comment - The BMJ...comment T he blood lands on my left shoe as the needle hits its mark. The adrenaline travels slowly to the heart, sucked onward through the chest’s recoil. 1-2-3-4-5

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The blood lands on my left shoe as the needle hits its mark. The adrenaline travels slowly to the heart, sucked onward through the chest’s recoil. 1-2-3-4-5. 1-2-3-4-5. 1-2-3-4-5. The

compressions continue, pressing out the patient’s blood, as well as the pusher’s humanity.

She is 89. She was a daughter, a mum, a man-gu (the Welsh word for grandmother), a strong woman, a singer, a real character in life, and then a real character in her nursing home. “But the paperwork wasn’t completed” is overheard, as the decision to perform CPR is questioned. 1-2-3-4-5. 1-2-3-4-5. 1-2-3-4-5. As I watch, I wonder whether the doctor in training, performing CPR straight out of a textbook, has read Dylan Thomas’s poem Do Not Go Gentle Into That Good Night .

Writing the poem after his dad’s untimely death, Thomas was both right and wrong. As I turned 40, a surprise trip to a spa hotel sent me driving past his boathouse, where he wrote such powerful poetry. Being new to the art of words, I had to stop. I went in, past the gift shop selling fudge and Welsh cakes. In front of me were those words: “ Do not go gentle into that good night; Old age should burn and rage at close of day; Rage, rage against the dying of the light .”

Thomas was right in many ways. In my world of the intensive care unit, the urge is to rage against the dying of the light. Young men with brain injuries, middle aged women with blood in their heads, older men brought back to life after a cardiac arrest out of hospital. Brilliant. My kind of work. And it’s why 200 nurses in the critical care unit in Cardiff wake up at 5 am every grey, rainy Welsh morning.

But Thomas was also wrong. Consider the patient with end stage chronic disease where drugs prolong death, not life. The granddad with dementia even before his stroke. The 89 year old lady on the ward,

not dying from sepsis but dying with it, after 89 long, happy, life fi lled years. She doesn’t want survival at all costs: she wants survivorship. Something that pressing on her breastbone won’t achieve.

Reading about a similar story, where a nurse working in a care home was recently found at fault for not doing CPR on a patient with severe end stage chronic disease, I hang my head in my hands. I’d rather be sued for doing CPR than for not doing it.

And deep down, even watching his dad die, that’s what Dylan Thomas was trying to tell us. After the passion, the denial of a fi nite life, and the love for his dad, he writes: “ Though wise men at their end know dark is right . . . ” The trouble is that those wise men and women are often not the ones doing the CPR—they are the ones having it . Matt Morgan, intensive care consultant ,

University Hospital of Wales

[email protected] @dr_mattmorgan

Cite this as: BMJ 2020;370:m3722

the bmj | 3 October 2020 21

I’d rather be sued for doing CPR than for not doing it

CRITICAL THINKING Matt Morgan

Why Dylan Thomas was wrong—and right

“Who is fit to leave hospital is for clinicians to judge, not bureaucrats” DAVID OLIVER“I'm dismayed that mistakes from March are about to be repeated” HELEN SALISBURYPLUS Mental health toll of studying medicine; acknowledging long covid

22 3 October 2020 | the bmj

In medical school, while acquiring knowledge, I also picked up some bad habits, like not taking time for doing the things I enjoyed, not getting enough sleep, comparing myself to

others, and excessive rumination. Medical school equipped me with the skills to diagnose and treat my patients but not the skills I would need to deal with the stresses of the job.

During one of my many marathon study sessions in my third year, my bleary eyes took in the diagnostic criteria for depression. It was almost an exact description of how I had felt and behaved for the past year or longer. I thought that I was weak and wouldn’t be allowed to be a doctor if I mentioned this to anybody. I read that as a young man the thing most likely to kill me was myself. I wrote this down on fl ash cards and carried on studying. I had just realised that I had depression and that, statistically, it was the biggest threat to my life. I used it as a revision aid.

After graduation, these pathological thoughts continued. I felt that being a doctor was all that validated my existence. It deserved every ounce of eff ort, every second of my time. This coupled with the enormous systematic and personal pressures I was exposed to as a doctor left me fl oundering in a sea of stress, depression, and anxiety. All

the while, I kept thinking that the answer was working harder, staying later, studying more.

Unfortunately, my story is not unique. Cases abound in the media of healthcare professionals, not just doctors, buckling under the strain of their jobs and, tragically, in some cases taking their own lives. I was completely unaware of the need to care for myself and of the support services that are available.

Openly discussedPerhaps if trusts were as interested in my mental health as they seemed to be about my manual handling training, I would have felt that it was something hospitals were prepared to help with. If this was something more openly discussed and for which support was signposted, it would have reassured me that professionals had experienced this before, that I wasn’t an anomaly, and that help was there for me and I wasn’t weak by asking for it.

I now recognise how the pathological thought processes that exacerbated my depression began in medical school. My family would beam with pride at “how hard he works” and how “he’s always studying,” and I liked it. I constructed a persona in my head of the selfl ess medic who sacrifi ced his own free time for the betterment of his patients, placing more pressure on himself, and I tried to live up to this ideal. This

archetype has permeated popular culture as well. When was the last time you saw a TV doctor taking time out for lunch?

Medical schools have a responsibility to deliver a curriculum that sets students on the path to becoming safe and eff ective doctors. They also have a responsibility to equip graduates with the skills to prevent the pressures of the job taking a heavy toll on them—not as a tokenistic, tick box exercise but in a real and engaging way. I feel that this is an area in which my medical school failed me, and I doubt that I’m alone in this.

The prevalence of burnout and depression among medics, its consequences, and ways to prevent it weren’t discussed with us in anything more than a superfi cial way. If we were presented with the facts and taught about this illness, which aff ects us and our patients, in a more honest, personal way, then it could have made all the diff erence. Being taught about this as a hazard of the job rather than an abstract headline would remove some of the stigma. To hear another doctor talk openly and frankly about what they went through,

The all party parliamentary group (APPG) on coronavirus exists to help the government learn lessons ahead of a potential second wave of the pandemic this winter, and beyond. The aim that has brought together MPs and peers from across the political spectrum is to save lives.

