Investigating undergraduate medical education on myalgic encephalomyelitis/chronic fatigue syndrome

Abstract:

Background and Objectives: ME/CFS is a poorly understood, highly stigmatised condition which significantly reduces patients’ quality of life. ME/CFS had been identified as a gap in many health professionals’ knowledge, therefore this research aims to explore the understanding of ME/CFS amongst UK medical students.

Methods: An online survey developed using Redcap was distributed to participants who were recruited via social media or via medical societies’ emails. The participants were undergraduate UK medical students.

Results: 94 students completed the survey from more than 16 medical schools. 35% of the students did not know what ME/CFS is and 88% say that the disease has not been covered in their course so far. 89% of participants would like to learn more about ME/CFS, specifically through elearning and videos.

Discussion: Participants were generally unaware of ME/CFS and its symptoms and had not received relevant teaching or exposure to the disease. Education on ME/CFS within undergraduate UK medical schools is currently inadequate and the interest expressed by students in this survey demonstrates a new teaching opportunity for UK medical schools.

Source: Victoria Alice Reid and Nina Muirhead.Investigating undergraduate medical education on myalgic encephalomyelitis/chronic fatigue syndrome. The British Student Doctor Journal (BSDJ), Cardiff University Press, Year: 2022, Volume: 6 Issue: 1, Page/Article: 35-40. https://thebsdj.cardiffuniversitypress.org/articles/308 (Full text available as PDF file)

Long COVID burden and risk factors in 10 UK longitudinal studies and electronic health records

Abstract:

The frequency of, and risk factors for, long COVID are unclear among community-based individuals with a history of COVID-19. To elucidate the burden and possible causes of long COVID in the community, we coordinated analyses of survey data from 6907 individuals with self-reported COVID-19 from 10 UK longitudinal study (LS) samples and 1.1 million individuals with COVID-19 diagnostic codes in electronic healthcare records (EHR) collected by spring 2021. Proportions of presumed COVID-19 cases in LS reporting any symptoms for 12+ weeks ranged from 7.8% and 17% (with 1.2 to 4.8% reporting debilitating symptoms). Increasing age, female sex, white ethnicity, poor pre-pandemic general and mental health, overweight/obesity, and asthma were associated with prolonged symptoms in both LS and EHR data, but findings for other factors, such as cardio-metabolic parameters, were inconclusive.

Source: Thompson EJ, Williams DM, Walker AJ, Mitchell RE, Niedzwiedz CL, Yang TC, Huggins CF, Kwong ASF, Silverwood RJ, Di Gessa G, Bowyer RCE, Northstone K, Hou B, Green MJ, Dodgeon B, Doores KJ, Duncan EL, Williams FMK; OpenSAFELY Collaborative, Steptoe A, Porteous DJ, McEachan RRC, Tomlinson L, Goldacre B, Patalay P, Ploubidis GB, Katikireddi SV, Tilling K, Rentsch CT, Timpson NJ, Chaturvedi N, Steves CJ. Long COVID burden and risk factors in 10 UK longitudinal studies and electronic health records. Nat Commun. 2022 Jun 28;13(1):3528. doi: 10.1038/s41467-022-30836-0. PMID: 35764621; PMCID: PMC9240035.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9240035/ (Full text)

Long covid: “Holistic” approach is best, given range of symptoms, say researchers

New research on long covid in adults and children supports the multidisciplinary approach to clinical care that is being provided at long covid clinics in England, experts have said.

“Long covid seems to be a condition where multiple symptoms are very common,” said Terence Stephenson, Nuffield professor of child health at the UCL Great Ormond Street Institute of Child Health in London, told a Science Media Centre briefing.

“I think the services that have been set up in England for young people do address that. They are holistic and comprehensive in their approach, rather than addressing single organs or single problems,” said Stephenson, who is the lead author of the Children and Young People with Long Covid (Clock) study, published in Lancet Adolescent and Child Health.1 “If you have a mixture of symptoms of headache, cough, and dizziness, you probably want to go to a service that can deal with you holistically with all your symptoms,” he added.

There are currently around 80 long covid clinics in England that take referrals from primary care for adults or children who are experiencing a range of symptoms that might include brain fog, anxiety, depression, breathlessness, and fatigue.

