4.1 - Getting Older and how to deal with it - with bestselling author Dr Lucy Pollock

Aural Apothecary 4.1 Transcript

[00:00:00] Gimmo: Hello and welcome to the Aural Apothecary podcast, authentic chat about medicines, pharmacy and healthcare in the UK.

[00:00:14] Jamie: Pharmacists Jamie, Gimmo and STC take on topical and controversial stories, but keep it edgy yet lighthearted

[00:00:20] STC: Pod-Guests share their desert island drugs. And joyful patient stories.

[00:00:24] Jamie: Welcome to the Aural Apothecary podcast.

[00:00:26] My name is Jamie Hayes, for our opening episode of series four, we're joined by Dr. Lucy Pollock. Lucy is a consultant, geriatrician, and author who loves her work and aims to deliver high quality patient-centred care for older people. For any of our listeners who are considering getting older, Lucy's book is a must read, one celebrity review calling it "the most important book about the second half of your life you'll ever read."

[00:00:48] We will welcome Lucy in a moment as she shares her desert island drug, her career anthem, and recommends a book for the Aural Apothecary library. The micro discussion is back, too, as we look at shared decision making between older people with multi morbidity and general practitioners. But first, let me welcome my two fellow apothecaries.

STC is in Bournemouth and Gimmo is in Cardiff. Welcome both.

[00:01:08] Gimmo: Good evening.

[00:01:09] STC: How you doing?

[00:01:10] Jamie: It's been a while.

[00:01:11] Gimmo: Yeah. No, it's been a while. I was just looking back through the diary and it's actually been, it's quite quiet on the news front for me. I think, was the last episode recorded end of January, was it February?

And since then we've had the live show go out, so that's exciting. If you haven't listened to that, have a listen. I guess the one bit of news I was reflecting on is suddenly I'm taking a lot of medicines.

[00:01:31] STC: You're getting older!

[00:01:32] Gimmo: I well, I am. Yeah. So, I've got knee problems, so I'm on stuff for my knee pain.

[00:01:38] STC: Turmeric?

[00:01:38] Gimmo: Well I was taking turmeric, yeah. So Naproxen, paracetamol, fexofenadine. You can guess all the things I've got

[00:01:47] STC: That doesn't work for knees, mate.

[00:01:48] Gimmo: Which one doesn't work? Fexofenadine? No, I suppose the point, the point I'm saying is that, you know, it's only when you have to take medicines, you suddenly realise what an absolute pain in the backside it is.

And that's a really simple regime, sort of one, twice a day alongside an omeprazole in the morning and an antihistamine in the morning. Really pretty simple as regimes go. And even that, and I've just realized now as I'm speaking, I've forgotten to take them this morning! So I am getting old. So I'm looking forward to, to speaking to our guests about that later on.

And I guess in terms of recommendations I'm sure I'm not gonna be the only person who mentions this today, but I think we've all fallen in love with. "The rest is politics" podcast. So, if you haven't listened to that already that's my podcast recommendation for the week. But other than that, it's been fairly quiet, what about you, Steve?

[00:02:30] STC: I'm just gonna talk to you about regimes versus regimens. I remember an ex-boss of mine, Jonathan Cook once picked me up on this and said, regimes are what you get in South American countries. And regimens are what you get in relation to, you know, treatment regimens, whether it's chemo or types of medicines.

So just, you know, to keep it, keep it, uh, lively.

[00:02:52] Gimmo: I'll remember

[00:02:53] STC: that. I agree with you about "The rest is politics" - really great, isn't it? Listened to a lot of those. I've done quite a lot of reading over this time that we haven't been on. As you won't be surprised to know that I feel like a coiled spring tonight.

It felt like one more sleep till Christmas last night thinking that, you know, we'd be back on the air. So I was reading this, you can't see it listener, but "Factfulness" by Hans Rosling who sadly died towards the end of writing the book. And he was a public health doctor from Sweden. And what I really liked about it, it's very got overtones with the More or Less Tim Harford guy , about really saying that journalism is lazy.

And we all have this perception that the world is a much worse place than we think it is. And so in other words, we need to peek behind the curtain, there you go. We need to peek behind the curtain and think critically, as scientists, whether you're a scientist or not, about well, where did that data actually come from?

And I think that's very relevant to us in healthcare. So I really enjoyed this book. My Dad gave it to me. No he didn't! Somebody bought it for me. I gave it to my Dad for Christmas. So it's a fantastic book. "Factfulness" by Hans Rosling.

[00:04:01] Gimmo: Did you re-gift it to your dad?

[00:04:03] STC: No, no. I just went on about it with somebody and they sent me one in the post.

How lovely is that? Keiran Hand, in fact.

[00:04:10] Jamie: Old school. Old school.

[00:04:12] STC: What about you, Jamie? You always get to go last.

[00:04:14] Jamie: Yeah, I do, look, the asparagus season is here. So that's exciting. One of my specialist topics and I was chatting to our guest yesterday, but the house Martins haven't arrived back yet, so we might chat about that a bit later.

I need to shout out our man in Vienna, cause I thought he did a brilliant job over there at the EAHP conference. So for those of you who haven't seen the video clips and our guests' desert Island drugs from around the globe, Thank you to our man in Vienna,

[00:04:42] Gimmo: and you can watch them on YouTube if you want to.

[00:04:44] STC: Are we gonna say who that was? We can do, yeah. It was Jonathan Underhill. Of course it was, because I had Covid. I was supposed to be there too, but I had Covid.

[00:04:51] Jamie: Finally caught up withDopesick.

[00:04:53] STC: Oh, brilliant.

[00:04:53] Jamie: Had to subscribe to Disney Plus, which was annoying.That's about the eighth subscription service that I've had to get to watch it. But, yeah, watched that, enjoyed that. Look before we introduce our guest, a quick thank you to our followers in Portugal that sent the live show episode up to number three in the charts. And we've, we've stayed in the Portugal charts for the last couple of weeks. So if you're listening in Portugal, thank you very much for your support.

[00:05:17] STC: It's a very important market that.

[00:05:19] Jamie: Well, it is with Lisbon on the agenda for next year. Let's hope. Oh, yes. Okay, let's move on. So it's a great pleasure to welcome Dr. Lucy Pollock to the Aural Apothecary. Lucy's full bio will be available in the show notes.

Here is a snapshot for you. Lucy's a consultant, geriatrician and clinical director for frailty at Somerset NHS Foundation Trust. She has chaired a clinical ethics committee for 10 years and represented geriatric medicine at NICE . Lucy is also involved at Bristol University Medical School in what she claims is the most comprehensive, effective and popular undergraduate training in geriatric medicine in the world.

She enjoys slow running and even slower swimming and being connected with her family and friends. And in 2021, she published "The Book About Getting Older (For People Who Don't Want To Talk About It)". It's available in Canada, Australia, New Zealand, Germany, and Ireland. And I know what you're thinking and you're correct.They are all strongholds for the Aural Apothecary Podcast, too. The book is due out in South Korea. I think we've got a bit of work to do there. And the paperback version is in the shops at the end of May. Welcome, Lucy.

[00:06:25] Lucy: Thank you so much. Hi. I am excited.

