Medicine and Science from The BMJ

Interest in vitamin D, and it’s association with a range of health outcomes continues - at least if the regular flurry of papers on the subject that are submitted to The BMJ are anything to go by, and with Covid-19, interest has piqued again. GPs are regularly asked to prescribe it, and to test for deficiencies. Low levels of vitamin D are associated with a large number of health outcomes, but, given the high costs and low accuracy of tests, would it be easier just to recommend taking supplements without testing vitamin levels first, taking a “won’t hurt but might help” approach? If so, should we all be taking them, and would doing so help to prevent against COVID-19? Our guests: Andrew Grey is an endocrinologist and an associate professor of Medicine at the University of Auckland. Tom Chatfield is a philosopher, author and broadcaster, whose work looks at humans and technology, as well as cognitive biases.

Fresh outbreaks of covid in Europe and a wave of infections in the United States have been in the news this week, highlighting the renewed need for social distancing – but to what extent? In this edition, we explore the real-world evidence for physical distancing measures as well as the research into whether or not facemasks make us behave more recklessly. We also discuss the non-covid themes of research transparency and a BMJ investigation into the lucrative business of orphan drugs.

In light of the publication of the Independent Medicines and Medical Devices Safety Review (the Cumberlege report) in early July, which assessed the use of vaginal mesh, sodium valproate and Primodos and their associated under-acknowledged complications, this week we discuss trust between patients and doctors, and how that relationship of trust can break down when patients feel that their concerns and their pain are not being recognised and supported. We talk about the influence of racial inequalities on trust and healthcare outcomes, GPs being an advocate for their patients, and we ask what structural changes to the healthcare system need to happen to allow us to spend more time with our patients and build up that trusting relationship with them? Our guests: Karen Praeter works on the admin team of Sling the Mesh, a campaign which raises awareness of the risks of having a vaginal mesh implant, having joined two years after her own mesh implant operation in 2015 which led to painful complications. Rhea Boyd is a paediatrician at the Palo Alto Medical Foundation in California, and she is also a public health advocate and scholar.

Lockdown has been such a stressful period that many healthcare professionals developed abnormal behaviours to cope. Addiction is one such behaviour, be it to a substance – alcohol for example – or any other obsessive activity like exercise. Dr Caroline Walker, an NHS psychiatrist and therapist who has personal experience of addiction discusses the harmful behaviours to look out for and what to do about them.

This time of year we would usually be doing some podcasts from the BMJ awards - but the pandemic has delayed our plans. We’re still working on acknowledging some of the best medicine from around the UK, but in the meantime we’ve decided to give out the awards for outstanding contribution to health, and research paper of the year. In the following interview, Fiona Godlee - the BMJ’s editor in chief, talks to Marian Knight, lead author of the ANODE trial - The BMJ's research paper of the year. For more about The BMJ Awards categories and previous winners; https://thebmjawards.bmj.com/

This time of year we would usually be doing some podcasts from the BMJ awards - but the pandemic has delayed our plans. We’re still working on acknowledging some of the best medicine from around the UK, but in the meantime we’ve decided to give out the awards for outstanding contribution to health, and research paper of the year. In the following interview, Fiona Godlee - the BMJ’s editor in chief, talks to David Pencheon, director of the NHS sustainability unit about his work. For more about The BMJ Awards categories and previous winners; https://thebmjawards.bmj.com/

As the pandemic play out, we’ve seen ways in which the collection of covid data - and it’s sharing, has been flawed, with reports in the UK that local authorities haven't got granular data, and in the US that the CDC is being circumvented for data reporting. Kathleen Bachynski, assistant professor of public health at Muhlenburgh College, and Sridhar Venkatapuram, director of global health education & training at King's College London join us to discuss why data is fundamental to the social contract between the public and their government, and why undermining it is so dangerous.