Read the rest of this article HERE.

Source: Iacobucci G. Long covid: “Holistic” approach is best, given range of symptoms, say researchers. BMJ. 2022 Feb 8;376:o336. doi: 10.1136/bmj.o336. PMID: 35135781. https://www.bmj.com/content/376/bmj.o336.long (Full text)

An Audit of UK Hospital Doctors’ Knowledge and Experience of Myalgic Encephalomyelitis

Abstract:

Background and Objectives: There is some evidence that knowledge and understanding of ME among doctors is limited. Consequently, an audit study was carried out on a group of hospital doctors attending a training event to establish how much they knew about ME and their attitudes towards it.

Materials and Methods: Participants at the training event were asked to complete a questionnaire, enquiring about prior knowledge and experience of ME and their approaches to diagnosis and treatment. A total of 44 completed questionnaires were returned. Responses were tabulated, proportions selecting available options determined, 95% confidence limits calculated, and the significance of associations determined by Fisher’s exact test.

Results: Few respondents had any formal teaching on ME, though most had some experience of it. Few knew how to diagnose it and most lacked confidence in managing it. None of the respondents who had had teaching or prior experience of ME considered it a purely physical illness. Overall, 91% of participants believed ME was at least in part psychological. Most participants responded correctly to a series of propositions about the general epidemiology and chronicity of ME. There was little knowledge of definitions of ME, diagnosis, or of clinical manifestations. Understanding about appropriate management was very deficient. Similarly, there was little appreciation of the impact of the disease on daily living or quality of life. Where some doctors expressed confidence diagnosing or managing ME, this was misplaced as they were incorrect on the nature of ME, its diagnostic criteria and its treatment.

Conclusion: This audit demonstrates that most doctors lack training and clinical expertise in ME. Nevertheless, participants recognised a need for further training and indicated a wish to participate in this. It is strongly recommended that factually correct and up-to-date medical education on ME be made a priority at undergraduate and postgraduate levels. It is also recommended that this audit be repeated following a period of medical education.

Source: Hng KN, Geraghty K, Pheby DFH. An Audit of UK Hospital Doctors’ Knowledge and Experience of Myalgic Encephalomyelitis. Medicina (Kaunas). 2021 Aug 27;57(9):885. doi: 10.3390/medicina57090885. PMID: 34577808. https://pubmed.ncbi.nlm.nih.gov/34577808/

An audit of UK hospital doctors’ knowledge and experience of Myalgic Encephalomyelitis

Background and Objectives: There is some evidence that knowledge and understanding of ME among doctors is limited. Consequently, an audit study was carried out on a group of hospital doctors attending a training event to establish how much they knew about ME and their attitudes towards it.
Materials and Methods: Participants at the training event were asked to complete a questionnaire, enquiring about prior knowledge and experience of ME and their approaches to diagnosis and treatment. A total of 44 completed questionnaires were returned. Responses were tabulated, proportions selecting available options determined, 95% confidence limits calculated, and the significance of associations determined by Fisher’s exact test.
Results: Few respondents had any formal teaching on ME, though most had some experience of it. Few knew how to diagnose it and most lacked confidence in managing it. None of the respondents who had had teaching or prior experience of ME considered it a purely physical illness. Overall, 91% of participants believed ME was at least in part psychological. Most participants responded correctly to a series of propositions about the general epidemiology and chronicity of ME. There was little knowledge of definitions of ME, diagnosis, or of clinical manifestations. Understanding about appropriate management was very deficient. Similarly, there was little appreciation of the impact of the disease on daily living or quality of life. Where some doctors expressed confidence diagnosing or managing ME, this was misplaced as they were incorrect on the nature of ME, its diagnostic criteria and its treatment.
Conclusion: This audit demonstrates that most doctors lack training and clinical expertise in ME. Nevertheless, participants recognised a need for further training and indicated a wish to participate in this. It is strongly recommended that factually correct and up-to-date medical education on ME be made a priority at undergraduate and postgraduate levels. It is also recommended that this audit be repeated following a period of medical education.
Source: Hng KN, Geraghty K, Pheby DFH. An Audit of UK Hospital Doctors’ Knowledge and Experience of Myalgic Encephalomyelitis. Medicina. 2021; 57(9):885. https://doi.org/10.3390/medicina57090885 https://www.mdpi.com/1648-9144/57/9/885/htm (Full text)