Jamie: Well, we are all excited!

STC: More excited than me by the sounds of it.

Jamie: Big fans of the book, Lucy.

STC: We are, loved it. Yeah. Fantastic.

[00:06:33] Lucy: This is really lovely. I have, I haven't done a proper podcast and this is very exciting

Jamie: And you still haven't done a proper podcast, Lucy.

[00:06:41] Lucy: Yeah, this is a really good one to start with. You know, what a profession. I owe pharmacists a lot. Probably my GMC registration to be honest. This is a major treat. And obviously the whole of pharmacology and drugs, I'm a physician and medications are my surgeon's knife.

Jamie: Not a pharmacy podcast, mind, Lucy.

[00:07:04] Lucy: It is not a pharmacy podcast. I'm gonna go off piste now and say your audience I bet is very diverse. Do you know what your listenership is?

[00:07:12] Jamie: No. We've got idea of the demographic, which may reason this episode may be very popular to them. because we are all looking after older parents, I think. And grandparents and that type of thing.

[00:07:22] Gimmo: I think we know it leans towards pharmacists, but there's medics and, and other healthcare professionals out there with a smattering of the general public as well.

[00:07:31] Lucy: Yeah, they are. I've definitely, I've met general public who've, who've listened and definitely medics as well, for sure.

[00:07:37] Jamie: Let me throw a quote at you then, first quote of the evening from your book, Lucy, "We all become old if we are lucky. Older people are just the rest of us, grown up."

[00:07:46] Lucy: Yeah, grown up and with really good stories which is probably one of the reasons that I became a, a geriatrician, really. You've gotta be very nosy to be a geriatrician.

If you like people, it's a very good role because you need to know about your patient. You need to know more than their EGFR, their kidney function and you need to know about what their hopes and wishes are, and you need to know about how they fit into their family, and you need to know about what matters most. And it makes it a really great specialty for someone who is interested in human beings, so, yeah. I, if we're lucky, we will become old and, and I say, yeah, we're all apprentice old people. We need to learn from the people who've gone before us, at the same time as looking out for them.

And it's a big theme in my life at the moment as well. It's thinking about, Why are old people good for us? What are old people for? I think that's actually a question that's become a little bit sharp at the moment. And one of the things that I have been thinking about a lot is we know that young people are really good for old people, but sometimes asking the question the other way round isn't so obvious.

[00:08:55] And I look at the way that older people interact with younger people, both in families and in healthcare and in care settings. One of my colleagues put it really beautifully. It's about perspective and younger people are exposed, I think all the time now to perfection and everything has to be perfect. They have to have the perfect A levels, perfect boyfriend, perfect job, perfect degree, perfect holiday, perfect cocktail bar and infinity pool and the rest of it. And older people know that life just isn't like that. And they get to the end of a long life and they will often look back, as my colleague says, it's the rollercoaster.

[00:09:28] So the kids don't necessarily realise it's a rollercoaster. And when you lose your job or you split up with your boyfriend, you think it's the end of the world. And older people have reached the end of the rollercoaster and they're, they've stepped off it. They can see the whole picture. I think that's one of the most important things we learn.

[00:09:42] Gimmo: What you said reminded me, I, I think we've mentioned it before, there's a book that we read, Jamie, didn't we, "4,000 Weeks" which mentioned something very similar to what you talked about. It's this idea that, in that we're all trying to do a million things and achieve the perfect life, whereas his philosophy is exactly as you described, is around making the most of, of the small things and, and realizing that life's never gonna be perfect. And it is, you know, that's a really good read as well. I mean, I was really struck in the book, similar to what you just said, is, is that you're at great pains to sort of not to describe the elderly as a homogenous sort of group. And I guess that's what we as healthcare professionals are often in danger of doing, isn't it?

[00:10:19] If you lump the elderly as a term we described it’s a group of people that really don't warrant a single description.

[00:10:27] Lucy: Yeah. None of us like being put in boxes really. We, we all regard ourselves as different individuals and we might have our tribes and our groups and people we like and whatever, but we are all definitely individual.

[00:10:38] And I think one of the things that's really tricky about medicine is when it's very complicated, it gets depersonalized and it drives me nuts in hospital when I hear people talk about B3 or room 42 and I just want to say to them, that is not the name of a person, that is a bed number and people are, you can, if you really can't remember her name, you can say the woman in b3, that's fine, but you do not call a person b3.

[00:11:03] STC: Yeah I've said this before, but I worked for 25 years in hospitals, Lucy, mainly medical admissions and I spent most of my career and was really trained by endocrinologists and geriatricians and so I share your love of being nosy. But I think when I moved into general practice six years ago, and I got a lot of flak when I said this at a hospital pharmacy conference about two years later, but I absolutely stand by it. It’s not in specialist clinics where you might see people, like they've got adult cystic fibrosis and you see them regularly, but in a lot of activities go on in a transactional way in a hospital. I felt that I moved from treating bed numbers to looking after people.

[00:11:45] Lucy: Yeah, I mean, I completely agree. Primary care, obviously is where it's at. And you may be involved in looking after a whole family, and, you know, multiple generations and in many societies you're looking after cousins and the rest of it, whole family structures.

[00:12:00] You might know the employer as well as the employee. You know, that sort of intimacy with the whole of society is much more obvious I think, than in hospital. You are absolutely right Steve. And it, and it has its challenges, especially in confidentiality and things like that, but also incredible rewards.

[00:12:18] STC: Yeah. I mean, your book is so well observed, but it's also beautifully written. Honestly, it's one of those phrases where people say, you know, “I couldn't put it down”. It really was like that. It felt like it was just so real. And all the cases that you used, were real. And some of those were similar perhaps to people that I had come across, but some of them were completely different because they're all individuals.

[00:12:41] And there's a lovely bit in the book where I think you talked about a, a patient who was wearing funky clothes or something and you know about the individuality of these people. And it reminded me that I took a phone call recently and I was talking to this lady and she was talking to me about her father, and then she stopped me and she said, "you made my mother's day" and I said, "Sorry?" She said, “well, I came with her, you saw her and you remarked how funky she was with the clothes that she was wearing in her nineties”. And she said “she's dead now, but she still went on about that for weeks afterwards”. And I, wanted to cry.

[00:13:18] Lucy: Yeah, I know. That is really lovely, Steve. It's those little things that you notice about somebody and you suddenly realize kind of things fall into place about what kind of person they are. I've got a little bit of a thing about old ladies who wear leopard skin, leopard print. I'm not sure what it is, but there is something a bit special about an older woman with a bit of leopard skin Slightly embarrassingly, my husband and I went for lunch with some really smart people that we'd never met before in this incredible…, we were invited for a lunch and they were in their eighties, but they were enormously smart. It was a beautiful house full of fantastic things. And I brought up this fact for some reason, and this lady said, “ I'm not wearing any leopard skin” , and my husband said “not that we can tell Pamela” and she just was flirting , and it was just the most fantastic moment, this kind of little bit of flirtation.

[00:14:07] We forget that flirtation is very important. We could talk about that another time, but actually that is something that I watch playing out, and you have to be careful. Cause obviously sometimes people are badly behaved and say inappropriate things, but actually there's a little bit of the way that there's sometimes a bit of a nudge and a wink about things that is very life-affirming.