Vaccines have been in the news this week - but when you dig into the stories, it turns out that the hype is about phase 1 trials. We're a long way from being sure any of the 150 possible vaccines being developed actually work. In this talk evidence we're talking to a researcher, a regulator, and a manufacturer about the way in covid-19 is upending normal vaccine development, which hurdles they'll have to reach to get onto the market, and how we'll know which one to choose when they are there. This week (1.10) We said that covid would have a knock-on effect on other treatments, and Helen looks at some research into acute coronary syndrome admissions in the UK. (6.53) Peter Doshi, assistant professor of pharmaceutical health services research at the University of Maryland School of Pharmacy and an editor for The BMJ, tells us what to watch out for in the PICO for a vaccine study. (15.20) Marco Cavaleri, head of Biological Health Threats and Vaccines Strategy at the European Medicines Agency, explains what regulators are looking for when thinking about licencing a vaccine - and how covid has made different agencies around the world align their requirements. (22.22) Philip Cruz, UK head of vaccines at GSK, explains how a manufacturer tests their vaccines, and how they use adaptive study design to past regulatory hurdles and provide information for those choosing which vaccine to use. Reading list Lancet paper - COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31356-8/fulltext ONS Data - Deaths registered weekly in England and Wales, provisional: week ending 3 July 2020 https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredweeklyinenglandandwalesprovisional/latest The BMJ editorial - Vaccines, convalescent plasma, and monoclonal antibodies for covid-19 https://www.bmj.com/content/370/bmj.m2722 WHO report - Draft landscape of COVID-19 candidate vaccines https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines Research Methods & Reporting The Adaptive designs CONSORT Extension (ACE) statement: a checklist with explanation and elaboration guideline for reporting randomised trials that use an adaptive design https://www.bmj.com/content/369/bmj.m115

The signs and symptoms of racism have long permeated our society, and are embedded in our clinical practice and medical education. Recent events in the US, including the murder of George Floyd, have brought the Black Lives Matter movement to the fore of public consciousness, and have sparked outrage and protests in countries around the world. COVID-19 has exposed the inequalities in our healthcare systems, as the virus has had a disproportionate impact on some ethnic minority communities. In this week’s episode, we discuss colonial undertones to contraception policy-making, how doctors remaining silent on racial issues are seen as complicit, and the lack of diversity in learning resources used in medical schools. How can we use the current climate as a teaching moment to engage with people, clinicians and patients, about their experiences of healthcare? And how do we begin to make reparations in medicine for centuries of institutionalised racism? Our guests: Annabel Sowemimo is a community Sexual & Reproductive Health registrar, working in Leicester. She is also the founder of Decolonising Contraception and a trustee for Medact charity. Shani Scott works as a general internist at Montefiore Medical Center in the Bronx. She is an associate program director for the Moses-Weiler Internal Medicine Residency Program, and is also the co-director of Diversity & Inclusion for the Department of Medicine at Montefiore Medical Center. Joan Saddler OBE is the director of partnerships and equality at the NHS Confederation, and the co-chair of the NHS Equality & Diversity Council. She was awarded an OBE in 2007 for services to health and diversity. Resources mentioned by Jenny: NEJM Perspective, "How Medical Education is Missing the Bull's-eye" by LaShyra Nolen https://www.nejm.org/doi/full/10.1056/NEJMp1915891 America Did What?! Podcast with Blair Imani & Kate Robards Episode 1: Redlining and the GI Bill https://www.stitcher.com/podcast/america-did-what

A series of medical scandals prompted Jeremy Hunt, former UK health secretary to launch the Independent Medicines and Medical Devices Safety Review - with the explicit aim of strengthening the patient voice in order to help build a "system that listens, hears and acts – with speed, compassion and proportionality" That report is out, and describes a system that does anything but. In this podcast, Sir Cyril Chantler, the review's vice chair discusses their recommendations, for better regulation, transparency and patient advocacy in the use of medicines and medical devices. Read the full report: https://www.immdsreview.org.uk/ The BMJ report into what we must learn from mesh https://www.bmj.com/content/363/bmj.k4254

US President Donald Trump has been pushing hard for an American vaccine against Covid-19. He's named the program Operation Warp Speed, which has many people worried that safety tests will be rushed. What are the prospects for an American vaccine against Covid-19? If the US is first, will it make its vaccines available to other countries? And what if it's not first? Three American vaccine experts talk with the BMJ about prospects for an American vaccine against the new coronavirus. Joining us are; Nicole Lurrie - senior lecturer at Harvard Medical School and a strategic adviser to the foundation working on global vaccines, CEPI. Paul Offit - professor at the University of Pennsylvania, and co inventor of a rotavirus vaccine. Prashant Yadav - senior fellow at the Centre for Global Development and a lecturer at Harvard Medical School.