In August, we heard from people living with long covid, and hundreds more submitted written evidence to our inquiry. Their testimonials were moving and concerning. What was clear was that we needed to make some urgent recommendations to the prime minister; the health, wellbeing, and employment arrangements for those living with long covid have not been considered. And as the number of people with long covid grows, the situation gets more urgent.

So, on 24 August, I wrote to the prime minister

with the APPG’s recommendations. We called on the government to formally recognise long covid; commit resources to a rapid, comprehensive study of the condition; and provide support as a matter of urgency. Although some research into the condition, and its long term effects on people’s health, is ongoing, it needs to be expanded to include those who were never admitted to hospital or tested.

Furthermore, the government must set up a working group to tackle the needs of people living with long covid, including the development of guidelines for employers and GPs. It is only fair on those experiencing this condition, as well as for our NHS and

Awareness of long covid, and its seriousness, is too low in Westminster

It’s time to recognise the needs of people with long covid

PERSONAL VIEW Perry Crofts

How s tudying medicine affected my mental health A competitive culture and the stigma of “not coping” take their toll

BMJ OPINION Layla Moran

If this was more openly discussed, it would have reassured me that help was there

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how they overcame it, and the lessons they learnt would have helped me so much.

So, to any medical students or junior doctors reading this, I’d like to say study hard and be prepared for long hours and night shifts. But don’t forget to look after yourself. Take a break from studying. Don’t compare yourself with other people. There’s so much more to being a doctor than the knowledge you need to pass exams, I promise.

For a while depression and burnout stopped me from giving my best to patients and I will always regret that. If I had learnt to care for myself, built the self-care habits I needed earlier on, and sought help sooner, I might have prevented some of this fallout.

Medical students must take the initiative and build and maintain helpful habits and attitudes. Put yourself fi rst once in a while, and keep doing it. Being a doctor is more than a job to me, but I know that there’s more to life than practising medicine. And I’m a better doctor for it . Perry Crofts , GP specialty trainee year 2 , Princess of

Wales Hospital, Bridgend [email protected] Cite this as: BMJ 2020;370:m3664

employers, that we are better able to understand how to enable people to access help, and return to work when they’re ready.

At the time of writing, I have not received any response to our recommendations. If we can’t respect those suffering with this condition by acknowledging their situation, how are we supposed to put in place the support that is needed?

What’s clear is that general awareness of long covid, and its seriousness, is too low in Westminster. I hope readers of The BMJ will join me in challenging the prime minister to take our recommendations seriously (as he promised to me he would in prime minister’s questions in July), respond to us, and take action now.Layla Moran, Lib Dem MP and chair of the all party

parliamentary group on coronavirus

It gets dangerously close to systems where insurers call the shots

Whose job is it to decide when patients are ready to leave hospital, with the support of families and community services?

The government has provided an extra £588m of funding to help cover the cost of recovery and support services, rehabilitation, and care for up to six weeks after discharge. In return, it expects action to help keep hospital beds free for patients with the most pressing needs. New guidance revolves around a “discharge to assess model” that channels patients who leave hospital into four indicative pathways. It also requires eligibility and fi nancial assessments for social and NHS care to continue outside the acute hospital setting, rather than have patients waiting in beds.

The guidance also sets out “eligibility to reside” criteria, instructing hospitals to review all patients twice daily against them and to report their organisational data. Presumably this is for NHS England scrutiny of performance pressure and for ministerial assurance on value for emergency funding.

The use of such criteria gets dangerously close to systems where insurers call the shots on how long patients are “allowed” to stay in hospital. The model also pushes problems out to community services and primary care. And where does it take account of outcomes after leaving, such as emergency readmissions, whether patients make it back home, or the experience of rushed or pressurised discharges? Clearing hospital beds cannot be an end in itself.

Most of all, though, the “criteria” are restrictive. There are

some “get-outs” in the form of a NEWS (national early warning score) greater than 2 or 3 and “acute loss of function beyond the community’s capacity,” which will probably be “catch-alls” for many patients. However, NEWS was designed to recognise physiological deterioration for early intervention. You could have a NEWS of 1 and still be far from optimised or one of 4, owing to chronic illness, and be fi ne to leave.

Other criteria include staying longer than two days after lower limb surgery or three days after major abdominal or thoracic surgery. Obviously, not all of these patients are stable enough to leave at that stage. Another criterion is people in the “last hours of life.” So if you are dying, which might take days, you have to leave whether or not you want to? Humanity, compassion, and person centred care surely count?

Above all, the judgment as to who really is “medically optimised” enough to leave, and who has suffi cient support at home, is best made by the clinicians who are with that patient and their family daily.

T his is not a matter for bureaucrats. The extra burden of data collection may distract from teams doing their jobs and, perversely, stop them getting on with the actions that might help patients leave hospital. When things go wrong, any formal complaint or coroner’s verdict, or any negligence claim, will be answered by clinicians, not NHS

England offi cials. David Oliver, consultant in geriatrics and

acute general medicine , Berkshire

[email protected] @mancunianmedic


ACUTE PERSPECTIVE David Oliver

Misuse of “criteria to reside” tick boxes


Doctors like to have answers: it makes us feel useful. GPs take pride in our tolerance of uncertainty, but even we are being pushed beyond our

comfort zone by current circumstances, and many of us are very apprehensive.

Having lost patients and colleagues during the fi rst wave of the covid-19 pandemic, I now fear—despite voices raised in dismay, then and now—that some of the mistakes from March are about to be repeated.