So yeah, I think comments on your earrings is a good thing.

[00:14:30] Jamie: There is a connection, Lucy, between STC and Gimmo in the book actually, that they won't, they won't know, but I'll share it with them. Cuz you shared with me yesterday, that half of the book was written in Wales. It was, do you wanna tell them where it was written?

[00:14:42] Lucy: I'll tell you where it was written. It was written in a little tiny cottage that I was allowed to borrow for a few weeks at a time in the winter of 2019. I was incredibly lucky because I'm really distractable, as you can probably tell, and I was lent this cottage by some friends and it is miles away from anywhere at the very end of Pembrokeshire, beyond Haverfordwest.

And it's the most beautiful place and there are just loads of birds and there were no people for miles around. But to be honest, even the birds were distracting, the first time I went there I realized that I actually had to close the curtains cuz I just would be sitting there looking out the window instead of writing.

But it was most brilliant place to write. I got a lot done.

[00:15:24] STC: Where exactly was it? Cause I lived in Pembrokeshire.

Lucy: Oh, okay. Well beyond Marloes

STC: Marloes Sands. Yeah.

[00:15:29] Lucy: Yeah. And then you go basically as far as you can go towards Skomer Island. That is, is where I was. And it also made me realize, Wales is this flipping long!

I mean, you cross the bridge and then you drive a long way, which was actually very good for me because it gave me about four hours of journey time where I kind of left the domestic and the hospital behind and just focused on what I was gonna be writing about. It was a nice place to be.

[00:15:55] Jamie: It's just that we stopped building motorway, sort of halfway along that track, really. And so that's why it feels long.

[00:16:01] STC: Actually, I've just remembered. I lived in Pembrokeshire and I've just remembered I've just broken the first rule of Pembrokeshire. We're not supposed to say how nice it is. We don't want people going down there. We want people to go down to Devon and Cornwall. That's where everybody goes.

[00:16:13] Lucy: Yeah. Yeah. And it was pissing with rain the whole time. You couldn't see, see a flipping thing and it was a howling gale . And you can't eat any decent food there either. Yeah. No never go to Wales.

[00:16:21] Jamie: Yeah. You're not to use the term "Little England" in any of your marketing brochures now, either. Lucy, one thing before we go on, which is a current one, I suppose, and I've just, we've stayed away from Covid for the duration of the podcast, and now that we feel as though we are sort of in a slightly different place, I've just seen your Twitter posts around lockdown deconditioning.

Would you wanna share with us your thoughts and what you're seeing?

[00:16:40] Lucy: I saw another patient today who I feel has been effectively aged about five years, probably by lockdown. And so many people are coming in now with falls, our orthogeriatric service is absolutely buzzing with people with fractures.

And we're seeing people with falls and with breathlessness and fatigue, and so it's not just, sort of leg muscle strength from not walking, it's also cardiovascular strength as well. And to be honest, it's mental as well, so there are, I think people who already may have been developing dementia have had that clearly accelerated as well.

So it's brain deconditioning, too, because of the pruning of social connections. We know that social connections are very important and doing different things and learning different things is really important. And for so many older people, that effectively two years of isolation has been absolutely devastating and we are definitely seeing the effects of that in hospital.

So it's a big, it's a really big challenge. On the upside, I'm a patron of Age UK Somerset, and I watch, they do loads of balance and safety classes and Tai Chi classes and Pilates, and I'm watching every time I open their website to look up for a patient where there's another class that might be near them.They are springing up all over the county, and I think they're very popular. Loads of people realize that they've run into trouble and they're keen to get moving again. But yeah, it is, it's a really big challenge.

[00:18:04] Gimmo: I think that deconditioning is a, that's a really good word, and I think, for example, I work in a health board that is struggling with post covid demand, which obviously you've got the obvious stuff around recovery lists and stuff, but it's the sort of patterns of demand that are just really difficult to explain. You know, why is primary care being swamped and, you know, we are not seeing the lull that we'd normally expect, now the weather's getting warmer, and you're probably seeing that with, it's interesting you said falls and it makes me wanna go and look at falls data now because the demand is just, it's unexplainable at the moment, it doesn't sort of follow any logic.

[00:18:37] Lucy: I think you're right. And I think there may be some surprising things that, that come out of this that we may not have predicted or not be really prepared for. So, I think we're gonna need to be as flexible coming out of Covid as we found when we were going into it in terms of innovation and kind of grabbing every opportunity to improve things.

And the deconditioning thing, that's not a word I would usually use with patients, but when I'm trying to explain to patients, you know, when they come into hospital and they may be in bed and they don't really want to get outta bed. And I say, you know, if we let you stay in bed, your muscles are gonna melt away.

And people recognize that, they immediately look down at their legs and they think, yeah, I don't want my muscles to melt away. And they're very aware of it. But, equally, people get quite frightened of knowing what to do about being, becoming more exercised. So here's Steve with all his lycra on, but actually it's really important that people realize that you don't have to be… Sorry, your audience may not have realized that Steve is wearing lycra.

STC: Are you flirting with me?

Lucy: Haha, I am not gonna say anything. But the, I can't take my eyes off the flipping lycra now, Steve. You've really blown it.

STC: It's the Welsh dragon, isn't it?

Jamie: If you need to compose yourself, Lucy, for a few minutes, then...

Gimmo: No, it's a good job he hasn't worn his leopard skin lycra is all I can say.

Lucy: Exactly. Ah, very good , now wait a minute, where was I before I got so rudely distracted? I was thinking about, yes, about how old the people do start moving again, because if you present it as exercise, I think that puts a lot of people out and they think they do have to get the leotard on and whatever, whereas of course, actually what it is, is about tiny incremental gains.

[00:20:11] And so the people who are already running a marathon are not gonna gain that much by running another marathon. But it's the people who are doing very, very little, people in the lowest quartile of physical activity, who are the ones who've got the most to gain from simply getting up off their bum and walking around and just, and also I think people are quite scared of being breathless.

It's something I've noticed even in young people now, and I say, you know, do you walk? And they say, oh no, I get breathless if I walk too fast. And I think that's what's supposed to happen when you walk too fast. That's a good thing, not a bad thing. And people seem to feel that breathlessness is a sign that you should stop, whereas actually, unless you've got ischemic heart disease and a kind of angina equivalent, breathlessness is usually a sign that you're doing the right thing.

[00:20:54] STC: Yeah, I think that's where we tend to use the word physical deconditioning is exactly that. So horrific stat: I read this last couple of months, it said that 76% of UK men were now overweight or obese. So when people say that they're breathless, and then you know, ask the questions to find out what causes it. Actually, it's because of physical, some of it's because of being physically unfit. And so people like to use the word physically deconditioned, don't they? As almost like a medical way of describing that that's part of the problem.

[00:21:26] Lucy: It's an awkward subject, isn't it? And we do have to be honest about it. And we see people who are breathless simply because they are very, very large, and that's a difficult thing to share with a patient in a non-judgmental way, in a supportive way, but an honest way.