We all know that healthcare professionals are stretching themselves to provide the care that’s needed right now. But there are instances when you might find yourself out of your comfort zone or being pushed too hard or fast. When is it ok to say no to these demands? We spoke to Kate Burnett who educates NHS staff on empowerment about how to voice your position clearly and how to reconcile the guilt you might feel of letting the side down. www.bmj.com/wellbeing

In this week's Talk Evidence we're hearing about how the death rate has dropped below average, disappointment about HIV drugs for covid-19 treatment, a trial to reduce polypharmacy, and why academic promotions matter to everyone else. 1.35 - Carl gives us one of his death updates 3.30 - Helen asks if it’s finally time to be able to do the international comparisons we’ve been waiting for? 16.10 - New research suggests that extreme PPE prevents transmission - but PPE came with a whole range of other viral suppression measures, and they all work together. 21.30 - The Recovery trial has said that lopinavir-ritonavir isn’t effective against covid - enough for them to stop the arm of that trial. We talk about this and more treatment evidence. 24.00 - Can a digital intervention reduce poly pharmacy? A new trial on bmj.com says no, but we talk about the composite endpoint and the way the trial is powered. 36.25 - Why academic promotion matters to non academics

The relaxation of the COVID-19 lockdown regulations is raising a lot of questions, both for doctors and for patients. This week, we discuss how the lack of clarity and coherence in public health messages over the past few months has caused anxiety and confusion for our patients, especially those who have been told to shield. We talk about GPs tailoring shielding advice to suit the individuals they treat, the politicisation of mask wearing, and the flaws of ‘abstinence-only’ health messaging. How do we balance prompting overall health, rather than just working to prevent disease, and how do we start taking baby steps towards returning to normality? Our guests: Julia Marcus is an infectious disease epidemiologist and Assistant Professor at Harvard Medical School’s Department of Population Medicine . She is also an HIV researcher. Carol Liddle, a COPD patient, is a patient advocate on the panel for NACAP (National asthma and COPD audit), as well as a patient representative for the Taskforce for Lung Health, which is run by the British Lung Foundation. Tom, Navjoyt and Jenny mentioned some resources they have found useful while looking at racism in medicine - which we have compiled into this document https://bit.ly/DBIRacismResources

For a long time, the BMJ has been interested in conflicts of interest and how that skews the research base. We also heard in our podcast on "Big Tan" that science is being used to sow seeds of doubt into the association between sunbeds and skin cancer, by scrutinizing the minutiae of a research paper, but ignoring it's bigger message. Now it's all just happening in medicine. This is an industry tactic. And to talk about that we're joined by David Michaels - who was the longest serving head of the Occupational Safety and Health Administration, and an epidemiologist and professor at the George Washington University School of Public Health. Read The BMJ's collection - Commercial influence in health: from transparency to independence https://www.bmj.com/commercial-influence To find out more from David, plus his two books on the influence of industry https://www.drdavidmichaels.com/

In the third part of our series of podcasts “Corona Virus as Seen Through a US Lens,” features editor for The BMJ, Joanne Silberner, talks to Dr. Adeline Goss about the experience of being a new mom and a hospital resident during the crisis. In The BMJ, Dr Goss recently wrote about the challenges facing medical residents as they deal with working during the virus. When she went on maternity leave a few months ago, nothing seemed amiss, beyond the normal stress of being a new mom. But when she returned to full time work on June 1, everything had changed. Goss kept an audio diary of her experience preparing and going back to work and we hear some of that during the podcast. For more of The BMJ's covid-19 coverage www.bmj.com/coronavirus

This week we're looking beyond the press release for dexamethasone, the long awaited review of antibody testing, and how well people are recovering after surviving acute covid-19. (2.36) The preprint for dexamethasone is finally out - considerably after the press release. Carl digs into it to find out how good the news actually is. (8.49) There are a couple of newly published systematic reviews on antibody testing, so we return to our testing guru Jon Deeks - professor of biostatistics at the University of Birmingham to give us an update. (23.52)Covid-19, it became apparent as the pandemic grew, was more than a respiratory disease - there are systemic effects on almost all organs. As people are recovering from the worst ravages of the disease, the long term consequences of those effects are becoming more clear - Lynne Turner-Stokes, professor of rehabilitation medicine at King's College London. Reading list; Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1 Cochrane review of antibody tests for covid-19 DOI: 10.1002/14651858.CD013652 British society of rehabilitation medicine guidelines for rehab after covid-19. https://www.bsrm.org.uk/downloads/covid-19bsrmissue1-published-27-4-2020.pdf