We were told in June that a functioning test, track, and trace system was the key to getting England safely back to work, but it’s still lacking. As schools go back there’s an inevitable rise in viral illnesses, and the resulting fevers keep whole year groups and their families off school and work. At the time of writing the demand for tests is massively outstripping supply, which has apparently taken Dido Harding, head of the testing service, by surprise. Would someone with a health background have been a better pick?

Last week in our primary care network, we had a new member of staff delay starting by two weeks because of fever in the family. Our winter plans need to allow anyone with children to be able to work from home at short notice. This may not leave many of us available at each practice to provide face-to-face consultations—but thanks anyway, NHS England, for that ill judged

and insulting letter reminding us of our obligation to do so.

Leaving aside the thorny problem of where to assess febrile children without any increase in risk of infection to the rest of our patients, we’re generally confi dent at judging how ill a child is. However, for reasons clearly outlined by Rammya Mathew in The BMJ , we’re unable to say whether their symptoms are a result of covid-19—and that’s the crucial piece of information parents require. They’re understandably baffl ed, and sometimes angry that, on top of this, we can’t help them access a coronavirus test either.

In the face of all this, how do we keep going and stay cheerful? This weekend, practices around the country are pulling out the stops to run socially distanced fl u vaccination clinics. It brings gratitude from patients and satisfaction in a job well done. It’s a great team building exercise, and it certainly beats crafting a tower from straws and sticky tape or other “training day” specials.

We must keep this team spirit going, looking out for people who are struggling and doing our best to remain calm and positive. Personally, I’ll try, at least in public, to steer a midcourse between Pollyanna -ish optimism and showing my real fears for the winter ahead .

Helen Salisbury , GP, Oxford

[email protected] Twitter @HelenRSalisbury


Listen and subscribe to The BMJ podcast on Apple Podcasts, Spotify, and other major podcast apps

Edited by Kelly Brendel, deputy digital content editor, The BMJ

In the face of all this, how do we keep going and stay cheerful?

PRIMARY COLOUR Helen Salisbury

Clutching at straws—and flu jabs LATEST PODCASTS

Talk Evidence: covid-19 in childrenChildren are back in school and many people are worried about how this may affect the spread of covid-19. In this episode of Talk Evidence, David Ludwig, a professor of paediatrics at Harvard Medical School, shares his thoughts on the state of evidence about covid-19 in children.

“A big, ongoing biological mystery is why children are relatively protected from severe illness. In contrast to some other viral illnesses that tend to strike children and older adults most severely, in this case we don’t have that U shaped relationship. With the exception of very young infants, who may be at increased risk, young children are remarkably protected, and that risk of severe illness increases with every passing decade. So, why is that? What about children’s biology is protecting them? If we can answer that question, we may get insights into ways both to prevent and treat the disease throughout the population.”

Freshers’ firstsThis is a strange time for students to be starting their first year of medical school, as covid-19 changes the ways in which students learn and socialise. The Sharp Scratch podcast team have done two live episodes to help students through this as they, along with special guests, discuss and reminisce on their first years. Here Anna Harvey, medical student and former BMJ editorial scholar, talks about handling dissections:

“It really is a totally foreign experience in some ways, and it’s OK to allow yourself to have these feelings about it because it is a privilege and a rite of passage. But it is also totally disjointed from any other experience that you might have, especially if you’re 18.”


As covid-19 turns from a societal threat into a matter of risk management, it is vital that the associated risks are understood and clearly communicated. 1 But these risks vary hugely between people, and so fi nding appropriate analogues is a challenge. Although covid-19 is a complex multisystem disease that can cause prolonged illness, here I focus solely on the risks of dying from covid-19 and explore the use of “normal” risk—the risk of death from all causes each year—as an aid to transparent communication.

In normal circumstances, the average annual risk

of death doubles for each seven years of extra age

Population fatality risks in terms of normal risks

The population fatality rate tells us the proportion of the total population getting infected and then dying with covid-19 over a specifi ed time. This can be directly obtained from death registrations in which covid-19 is mentioned on the death certifi cate in England and Wales. 2 It will include those dying both from and with the virus, while underestimating the true number of deaths linked to covid-19 because of underdiagnosis in people who did not display classic symptoms, were not tested, and so did not have covid-19 mentioned on the death certifi cate.

In the 16 weeks (112 days) between 7 March and 26 June 2020, 218 354 deaths were registered in England and Wales, compared with an average of 159 595 for this period over the past fi ve years. This is an absolute excess of 58 759 deaths, corresponding to a relative increase of 37%; 49 607 (84%) of these excess deaths had covid-19 mentioned on the death certifi cate. Figure 1 shows the age and sex specifi c population fatality rates on both logarithmic and linear scales, compared with the age and sex specifi c annual “hazards”—that is, the proportion of people of each age who do not reach their next birthday—obtained from the life tables provided by the Offi ce for National Statistics 3 and scaled to 16 weeks.

The actuarial risks show an early peak related to congenital diseases and birth trauma, then a minimum at around age 9 or 10 and a steady increase, which is remarkably linear apart from a bump in the late teens and early 20s associated with deaths from non-natural causes. This near linearity on a logarithmic scale corresponds to an exponential increase—from age 35, the annual hazard increases at an average 9.7% a year for men and 10.4% a year for women. This means that, in normal circumstances, the average annual risk of death doubles for each seven years of extra age (since a 10% a year increase (1.1) over seven years leads to a total increase of 1.1, 7 which is roughly 2).

ANALYSIS

Use of “normal” risk to improve understanding of dangers of covid-19 Accumulating data on deaths from the coronavirus show an association with age that closely matches the “normal” risk we all face. Explaining risk in this way could help people understand and manage their response, says David Spiegelhalter

Log scale

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Fig 1 | Observed population fatality rates for 49 607 deaths mentioning covid-19,

registered in England and Wales between 7 March and 26 June 2020. The covid-19

death rates create a remarkably straight line on a logarithmic scale (top), indicating

an exponential increase of risk with age. The “normal” risk (broken lines) is the

actuarial annual mortality, scaled by a factor 16/52 to reflect the risk over 16 weeks

KEY MESSAGES

• It is diffi cult to communicate the huge range of individual mortality risks from covid-19 experienced by people of diff erent ages.