And that certainly happens in older people. I definitely now see people in their eighties, not so much in their nineties, I have to say, but in their eighties, who are very, very big. And it has such a difficult, it makes life so difficult for them in so many ways. You know, mobility is one, but that exhaustion as well.

And then there's that shyness as well that goes with being very large and a sort of awkwardness about it. That is, it can be a really difficult subject to broach. And also I think people, as they get older, they feel very helpless. They think, I'm never gonna change. But actually, again, you don't need to lose an enormous amount of weight to make a big difference.If you've got two really creaky arthritic knees, if you can just change the ratio of muscle to adipose tissue in your thighs a little bit, you are gonna be making a huge difference. For a lot of people, it's that difference between being able to stand up out of a chair that makes the most phenomenal difference to quality of life.

[00:22:36] Gimmo: I think we get our messaging wrong on that. I think we make people terrified of exercise. You know, we say before you go to the gym, you need to see your GP. You know, you've got sore knee, so don't walk and be carefully, don't fall. And so I think we just need to get our messaging right on that.

[00:22:49] Lucy: Absolutely. Exactly. Do more, not less and all. Yeah. The poor GP , I always think, what are they supposed to say?

[00:22:55] STC: One other thing that I really liked about your book, Lucy, we may come back to this, but sometimes you were very sharp about some of your single-organologist colleagues, and so listeners to this podcast will know that that is a favourite subject of mine. But just while we're on the matter of breathlessness, I'm going to give a tick in the box for cardiologists and what I like, a phrase that a lot of them use is, "it's okay to be comfortably breathless, but if you become uncomfortably breathless, then that's worrying." So I'm gonna give a tick in the box for cardiologists there.

[00:23:26] Lucy: That's brilliant. That's if you are breathless and proud, then you are, you are doing the right thing. If you're breathless and terrified, you might be, you know, I know lots of really lovely cardiologists, so I don't have it in for all of them.

Jamie: I can hear cardiologists rejoicing throughout the land.

[00:23:44] Lucy: But, but it's hard, and I was talking to somebody today about it. I'm working with a fantastic junior doctor, but can I just do a shout out to our international medical graduates at the moment. My god, they have come to the rescue. We need lots of extra junior doctors at the moment. So our own homegrown ones are being fantastic. But through the pandemic we have taken on loads and loads of doctors from all over the world. And I work with different ones all the time cause I'm constantly chopping and changing wards and I have locums and temporary doctors and they are so fantastic to work with. They are so adaptable. A lot of them haven't worked in the NHS before.

[00:24:20] There are language barriers which they overcome really quickly. They overcome some bits of discriminatory behaviour. They are kind and funny and miles from home. I was on call at Christmas for a really young one who was just so far from home and had no family in this country and spoke five different languages and just was enchanting and I just think jeepers, they are fantastic. Anyway, onwards single-organ specialists, it's really hard, Medicine is really complicated and you get to know your specialty really, really well and you know all your drugs really well and you know the evidence base for them in 64 year old men. And then you try and apply all that lot to an 89 year old who's taking 11 other medications already and whose kidneys are dodgy and eyesight is poor.

And you haven't even looked at the state of her hands or the state of her house or any other part of the prescribing that we all know is good stuff. And you're completely lost. How are you supposed to be able to start thinking about interactions or the suitability of that medication?

[00:25:27] And then I look sometimes at, we were looking at the guidance that's out there for people who are trying to prescribe in Multimorbidity. And I have to say I love ''NICE''. And I think it's a world beater. And when 'NICE' started, we should be very proud of it. It is one of our national institutions of which we should be proud cause it's done fantastic work. But I look at the multimorbidity guidance and in particular, I was reading, you sent me an article about shared decision making between older people and GPs.

STC: Oh, we're gonna talk about that as part of the micro discussion

Lucy: okay. Well, in that case, I shall hold my thought.

[00:26:04] STC: Now might be a good opportune time then to move on to the most interesting section, I think of the being an Aural Apothecary guest. And I know that you've listened to some episodes, so thank you for that. So the first thing we like to ask people for is a desert island drug, and you can only have one, otherwise Jamie gets very upset. And just a little aside, I'm pleased to tell you that although I don't have the little “TM”  yet, I one Sunday afternoon thought, what the hell? And so I applied to the Intellectual Property office to trademark 'Desert Island Drugs'. So I'm hoping that in a couple of months’ time, if the BBC doesn't object because of Desert Island Disks, and there's also a Desert Island Desserts podcast. But if they don't object, Desert Island Drugs is ours. But anyway, it's not about us. It's about you. And so, what we are interested in is a drug that you have an affinity for, it has a real sort of connection. So what would you like to give us?

[00:27:04] Lucy: Okay. I've got a prop here. I've brought a packet with me and…

STC: Ooh, first person, I think first guest to actually bring the prop with them.

Jamie: Are you meant to have those tablets in your possession before we, put them ?

[00:27:17] Lucy: I'll just confess right now that the box is empty. And actually I have more of where that came from. That is, they're part of a, a set of props that I use for teaching medical students. And my junior doctors will fall off their chairs if they think amlodipine is my desert island drug. But I've learned a lot from this drug. So I know that this drug has prevented lots of strokes. and it has therefore improved quality and quantity of life for millions and millions of people. However, I've learned a lot of other things about it. One of which is that of course it's an ingredient of the prescribing cascade.

And anybody who works in geriatric medicine and in primary care will recognize people who are taking amlodipine and a loop diuretic like furosemide and they're taking the diuretic because the amlodipine gave them ankle swelling. And it's an absolutely classic prescribing cascade. And to be honest, I won't be sorry to see the back of it. The more education we do, it will stop happening, but actually it's incredibly satisfying, intervening on that one because you see somebody who's got really bad woody leg oedema , often with leg ulcers,  and they're miserable and you stop their amlodipine and it improves their quality of life incredibly much. So, it's a drug that has generated thank you letters for me. But there's something else I learned from it, which is probably more important. And that was something about listening to patients. So I first encountered this drug probably when it was first... I am quite old. I'm very old.

I encountered it when, I'm not quite sure what year it came out, but it was a new antihypertensive, and I was at the Wittington Hospital in North London and I had an old lady on my ward and I said that this was the drug for her. And a couple of days later she said she wasn't gonna take it anymore. And I said, well, why not? And she said, it makes me feel terrible. And I said, well, that's not a side effect to that drug. And I said, come on. What do you mean by terrible? Do you mean lightheaded? No, it wasn't that. Do you mean ankle swelling? No, it wasn't that. She said, it makes me feel sick, and I said, well, It's brought your blood pressure down and if your blood pressure stays up, you're gonna have a stroke.

[00:29:26] You know, in those days I thought that if your blood pressure stayed above 160 mm Hg for more than five minutes, your head was going to explode. And, you know, at two in the morning ,I had a bit of a battle with her and I said, you know, okay, you can go home if you, if you take the drug. And I offered to see her in clinic and she came back and I've never forgotten her. She was a really small woman in a red dress with a red coat with gold buttons on. And she was a smart lady and she said “I am not taking that medication”. It makes me feel terrible. And I looked at the side effects , I had to go to the library. This was pre-internet days so I had to go actually to the BNF, I had to get a BNF out and look up the side effects again. And I looked through them and the first side effect is Asthenia. And I thought, well, she hasn't got that because I dunno what that means, so I skipped over that one and then went to constipation and oedema and the rest of it. And then I went back to a senior and I had to go to the library to look up in a dictionary what asthenia meant.

