79% stay in IAPT services after qualifying, 61% become CBT supervisors and 23% progress to more senior roles. It also possible to self-fund training to qualify as a CBT therapist, by undertaking a postgraduate course accredited as Level-2 by the British Association for Behavioural and Cognitive Psychotherapies (BABCP). 

4. “Remember at the end of the day, it’s just a job”. This was the best advice I was given before I attended my interviews for the Clinical Psychology Doctorate. A qualified Clinical Psychologist called me to give me some advice, and these words helped remind me that I wasn’t auditioning for the X-Factor: at absolute best, I would become a qualified psychological therapist. Imminent fame, stardom and riches were not around the corner. Being a Clinical Psychologist in the NHS is a wonderful job, but it is not without stress and strain, like any other healthcare related job. So, relax: it’s just a job.

5. Vary your experiences. Working as a research assistant or assistant psychologist will give you great experience for the Clinical Psychology doctorate, but more than a year in any one post will have diminishing returns. While you will always need to balance the opportunity to gain varied experience with the need to pay your rent and bills, it’s worth remembering that having a broad skillset will give you the strongest CV and application.

6. Treat applications like assignments and interviews like exams. You cannot assume that the knowledge and experience you have will naturally shine through: work hard to sell yourself. Consider carefully the range of experiences you have had. For example, what is the range of client groups you have worked with? What experiences have you gathered? Think carefully about the knowledge you have in relation to engaging different client groups, conducting assessments, collecting and storing sensitive data, managing risk, and applying psychological theory to individuals, for example by contributing to formulations or interventions. Also consider carefully the job which you are applying or interviewing for: who is interviewing you, and what is their area of interest? Which client group will you be working with, and what things might you need to be conscious of? Which therapeutic modalities might you be using, such as CBT or psychodynamic approaches? One way to impress your interviewers is to appear prepared for the opportunity they are offering.

7. Consider alternative psychology disciplines. If you have a BPS-accredited undergraduate degree, Clinical Psychology is not your only option for working therapeutically. For example, many posts which are open to Clinical Psychologists are also open to Counselling Psychologists. To train as a Counselling Psychologist, you can either do a self-funded doctorate degree or the BPS qualification in counselling psychology; this involves three years of supervised practice. More information is available here. Alternatively, for psychologists interested in working with forensic populations, Forensic Psychology may offer a fulfilling alternative career to Clinical Psychology. In some secure hospitals, much of the work of Forensic Psychologists involves delivering psychological therapy. To train as a Forensic Psychologist you can either complete a Doctorate in Forensic Psychology or a Masters in Forensic Psychology followed by two years of BPS training and supervised practice. More information on becoming a Forensic Psychologist is available here. It is also worth noting that the University of Birmingham now runs a four-year doctorate which offers candidates a dual qualification in both Forensic and Clinical Psychology (see here). 

8. Look for research opportunities. As an undergraduate I undertook some voluntary work as a research assistant with a professor and lecturer in my department. It was one of the best decisions I made: it paved the way to my Medical Research Council-funded PhD in Resilience to Suicidality and kick-started my love of improvement in healthcare. It also helped me to gather a range of experiences in working with clinical populations, as my PhD involved undertaking psychological assessments with people with psychosis and testing a novel mood-boosting intervention in this group. I would highly recommend seeking research opportunities to aspiring Clinical Psychologists. If you are currently a psychology undergraduate, seek opportunities with clinically-oriented researchers in your department. If you are a psychology graduate, sign up for job alerts at jobs.ac.uk and look for opportunities which would allow you to gain experience working with clinical psychologists and/or researching with clinical populations.

9. Keep your eye on the proposed role for ‘Clinical Associate Psychologists’. This is anticipated to take the form of an apprenticeship which will last 18 months and produce psychology professionals who undertake psychological assessment and formulation, and who deliver psychological interventions. At the moment, it is suggested that each Clinical Associate Psychologist will train on a Band 5 salary and be paid at Band 6 once qualified. The plans are currently in development, but should be in place in the coming year. 

10. Take heart: the need for psychologists is not diminishing. While the sense of competition may feel overwhelming, the demand for psychological therapies is increasing, which is reflected in the introduction of the IAPT initiative and the new role of the Clinical Associate Psychologist. While getting a place on the Clinical Psychology Doctorate may be challenging, if you have a passion for psychological work, the future is bright!