Earlier this year, the bmj published a racism in medicine issue - the issue was guest edited by Lord Victor Adebowale, chief executive of the NHS Confederation and Professor Mala Rao, professor of public health at Imperial College London. At the event to launch the issue, they managed to persuade Simon Stephens , chief executive of the NHS, to put money into a “race in health observatory” Mala joins us to talk about what that observatory is going to do, how it will maintain independence, it's role in synthesising, commissioning and implementing research, and where the organisation might begin in tackling the issue. Reading list NHS launches Race and Health Observatory after BMJ’s call to end inequalities https://www.bmj.com/content/369/bmj.m2191 The BMJ's racism in medicine issue (free to access) https://www.bmj.com/racism-in-medicine Interview with Yvonne Coghill https://podcasts.apple.com/us/podcast/yvonne-coghill-is-trying-to-fix-racism-in-the-nhs/id283916558?i=1000466962555 Interview with David Williams https://podcasts.apple.com/tr/podcast/david-williams-everyday-discrimination-is-independent/id283916558?i=1000465493980

In this week’s episode, our focus is on what the post-COVID world of general practice might look like. The pandemic has exposed the inequalities in our social and healthcare systems, but has also given GPs some much-needed headspace to reflect on changes to make going forward. Will we be able to turn general practice off and on again, like a faulty computer? Will we just drift back to the status quo, or will we seize this opportunity to shake up the old routines in order to redefine the role of the GP and to benefit the ever-evolving needs of our patients? Our guests: Martin Marshall is Chair of the Royal College of General Practitioners, a professor of Healthcare Improvement at UCL, and a GP practising in East London. Jenny Doust is a Clinical Professorial Research Fellow at the School of Public Health at the University of Queensland, and practises as a GP in Brisbane. Toyin Ajayi is Chief Health Officer, and co-founder, of Cityblock Health, which is a New York-based health and social services company delivering personalised healthcare to marginalised communities. Tom, Navjoyt and Jenny mentioned some resources they have found useful while looking at racism in medicine - which we have compiled into this document https://bit.ly/DBIRacismResources

At the end of May, the WHO said that South America has become the new epicentre of the covid-19 pandemic. The majority of those with covid are in Brazil - not entirely surprising given it is the most populous - but in neighbouring Peru, numbers are growing too. And it’s to Peru that we turn to talk to our guest today, Valerie Paz-Soldan is a social scientist and director of the Tulane Health Office for Latin America - part of the university’s school of public health and tropical medicine. She joins us to talk about the pattern of the virus in Peru in particular, but elsewhere in the region, and how the pandemic is overwhelming an already stressed healthcare system. https://www.bmj.com/coronavirus

n normal times, around this time we’d start thinking about weekend breaks and summer holidays abroad. More than most healthcare staff and other key workers are in dire need of time out. Given the uncertainties around foreign travel, how can we recreate in some way that holiday feeling. Simon Calder, travel correspondent for The Independent newspaper, offers his staycation tips and alternative travel advice.

This week, we’re asking questions about surgisphere data, and how it might have got into such high impact journals, we’re also talking about the protests around the world about structural racism - and how they intersect with the covid pandemic. (1.39) Helen and Carl talk about the data underlying the newly retracted papers on hydroxychloroquine and ace-inhibitors or ARBs and covid. (7.45) Fiona Godlee, the BMJ’s editor in chief, comes onto the pod to talk about retractions, and why they’re often called for, an rarely done. (25.10) We talk about the protests, and Carl gives us his opinion on the risk of covid transmission during them (spoiler; he thinks it’s low) (37.40) Sonia Saxena, professor of primary care at Imperial College London gives her verdict on the Public Health England report into this disproportionate effect of covid on ethnic minorities in the UK, and pushes back against it being a biological instead of a sociological determination. Reading list: Sonia’s analysis into transforming the health system for the UK’s multiethnic population https://www.bmj.com/content/368/bmj.m268 News Analysis - Covid-19: PHE review has failed ethnic minorities, leaders tell BMJ https://www.bmj.com/content/369/bmj.m2264 The PHE report into the disparate risk of covid to ethnic minorities https://www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes

How might Burmese Buddhism help deal with pandemic stress? Christopher Bu drew on his familial heritage and the tradition of practicing mindfulness to cope with the stresses of studying to be a doctor. He invites us to consider how the same techniques might be useful psychological tool for all healthcare workers during this challenging time.