• For the general population, the risk of catching and then dying from covid-19 during 16 weeks of the pandemic was equivalent to experiencing around 5 weeks extra “normal” risk for those over 55, decreasing steadily with age, to just 2 extra days for schoolchildren

• For those over 55 who are infected with covid-19, the additional risk of dying is slightly more than the “normal” risk of death from all other causes over one year, and less for under 55s.

• Analogy with normal risk seems an appropriate and useful tool for risk communication of lethal risk, although it does not deal with longer term harm to survivors.


The population fatality rates for covid-19 display even stronger linearity on the logarithmic scale. Table 1 shows the death rate during this 16 week period was around 12-13% higher for each year older, corresponding to doubling for every fi ve to six additional years of age, and this relation is consistent from childhood to old age. On average, men experienced around 70% additional risk compared with women the same age. Other countries show a similar gradient. 4

The relation of covid-19 mortality risk with age is slightly steeper than it is for normal actuarial risk, but for ages over 45 the lines are fairly parallel, indicating that the average risk of catching and then dying from the virus were roughly proportional to the average normal risk over the same period.

The risks of catching and dying from the virus vary 10 000-fold depending on age, as shown in the linear graph, and it is challenging to communicate such a massive range. Table 2 represents an attempt to communicate the additional risk of dying from covid-19 in terms of extra days of normal risk, represented by the fi ve year average for these 16 weeks in order to adjust for seasonal eff ects.

For example, among nearly six million people aged 65-74 in England and Wales, 7319 were registered as dying from or with covid-19 over 16 weeks, a rate of around 124 in 100 000, or 1 in 807. We would normally expect around 26 617 deaths in this age group over this period, and so covid-19 represented a 28% increased risk. This is equivalent to around 31 days’ extra risk of dying during 112 days of the epidemic.

The second row of table 2 shows that three deaths from covid-19 have been recorded among over seven million schoolchildren aged 5 to 14 (around 1 in 2.4 million), an extremely low risk that represents only 2% of the average normal risk faced by this group. This amounts to around two days’ extra risk of dying during the 112 days of the epidemic. In the same period this age group experienced 138 deaths from other causes.

At the other extreme, 2% (1 in 49) of all those aged over 90 in England and Wales were registered as dying with covid-19 in these

16 weeks; this represents around 4300 times the risk of catching and dying from covid-19 compared with 15-24 year olds. These 10 790 deaths can be compared with the average of 33 722 for this period over the past fi ve years, so the potential exposure to covid-19 represents an additional 32% over normal mortality risk. So living through this 112 day period of the epidemic is as if these people have on average been exposed to an extra 36 days’ risk (32% of 112).

Taken as a whole, 1 in 1192 of the population died and had covid-19 on their death certifi cate, which represents a 31% increase over the normal risk, equivalent to an extra 35 days over and above the 112 days to which they had been exposed, although this additional relative risk was far lower for under 45s and extremely small for under 15s.

In summary, those 16 weeks (112 days) of the pandemic led to those aged over 55 experiencing around fi ve weeks’ extra risk, while younger people were exposed to steadily smaller amounts: for schoolchildren it corresponded to just two additional days.

These are observed historical rates in the population and cannot be quoted as the future risks of getting covid-19 and dying. The risks of infection will be altered by factors that limit exposure and have dropped as the epidemic has been brought under control. There may also have been some selection of frail elderly people, bringing their deaths forward and leaving a temporarily more resilient cohort.

Infection fatality risks in terms of normal risks

In contrast to the population fatality rate, we might expect the infection fatality rate—that is, the risk of death if infected—to remain fairly stable over time.

In March 2020 researchers from Imperial College London published an infl uential report containing age specifi c risks of dying after infection with SARS-CoV-2. 7 They estimated an overall infection fatality rate in the UK of 0.9%, with a 95% uncertainty interval of 0.4% to 1.4%, and provided rates and intervals for diff erent age groups, with both sexes combined. Uncertainty intervals corresponded to a relative error of ±55%, showing the caution about these early estimates based on experience in Wuhan and aboard the Diamond Princess cruise ship.

In March 2020 I compared these estimates with the annual actuarial risks shown in fi gure 1 and found the agreement was reasonable, 8 with the covid-19 risk estimates following a similar pattern to the background risk (fi g 2, top).

Table 1 | Estimated effects of sex and age on population fatality rates for covid-

19 based on 49 607 deaths registered in England and Wales between 7 March

and 26 June 2020*

Estimate 95% confidence interval

Increased risk: each year older 1.128 1.125 to 1.131

Years to double risk 5.75 5.61 to 5.88

Increased risk: male v female 1.71 1.63 to 1.77

*Based on a Poisson regression, log linear assumption, with allowance for overdispersion. If the

increased risk per year is c , the years to double risk, d, obeys the rule 2= c d , or d= log(2)/log( c ).

