Episode 2.1 - Jonathan Underhill, Shared Decision Making, NICE and POOs - not DOOs.

Aural Apothecary Episode 2.1

Jamie: Welcome to series two.This is the Aural Apothecary podcast. My name is Jamie Hayes. Coming up in today's episode, we're joined by Jonathan Underhill. Jonathan is a pharmacist and consultant clinical advisor for the National Institute for Health and Care Excellence (NICE). Jonathan will get to share his desert island drug, his career anthem, and recommend a book for the Aural Apothecary library.

 In keeping with a NICE theme, our micro discussion will look at the new five-year strategy from NICE. Exciting. I know, but you must contain your excitement. The new strategy has the strap line, dynamic, collaborative, excellent. All words used to describe the Aural Apothecary. So, we said we're going to have a debrief after Season 1, and we did. And you'll be distressed to hear that we haven't changed anything. No changes whatsoever.

Before we go any further, I've missed them, and I know that you've missed them too. Let me welcome my two fellow Apothecaries. STC is in Bournemouth and Gimmo is in Cardiff. And just to clarify, Gimmo is our social media manager and STC is our social media tart. Welcome both.

Gimmo, what have you been up to?

Gimmo: Welcome boys. Yeah, nice to be back. Miss doing the podcast, obviously. Actually, quite a lot's changed since we last did it. I think it's only been a month, but everything's back to normal. A month ago, everyone was craving getting out and doing stuff, and now I'm already sick to death of taking the kids to football and rugby and swimming and all that sort of stuff.

And I was stuck in traffic earlier. So, things definitely back to normal. Yeah, it's been business as usual really. I've done my first shifts volunteering at the mass vaccination centre. So, that's been really good, actually. You got to see an amazing logistical operation in action.

Everyone down there pretty much is a volunteer, so there's a good spirit. I'm late to the party, but big shout out to anyone who's doing that. It's really good. Enjoyed that. Very good, STC?

STC: Good evening, everybody. Yeah. Good to see you all. I've got quite a few things to say as you might imagine. But I must just start by saying, Jamie, it's not season. Okay? We're in the UK. We are not American. It's series. Anyone. Do you want to join me? Anyone? Anyone? I'm going for Mass Market. Yeah, no, we're doing that.

Secondly, I was going to say that I love to listen to feedback, so you'll be pleased to know that I have a non-click pen with me tonight. Very good.

 Thirdly, I've spent a lot more time listening to podcasts, and I would like to give a shout out to “Sudhir Breaks the Internet”, which is from the Freakonomics Radio stable that I listen to. And it is fascinating because it's a guy who's a sociologist who was working with the FBI on crime. And then Mark Zuckerberg asked him to go and work at Facebook and then he went to work at Twitter, and it's really fascinating about how social media and how we've kind of got to where we are, and are we going to be able to fix it.

I've also enjoyed the Rob Brydon podcast, and if you're interested in medicines, then the one where he talks to John Bishop, who was a pharmaceutical rep is fantastic. And the last one, which one of our listeners to the Aural Apothecary put us onto is “The Placemat” which is also very funny. It's a bit like, Have I got news for you for the NHS with a lot of jingles. So, I'm quite keen to get 'Steve the Chemist Morning Medicine Show' jingle back. And the last thing I'm gonna say is when, oh, when am I gonna be able to stop putting something up my nose twice a week?

Jamie: Welcome back.

Gimmo: Yeah, welcome back, Steve. We've missed those sorts of monologues!

Jamie: So, I got a few things for you, look, a challenge for us.

First, before we go any further. Second series podcast syndrome. That's what we're facing. Call it what you will, writing the follow-up to an explosive podcast has always been difficult, a difficult proposition for any podcaster, particularly one that found immediate success with their debut. And we are under immense pressure to record and release a follow-up before the hype disappears. Surpass your debut and you keep your fans, disappoint them and you're nothing but a flash in the pan. So that's what we're up against. Second album syndrome.

STC: Yeah, we're up for the challenge. We have got a new sponsor, haven't we?

Jamie: Yeah, we will have. We will. Placemat has got some sponsorship, hasn't it?