In this episode of Talk Evidence, we'll be finding out if second waves are inevitable (or even a thing), how the UK's failure to protect it's care homes is symbolic of a neglected part of public life, and why those papers on hydroxychloroquine were retracted. This is Talk Evidence - the podcast for evidence based medicine, where research, guidance and practice are debated and demystified. Helen Macdonald, UK research editor for The BMJ, and Carl Heneghan, professor of EBM at the University of Oxford and editor of BMJ EBM, talk about some of the latest developments in the world of evidence, and what they mean. This week: 2.00 - Helen looking into a second wave - and finds out from Tom Jefferson, an epidemiologist with the Cochrane Collaboration's acute respiratory infections group, that a "wave" might be a misnomer. 12.00 - Mary Daly, professor of sociology and social policy at the University of Oxford, tells us where the UK went wrong with care homes, and what we’d need to do to stop it happening again. 31.20 - Carl and Helen discuss those hydroxy chloroquine papers, now retracted. This was recorded before that happened, but we decided to keep this section in, because they talk about the reasons the papers should be viewed with caution, and the importance of scrutiny of the data. Reading list: The talk from Mary Daly at Green Templeton College. https://www.gtc.ox.ac.uk/news-and-events/event/covid-19-and-care-homes-what-went-wrong-and-why/

The Trump administration was left a playbook for pandemics when they entered the Whitehouse, but even before covid-19 was a threat systematically dismantled the public health protections put in place to follow that playbook. In this podcast, Nicole Lurie, Gavin Yamey and Gregg Gonsalves talk about how the US response to public health was mismanaged, how it has become politicized, and what that playbook suggested should have been done. They also talk about rebuilding public health in the US after this is all over. Our guests; Nicole Lurie, former Assistant Secretary for Preparedness and Response under the Obama administration, senior clinical lecturer at Harvard Medical School and advisor to the Coalition for Epidemic Preparedness Innovation Gavin Yamey, professor of global health and public policy at Duke University Gregg Gonsalves, assistant professor of epidemiology at Yale School of Public Health. This podcast is hosted by Joanne Silberner.

For GPs, testing patients is their “bread and butter”. This week, we discuss the “better safe than sorry” attitude towards testing, which is so common among doctors – are we guilty of over-testing purely out of force of habit, or are we worried about missing something vital, and therefore find reassurance in doing them? How should we interpret test results, and how do these results affect the way we manage our patients? And, with the huge focus on COVID-19 testing in the media, how do we communicate the current risks and uncertainties surrounding it to our patients? Our guests: James McCormack is a professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia, and the co-host of a popular weekly podcast called Best Science (BS) Medicine podcast. His work focuses on helping healthcare professionals to understand medical data, by taking the best available evidence and making it as simple and practical as possible. Jess Watson is a GP, working in Bristol, and an expert on medical testing. She is a researcher with an interest in the use of diagnostic tests in primary care, specifically inflammatory marker blood tests. Reading list: James's BS Medicine Podcast https://therapeuticseducation.org/ Jess's Practice Pointer - Interpreting a covid-19 test result https://www.bmj.com/content/369/bmj.m1808

That remdesivir study has finally been published - what does it say and is it as independant as claimed. Also, as the world's focus turned to covid, so have researchers - and they've produced over 15000 papers. How can we sift through the flood of research and know what's any good? (2.30) Helen Macdonald talks to Elizabeth Loder about the volume of research we're seeing, and why journals and peer reviewers are struggling to check it all. (8.15) The study on remdesivir has been published - the trial was stopped early, and the primary outcome switched - we talk about how that increases uncertainty over the results, and could actually delay the treatment. (26.50) We hear from a couple fo readers who wanted to correct us about averages, means, medians. Reading list: The US NIH AID study on remdesivir, published 22nd May in the New England Journal of Medicine Research - preliminary report https://www.nejm.org/doi/full/10.1056/NEJMoa2007764 NEJM - looking at the dose duration https://www.nejm.org/doi/full/10.1056/NEJMoa2015301 Editorial - an important first step https://www.nejm.org/doi/full/10.1056/NEJMe2018715

*Non covid content alert* While the last couple of months have been covid-19 focused, the work of the beforetimes carries on - including a topic the BMJ is perennially interested in, industry funding of medics. Ray Moynihan, researcher at Bond University, has been looking at financial ties between some healthcare association leaders, and industry, in the US, and reports that in new research published this week in The BMJ. Read the full open access research; Financial ties between leaders of influential US professional medical associations and industry: cross sectional study - https://www.bmj.com/content/369/bmj.m1505

How might stress affect your performance as a healthcare worker? That’s the question that Mark Stacey, a consultant obstetric anaesthetist in Cardiff, has been interested in for the past 10 years. He saw similarities in the aviation industry, which uses a theory of human factors to explain why things go wrong when humans interact with complex systems. Stress was a major culprit, in both aerospace and medicine, so he began to explore wellbeing as a way to reduce stress and, in turn, reduce adverse events. He has developed the idea of writing yourself a wellbeing prescription, which includes practical techniques such as the Baker’s Dozen and a gratitude diary. Useful tools Bakers Dozen https://www.cardiff.ac.uk/__data/assets/pdf_file/0003/808950/Bakers-Dozen-Toolkit.pdf A 30 day plan that Mark has put together http://www.cardiffandvaleuhb.wales.nhs.uk/improving-resilience-in-anaesthesia