Table 2 | Deaths registered in 16 weeks between 7 March and 26 June 2020 in England and Wales: 49 607 deaths with covid-19 on death certificate. Five year

averages and populations from the Office for National Statistics 5 6

Age (years)

No of covid-19

deaths Population

Covid-19 rate/

100 000

Covid-19 rate

(%)

Covid-19 rate

(1 in …)

No of non-covid

deaths 5 year average

Covid-19 as % of

5 year average

Equivalent days of

normal risk

0-4 3 3 515 430 0.1 0 1 in 1 171 810 848 932 0 0

5-14 3 7 159 102 0 0 1 in 2 386 367 138 179 2 2

15-24 33 6 988 755 0.5 0 1 in 211 780 470 659 5 6

25-34 128 7 998 302 1.6 0 1 in 62 487 1141 1295 10 11

35-44 369 7 460 856 4.9 0 1 in 20 219 2577 2610 14 16

45-54 1283 8 142 528 15.8 0.02 1 in 6346 6577 6449 20 22

55-64 3476 7 019 590 49.5 0.05 1 in 2019 13 565 12 722 27 31

65-74 7319 5 906 928 124 0.12 1 in 807 27 184 26 617 28 31

75-84 16 043 3 476 922 461 0.46 1 in 217 47 729 45 300 35 40

85-89 10 160 918 437 1110 1.1 1 in 90 30 703 29 108 35 39

90+ 10 790 528 959 2040 2.0 1 in 49 37 815 33 722 32 36

All 49 607 59 115 809 83.9 0.08 1 in 1192 168 747 159 593 31 35

1 in 1192 of the population died and had covid-19 on their

death certificate—a 31% increase over the normal risk


This agreement between the estimated covid-19 risks and the average annual mortality rates suggests that, based on the fi gures provided by the Imperial College team in March 2020, being infected with SARS-CoV-2 contributes about a year’s worth of extra risk of dying for those aged over 20 and less than half this risk for those aged under 20. There is a simple reality check on this fi gure. Ferguson et al 7 estimated that if the virus went completely unchallenged, around 80% of people would be infected and there would be around 510 000 deaths. So if everyone got infected we would presumably expect 510 000×100/80=637 500 deaths, which is fairly close to the “normal” annual total of around 616 000 deaths in the UK (2018).

Unfortunately, the message that covid-19 risk was about the same as the annual risk (and hence that catching the virus roughly doubles the risk of dying this year) was misinterpreted by some as meaning that it did not increase the annual risk at all. In fact, if the risk of dying this year from covid-19 is p , and the risk of independently dying from something else is also p , then probability theory tells us that the overall risk of dying this year is one minus the chance of surviving both hazards—that is, 1−(1− p )(1− p ) or 2 p − p 2 . For low p , this will be very close to 2 p , and so it is generally fi ne to say that covid-19 would roughly double the risk of dying. But if you were frail and had a 60% risk of dying next year, then with infection this would rise to 2×0.6–0.6 2 =0.84, so altogether you would have an 84% chance of dying. (The events may also not be independent: survivors may be weakened by the disease or show increased resilience.)

The true infection fatality rate remains contested, with one review claiming a global rate of 1.04%, 9 while another has claimed a range

from 0.02% to 0.4%. 10 In July, the MRC Biostatistics Unit estimated updated infection fatality rates for the UK (fi g 2, bottom). 11 These correspond to an overall rate of 1.3% (1.1% to 1.5%), rather more than the early estimates from March, and also show a steeper gradient than the background risk, increasing at 12.8% per additional year of age, precisely that observed for the population fatality rates (fi g 1). This steeper gradient suggests that the additional risk from being infected is rather more than the normal annual risk for those over 55, and rather less than the annual risk for those under 55.

All this analysis refers to averages over populations, and although age seems to be the overwhelmingly dominant infl uence on mortality, clearly other factors aff ect individual risk. More than 90% of people who have died with covid-19 had pre-existing medical conditions. 12 However, it may be reasonable, to a fi rst approximation, to assume these comparisons apply to more highly stratifi ed groups. The idea that covid-19 multiplies the “normal risk” of dying in the following year forms the basis for the analysis of Banerjee and colleagues, 13 who assume a fi xed additional relative risk from covid-19, such as 0.5 (6 months’ normal risk) to 1 (a year’s normal risk) to be applied to actuarial estimates for one year mortality based on age, sex, and pre-existing conditions.

Importantly, all the risks quoted are the average (mean) risks for people of the relevant age but are not the risks of the average person. This is because, both for covid-19 and in normal circumstances, much of the risk is held by people who are already chronically ill. So for the large majority of healthy people, their risks of either dying from covid-19, or dying of something else, are much lower than those quoted here. Of course, while death is the most serious and easily recorded outcome, information is growing on the number of people experiencing prolonged symptoms of covid-19. This mounting problem presents a whole new challenge for surveillance, risk assessment, and risk communication.

Conclusions

The UK has experienced some of the highest per capita mortality from covid-19 of any country. The covid-19 population fatality rate over the 16 week (112 day) peak of the epidemic in England and Wales was equivalent to those over 55 experiencing around 5 weeks extra mortality risk above “normal,” and steadily less for younger age groups, reducing to just two extra days for schoolchildren.

The infection fatality rate was estimated back in March to be roughly equivalent to the age specifi c annual mortality: currently it seems to be slightly more than a year’s worth for over 55s and less than this for under 55s.

Normal risk appears a reasonable comparator for interpreting both population and infection fatality risks, although incorporation in any public facing tool would require careful evaluation, especially in light of the growing concerns about the prolonged impacts of infection. It should always be remembered that these are risks to the individual: there is still a responsibility to consider the potential risks an individual may cause to others. David Spiegelhalter, chair , Winton Centre for Risk and Evidence Communication,

Statistical Laboratory Centre for Mathematical Sciences, Cambridge

[email protected]


Imperial College London

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Estimated additional mortalityif infected: March 2020

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Estimated additional mortalityif infected: July 2020

Fig 2 | Estimated infection fatality rates with covid-19 superimposed on

background annual risk. Top: estimated covid-19 infection fatality rates

are from Imperial College London, March 2020. Error bars on the estimated

age specific covid-19 mortality assume a relative error of ±55%. Bottom:

estimated covid-19 infection fatality rates from MRC Biostatistics Unit

analysis, July 2020

More than 90% of people who have died with

covid-19 had pre-existing medical conditions


LETTERS Selected from rapid responses on bmj.com

LETTER OF THE WEEK

Don’t overlook olfactory dysfunction “One of the most distressing aspects of living with long covid is the dismissive attitude of some doctors.” This quote from Paul Garner in The BMJ resonates closely with views expressed by patients coming to terms with persistent olfactory dysfunction as a consequence of covid-19. Loss of smell and taste is one of the most prevalent symptoms of covid-19 and the best predictor of covid status. A substantial proportion of patients experience at least partial recovery of their loss of smell, but 10% report persistent loss eight weeks after onset. Parosmia—distortion of the sense of smell that can severely impair appetite owing to familiar foods triggering a foul smell—also seems to be prevalent in patients with covid-19.