STC: Oh yeah. Well, they have got a big budget.

Jamie: Yeah. Golf is back on the agenda for me, so I've been out on the golf course a bit. One of my mates on the golf course, week before last took a phone call from his wife to say, the dogs have just eaten all the ibuprofen, which, you are all dog lovers on this, aren't you?

STC: Oh, is it like aspirin for cats?

Jamie: Yeah. £1200 later. So that reminded me. I was on call in the hospital years ago and I had a call for the dog Snowy, who'd been bitten by an adder. And so even though we've changed nothing, I'm suggesting we go with, let's hear your drugs and animal pet stories.

I'll leave that with Gimmo.

Gimmo: Well, I'm, it's not a drug, it's a sort of drug thing. New Year's Eve, a couple of years ago, quarter to 12, one of the kids comes down and said the dog's eating some chocolate. So, I went up and it wasn't just some chocolate, it was Christmas, it was one of those 500g bars of Galaxy had gone missing.

But there is a pharmacy link to this because as it happened, my wife was on call, she's a pharmacist and so she hadn't been drinking. It was New Year's Eve. So as the bells of New Year's Eve went, she was in the emergency vet surgery watching Jasper get his stomach pumped. That was a four-figure sum as well, that ended up costing us.

So yeah, ibuprofen and chocolate.

STC: So, not to be left out. Same thing happened to our dog. This is obviously a theme. Little Missy, stomach pumped over Easter. An Easter egg! Not good.

Jamie: Okay, my great pleasure to welcome Jonathan Underhill to the Aural Apothecary podcast. As I mentioned, Jonathan is a consultant, clinical advisor for NICE.

He inputs into those clinical guidelines that have a large medicine component and oversees outputs from NICE medicines teams, such as their evidence summaries on new medicines and antimicrobial prescribing guidelines. He's also an honorary lecturer at Keele School of Pharmacy teaching undergrads and post grads.

 As well as pursuing his research interest in evidence-informed decision-making. He's also a member of the Scientific Committee of the European Association of Hospital Pharmacists, and, like Gimmo, is a qualified Covid-19 Vaccinator. Welcome, Jonathan.

Jonathan Underhill: Thank you, Jamie. Yes. You must call me Jonathan, otherwise my mum will not be pleased with you. I'm not allowed to answer to Jon. So there we go.

Jamie: Welcome Jonathan. How are you doing?

Jonathan Underhill: I'm very good, thanks. I'm just revelling in the conversation about dog stories because, as you rightly said, Jamie, I've got a beautiful border terrier called Bobby, who was the absolute centre of my universe. And about four years ago, he had a bit of an issue with his back, and we took him to see the vet. And the vet automatically gives them a dose of steroid, a dose of antibiotics,

STC: CT scan.

Jonathan Underhill: Well, it was an x-ray, which they require a general anaesthetic for. So, you had a general anaesthetic, coming out of the general anaesthetic, had a grand mal fit, went into status-epilepticus.

Bit of a sad story. It's a good story Because he survived, but it's a bit of a sad story because of the trauma and indeed the cost of it all. But he ended up on three different anticonvulsants, including potassium bromide, levetiracetam, and phenobarbitone with this amazingly complex regimen, which taught me as a pharmacist how difficult it is for people to remember to take their medicines, because me trying to remember all the different medicines for Bobby was a nightmare. But, as I say, good story in the end, he's off his medicines. He's now, you know, four years down the line, no fits. We're all happy.

Jamie: It's a whole new podcast, isn't it?

STC: And can I just say, Jonathan, it tripped off the tongue: levetiracetam, big on you. Love it.

Jonathan Underhill: Thank you very much.

Gimmo: And I'm just wondering if it's a pharmacy thing that, do we all look at when the dogs get medicines for the vets? Do we all think I could get this for a 10th of the price from where I work, should I do it?

Jamie: So, what's on your agenda at the moment, Jonathan?

Jonathan Underhill: Well, I mean, you mentioned the NICE strategy. I think we'll talk about that later, but that is quite an exciting time for us and it'd be good to talk about that later on. There's lots of stuff on my agenda. We were very busy with, during the Covid pandemic, producing guidelines in super-fast time, which I think made us think about how we need to approach guidelines, going forward.