This last week has seen questions raised about the integrity of some of the epidemiological data being produced by US states, and as rates continue to grow in some countries international comparisons are being questioned. To discuss the implication of that are; Sridhar Venkatapuram associate professor global health & philosophy at King's College London Kathleen Bachynski Assistant professor of public health at Muhlenberg College Martin Mckee Professor of European health at the London School of Hygiene and Tropical Medicine

This week we're focussing on what kind of information we need to be able to collect and use as the country transitions out of lockdown - and why local lockdowns may be here for some time. We also hear about the new antibody tests which are available in the UK - are they actually a game changer? (2.00) Helen explains what some new evidence says about hydroxychloroquine (spoiler; don’t take it for covid-19) (6.40) *Non covid alert* - Carl tells us about new research on compressions stockings for thromboprophylaxis, and the importance of doing research on non-pharmacological interventions (10.30) David Nabarro, Special Envoy of WHO Director-General on COVID19, (28.00) Helen goes back to Jon Deeks, professor of biostatistics at Birmingham, to find out more about these “accurate” tests for covid, endorsed by the government this week. Reading list: Clinical efficacy of hydroxychloroquine in patients with covid-19 https://www.bmj.com/content/369/bmj.m1844 Hydroxychloroquine in patients with mainly mild to moderate covid-19 https://www.bmj.com/content/369/bmj.m1849 David Nabarro’s website, with daily briefings https://www.4sd.info/ News Covid-19: Two antibody tests are “highly specific” but vary in sensitivity, evaluations find https://www.bmj.com/content/369/bmj.m2066

With COVID-19 still ongoing, and at the forefront of the minds of doctors, patients and members of the public alike, difficult conversations are taking place - GPs are encouraged to talk about death with those who might not be ready to discuss it, and families are losing loved ones without being able to say goodbye. In this episode, we also look at survivor guilt, the range of emotions that grieving encompasses, and how to address the potentially thorny subject of advance care planning with COVID-19 patients. Our guests: Katherine Shear, internist and psychiatrist, is Director of The Center for Complicated Grief at Columbia University’s School of Social Work. She has been involved in research into treatments for grief for over 20 years. Scott Murray, a recently retired GP, has key interests in disease trajectory and advance care planning. He led the first Primary Palliative Care Research Group and he chairs the International Primary Palliative Care Network. He advocates high-quality palliative care for everyone. This week's deep breath out is the Viral Counterpoint of the Coronavirus Spike Protein (2019-nCoV) - https://soundcloud.com/user-275864738/viral-counterpoint-of-the-coronavirus-spike-protein-2019-ncov

Does history count as a non-pharmaceutical intervention? Much of our view on what to do in this pandemic has been influenced by the 1917 Spanish 'flu outbreak - even though covid-19 seems to be acting differently. In this podcast, we talk to Howard Markel, a professor of pediatrics at Michigan, as well as professor in the history of medicine. He's written books on quarantines and epidemics, and was part of a team that did the medical and historical work that first showed the value of flattening the curve. This is the first of 4 podcasts from our US colleagues, looking at the disease in that country, which will be published over the next 2 months. For more on covid-19 www.bmj.com/coronavirus

Hydroxychloroquine is in the news again - as Trump and some news organisations are pushing it as a treatment, despite evidence (published in The BMJ) showing it lacks efficacy, and has a load of potential negative effects - including arrhythmias. We know that kind of information spreads online - particularly through social media, but how does it do that? In this podcast we talk to Adam Kucharski, and epidemiologist from the London School of Hygiene and Tropical Medicine, who has used disease modelling tools to look at fake news spread, and has some ideas about creating an online social distance. For more covid coverage www.bmj.com/coronavirus

Big data is being crunched to help us tackle some of the enormous amount of uncertainty about covid-19, what the symptoms are, fatality rate, treatment options, things we shouldn't be doing. In these podcasts, we're going to try to get away from the headlines and talk about what we need to know - to hopefully give you some insight into these issues. This week. (3.10) Calum Semple, professor of outbreak medicine at the University of Liverpool talks about the ISARIC project - predesigned research brought off the shelf and deployed during a pandemic. (14.20) Ben Goldacre, doctor, researcher and director of the EBM datalab at the University of Oxford, joins us to talk about how his team have managed to pull together records from 40% of NHS patients to look for patterns in covid-19 morbidity and mortality. Reading list OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1 Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol https://www.medrxiv.org/content/10.1101/2020.04.23.20076042v1