Finally, I want to note that while the cap on funded places for the Clinical Psychology doctorate produces a low success rate at the point of enrolment, I believe it also offers significant benefits. First, the competition that the cap creates means that aspiring Clinical Psychologists need to seek additional experience and training after their undergraduate degrees to strengthen their applications. This experience ensures that all doctoral trainees know the discipline they are working in and can feel confident in their career choice before they sign-up to the three-year course. This is reflected in the high retention rates of courses (99.4%): students rarely fail to complete their doctorate, once they’re on it. Second, it means that once qualified, Clinical Psychologists have good job prospects: 95% are employed in a clinical psychology job within 12 months of graduating. Deregulating the number of doctorate training places could shift this balance, creating the possibility that qualified Clinical Psychologists could become unable to find employment. By ensuring that applicants are experienced and committed, I believe that continuing to fund all forms of postgraduate psychological training offers the best outcome for applicants, healthcare providers and clients.

Six ways that breaking bad and difficult news in ultrasound is different to other settings

Not all pregnancies follow the textbook. Around 1 in 6 are lost to miscarriage or stillbirth and in 1 in 20 there is an unexpected finding on an ultrasound scan which could suggest the baby has a health condition (Ahman et al., 2014; Blohm et al., 2008; Skupski et al., 1996). Altogether around 150,000 families in England and Wales are affected by one of these complications each year (ONS; 2016). These events are deeply upsetting; parents who experience them are at higher risk for depression, anxiety and even symptoms of trauma (Blackmore et al., 2011; Cumming et al., 2007; Korenromp et al., 2005).

The role of ultrasound

Ultrasound is an important tool for diagnosing these complications and in the UK sonographers are the first to break the news to parents about what they have found. The way this is done is important, as it has a strong emotional impact on expectant parents (Bijma et al., 2008; Johnson et al., 2018). However, there is currently no evidence-based training to support sonographers with news delivery. The training which is available is generally based on research which has been conducted in oncology and other healthcare settings.

The need for an evidence-based training intervention

When I have suggested that new research is needed to understand how bad and difficult news can be better delivered via ultrasound, one question I have been asked is whether this is really needed. Isn’t there plenty of research in other settings to inform training? In this blog, I will present six ways that breaking bad and difficult news via ultrasound is different to breaking bad news in other settings.

1. There is no time for sonographers to prepare before delivering the news

A large body of research tells us that expectant parents study the sonographer’s face as they do the scan: they are attuned to their body language and facial expression and quickly sense when something is wrong. The sonographer is unintentionally communicating news before they even speak, and they have no time alone at all to mentally prepare before sharing what they have found with parents. In cancer care, this would be the same as a doctor having to open test results, read and interpret them while the patient watches them.

2. Having a baby isn’t primarily a healthcare event, it’s a rite of passage

Few people will spend years thinking about their future with a diagnosis of cancer, but many people, consciously or subconsciously, gather quiet expectations about what their future will be like with a child. When you deliver difficult news as a sonographer, you deliver it into a world of positive expectation, which is further fuelled by people sharing scan pictures on social media, and television shows like One Born Every Minute. Because of this, the situation is particularly high stress for both those delivering and those receiving the news.

 3. The need for a second opinion

When a sonographer identifies a miscarriage, stillbirth or fetal anomaly a second opinion is necessary to confirm his. The sonographer needs to leave the scan room to find another qualified healthcare professional who can confirm what has been seen. This is a difficult point, and one that is not encountered in other areas of healthcare. Sonographers are often torn over how much to disclose to the expectant parent before the second opinion has been gathered, especially if they are not confident themselves in what they have seen. Failing to disclose their concerns to the parent can result in parents feeling anxious when they find a second professional has been invited into the scan room without explanation. However, immediately disclosing concerns to parents that are then not confirmed can cause unnecessary anxiety. It’s a dilemma that sonographers regularly face which is not found in other difficult news delivery scenarios.

4. The news may be uncertain

When receiving difficult news in other settings, patients can rightly expect that the healthcare professional telling them this news will be informed about their condition and be able to provide detailed information on this. However, sonographers do not have this luxury. While scanning technology has advanced significantly in the last few decades, it is not always possible to provide accurate diagnoses and prognoses immediately. Because of this, sonographers are often communicating difficult news which is uncertain, and which could change in light of subsequent investigations.