STC: Oh, wait a minute. You're obviously not a listener, Jonathan, you're not allowed to say going forward.

Jonathan Underhill: Okay. Sorry. Is that a pound for the jargon jar.

STC: Charity of your choice.

Jonathan Underhill: Okay, fair enough. But I guess that the other big thing that I'm interested, you mentioned my research and indeed professional interests around evidence informed decision making, but in particular shared decision making and patient-centred care. Obviously, what the world needs is a NICE guideline on shared decision making. So, that's what we've done and we're publishing that in June, which is great, and guidelines can only get you so far. But what I've been working on with some colleagues at Keele is some implementation support materials for the shared decision-making guideline, which includes an e-learning suite with lots of very interesting learning materials for people around shared decision making.

And I think that the big thing about shared decision making is that I think a lot of people think they do it, but they don't do it. I had a clinician say to me, "Yeah, I do shared decision making, I make a decision and I share it with the patient." And it's like, no, that's not what shared decision making is about. It's a joint process. It's about supporting a person to reach a decision about their care. Not imposing your values and your interpretation on what you think is important to that person. Rather having a conversation that opens it up to them to be able to express their values and preferences. Because that's the, I think that's the thing about evidence-based medicine, that perhaps certainly got me interested this stuff a while ago, that the original definition of evidence-based medicine by David Sackett and colleagues was about best available evidence, but it was also about using clinician expertise and experience and also taking into account patients' values and preferences.

This is not a new thing. That was in 1995 that Sackett et al. created that definition, and it's taken a long time for that true patient-centeredness to come to the fore.

Gimmo: You know, I first met you, Jonathan, and, and similar to sort of how I met Jamie was through the stuff you guys were doing with the National Prescribing Centre and, you know the early days of the evidence-based practice sort of movement and information mastery and all that sort of stuff.

You know that movement went off the rails a bit. A lot of it became about following guidance as opposed to the other bits of that you just described that sharing the decision with the patient. And I think it's still really difficult, isn't it? It's still not necessarily happening the way it needs to, and people do struggle with it because it does require a different way to practice.

And I think NICE is, you know, particularly in the early days, what it has encouraged is perhaps a more slavish sort of, following of guidelines than perhaps was first intended.

Jonathan Underhill: Completely agree with that. So, the previous chair of NICE was a GP called David Haslam. And he came out with the classic mantra, which was 'guidelines, not tram lines'.

So, the clue is in the title, they're to guide your practice. They're not something that you slavishly follow without thinking. They're guidelines that you have to then take into those consultations, those conversations with people, apply it to the individual and then agree the best way forward that suits them at this point in time.

STC: So, Jon, as you know, I'm still very much a practicing clinician and every single day

Jamie: Have you mentioned that?

STC: Haha! Every single day I'm performing shared decision making. And you also know that one of my pet subjects is anticoagulation, as you know, NICE has recently put out a new guidance about anticoagulation.

I think that's a classic example, and we've talked on this pod before about as an advanced generalist I have fears around single-organ-ologists making decisions in perhaps a non-shared decision-making way for people with frailty, polypharmacy, multi-morbidity. And I'm afraid to say, that in my opinion, there are quite a few cardiologists who really would like to see DOACs put in the water, quite honestly. I looked this up before because I didn't wanna say this without it being correct, and it sounds really harsh, but the word “bigoted” is around being utterly intolerant of the opinion that differs from one's own. And I sometimes feel, that for a small majority, that is how they see it, and they absolutely insist, and if you think or question about "should we not be offering anticoagulation and then making a decision with the patient?", they think I'm speaking from Mars.

Jonathan Underhill: Yeah, I completely agree with that. For me, the choice, and it's an important word, the choice to take an anticoagulant, either a DOAC or warfarin, is a preference-sensitive decision.