If you’re a regular listener to our podcasts, you’ll have heard how Covid is exposing the cracks in our systems of healthcare - from showing how poorly provisioned elderly social care is, to how antibody testing issues have exposing how innovation is uncoordinated and driven by the worst bits of the free market. In this podcast we talked to Soumya Swaminathan, the WHO’s first Chief scientist, and ask about how the world’s foremost normative body for health tackle some of this issues. We talk about agenda setting - and how the WHO is trying to prioritise neglected areas of research, how they’re starting to set standards for evidence driven by public rather than commercial priorities, and how, if and when a vaccine for corona virus is finally created - they can help it be distributed equitably, rather than to those with the most money to spend.

The first peak of the pandemic has passed, the situation in hospitals is more manageable. While healthcare workers are preparing for the long haul, Abi and Cat discuss how to deal with this period of post-crisis crash. In this podcast, we speak to Ali Milani, a former Labour politician who ran against Prime Minister Boris Johnson in his London constituency during the 2019 election. How might Milani’s experience of a year-long campaign and fallout compare to the current post-emergency stage of Covid-19? www.bmj.com/wellbeing www.bmj.com/coronavirus

We’re at the point in the pandemic that restrictions on the way people live and work are being relaxed around the world, but how that changes safety for the population is very different depending on your demographic - will you have to work with other people, will you have to take public transport to work, and can you wear a mask in public safely? To talk about the importance of not neglecting those most affected by covid-19 we’re joined by Kathleen Bachynski, assistant professor of public health at Muhlenberg College and Sridhar Venkatapuram, associate professor global Health & philosophy at King's College London For all The BMJ's covid coverage www.bmj.com/coronavirus

For the next few months Talk Evidence is going to focus on the new corona virus pandemic. There is an enormous amount of uncertainty about the disease, what the symptoms are, fatality rate, treatment options, things we shouldn't be doing. We're going to try to get away from the headlines and talk about what we need to know - to hopefully give you some insight into these issues. This week: (1.20) Carl gives us an update on the England and Wales admission data. (3.00) Helen talks about ways in which spread and severity of infection amongst household contacts. (8.20) We talk natural history of covid-19, and Harlan Krumholz, cardiologist at Yale, tells us what we know, and why it's difficult to have a full picture at the moment. (15.10) Helen picks up on a study from Tim Spectre and colleagues using an app to track cases. (20.00) Henry Scowcroft, one of The BMJ's patient editor, who also works for Cancer Research UK, joins us to talk about patients who are taking part in clinical trials, and how this is affecting them. He also touches on the thin patient participation in the design of covid treatment guidelines. (24.10) Carl talks rapidity of publishing, and where researchers should most target their evidence outreach. Reading list: Reducing risks from coronavirus transmission in the home https://www.bmj.com/content/369/bmj.m1728 Rapid implementation of mobile technology for real-time epidemiology of COVID-19 https://science.sciencemag.org/content/sci/early/2020/05/04/science.abc0473.full.pdf The BMJ Public and Patient participation twitter chat https://twitter.com/hashtag/BMJdebate

We are more than six weeks into the lockdown and if you were to gauge the mood of the nation, it would be one of fatigue. It started as an all-hands-on-deck emergency situation, but it now transpires that the current work situation for healthcare professionals is not going to change any time soon. This is a marathon rather than a sprint. So how can we better look after ourselves to cope with this new realisation? In this podcast we speak to Dr Caroline Walker, an NHS-based psychiatrist and therapist. Wait til the end for Caroline's simple technique she uses to help when feeling overwhelmed. Read Caroline and Clare Gerada's opinion piece https://blogs.bmj.com/bmj/2020/03/31/extraordinary-times-coping-psychologically-through-the-impact-of-covid-19/