And asthenia is a side effect still now today of over 150 drugs in the BNF. And I can tell you now, almost no doctor knows what that means. I'm not sure how many pharmacists know what that means.

STC: Is it makes you feel sick?

[00:30:36] Lucy: Makes you feel sick, exactly. So when I'm teaching the students, I say, or junior doctors, nobody knows what this means. The old neurologist with a classical training knows what this is. Okay, so you think they will because it's Latin. So you think, what is myasthenia gravis? My means muscle Gravis means terribly bad. Asthenia means weakness. Oh my God. asthenia is the BNF for weakness.

Jamie: I didn't know that. Who knew?

Lucy: Basically, what I learned from that is a few things. One is you need to listen to your patient. If she says she's got a side effect, it doesn't actually matter whether it's in the BNF or not. It doesn't matter whether it's a recognized side effect. If it makes her feel like that, then it is a side effect for her and you have to listen to it.

You can't just say, well, that's not a side effect, or that doesn't happen with that drug. It does for her. That's fine, listen to her and do something different. And then the other thing is that prescribing is a “rat's nest” and there are forces at work that are not necessarily on your side. And so for example, I've written to the BNF to say, please don't use the word asthenia, could you change it? because nobody knows what it means. Could you use the word weakness? And I've had the message back from the BNF saying, we base our list of side effects on the summary of product characteristics provided to us by the manufacturers. So, we will not change it because that's what the manufacturers call it.

Gimmo: We can work with you on that one, I think, Lucy, afterwards.

 Lucy: I would love that. I would love that if we can do a campaign,

[00:32:11] STC: but I think that's the first guest (genius by the way). But I think that's the first guest that's had a prop. But the learning from that patient that you've remembered, and as you say it is incredibly common and no word of a lie one of my telephone consultations today was about the very subject of swollen ankles and amlodipine, but a great story, which is what we are really after. That's what Desert Island Drugs is about. It's, you've remembered it for very many reasons and you now still use it for teaching. So we can't ask better than that.

Gimmo: And I just think it's great cuz, again, it's what we do. We have to categorize everything. We have to name something. You have to define something. And it doesn't matter does it? If something's making you feel a bit crap, that's what matters. It's not sort of nailing it down. We talk about plain English and shared decision making and communicating with patients and you've raised a really important issue is how, how we all converse with each other as well. Cuz probably, we've all read that word a million times, not understood it and done exactly what you did and thought, ah, I bet it's not the only one as well.

Lucy: Yeah, well, you may be right, I think, but actually most of the others are all right. I think for some reason everybody's got a blind spot about that one. They think that if you've not heard of it, it can't be important.

 Gimmo: We'll make a fuss of that on, on Twitter and see if, see what people think, see whether they agree with you or not.

[00:33:20] STC: Okay. So Amlodipine makes it into the Aural Apothecary formulary. Excellent starter for 10. Now then, the next thing we're after from our guests is a career anthem that goes into the Aural Apothecary Spotify playlist, which is on Spotify, and you can find it and see all the guests’ choices and listen to it. Fantastic list. So Lucy, I believe you're a bit of a music buff. So I'm looking forward to this. What are you gonna choose?

[00:33:48] Lucy: You asked for honesty in the brief that you sent me, and so I'm going to say I listen mostly to classical music. I love all kinds of music and all of my family listen to all kinds of other music. But for me, when I am needing to be cheered up or when I am needing to be calmed down, I listen to classical music. And in fact, I brought another prop because I am so old-fashioned that I listen to it on a CD. This isn't actually a career anthem. I only heard this piece of music, actually quite shortly before the first lockdown, but it's a piece of piano music. It's by Brahms. It's an intermezzo, so it should have a better name, but it's Intermezzo Opus 117 number one.

And my version is played by an amazing Romanian pianist called Radu Lupu, who has just recently died. And it's about five minutes and three seconds of complete perfection. Covid was, I mean, it's been awful and  I had Covid very early on, so I didn't feel at risk of catching it for a long time. And I ended up looking after people with Covid for a very long time. And they, you know, we all know that most people with Covid in hospital were not in intensive care, they were older people on Covid wards and, and some young people, and it was miserable. And for a long time I listened to that bit of music pretty much every day on my way into work. And I usually listen to it on the way out of work as well. And for some reason, despite the fact that it conjures up enormous amounts of sadness, it also, every time I hear the opening bars of it, it makes me smile.

And it's just incredibly beautiful. I also thought at the beginning when everybody was doing lockdown projects and, people say, oh, I'm gonna do this and that. I fondly thought, right I am really, I'm gonna get the piano out and I'm going to start practicing the piano. And I listened to that piece and I thought, do you know, I could learn that piece of music? It's so beautiful. Maybe I could learn it. So I actually ordered the, the sheet music for it. Oh my God. It may be slow. it is absolutely impossible , not a cat's chance, am I ever gonna be able to play it.

Gimmo: I thought you were gonna be the first person to play it for us on.

Lucy: Oh, not a flipping hope. I can't play the first bar and it's really slow. But he is so incredible that he makes sounds come out. I can't explain it because I'm not a musician, but he makes sounds come out of this music that, that aren't there when you play it, so it's good stuff.

Jamie: I thought, Lucy, you were brandishing a Richard Clayderman CD

STC: Oh, so did I. Lucy, you don't know the story of this, but that would've been, I would've exploded if it had been Richard Clayderman, because Jamie used to bloody play Richard Clayderman when we at University Rocking and Rolling and he'd be, have Richard Clayderman on.

Jamie: Just to clarify, I used to play Richard Clayderman CDs.

Gimmo: Never have Brahms and Richard Clayderman been spoken of in the same sentence.

[Jamie: But you're not the first, classical to go on the on the playlist, Lucy, you'll be pleased to know, two of our general practitioner colleagues have both come in with similar.

STC: Tessa Lewis picked a piece that she did actually play on the cello.

Lucy: Oh wow. That is quite something.

Jamie: And in Tessa's episode, do see Tessa likened it to, she'd been playing the cello throughout, you know, when she, from when she was a medical student all the way through her career as a GP and she likened trying to master the cello piece to trying to master general practice. You, you know you can improve every day, hopefully, but very, very difficult.

STC: So let me lower the tone. I also do really like classical music, but for the listener, which advert has it been used in?

Lucy: Oh my god. Do you know? I'm not sure that it ever has

STC: Oh, well that's okay. It wasn't a trick question. Maybe the tone of my voice got it wrong. All I meant was if we said which advert it was in, do you think people would, would recognize it?

Lucy: I don't, but I don't think so. But it might have been. It might have been.

STC: we'll post it on socials if it has,

Lucy: I'd really like to know.Yeah, I'd love to know that.

STC: Paul will google it now while we're listening, so, okay, great. So we'll definitely accept, that's a fantastic piece of music from what you've said and we'll listen to that and we'll add it into the Aural Apothecary Spotify playlist. And the third thing that we ask is something for the Aural Apothecary Library, which is a book that you think the listener really needs to read, and why would that be?