It's not something that should be mandated to everyone. Because there may well be some people who, when they look at the benefits and the risks of taking an anticoagulant will say, "well actually I prefer not to take one because I'm worried about my risk of bleed". And there's the immediacy of that risk that perhaps maybe weighs stronger in your mind than it does putting off the risk of a stroke happening maybe three or four years down the line. I still think that that is a preference-sensitive decision, and there is enough, I think, within the guideline, the new guideline on AF to give clinicians the space to be able to have those conversations with people so that it is still a choice, rather than something that I hope people don't go around mandating and measuring, prescribing data and then beating clinicians up because their prescribing data is perhaps not in line with what they think it should be. I think it's about finding the way of capturing that so that you've had that conversation with someone and the patient said, "thank you very much for explaining that to me, on balance, I prefer not to take this anticoagulant on this occasion." That's perfectly fine if you've done that. And actually, you could argue that's a 'Montgomery-compliant' consultation there.

STC: And the final point is, that's such a big decision. You don't have to make it then and there.

Jonathan Underhill: Absolutely.

STC: I've always said to people, "here's all the information, go away, have a think, go to these websites, talk to other people, and let's talk again in a couple of weeks’ time."

Jonathan Underhill: Absolutely. So again, without wanting to give away what's in the shared decision-making guideline, although the version that went out for consultation is pretty close to what the final one will be. One of the things we talk about there is the 'three talk model' of shared decision making. I don't know if you guys have come across that.

So, you have a 'team talk', you make it clear that there's a decision that has to be made. How much say would you like to have in this decision? Do you want me to make the decision for you? Or how much say do you wanna have in that decision?

Then you've got your 'option talk', where you explain the benefits, risks, alternatives, and what happens if we do nothing.

And then the 'decision talk', where you establish what matters most to the person, so again, that's where their values and preferences come in.

We're all wearing different clothes today, aren't we? Different colours. That's a preference that we've expressed. It would be boring if we all chose the same clothes, wouldn't it?

Gimmo: Although Jamie does wear that shirt every time.

STC: That is so true.

Jamie: It's Steve Jobs, isn't it? I take that decision out of the day. I have 12 of these shirts.

Gimmo: You know, I was thinking about this and I think in a way, NICE is damned if it does and damned if it doesn't, isn't it, it is presenting that expert specialist decision with the evidence. And then that allows you, doesn't it, Steve, as a generalist, to apply that in the context of your practice.

So I think that's what NICE needs to do. I think if NICE tried to sort of balance everything, it, it wouldn't publish anything. You know, there's been a really interesting conversation on the pain guidance, hasn't there as a case in point. And that's really polarized people, but I read it and at the end of the day, it presented the information, it presented some specialist information.

It presented what evidence we've got, and as I read it, the decision is still there with the practitioners. It's not saying, if you don't follow this guidance, you're gonna get told off, it's presenting all of the information, guiding you towards what they think is the recommended choice. But it's still the choice of the prescriber.

And I think that's what it does. We take it for granted now but we never used to have that.

Jamie: Am I still allowed to like BRAN? Can I do the benefits, risks, alternatives, and do nothing. Is that still a thing?

Jonathan Underhill: Yeah, that's what I just said about the option talk. That's exactly it. So, it comes from the N C T, the National Childbirth Trust, way of achieving consent. But yeah. I really like that as well.

Gimmo: I've got a quiz for you, Jonathan, when was NICE created?

Jonathan Underhill: Well, given that we've just celebrated our 20th anniversary in 2020, is that close? 2000 Frank Dobson.

Gimmo: 1999.

So it's close enough. The reason I asked, what was its first piece of guidance

Jonathan Underhill: Was it Zanamivir?

STC: Yes, I think it was.

Gimmo: Oh, Zanamivir. That's it. Yes. It links to what we were just saying because it was the first piece of guidance. It was obviously this new drug flu. And if I remember rightly, the pharmaceutical industry went nuts because you didn't really go for it. You know, how things have changed.

Jamie: He wasn't in NICE at the time.

Jonathan Underhill: No, I wasn't. We came into NICE from the National Prescribing Centre, shortly after that, but I remember it very well. It's an interesting one that, because I think philosophically as well, if NICE wasn't around, I think we would need to invent it.