Predicting GP Visits: A Multinomial Logistic Regression Investigating GP Visits Amongst a Cohort of UK Patients Living With Myalgic Encephalomyelitis

Abstract:

Background: Myalgic Encephalomyelitis (ME) is a chronic condition whose status within medicine is the subject of on-going debate. Some medical professionals regard it as a contentious illness. Others report a lack of confidence with diagnosis and management of the condition. The genesis of this paper was a complaint, made by an ME patient, about their treatment by a general practitioner. In response to the complaint, Healthwatch Trafford ran a patient experience-gathering project.

Method: Data was collected from 476 participants (411 women and 65 men), living with ME from across the UK. Multinomial logistic regression investigated the predictive utility of length of time with ME; geographic location (i.e. Manchester vs. rest of UK); trust in GP; whether the patient had received a formal diagnosis; time taken to diagnosis; and gender. The outcome variable was number of GP visits per year.

Results: All variables, with the exception of whether the patient had received a formal diagnosis, were significant predictors.

Conclusions: Relationships between ME patients and their GPs are discussed and argued to be key to the effective delivery of care to this patient cohort. Identifying potential barriers to doctor patient interactions in the context of ME is crucial.

Source: Walsh RS, Denovan A, Drinkwater K, Reddington S, Dagnall N. Predicting GP visits: A multinomial logistic regression investigating GP visits amongst a cohort of UK patients living with Myalgic encephalomyelitis. BMC Fam Pract. 2020;21(1):105. Published 2020 Jun 10. doi:10.1186/s12875-020-01160-7 https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-020-01160-7 (Full text)

Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified

Abstract:

BACKGROUND: Improving Access to Psychological Therapies is a UK Government funded initiative to widen access to psychological treatment for a range of common mental health complaints, such as depression and anxiety. More recently, the service has begun to treat patients with medically unexplained symptoms. This paper reports on a review of treatment protocols and early treatment data for medically unexplained symptoms, specifically the illness myalgic encephalomyelitis/chronic fatigue syndrome.

MAIN TEXT: A series of seven core problems and failings are identified, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.

CONCLUSIONS: There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients’ physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

Source: Geraghty K, Scott MJ. Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC Psychol. 2020 Feb 5;8(1):13. doi: 10.1186/s40359-020-0380-2. https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-020-0380-2 (Full article)

Defining the prevalence and symptom burden of those with self-reported severe chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a two-phase community pilot study in the North East of England

Abstract:

OBJECTIVES:
To define the prevalence of severe chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and its clinical characteristics in a geographically defined area of Northern England. To understand the feasibility of a community-based research study in the severely affected CFS/ME group.

DESIGN: A two-phase clinical cohort study to pilot a series of investigations in participants own homes.

SETTING: Participants were community living from the area defined by the Northern clinical network of the UK.

PARTICIPANTS: Adults with either a medical or a self-reported diagnosis of CFS/ME. Phase 1 involved the creation of a database. Phase 2: five participants were selected from database, dependent on their proximity to Newcastle.

INTERVENTIONS: The De Paul fatigue questionnaire itemised symptoms of CFS/ME, the Barthel Functional Outcome Measure and demographic questions were collected via postal return. For phase 2, five participants were subsequently invited to participate in the pilot study.

RESULTS: 483 questionnaire packs were requested, 63 were returned in various stages of completion. 56 De Paul fatigue questionnaires were returned: all but 12 met one of the CFS/ME criteria, but 12 or 22% of individuals did not fulfil the Fukuda nor the Clinical Canadian Criteria CFS/ME diagnostic criteria but 6 of them indicated that their fatigue was related to other causes and they barely had any symptoms. The five pilot participants completed 60% of the planned visits.

CONCLUSIONS: Severely affected CFS/ME individuals are keen to participate in research, however, their symptom burden is great and quality of life is poor. These factors must be considered when planning research and methods of engaging with such a cohort.