Greenhalgh and colleagues’ otherwise excellent article on the management of post-acute covid-19 emphasises the broad range of symptoms experienced by patients with what has been termed long covid (Practice Pointer, 5 September), but does not mention smell or taste disturbance. A patient led project evaluating covid-19 recovery with a survey found that loss of smell and taste was reported by more than 50% of respondents; loss of appetite and nausea even more frequently. The terminology used in such surveys, “loss of smell or taste,” probably underestimates the extent and health consequences of parosmia. If we are to provide appropriate support and advice, the questions we put to patients should be reframed as “alterations in smell and taste” to better capture the effect of covid-19 on olfactory and gustatory function. We are currently working with a large group of patients who are struggling to manage their persistent olfactory symptoms and feel that they are being overlooked by the healthcare system. Greenhalgh and colleagues’ article suggests that they might be right. Claire Hopkins, professor of rhinology , London

Duika L Burges Watson, lecturer in population and health ,

Newcastle on Tyne

Chrissi Kelly, founder , AbScent Charity

Vincent Deary, professor of applied health psychology ,

Newcastle on Tyne

Barry C Smith, director , Institute of Philosophy


Telemedicine: unseen unknowns Conversations around the blanket switch to remote consultations as default (Helen Salisbury, 22-29 August) have largely focused on clinical safety and the “unknown unknowns” rather than barriers to healthcare.

As one of the few remaining areas of the NHS that are truly open access and free at the point of use, GP surgeries are a place where marginalised people can be seen and receive care. The switch to remote consulting will remove this safe place for many. People who can’t afford a mobile phone, don’t have internet access, or can’t speak English will have difficulty navigating the remote entry points to GP consultation. Doctors of the World uses the term “digital exclusion” to describe these barriers.

Far from the hope of a bright technological future for general practice, Matt Hancock’s announcement was yet another occasion when these people—“unseen unknowns”—were pushed further away from accessible healthcare. Nathaniel J T Aspray, GP registrar , Newcastle upon Tyne


Compromising patient safety and job satisfaction The pendulum has swung too far. Matt Hancock’s assertion that all initial general practice consultations should happen on the phone or online fundamentally misunderstands the primary care presentation. Salisbury says that Hancock’s suggestion misses “vital questions about quality, choice, and relationships.” I would go further and say that patient safety, the acquisition and maintenance of clinical examination skills, and professional satisfaction are all compromised.

The patient-doctor relationship is vital to the success of remote consulting: this can be established by continuity of care, now only available if it is deliberately built into appointment systems, taking sessional working into account. A succession of random clinical “snapshots” incurs greater clinical risk and reduced professional satisfaction than “clips of cine films.”

Stressed GPs counterbalance their pressure with job satisfaction—reduce the latter and more will depart their profession. Perhaps it is fortuitous that medical schools will increase their intakes this autumn. Vernon H Needham, retired GP , Andover


TELECONSULTATIONS FOR ALL

Could medical students give flu jabs? The expanded flu programme covers 30 million people, double the number vaccinated last year. The importance of vaccination to prevent a surge of flu alongside covid-19 is unquestionable but, as Mathew alludes, we need to find an alternative way of staffing this programme (Rammya Mathew, 22-29 August).

Medical students could help—we are trained in giving intramuscular injections, are aware of infection control procedures, and have experience dealing with patients. We could practise injections, hone our communication skills, and be able to give back to the patients who have taught us so much. One experienced professional could supervise a group of students so that many more vaccinations could be delivered in the same amount of time. This could be further expanded to include nursing and pharmacy students.

Venues, social distancing, and personal protective equipment would need to be resolved, but maybe medical students are the answer to this staffing problem. Jack O Lyon, fi nal year medical student , Manchester


FLU VACCINATION PROGRAMME


DEMISE OF PUBLIC HEALTH ENGLAND

Health promotion is at a crossroads We have serious concerns after the recent announcement that Public Health England will be disbanded (Editorial, 5 September).

We are in the middle of a pandemic, and many non-communicable causes of disease need urgent and major action. Health promotion is at a crossroads: the choice is between its continued decline or a paradigm shift in the country’s thinking towards a positive view of health and recognition of the key role of health promotion in securing health. We need increased investment in health promotion action at two levels: locally, led by directors of public health, and nationally, led by an organisation that has a well resourced workforce who are at the cutting edge.

Senior positions should be filled with elite professionals who are qualified and skilled and have extensive experience of public health. We urge the government to revitalise its efforts and appoint an appropriate senior person to drive this agenda forward. Michael Craig Watson, trustee

Sylvia Tilford , vice president , Institute of Health Promotion and Education


AIR POLLUTION AND ASTHMA

Why won’t we listen to the evidence? Holst and colleagues discuss the asthma risk to children of being exposed to fine particular matter (Research, 22-29 August). Their findings should be of concern to everyone interested in public health.

Covid-19 has revealed the willingness of society to act on public health problems. The closure of borders, shuttering of economic activity, and acceptance of restrictions on personal liberty show support for making sacrifices to protect people’s wellbeing. But this has not been replicated when it comes to air pollution. Holst and colleagues’ study shows the risk of harm and respiratory disease burden from exposure to toxic pollutants. That the message is so clear leads to the question—why won’t we listen to the evidence on air pollution?

We need to consider what future we want for our children. We need a globally coordinated political, economic, and social response to reduce the sources of air pollution and improve population health. Gabriel L Van Duinen, senior peer assisted learning facilitator , Sydney


FACE MASKS AND HEARING

Covid-19: face shields are better in hearing loss Chodosh and colleagues highlight that wearing face masks can be devastating for people with hearing loss (Editorial, 25 July-1 August). They overlook, however, the use of face shields, hoods, and other clear barriers that decrease disease transmission, facilitate lip reading, and reduce muffling.