I think it's very nice for the government to have, it's not about blaming someone, but having this organisation that's fiercely independent and has methods and processes that are some of the best in the world that you can say, these guys have made this impartial decision, we've taken politics and emotion out of it, and we've done an assessment of the evidence that says this is where it's place in therapy is. Alongside the patient's preferences and indeed the clinical expertise of the healthcare practitioner.

Gimmo: And that's why I've always been a fan of NICE because I was the sort of prescribing advisor in the years just before NICE came along. We had our problems. But NICE has in general, made life a lot easier and made those decisions much more consistent across different areas.

Jamie: Gimmo's forgotten protocol hasn't he, STC?. He's not even putting his hand up to speak.

Gimmo: Sorry.

STC: I was gonna say, look, while we're at it, let's just finish off the strategy because we're so deep into NICE.

So, you know, I know what these documents are like. I know you've listened. You've gotta speak to so many people and you've gotta get it out there. And it's gotta be a strategy. You've gotta have a mission statement. Can I just say one thing, Jonathan, about it? And I'm not saying you are responsible for it, but here's one thing, not to you then, to everybody and the listener for all the things that we've talked about on this podcast around multi-morbidity! And it does not feature, and for me, that is one of the key things of the next five years, and NICE said it, but I'm not seeing it. How is it going to adjust its guidance so that it is not disease specific and it is more for people with multi-morbidity?

Jonathan Underhill: So I don't think you're going to get any change in the way that guidelines are produced on a sort of a single disease basis because that's where the evidence is. Rather, I think it's more important that the clinicians use the guidance to then apply to the individual with four different comorbidities and take that into account.

I don't think you're ever gonna get a sophisticated enough data and evidence to be able to say there's a 75-year-old lady with type two diabetes, heart failure, atrial fibrillation, high blood pressure, and osteoporosis. What's the best, what does the evidence say about how I should manage her heart failure?

Because those people aren't in the clinical studies, Steve, and never will be. You couldn't include them ethically and until we have really powerful real-world data, with modelling to be able to do that, then you're never ever gonna get guidelines that do that. I think what we are gonna be able to do within the strategy is to make our guidance easier for people to find.

Because I think it's one of the big criticisms that we have about, and I have about the NICE website. You almost have to know what you're looking for and where to find it, to be able to find it. One of the big things about the strategy is about making the guidance not only useful, but usable and used as well, so we can measure whether it's being used.

STC: I hear what you're saying about real world data. But, I just think there's a risk that if we don't come to terms with how we present that it's going to begin to lack some relevance and credibility. That's a personal opinion.

Jonathan Underhill: Yeah. I do agree with that and I would actually take this back to some of the fundamentals around shared decision making, here, as well. Because, I think what this lends itself to, again, there isn't any escaping it. You need to have a conversation with the person that you are seeing in your clinic to find out what it is that's most important to them. And that is a skill that I don't think too many healthcare professionals have. And it's a skill that people need to really work on.

And there's lots of things you can think about. I mean, can I ask you guys a question? So if you are having a conversation with a patient, right, and you asked the question, how can I help? Okay. How long do you think on average it would take before the healthcare professional would interrupt the patient after asking that question?

STC: Is this based on research?

Jonathan Underhill: Yes.

STC: Oh, probably like three seconds.

Jonathan Underhill: It's 10 seconds that they would interrupt and it can be as short as three seconds. And if you think about when you're having conversations and consultation skills. Again, going back to what David Haslam said, the four things that he said about consultation skills, that healthcare practitioner need is to shut up and listen. Because if you're not, if you don't shut up, you can't listen. You need to care and show empathy. I can see Gimmo getting upset already Because I heard one of the original podcasts about compassionate empathy. But, but caring is really important and you need to know something. You don't need to know everything, but you need to know something that's gonna help people.

Just as a follow up to that, and if people are left to speak freely. How long do you think people talk for before they shut up?

Gimmo: 30 seconds.

Jonathan Underhill: Yeah. It's about 30 seconds before people shut up and people think five minutes, and I think that's part of the problem. I think some of the defensiveness around why we don't do that, why we don't ask open questions and consultations is because I'd never get my consultation finished because people would ramble on for 10 minutes. Actually, no. People will talk for about 30 seconds. And then if you don't ask open questions, how can you find things out about what's important to people?