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Source: Strassheim VJ, Sunnquist M, Jason LA, Newton JL. Defining the prevalence and symptom burden of those with self-reported severe chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME): a two-phase community pilot study in the North East of England. BMJ Open. 2018 Sep 19;8(9):e020775. doi: 10.1136/bmjopen-2017-020775. https://bmjopen.bmj.com/content/8/9/e020775.long (Full article)

MPs demand more biomedical research for cruel ‘death sentence’ disease

Press Release: ME Association, June 21, 2018. Less than £1 is spent each year on people suffering from the devastating invisible illness M.E. (myalgic encephalomyelitis), a condition which leaves tens of thousands bedbound, housebound and unable to work.

Parliament heard in a landmark three-hour debate of the chronic lack of funding for medical research and how many doctors still don’t know how to diagnose or manage the condition.

End to controversial therapies and to stigma

Politicians said that controversial psychotherapy and exercise therapies recommended by the NHS after a flawed medical trial must stop NOW – because they are making patients worse.

And they called for an end to the stigma and myths surrounding M.E., which at worst, leaves sufferers to endure a tortuous existence.

Westminster Hall was told how people with M.E. are six times more likely to commit suicide.

Carol Monaghan (SNP Glasgow North West) told how ME costs the UK £3.3bn per year.

She said: “Despite the number of people affected and the devastating effect of the disease on sufferers and their families, it is very much a hidden illness, which is characterised by some as ‘yuppie flu’ and misunderstood by doctors, the public and politicians alike.”

M.E. tragedies

Westminster Hall heard of the tragic case of 21-year-old Merryn Crofts, who last month had M.E. listed as the cause of her death at inquest, and how ME Association fundraising manager, Helen Hyland, broke the news of her husband’s suicide to her children.

Yet Ms Monaghan added: “Some people consider M.E. to be a psychological condition, despite the fact that people with M.E. are not allowed to be blood or organ donors.

“Unfortunately, those who hold such beliefs often are in influential positions and have a blinkered view of the condition.

“I wonder what they have to fear from proper biomedical research into M.E. If such research showed they were correct, their views would be vindicated. However, if it threw up new information that had an impact on M.E. treatment and care, as medical professionals they should surely support that.”

The discredited PACE trial

Ms Monaghan drew particular attention to the PACE trial results in 2011, that examined graded exercise therapy (GET) and cognitive behaviour therapy (CBT).

The researchers claimed the results demonstrated both treatments were ‘moderately’ effective and led to recovery in over a fifth of patients.

But the trial has since faced intense criticism, and not only from patients in the UK. Clinicians, researchers, as well as charities, like the ME Association, have all expressed concern about how the results were obtained, analysed and presented.

Parliament has previously heard claims that the PACE trial data was deliberately flawed to “remove people from long-term benefits and reduce the welfare bill”. The PACE trial endorsement of GET and CBT helped form the basis of the NICE clinical guideline – which is now being reviewed.

PACE has had a wide-reaching influence

Ms Monaghan said one of the key authors behind the PACE trial, Professor Michael Sharpe, admitted that some involved in the trial had worked for insurance companies.

She said: “The PACE trial, which recommended CBT and GET, influences how health insurers and the DWP make their decisions.

“Insurance companies refuse to pay out unless a programme of GET has been undertaken, and many people who apply for benefits are told that they must carry out GET—or, indeed, that they appear well enough to work.

“PACE is unique in UK medical history, in that it was part-funded by the DWP.

“The links of some of its ​main authors to health insurance companies are troubling. One of those authors, Professor Michael Sharpe, states in his briefing for the debate:

“Several of the investigators had done small amounts of independent consultancy for insurance companies, but this was not relevant to the trial. The insurance companies played no part in the trial.”

“I will leave hon. Members to make up their own minds about that.”

Westminster Hall was told how the U.S. Center for Disease Control (CDC) and the Dutch Health Council have both abandoned GET as a treatment.

Ms Monaghan added: “If those countries acknowledge the flaws of GET, why are ME sufferers in the UK having to fight so hard for similar acknowledgement? The ME community hopes that GET will not feature in the NICE guidelines for ME treatment after they are revised.”

‘Unbecoming’ behaviour?

“Interestingly, Professor Sharpe, one of the authors of the PACE trial whom I already mentioned, emailed me this week and told me that my behaviour is “unbecoming ​of an MP”.