[00:38:17] Lucy: Okay. The book I would recommend is this, it is called Stuart: a Life Backwards, and it's by a chap called Alexander Masters. And if you don't want to read the book, it was made into a fantastic short film some years ago with a very young Benedict Cumberbatch and Tom Hardy and it’s a short Channel 4 film. Tom Hardy, as you have never seen him before.

So this book is a really beautiful book and it's a biography of Stuart who Alex Masters met, he was meant to be doing a PhD. Alex was obviously, again, somebody quite distractable and he started working on a campaign. There were two people who ran a hostel in Cambridge for people who were homeless and with drug addiction problems. And they had been sent to prison cause they had been accused of allowing people to deal drugs on the property. And there was a campaign to get them released. And during that campaign, Alex Masters met Stuart. And this is a biography of Stuart. Stuart is a chaotic, horrible, violent, sweary, foulmouthed, unpleasant, dirty, difficult individual, and we've all met him on a medical take in his filthy jeans and his horrible, smelly t-shirt, and he's completely pissed and he's hungover and he's violent and aggressive and God knows what he's taken the night before and he's giving the nurses a rubbish time and you really don't wanna see him.

And he is also funny and kind and caring and damaged and, he didn't set out to be the person that he is, and Alexander Masters took a long time to try and know Stuart and to work out where, how he got to where he was. And it's a life backwards because Stuart wouldn't tell him. So they had to start where they are now or that where they were, and then gradually, gradually overcome all the barriers about Stuart being able to tell him about where things started.

It's also, it's very sad and it's very funny and it's very, you just learn masses from it. You learn about how difficult it is to get off the streets once you've spent one or two nights on the streets and you learn about how difficult it is to negotiate, you know, lots of people in medicine like me come from a very privileged background.

I'll be honest about it. Lots of people in medicine haven't met people whose lives are more difficult than their own. And this book makes you really think about it. And I give this to my best medical students cause they get a lot out of understanding this. I think it's a game changer. I think everybody should read it, it's a brilliant book.

[00:41:07] STC: Okay. Well, can't say fairer than that. And funnily enough, Dr. Mark Holland, who, I dunno if you know, because he was the president of the Society for Acute Medicine, but he was a geriatrician. I worked with Mark for a long time and he was a guest on here. And guys you might remember this, but he talks about a very similar story at the end of his episode where he talks a lot about the sort of person that you've just described who he didn't really want to deal with.

But one day he just sat down with him and he realized what a shit life that person had had and how things had got to where they were. And Mark gives a very similar and a very honest account of how bad he felt about all the times he had met him before. Which I suppose is why for people like you, geriatricians, and those of us that work with those people, who understanding them as individuals. I can, without even reading it, I can guess why you're so attracted to the book.

[00:41:56] Gimmo: Well, when we met Karen Sankey, hers was a very similar story, she's a GP who's having to fight and struggle to actually treat homeless people because the system just doesn't want you to,

STC: Jamie, you should come in at this point and mention Julian Tudor-Hart.

Lucy: No, no. I heard you talk about Julian Tudor-Hart, Jamie and Absolutely. He's a complete hero of mine as well. And it was interesting to hear you talk about Hans Rosling at the beginning. Between him and Michael Marmot in terms of the power of data, and understanding the imbalances in the world, but also the good stuff that can happen if investment goes into the right place, and how small amounts of investment in the place where you least want to put it, in the place that's actually making the least noise, but has the most demand is how to play it. Its' really important stuff. So those, you know, those are brilliant people for anybody to read. And if you've never seen, Hans Rosling does the most fantastic Ted Talk. It's a beautiful Ted Talk and his son used to help him with it. And then I think he helped finish writing that fantastic book after he died. It's an amazing Ted talk with great tech and the graphs are just fantastic.

[00:43:06] STC: Yeah it's a real skill in the ability to communicate complex things into very simple language. And I think each of us as educators, that's what we, I suppose that's why we, one of the reasons why we set off the podcast is we think that podcast is a good way to communicate information.

Okay. I'm definitely gonna be ordering that if I can, and that's Stuart: A Life Backwards by Alexander Masters. Excellent choices, Lucy. That definitely makes it into the Aural Apothecary Library.

[00:43:32] Jamie: Excellent. Okay, our micro discussion next. So continuing the theme we are looking at shared decision making between older people with Multimorbidity and general practitioners, and it's from the British Journal of General Practice by Emily Brown, who's an academic clinical fellow and GP trainee together with her colleagues from University of Exeter. We've got a big Southwest feel going on this episode, haven't we? Look, multimorbidity in the book, Lucy, you highlight the term multi-complexity rather than multi-morbidity. Which I, quite liked that with my first reading of the book, and you also bring us on to mention Mary Tinetti's work and the five 'M's

[00:44:09] Lucy: I love the five 'M's. So, Mary Tinetti was a fantastic geriatrician who published brilliant work about falls and she's worked her whole career in geriatric medicine. Then she got towards the end of her career and somebody said to her, what do geriatricians do? And she thought, jeepers, I don't know. In fact I think lots of people still don't know what geriatricians do, but she kind of distilled it down after a bit of thinking. So her five 'M's are the Mind, which obviously includes sort of mentation thinking, but also dementia, delirium and depression, “the nasty 'D's”.

And then she talks about Mobility. And then she of course talks about Medication. And then she talks about this interesting subject of Multi-complexity. So not just multimorbidity what illnesses you have, but also the bio-psycho-social complex that you live in that we talked about earlier about understanding the whole person.

And then she has this fifth 'M' of what Matters most and, we all know that really everything about looking after older people and about prescribing for older people is about what their goals are. What do you want? How can we help that happen? They are very good 'M's.

[00:45:22] Jamie: Very good. What did you make of the paper then? In the round?

[00:45:26] Lucy: Yeah. I thought it was a fantastic paper and I thought it was very honest and they're really lovely little interviews and snippets with people and there were a few things I picked out of it. I love clinicians commonly, yet incorrectly perceived, that effective shared decision making has been achieved. You know I am sure I'm brilliant. I walk away from that interaction, I think my patient's happy, I'm happy. And what it is, is they've agreed to take the stuff I want them to take and they smiled and said, thank you. You know, that's not shared decision making. And I love, there's a really honest bit with a, where a patient admires what a doctor says, and the doctor at one point says, you've got more wrong with you than most of my patients put together. It's making my job very, very difficult, and the patient loved it. They liked the fact that. The doctor was honest and recognized that they were complicated.

I thought that was fantastic. What else? The other theme that came out and I was interested in was medico-legal vulnerability. And I wonder whether that's more of a theme in primary care than it is in secondary care. I need to be careful, cause if I say that I'm almost certain to make some absolutely horrific drug error either today or this time last year and find myself in court before I know it, because we make mistakes all the time or we make decisions that come out wrong. Steve's waving at me.