Jamie: Well, you can prescribe then, can't you? To finish the

STC: There's my door.

Gimmo: Well, yes. I mean that is really fascinating. And I think, I know when I talk to a lot of GPs and they've talked about shared decision making, that spectre, I know what you, you're referring to there, isn't it? The spectre of the nine-minute consultation just comes up time and time again. That's what we've gotta do, isn't it? Is we've gotta convince people that shared decision making process is possible within that shorter amount of time. And actually it's beneficial because it probably saves time, effort, and money in the long run.

Because you get a better outcome. We need to be realistic. You have got nine minutes, if you're lucky, and it's possibly on Zoom now. So we have to incorporate that shared decision framework in that environment as well. But it, it is doable because I've seen it. I've seen it done.

STC: And it's an invest-to-save. And going back to the original podcast, Jamie, about failure demand and value demand, this is a classic example and it's this fear that if I spend a lot of time now that it's gonna cost me in time, but that's a misconception in my view and it's time well spent so that you are then not having to fish back and have failure demand six months, twelve months, two years down the line when actually at the beginning, and I know that's difficult for people to see, but I see it clear as day.

Jonathan Underhill: The other interesting one, again, from NICE evidence-based all the rest of it, but the Cochrane review on the use of patient decision aids in consultations showed that there was hardly any difference in the length of consultation when patient decision aids were used.

The skill required to be able to have those conversations and use the patient decision aids in the consultation requires a bit of effort from the healthcare practitioner. But once you've done that, once you've got your spiel practiced, and you know what you're gonna say, you've got your, if you like, your checklist in your head that you can then use to manage the conversation.

It actually doesn't make any difference to consultation times, and as you say, a happy patient is less likely to reconsult in the future, and they're more likely to be happy if they've been part of that conversation and you've made a shared decision with them. The other thing that I think we're gonna work hard at is integrated guidance.

And DOACs is a great example. You might have five different technology appraisals on the DOACs and a guideline, but how do you fit them together as a clinician? So, we need to move, we need to get better at how we integrate that content and make it available for people.

STC: Okay. Jonathan, I think we have spoken a lot about NICE and lots of great stuff there about shared decision making, but obviously the reason that you were so desperate to be the first guest on series two of the Aural Apothecary, lay it on us. What are you gonna give us as your desert island drug?

Jonathan Underhill: The medicine that I would choose would be Torcetrapib.

Now, boys do, do you remember Torcetrapib at all?

STC: You're probably saying it wrong!

Jonathan Underhill: I might be, do you want me to spell it for you and you tell me how to say it. Torcetrapib was an anti-lipid medicine that was developed in the 2000s. It was a CTP inhibitor. Clinical trial was done. 15,000 people that did this study , there was a 72% increase in HDL cholesterol and a 25% decrease in LDL cholesterol as well as a 10% decrease in triglycerides. So they're your disease oriented outcomes (DOO) for a medicine. And you think on the basis of that, what a fantastic drug. Get NICE to do an appraisal of this and let's get it out to people as quickly as we can.

As part of the development of this medicine, the FDA made them do patient-oriented outcomes (POO) as well. And what they found was that there was an increase in the risk of death, non-fatal MI, stroke and hospitalisation. And indeed an increase in total all-cause mortality. The development of this medicine was stopped in 2007. I just think this is a really good example of why we need POOs, patient-oriented outcomes for medicines rather than DOOs, rather than disease-oriented outcomes. And there's lots of other examples on that as well, which I'm sure you, which I'm sure you know about as well.

STC: Are we gonna have to put explicit on the show notes now that you said POO?

Jonathan Underhill: So torcetrapib. POOs, not DOOs, please.

STC: Okay. POOs not DOOs. Yeah.

Jamie: And that's never came up before, so.

STC: Yeah, I'm not sure anybody else, but we love that because obviously you are talking about evidence and as you've just said, so we not gonna argue with that, are we, Apothecaries? No. Fantastic. We love that.

What about then, a career anthem? I'm looking forward to this 'cause I know you're a bit of a musician yourself, aren't you?