Face shields are also easier to manufacture, clean, and reuse. They protect the user’s eyes and are more acceptable than masks in a paediatric setting.

The suggestion to adopt masks with clear windows is premature, given the lack of evidence that they are more effective than face shields. Using a laser particle counter, we found that face masks and Perspex barriers had similar efficacy in reducing airborne and droplet transmission across a slit lamp.

When a higher level of protection is required, clear ventilated hoods can be used. They have been successfully trialled with a view to widespread adoption. Ali Poostchi, registrar , Derby, Mong-Loon Kuet, registrar , Derby, Patrick S Richardson,

consultant , Derby, Moneesh K Patel, consultant , Derby


Are we doing students a disservice? I welcomed the news that medical school places will remain uncapped for the 2020 entry period with reticence (News Analysis, 5 September). More students mean more doctors in years to come rather than in the immediate future.

Equally, there is a question of quality over quantity. Doctors in training need hands-on experience, but medical education has changed dramatically because of covid-19. There is no substitute for physical interaction with patients, but student safety is also a priority. Increasing student numbers without the means to develop them as doctors might be doing them a disservice.

We need to achieve a balance between quality, clinical need, and supporting our students. Patients deserve well rounded doctors who are clinically adept and fundamentally human. Increasing numbers might seem the ideal solution, but beneath the surface there are many problems requiring careful consideration if we are to succeed in nurturing the next generation of doctors. Joshua L Davies, senior house offi cer , Walsall


Medical school places need appropriate funding An increase in the number of medical students is welcomed and somewhat tackles the shortage of doctors in the UK, but without an increase in government funding for clinical training, questions arise about the quality of future medical education.

Unless the increase in medical school places is accompanied by an equal increase in foundation school posts, there will be a surplus of qualified doctors unable to practise. At a time when the spotlight is placed on the mental health and wellbeing of healthcare professionals, a bottleneck will increase anxieties. This, in addition to the substantial bottleneck at the specialty level might disadvantage this cohort and lead to a high attrition rate.

If the government fails to support these changes with appropriate funding, we are likely to be faced with a disenchanted generation of future doctors who turn to other professions or move abroad in search of career progression and satisfaction. Sarah G Michael, fi nal year medical student , Manchester

William Reynolds, fi nal year medical student , Manchester

Kirolos Michael, core surgical trainee , Manchester


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LIFTING THE MEDICAL SCHOOL CAP


OBITUARIES

Stella Gibson Consultant in public

health medicine Paisley,

Renfrewshire (b 1927;

q Glasgow 1954), died from

old age on 22 April 2020

Stella Elizabeth Grace Gibson sat an MA in English literature while waiting to be admitted to medical school because priority was given to returning servicemen and a limit was imposed on female applicants. Her first post was assistant medical officer of health for Clydebank in 1960, and she became deputy medical officer, first for Clydebank, and then for Paisley in 1968. She was the lead consultant of port health. In 1972 she became a community medicine specialist and worked as a consultant in public health medicine at Argyll and Clyde Health Board until her retirement in 1988. She specialised in child health, well woman services, and family planning services. Stella never married but lived with her twin sister, Iris, until Iris’s death. She leaves her nephew, Robert; his family; and friends. Kate Gibson, Robert Gibson


Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

Tom Graham Paediatrician (b 1934;

q Queen’s University

Belfast, 1965; FRCP,

FRCPCH), died from natural

causes on 20 April 2020

Tom Graham always felt medicine was his calling, but his parents felt that a career as a teacher would be preferable. He completed his teaching certificate and taught mathematics, physics, chemistry, and biology in the Middle East. However, after an illness he returned home to his native Belfast and studied medicine as a mature student. He financed his own courses, with the help of his family. He joined the army as an officer cadet and then the Royal Army Medical Corps in 1963. He undertook his higher professional training at British military hospitals and Great Ormond Street. For most of his consultant career he was based overseas, principally serving in Hong Kong and Germany, before retiring to Cornwall in 2000. He leaves his wife, Christine, and three children from a previous marriage. David Ross


Sushma Sharma Family planning doctor (b 1932; q Amritsar

1955; DA), died from acute myeloid

leukaemia and coronavirus infection on

25 April 2020

My parents, Sushma Sharma and Umesh Chandra Sharma, came to the UK from India. Mum at first worked in anaesthetics in Shrewsbury. After a period in Edinburgh, Newcastle, and North Shields, the family lived in Liverpool, Wallasey, and Leicester before my father was appointed consultant orthopaedic surgeon at Scotland’s Stonehouse Hospital in 1977. Mum worked in anaesthetics at this time and was participating in a married women’s training scheme in Leicester. In Scotland she was unable to continue the training scheme formally, although she did continue training on an individual basis. She changed to psychiatry and also did family planning sessions, which she had been doing part time for some time. She carried on working until she was 73 years old. She leaves three children and two grandchildren. Devesh Sharma


Peter John Lewis Hunter Consultant ophthalmologist

(b 1921; q Birmingham

1946; DOMS, FRCOphth),

died from old age on

11 April 2020

After qualifying Peter John Lewis Hunter decided to specialise in ophthalmology, and in 1947 he took up a post in the eye department of the Royal Victoria Infirmary, Newcastle upon Tyne. During his army service he was posted to Germany. After demobilisation he was appointed to Bradford Eye and Ear Hospital and then a year later returned to the Royal Victoria Hospital in Newcastle as senior registrar ophthalmologist. In 1957 he moved to Norwich as consultant ophthalmic surgeon, where he remained for 25 years. During his time at the Norfolk and Norwich Hospital, he became involved with professional societies and various committees. From the early 1970s, teaching and tutoring became an important part of his career. Peter’s wife, Kathleen, predeceased him in 1992. They had five children and six grandchildren. Gillian Williamson