[00:46:50] STC: So just to be clear, I think around medico-legal vulnerability, the way I understood this  , and having done some qualitative research myself and knowing how hard it is to get people to take part , is whether or not this group of people that took part were representative of the whole of the UK? No they were not. But medico-legal vulnerability in this sense, not only are the clinicians saying about how important it is, but the patients independently, cuz there were two different focus groups, are saying that they understand that because of their complexity, they realize that maybe they are difficult for the GPs medico-legally. But the bit I think that this is about is, and the difference between primary care and secondary care, it goes back to our single-organologists, I'm afraid, is this issue about “If we agree to stop this” because we've gone through the BRAN, we’ve gone through the Benefits, we've gone through the Risks, we've gone for the Alternatives, we've done the Nothing.

We realize that you're not exactly the clinical trial patient, but you're a real patient. I know something about you. You've got lots of complexity. We agree that if we stop this anticoagulation, you accept the increased risk of stroke, but you don't want to have a stomach bleed , as you had one last year.

And what the Dr is worried about is that if that happens and then that person has a stroke that they will medico-legally not have a leg to stand on. And not only that, that their single-organologist colleagues will call them out for making a “bad “ “wrong “decision. That is what medico-legal vulnerability is about, and that is the bit that we've got to try to fix because that is the bit that is stopping Clinicians from feeling confident to do something that's in agreement with the patient who's making their choice. That is the problem.

[00:48:42] Lucy: I could not agree more. I could not agree more, and it is a real challenge and, I say in the book, good decisions can turn out wrong. You are allowed to make a good decision with a patient that goes the wrong way, and that's fine. It's, you know, lots of, this is a numbers game, it's a roll of the dice.

Lots of medications are making a rather small difference, one way or the other. And we all know that things have upsides and downsides. So, you make a decision together, and then, unfortunately, I think in relatively few cases you may end up with a court case, and if you do, you may end up with a single-organologist person saying, “well, of course that was gonna happen, you should never have stopped the drug that I started” , or whatever. That's not fair because doctors don't stop medicines or change medicines trying to cause problems. They're not being flippant or careless. I mean, we do make mistakes, but at the same time, if you sat down and you've had a conversation and you've weighed up the risks and benefits and you've talked to the person about what it matters to them, and they say, I'm rattling, doctor, can we stop some of these tablets?

Or my patients say, I think some of my tablets are fighting with their other, with my other tablets, it's a great phrase, they're worried about them and time after time patients feel better when their medications are cut down, whether or not they were actually causing side effects.

Simply having three tablets in your hand instead of seven makes you feel better at breakfast. It's a relief. So the sort of quality of life, it's so impossible to measure. There isn't an NNT for one less tablet, is there.

STC: One Less Pill

[00:50:15] Lucy: There should be, can we measure that? One less pill! That would be a really good NNT to measure.

So, you're right. And then I think, I was looking today at the NHS, so going back to the NHS Multimorbidity guidance, which is supposed to sure people up and it, it gives you some get out clauses and it says, consider the whole patient and consider the impact of different medications. And then it points you to the NHS database of treatment effects.

Oh my God. Have you ever tried to look at it? I think, you're a GP. You've got, this !

STC: Is the NICE  guidance, isn't it?

[00:50:49] Lucy: This is the NICE guidance. NICE multimorbidity. Yeah. So the NICE multimorbidity says, you know, take into account the treatment effects as listed here and it gives you a link to a thing that is a monstrous kind of, I think it's an Excel spreadsheet.

It comes with a user guide. Now, anything that you have to open a user guide first before you even begin to understand how you can possibly use it.

Gimmo: You're already inspiring confidence in the patient there, aren't you?

Lucy: oh my God, honestly. And I've tried to use it and it's got, it's got those cells with Fx at the top of them and Oh my, and you just think, I don't have a clue what this thing is doing. I could not make sense of it. So, you think that's not fair, that's not a realistic place for anybody, any clinician to use. I can't use that in my clinic, in general practice. That's completely impossible. So, I have to say, I think NICE should take that out and I think, well, what can they replace it with?

[00:51:44] Where are some handy bits of data? I love Scotland, in terms of medicine. I suspect Wales is gonna do exactly some very good stuff as well. And Sally Lewis's work is incredible. They're value-based care. I love it. And I think Sally is a complete hero. But for the minute the thing that I have found workable is the Scottish Polypharmacy Guide, which is really user-friendly.

There's seven steps for prescribing. I use it, I'm training a lot of pharmacists and advanced care practitioners. You know, and they're prescribing independent prescribing certificates. And that's where I would send them to learn about, you know, put the patient at the centre and then work out whether you're doing harm or good and balance it up.

And then it's got some really good NNT tables in it, that are very easy to read. So if your patient really wants to know, is this really making a difference? Those are easy.

[00:52:35] STC: We've had Jonathan Underhill on who works for NICE and we talked about the NICE Multimorbidity  guidance , and the boys will back me up when I, that I did say to him, I'm sorry, but it's not workable.

You know, it doesn't work. And his answer was accept that you're never gonna be able to find the studies that include all of these people with all the multimorbidity. But I think that is exactly the point. So, in other words, we have to, clinicians have to have confidence that they have to make decisions with people that are imprecise.

But there's loads of imprecision, even in the best studies because it included people who wouldn't have been included in the study. So, it's the imprecision that drives it.

[00:53:17] Lucy: Exactly. So that, that's why I like the Scotland one, because for each one it will tell you the average age of the people in the trial and some of the exclusion criteria.

And so you can see, OK the average age for a trial of Ramipril for example was 64 and 80% men. And you think, okay, does that apply to this 91-year-old woman in front of me who's got slightly creaky kidneys as well? And you immediately can, and it doesn't give you too much data, it gives you enough to go on.

So, I think, I dunno how we, how do we change it? I can understand that the people in NICE want to point you in the direction of the evidence.

[00:53:55] Gimmo: Well, it sort of hints at it in the paper, doesn't it? In that part of the solution is training people to be more comfortable with uncertainty and that includes the patients as well, doesn't it? So I think that, there isn't gonna be an answer to this. I mean, cuz someone in there said, you know, we need some more hard evidence. We're not gonna get it, and, and so it's about learning to live with that uncertainty and to make decisions based on a balance of risk, isn't it?

[00:54:21] Lucy: Yeah. And it's also, I think there are pragmatic things. Like, I love a trial of medication and saying to somebody, why don't you try this for a month? And if you don't like it, please stop it. So I say that about lots of different medications, which might include an ACE inhibitor

Jamie: not with insulin hopefully

Lucy: Not with insulin. No, with that one, I say, could you just keep taking the stuff? But even with sometimes with anti-epilepsy drugs, you know, lots of people get started on epilepsy anti epilepsy drugs where we're not absolutely sure they've really got epilepsy. Well, a trial of treatments a very good idea, but stop it if it's not making a difference.

Obviously the anticholinergics are a really good case in point. For some people, they are a complete game changer. For most people, they make no difference for God's sake. Stop taking it if it's not working. I really love drug holidays. I love saying to people, well, look, why not just stop taking a statin for a couple of months and see if you feel better?