Jonathan Underhill: Well, I wouldn't say I was a musician. I do sing in a band with some really good musicians. And I, and you probably expect me to pick a Bruce Springsteen song because I'm an absolute Bruce Springsteen obsessive.

But I'm not, I'm going to pick the greatest song for me that's ever been written. I happen to share this with my favourite song with John Peele, the late John Peele, and it's 'Teenage Kicks' by The Undertones. Two minutes and 36 seconds of absolute pure joy. It's simple. It's one verse repeated twice with a catchy chorus.

It's great guitar. It's got a vague meaning. Which I think is great when you're thinking about life and that sort of thing, it's quite naive. It's just brilliant. Absolutely brilliant. So, Teenage Kicks, please on the Spotify playlist, if that's okay.

Gimmo: That's a great song. I know John Peel always said it was his best song and I sort of, I love it, but I never quite got it as being the best song ever written.

But, I guess he knows more about music than I do. So you're in good company.

Jonathan Underhill: We all have different values and preferences.

STC: I was about to say the same thing, and that's what happens when you come on here with your Desert Island drug and your career anthem, because it's about a powerful memory, and we don't know what John Peel's memory of that was. It's a great song. I agree. We've got lots of great indie tracks on there. So I'm assuming this is when you were growing up, right?

Jonathan Underhill: Yeah, I mean  I think it came out in 1979, so I would've been 11. I remember loving the undertones. I was a bit of a, kind of a new-wave, punk rocker at the time. First time I ever heard it.

STC: Did you buy the single?

Jonathan Underhill: I did. I think I've still got it somewhere in the garage.

Jamie: So, John and I have had this conversation that, you know, because of the Bruce Springsteen, him being a super fan of the boss.

I've got two older brothers, one handed me Born to run years and years ago, obviously when I was a youngster, late in the seventies. And the other one, I think it was All wrapped up by the Undertones was there, you know, that album is still in my mum and dad's house, I think.

STC: Where did it all go wrong for you though, Jamie, musically?

I mean, you went on to Richard Clayderman.

Jamie: I did indeed. If you played Richard Clayderman for me now, I'd be able to recite my A-Levels and undergraduate studies.

Gimmo: My Bruce Springsteen story will make you sick. When I was at Glastonbury and Bruce Springsteen was there, I didn't really get him. So, I went and watched the Wonderstuff, I think it was in, in a little tent.

STC: I thought that was gonna involve magic mushrooms.

Jonathan Underhill: I'm going now, see you boys.

Jamie: I didn't really get him.

STC: That's two great picks. Now, then the more difficult one. But I think we all as Apothecaries, and I know some of the Twitter listeners have found this really helpful actually, and have really enjoyed the book choices.

So, what would you like to give our esteemed listener to add to their book list as a choice?

Jonathan Underhill: This was probably more difficult than the record. Like Jamie, I'm quite an avid reader, so there's some fantastic books that I've read that have had a massive influence on the way that I think about decision making and stuff.

So, any Danny Kahneman books. Any Atul Gawande stuff. Fantastic.

STC: Yeah. We've had those.

Jonathan Underhill: Yeah. But yes, exactly. So I thought, you know what, given that my great passion is around having meaningful conversations with people about medicines, choices or whatever else, how do you get to know people and what they're thinking, feeling, and the way to do that?

I think, the art of writing a letter is gone. You don't do it on a text message anymore. You don't often do it on a telephone call. The way that you get to know what people are thinking is by reading autobiographies. So, I've read loads and loads of autobiographies over the years, and I find them fantastic.

And if you read them about your heroes or people you admire and you find out what they were thinking at this point in time, what inspired them to do that, then I think it's fantastic. So I'm not gonna pick a Bruce Springsteen song, but I am gonna pick Bruce Springsteen's autobiography, which is called Born to Run, and it is, I mean, again I can't be objective about Bruce. I love him. I've seen him 40 times in concert. You know, I can't be objective about him. Reading his life story in his words was quite an experience for me to do that. He talks about his mental illness. He talks about the mental illness of his father.