5. Ultrasound presents opportunities and raises challenging choices

Unlike other areas of healthcare, ultrasound often provides a diagnosis before anyone’s health has been compromised. It can enable expectant parents to have missed miscarriages diagnosed and allow them to choose whether they want to shorten the length of their pregnancy by accepting a medical intervention. Ultrasound can also detect some fetal abnormalities.  If a baby is found to have a disability (or a possible disability) parents may need to decide whether to have invasive testing; whether to terminate the pregnancy; or in rare cases, whether to have prenatal interventions. These kinds of decisions introduce a huge weight of responsibility – could prenatal investigations and interventions put the baby or mother at risk? Is it morally wrong to terminate a pregnancy? Will not terminating a pregnancy detract energy from any existing children? When sonographers deliver difficult news they know they are often placing a burden of responsibility on expectant parents to make choices, in a way that is not encountered elsewhere in healthcare.

6. The warning shot is not always wanted

Most models for breaking bad news recommend the delivery of a ‘warning shot’ before the main news is imparted (e.g., Baile et al., 2000). This is designed to prepare patients that bad news is coming, and might run like this: “I’m afraid we have identified some concerning findings in your results”. My research has identified that this warning shot is not always wanted in ultrasound settings because parents have already received their warning shot from the sonographer’s body language and facial expression (see my blog on parent experiences here). These kinds of warning shots only extend the overall duration of the event and serve to increase expectant parents’ anxieties.  Furthermore, if the news being delivered is that the baby has a disability, this kind of warning shot can be taken as a negative value judgement by the healthcare professional, which may offend the expectant parent. Instead, parents prefer to be told things directly but kindly, in simple language. In my previous study in parents of children with limb differences, parents most preferred it when healthcare professionals simply said something like: “I can’t currently see your child’s arm below the elbow” (Johnson et al., 2018).

Summing up

There is strong evidence from other healthcare settings that training to improve news delivery is highly effective (see my blog on this here). However, there are clear differences between breaking bad and difficult news in ultrasound compared with other settings. Assuming that the same principles can be transposed from other healthcare settings into ultrasound without adaptation could at best reduce the effectiveness of training, and at worst, increase parental anxiety.

Tackling burnout in UK trainee doctors is vital for a sustainable, safe, high quality NHS: Our letter to the BMJ

In 2018, for the first time, the General Medical Council (GMC) included items on burnout in its National Training Survey. The survey was completed by 51,956 trainee doctors and 19,193 trainers, making it the largest burnout survey in UK doctors to date. The response rate was also extremely high – 96% of all doctors in training who were contacted completed it, as did 41% of all contacted trainers. As such, these results provide a reliable picture of the current situation in the medical workforce. The survey found that 24% of trainees and 21% of trainers feel burnt-out to a high degree or a very high degree (for the full report, see here).

When I read these results in the BMJ, I wasn’t surprised. Rates of stress and burnout are high in healthcare staff internationally; in the 2018 Medscape report on physician burnout and depression, out of 15,000 US doctors, 42% were burnt-out and 12% were categorised as ‘colloquially depressed’. I was also concerned: a growing body of research shows a strong and consistent link between higher staff burnout and poorer patient care. Papers I have authored and co-authored show:

• 70% of studies which have investigated burnout and patient safety in healthcare staff have found a significant link between the two (Hall et al., 2016).
• In nurses, higher burnout is linked with poorer perceptions of patient safety both at the level of the individual practitioner and the ward level (Johnson et al., 2017).
• GPs think that burnout affects the quality of patient care by reducing their abilities to emphathise, to show positive attitudes to patients and by increasing the number of inappropriate referrals made (Hall et al., 2017).

Together with Dr Maria Panagioti and Dr Christopher Bu, I decided to respond to the BMJ article on the survey findings to highlight the evidence that burnout in doctors affects patient care. In particular, our letter focused on a recently published systematic review and meta-analysis led by Dr Panagioti. The findings of the review are described in more detail in a previous blog post (see here), but in brief, the review reported that burnt-out doctors are at twice the risk of being involved in a patient safety incident and at twice the risk of having dissatisfied patients.

This research reinforces the importance of measuring burnout in the medical workforce and the need to reduce this. The best way to intervene is currently unclear; while evidence suggests that interventions which target organisations (for example, redesigning jobs) are more effective than those which target individuals (for example, delivering mindfulness courses; Panagioti et al., 2017), there are many interventions which blur this boundary. These include training interventions, which are delivered to individual practitioners but aim to support them in their work, rather than improve their personal coping skills. Evidence suggests these are effective for tackling burnout (Dreison et al., 2018). Clearly, more research is needed. However, while we wait for this, I would suggest that organisations respond to the expressed needs of their workforce, providing the interventions that are both requested and well utilised.

To read our letter to the BMJ, please see here.

To read my previous blog on tackling burnout, please see here.