Roy William Lamb General practitioner and

anaesthetist (b 1932;

q London 1956; DA, DObst

RCOG), died from renal

failure and pneumonia on

10 July 2020

From 1962 to 1993, Roy William Lamb was a GP and anaesthetist in Stroud, Gloucestershire. He grew up in London’s East End during the war and trained at Charing Cross Hospital—the first member of his family to access university education. Roy provided high quality care throughout his career, including home visits for everything from palliative care to mental health emergencies, and emergency resuscitation for the community hospitals. Through his NHS leadership roles, he was pivotal in several transformational healthcare initiatives, including the early introduction of cervical screening in Gloucestershire. He was awarded the Freedom of the City of London in 1987 and made a fellow of the BMA in 1997. Roy will be greatly missed. He leaves his wife, Marion; six daughters; and 16 grandchildren. Marion Lamb


Krishan Chandra Gupta GP partner Richmond Road

Medical Centre, Hackney,

London (b 1937; q Gandhi

Medical College, Bhopal,

India, 1961; DOphth), died

after a period of ill health

and frailty on 27 April 2020

Krishan Chandra Gupta moved to the UK from India in 1963, one of the many doctors recruited from India to support the NHS. His passion was ophthalmology, which he pursued for some time, working in many different hospitals across the country. He eventually decided on a career in general practice and was a partner for 25 years. He developed the London forensic medical examiners’ team during this time, supporting forensic medical examinations for the Metropolitan Police. He retired due to ill health in 2000, and spent many happy years travelling and socialising with friends and his grandchildren. His wife, Shashi, also a doctor, predeceased him in 2019. He leaves two daughters, who both followed him into medicine. Mina Scott, Nishi Gupta



Even though it was the swinging Sixties, Lester Grinspoon was a bit taken aback when his good friend and fellow Harvard assistant professor Carl Sagan off ered him a joint. “You’ll love it,” said the astrophysicist. But Grinspoon demurred, arguing the establishment line that it was bad for your health.

That encounter set Grinspoon off on a journey to prove his point. His rigorous research rediscovered the history of marijuana’s use as medicine over thousands of years, but little evidence that it was harmful, certainly not when compared with popular drugs such as tobacco and alcohol.

“The greatest potential for social harm lies in the scarring of so many young people and the reactive, institutional damages that are direct products of present marijuana laws,” Grinspoon wrote in Marihuana Reconsidered , published in 1971.

One reviewer wrote, “I can only express my admiration for the manner in which Grinspoon has extracted, analysed, and synthesised the most relevant literature to present the reader with a coherent, logical case.” Those words came from a pillar of the establishment, former commissioner of the US Food and Drug Administration (FDA), James

L Goddard, who was writing in the New York Times . The headline of the article was “The best dope so far.”

The US president at the time, Richard Nixon, was not a fan. “Every one of the bastards that are out for legalising marijuana is Jewish, this clown is far on the left,” he told the White House staff in secret recordings later made public. He offi cially declared a “war on drugs,” calling drug abuse “public enemy number one.”

“Imagine that, I got the attention of one of the world’s biggest jerks,” Grinspoon laughingly told the Boston Globe in a 2018 interview. “It’s a red badge of courage.”

Career Grinspoon was one of the fi rst people to use lithium to treat bipolar disorder, and his 1972 book on schizophrenia was widely praised. In 1979 he was a co-author of Psychedelic Drugs Reconsidered , a comprehensive evaluation of the subject, comparable to his work on marijuana, which only now is being given serious clinical research consideration in treating conditions such as post-traumatic stress disorder.

He was the founding editor of the American Psychiatric Association Annual Review and the Harvard Mental Health Letter .

He ran for president of the American Psychiatric Association (APA), hoping to get

the organisation and the profession to take a more active role in opposing nuclear weapons. But, as with so many things, he was ahead of his time. He was twice denied promotion to full professor at Harvard, in 1975 and 1997. One criticism was that much of his work was synthesising the fi ndings of others into a coherent whole rather than conducting original research. But it was also clear that the top echelon of the medical school was still smarting from the early 1960s escapades of another Harvard professor, Timothy Leary, and his promotion of LSD. People were uncomfortable with the controversial subject matter of Grinspoon’s work.

The B eatles Grinspoon had written Marihuana Reconsidered without ever having tried it; he didn’t want to taint his objectivity. After the book was published, he and his wife, Betsy, twice tried to get high, to no avail. On the third attempt one of their children happened to be playing the Beatles’ album Sgt Pepper’s Lonely Hearts Club Band , when the pot took hold, revealing “a fascinating new musical experience,” he would later write on a blog.

Grinspoon’s reputation led to his being called by the defence as an expert witness when the US government tried to deport John Lennon for an earlier conviction of possession of hashish in England. That testimony was essential to Lennon’s eventually being allowed to stay in the US.

Then tragedy hit the family when Grinspoon’s eldest son, Danny, was diagnosed with leukaemia while at high school. The disease and chemotherapy left him nauseous, with no desire to eat, and he began to waste away. Finally, Betsy asked a young friend to provide her son with a joint, which he smoked before the next treatment session. On the way home Danny shocked and delighted his parents by asking to stop for a submarine sandwich. They continued to use pot as an adjunct treatment to chemotherapy.

Lester Grinspoon died at a retirement facility in Newton, Massachusetts. He had celebrated his 92nd birthday the previous day He leaves his wife, Betsy; three sons; and fi ve grandchildren. Bob Roehr , Washington, DC [email protected] Cite this as: BMJ 2020;370:m2750

OBITUARIES

Grinspoon was one of the first people to use lithium to treat bipolar disorder

Lester Grinspoon (b 1928; q Harvard 1955), died

after a long time with cancer on 25 June 2020

Lester Grinspoon Psychiatrist who laid the intellectual foundation for marijuana reform

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