He talks about his struggles and how you deal with that. And it can be any autobiography, just read autobiographies would be what I would say. But if you want a good one to read one about your hero. My hero is Bruce Springsteen. Just to find out what motivates him, what he struggles with the dark side of him, as well as the kind of, the grit light side of him was just fantastic.

STC: And I suppose that's really good because too many people now in the media, in particular social media, they only present what everybody wants to see, if you see what I mean. They only give you the one side. And of course, we're all normal. We're all human. We all have dark sides.

Jamie: Self-proclaimed 'normal' from STC there.

Jonathan Underhill: Absolutely, Steve, I mean I'd agree completely with that. And how do you know what that person you're speaking to is going through?

Jamie: Just to add to the Bruce choice, it's also about massive, about friendship as well, isn't it, Jonathan? And his relationship with the band over 40 years is just incredible.

STC: Well, we haven't had an autobiography. We will definitely take that. So Born to Run by Bruce Springsteen enters into the Aural Apothecary library.

Gimmo: I really like that idea of reading autobiographies to help understand behaviour. I've never really thought about that, so that's a really good insight.

STC: Clever.

Jonathan Underhill: I did think about it.

STC: You did, not just thrown together.

Jamie: Okay. A big thank you to Jonathan for joining us on the Aural Apothecary and for sharing his stories and his Desert Island Drug, his career anthem, and the Bruce Springsteen autobiography. Coming up next time we'll be joined by Dr. Karen Sankey. Karen is a general practitioner with a particular interest in holistic co-produced models of care. She's particularly interested in the wider determinants of health and is committed to engaging and supporting vulnerable individuals and those with complex needs. So, we look forward to welcoming Karen on next time's Aural Apothecary.

Over to Gimmo now for our contact details. And the final ingredient.

Gimmo: Just wanted to give a mention out. So, I mentioned that things are getting back to normal and obviously the kids are starting to hang around together with each other. My son told me that his friends were embarrassing him by playing the podcast when they were all hanging out together down the park.

So, this is your dad. So, if you're listening, big thanks to and I think his name's OS Jamil ? So, well done, keep embarrassing him.

Jamie: So can I come back at you on that Gimmo quickly before you go on? Because today I went to pick my youngest up from school and I saw a friend/colleague walking down the street and I thought, oh, I better tell him about the Aural Apothecary.

So I pulled the car over and I said, " how's it going?" And he said, "I was walking on Strumble Head a couple of weeks ago, and I saw Gimmo." And I say, "Oh, he would've told you about the Aural Apothecary then, won't he?" And he said, "no."

STC: I've gotta get those t-shirts made.

Jamie: Yeah. So then my son was curling up by now.

Gimmo: I was wrestling with a springer spaniel on a cliff edge at that point. It was terrifying. So, yeah. So if you wanna get in touch with us, It's @AuralApothecary on Twitter, so get in touch with us that way. I'm gotta try something a bit different tonight, so bear with me.

It's a murder mystery quiz. So, you can all join in. This was one I picked up off Twitter, so I hope it's factually correct, because Twitter's known for its accuracy.

A 45-year-old man is found dead in the orthopaedic room at an emergency department. He has no signs of trauma and no past medical history. What do you think happened?

Okay, so here's the first clue. The man was hired by the hospital to clean the drain and the pipes, which was blocked by plaster being washed down the sink by the residents. The material used to make the splints was plaster of Paris. The man was using sulfuric acid to clean the drain and dissolved the clogged up plaster of Paris.

What happens to plaster of Paris? When it's gunked up in pipes, it gets chewed up by bacteria. So, under anaerobic conditions, bacteria makes a nasty, thick calcium sulphide sludge. So what happens when you mix a sulfuric acid with calcium sulphide?

STC: Come in, Jonathan.

Jonathan Underhill: Hydrogen sulphide released?

Gimmo: And the man was gassed by hydrogen sulphide.

STC: Oh, there we go, Jonathan.

Jamie: Did you Google that? Did you Google that?

Jonathan Underhill: I remember chemistry. Don't you remember Chemistry?

Jamie: Show us your hands.

Gimmo: And that was based on a real case, toxicology murder mystery. That was by a guy called Josh Trebek on Twitter. So, refer to him for the accuracy. I didn't check the chemistry.