“I say to Professor Sharpe that if listening to my constituents, investigating their concerns and taking action as a result is “unbecoming”, I stand guilty.

“If Members of Parliament are not willing to stand up for the most vulnerable in society, what hope do any of us have?”

Ministerial response

Minister for Health and Social Care, Steve Brine, was asked how the Department for Health is supporting training for medical practitioners on ME care and treatment, and asked if he would support proper funding for medical research into the diagnosis and treatment of ME.

Mr Brine said the government invests £1.7bn each year into health research.

And stated that the National Institute for Health Research and the Medical Research Council would welcome “high-quality” research into “all aspects of ME… to make a scientific breakthrough”.

He described the need to find a breakthrough as a “matter of good Christian humanity” and promised to help increase the awareness of M.E. with GPs.

Read the full Ministerial response and Ms. Monaghan’s closing remarks HERE.

He reiterated that patients with M.E. symptoms should be referred to NHS specialist services – within six months for mild symptoms, three months for moderate symptoms and immediately for severe symptoms.

But Mr Brine admitted that access to services remained “a big and ongoing issue” and that the configuration of services was down to local commissioning groups.

He added that all schools must have arrangements in place to support, with flexibility, children with ME.

NICE guideline review

On the NICE guidelines, he said it was a “jolly good job” the position on M.E. is being updated but said it would be “wrong for ministers to interfere” with the process.

On benefits, Mr Brine said the “DWP recognises that ME is a real and disabling condition” and that every patient must be assessed on a individual basis.

He added: “When assessing claimants, healthcare professionals are expected to be mindful of the fact that many illnesses—including ME—produce symptoms that vary in intensity over time, and they are instructed not to base their opinion solely on the situation observed at the assessment.

“The DWP assures me that all healthcare professionals are required to read an evidence-based protocol on ME as part of their training, as well as engaging in a programme of continuing medical education that includes modules on the condition.”

‘A completely unacceptable situation’

The ME Association campaigns to make the UK a better place for people with M.E. A spokesman said: “A three-hour parliamentary debate on M.E. is not before time. We are grateful to Carol Monaghan for securing the debate, to those MPs who took part, and to ME Association members for engaging with their parliamentary representatives ahead of the debate.

“Despite being recognised by the World Health Organisation as a neurological disease – and an earlier report to the Chief Medical Officer calling for more research and a network of hospital-based clinics – many doctors still don’t know how to diagnose and manage M.E. and lack of biomedical research means that we still don’t have any effective forms of treatment.

“This is a completely unacceptable situation for a disease that is twice as common as multiple sclerosis and where a new report has estimated that M.E. is costing the UK economy billions in lost taxes, and through healthcare and benefit expenditure.”

Counting The Cost – Chronic Fatigue Syndrome/Myalgic Encephalomyelitis

Foreword:
For the past 20 years there has been extensive argument in the UK about the causes and diagnostic criteria for this illness. For some considerable time, the conventional wisdom was that this illness was purely psychological in origin.
The World Health Organisation has clearly classified CFS/ME as a neurological disease in its International Classification of Diseases (ICD), section G93.3.
Despite this clarity, there is still a lack of universal agreement about CFS/ ME in the UK. This has led to a paralysis of research into both the biomedical causes of and treatments for CFS/ME, and the research that has been done has focused primarily on the psychological side.
The time has come for a proper research strategy for CFS/ME, looking at both bio-medical causes and treatments. In order to commence a dialogue with government and other interested parties, it is essential for everyone to be on the same page. To achieve that degree of agreement will be a challenge, but I believe the first step in that process is to start a new public conversation about this horrible illness.
The purpose of this report by the health think tank 2020health, sponsored by the Optimum Health Clinic, is to do just that. Nothing concentrates the mind like money. This is the first cost of illness study of CFS/ME to the UK economy combining direct costs (including primary and secondary care contacts, prescription and over the counter
medications, and complimentary treatments) and indirect costs (including work productivity losses, informal care and welfare payments). The results are staggering.
In commissioning this report, our hope is that we can:
* Demonstrate clearly all the costs of CFS/ME to the UK economy;
* Use this report to start a new public conversation about the illness;
* Start a dialogue with all interested parties to create a new strategy to research the bio-medical causes of and treatments for CFS/ME
You can read the full report HERE.