You know, I don't know if you're gonna feel better

[00:55:16] STC: That’s what we have to try and harness, isn't it? I do a lot of teaching around polypharmacy and deprescribing with Clare Howard, who was on the first episode, from Wessex AHSN. And it's all about building confidence to have those conversations. And a bit like when I was sounding off earlier that it doesn't help when…., and so that's the bit that we've got to get to.

We've almost got to, for most people who we have now trained, so people like of our age, we worked before, we had evidence-based medicine and perhaps we, through guidance,  then stopped thinking and maybe stopped listening? And now, I think we've gotta go the other way round. So, we've got the guidance, sorry, we've got evidence base.

And yes, if I'm gonna use an antihypertensive, I've got four classes with really good evidence, right? Give or take. But I've gotta find the right group that works for that particular patient. So I think we've got to harness that. And one thing, I was just listening to a podcast and we've also had him on as a guest and that's James McCormack who is from Canada and they are doing fantastic stuff in Canada.

[00:56:19] It's the Family Physicians of Canada and they have an equivalent to NICE. But this is an independent group. It's been running for years through academia, but with people, no drug sponsored people are allowed in, and they are actually creating guidelines. They've just done one about chronic pain where they've kind of tried to use the best, we know there's lots of imprecision, but we look at what's the best evidence and they've looked at osteoarthritis, chronic pain, and neuropathic pain as one piece of guidance, not three individual pieces of guidance like NICE would do, and saying there is imprecision, but if we look at the best we've got available to us, then for example, guess what? Exercise comes out best for osteoarthritis, so there is a way to do this, but it's hard. Really hard.

[00:57:02] Lucy: Yeah. I'm a fan of James McCormack. I've seen him in various formats and he is very, he's very honest. That's the big help. And obviously a fantastic communicator as well.

What else can we do to sure up the patient because patients, they do like certainty and, and a lot of older people especially will say, you know, you are the doctor, you decide, I want you to do what's best for me. Yeah, I love it when a patient comes in with a list that they've written of their medications and what they're for. And I love how many of my patients come to clinic, even though the letter says, please bring your medicines. And they go, oh, I didn't bring my medicines. And you think, What are we gonna do? And they, and I say, well, I can see the list that your GP has got, but I can promise you that what you are gonna be taking is not gonna be the same as what's on the GP list.

And, oh, it's hard, isn't it? But equally, I remember I was on my elective in Kenya in Mombasa when I was very, very young. And I was on a ward round, and the consultant said, which anti-malarials are you taking? And I thought, I have absolutely no idea, I just take them. And it was so embarrassing. And I talk in the book about my experience with doxycycline.That was embarrassing.

[00:58:12] STC: Now that was funny. I won't give it away, but your statement about doxycycline and it went over the page. Yeah. I mean, that was funny.

Lucy: Oh, oh, good. I'm glad you liked that. That is true. That's, that is a true story. They're all true stories. Of course, they're-

Jamie: All stories are true, some actually happened.

STC: Jamie, what, what was your take on this?

Jamie: Oh, I'm not gonna add any more to it other than what we've, you know, it was the multi-complexity bit that I wanted to get out, and again, I just went down sort of Mary Tinetti's work. It finishes up with the uncertainty bit.

Interestingly, we've mentioned Canada already, so Canada, the Deprescribing organization in Canada have started doing work with patients on preparing them to come into the healthcare system and having those conversations that, when you do come into the system, your clinicians will have these conversations with you where they will try and include you.

And so it's not that they're waiting for you to become a patient, they're trying to have these conversations almost like sensitizing the public to say, look, this is how we're trying to have these conversations with you when you come into contact with healthcare.

[00:59:13] Lucy: Brilliant. Yeah. Be warned, this is something we're going to ask you.

I'm doing, I'm very peripherally involved in a fantastic de-prescribing in Care Homes project, again, being done from Exeter with a really great young researcher who's had to get very nimble during covid, but interviewing people, carers, in care homes, staff in care homes, families and residents about the barriers to de-prescribing. And I think it's gonna be fascinating what comes out of that.

[00:59:37] STC: Just really finally, we talk about it a lot, but obviously we, again, we have to go back to being able to feel confident to work in the grey, don't we? I mean, that's essentially that we've moved away from the black and white and it's not helped as we've said before.

So, Yeah, a really interesting piece of work. And I think the Canada model is certainly one thing we should look at. Obviously in England we've got the new national over-prescribing report and Professor Tony Avery. And that's the kind of thing, because I was involved in some of that, and that's the sort of thing with bringing the public on board so that the messaging is correct is really where we're headed.

 But it is incredibly hard and, and it is complicated.

[01:00:14] Jamie: With your permission, I'm gonna summarize something back to you, Lucy, and it's one of my favourite quotes from your book. Okay. And then we'll close. "We're at a point in the history of humanity where more and more people are living to a very great age, but we don't really know how to be that old, and we don't always know the best way to live among and look after people who are that old."

A big thank you to Lucy for joining us on the Aural Apothecary and for sharing her stories, her Desert Island Drug, her career anthem, and her book for the Aural Apothecary library. Coming up next time we'll be joined by Rebecca Hunter. Rebecca is a pharmacist clinical leadership fellow working in health education and improvement Wales.

She has experienced across a wide range of healthcare settings, including community hospital and prison pharmacy. We look forward to catching up with Rebecca next time on the Aural Apothecary. You can contact us via Twitter at Aural Apothecary. We're on LinkedIn. You can email us at auralapothecarypodgmail.com over to Gimmo now for the final ingredient.

[01:01:12] Gimmo: Thank you, Lucy. That was fabulous. And, just a further plug for the book. So does anyone ever remember the first, I think it was the first ever final ingredient who it was about, well, I think it was Bruce Willis, so I hope I've remembered that right. And if you remember, he was acting grumpy in a pharmacy because he'd been asked, I think, to wear a mask.

But around that time he was generating quite a bit of a reputation for being grumpy. You know, he was short, he was uncommunicative. He was brisk. Well, I mean, I've see in the news recently that he's recently retired, a result of health issues and more specifically, something called Aphasia.  Is that pronounced correctly, Lucy, Aphasia? Now, I didn't really know much about Aphasia, so I looked into it and I think it's relevant to this podcast in today's discussion. It's a brain condition that's usually caused by injury, stroke, or dementia and it's defined as a disturbance of the comprehension and formulation of language caused by dysfunction in specific brain regions.

And so the essence of it is a disorder of linguistic processing. So I'm reading this out by the way. A disruption of the mechanisms for translating thought to language patients with aphasia can no longer accurately convert the sequences of non-verbal, mental representations that constitute thought into language.

But despite their appearances, it doesn't actually affect intelligence. So it's a real sort of issue of communication and a massive hindrance. And the Stroke Association estimate over 350,000 people have it. So it's probably something that we should be more aware of. The Royal College of Speech and Language agree. And so they've headed up a consortium of charities known as Communication Access, and they offer a training package for healthcare professionals who can display the communications access symbol so that patients with Aphasia know that they can talk to someone who's been trained. So I just thought it was interesting and maybe something for us all to be aware of. The package and supporting material is freely available, but I also thought maybe, on behalf of the Aural Apothecary, we should offer an apology to Bruce Willis, and offer him our very best wishes. Thank you very much.

Jamie: This was a 'Three Apothecaries' production