In this week’s episode, we discuss bystander guilt, convergence, brain hacks and “how you can sneeze on someone’s brain from anywhere in the world”. How can GPs cope with the myriad worries around treating patients during the current pandemic, both on the frontline and in general practice? How do we recognise and break unhelpful anxious behaviour habits and stop fixating on the news? Our guests: Monica Schoch-Spana is a medical anthropologist and a Senior Scholar at Johns Hopkins Center for Public Health. She specialises in crisis and risk communication, community resilience to disaster, public engagement in policy-making and public health emergency preparedness. Jud Brewer is an addiction psychiatrist and neuroscientist, specialising in anxiety and habit change. He is the Director of Research and Innovation at Brown University’s Mindfulness Center, an associate professor of behavioural and social sciences at the School of Public Health at Brown, as well as of psychiatry at the university’s medical school. Reading list: Monica's blog on the psychological impacts of covid-19 https://blogs.scientificamerican.com/observations/covid-19s-psychosocial-impacts/ Jud's article in the New York Times https://www.nytimes.com/2020/03/13/well/mind/a-brain-hack-to-break-the-coronavirus-anxiety-cycle.html GP course: https://drjud.com/health-care-provider-course/ Youtube animation of the NYTimes article: https://www.youtube.com/watch?v=900cOKCADIk&feature=youtu.be Youtube coronavirus daily videos: https://www.youtube.com/watch?v=w4NwsyXRbNw&list=PL6sRqjtLfiTTni7oXKpSj2cQ9290lkpKH

As the pandemic plays out - hospitals are reconfigured to increase critical care capacity, outpatient clinics become virtual, and elective procedures delayed. How are these affecting care for those who are in hospital but don't have covid-19? In this podcast, Matt Morgan,honorary senior research fellow at Cardiff University, consultant in intensive care medicine and Partha Kar, consultant in diabetes and endocrinology in Portsmouth, join us to discuss how their working week is changing. Read the BMJ's columns https://www.bmj.com/uk/news/views%20%26amp%3B%20reviews

For the next few months Talk Evidence is going to focus on the new corona virus pandemic. There is an enormous amount of uncertainty about the disease, what the symptoms are, fatality rate, treatment options, things we shouldn't be doing. We're going to try to get away from the headlines and talk about what we need to know - to hopefully give you some insight into these issues. This week: (1.10) Carl gives us an update on the UK's figures, and how deaths outside are now being counted. (2.10) When the pandemic slows down, and normal services resume - what should we start doing first? Helen picks up some evidence on what they might be. (6.05) There's a signal that covid-19 may be causing coagulopathies in some patients, and Helen picks up on a listeners request for more information. (11.22) John Deeks, professor of Biostatistics at the University of Birmingham, is leading a Cochrane initiative into examining the evidence around testing, and rivals Carl's rant when he explains how some research is being done behind a veil of confidentiality. (35.27) When there's a lot of uncertainty, and the stakes are very high, then tempers can flare. Vinay Prasad, hematologist-oncologist in the US, and host of Plenary Sessions podcast, joins us to talk about having a good, respectful, scientific debate.

How can we help frontline clinicians? Sometimes medics may feel uneasy or even guilty and that they could be doing more. That was what a junior doctor in Abergavenny in Wales felt and she did something about it. In this podcast, we speak to Josie Cheetham about how she started her initiative to provide support boxes in hospitals for her colleagues working at the frontline, and how that initiative inspired others and mushroomed across the UK.

Around the world, as the covid pandemic plays out, and some countries are starting to ease their restrictions, this narrative of the economy and public health being opposing weights on a set of scales keeps returning - they need to be balanced. But before this, a healthy population is very much seen as being supportive of the economy. So is a pandemic different, or is that dichotomy false. Joining us to discuss are; Martin Mckee, professor of european health at LSHTM Kathleen Bachynski, assistant professor of public health at Muhlenberg College Sridhar Venkatapuram, associate professor global Health & philosophy at King's College London

As the pandemic plays out - the way in which doctors in the UK practice is changing, hospitals are reconfigured to increase critical care capacity, GPs are working from home and doing their day to day work remotely. Some of the changes have come at the detriment of staff and patient wellbeing but covid-19 has also helped cut through some of the inertia to get welcome changes done. In this podcast, Helen Salisbury, GP in Oxfordshire, and Clare Gerada, GP in south London, join us to talk about the way in which general practice has changed, and how they and their teams are experiencing that.

For the next few months Talk Evidence is going to focus on the new corona virus pandemic. There is an enormous amount of uncertainty about the disease, what the symptoms are, fatality rate, treatment options, things we shouldn't be doing. We're going to try to get away from the headlines and talk about what we need to know - to hopefully give you some insight into these issues. This week: (1.00) Carl gives us an update on the UK’s covid-19 related mortality (7.40) When the evidence is uncertain, and the outcomes so massive, then the ethical dimensions of decisions become even more apparent. Helen talks ethics in guidelines with Julian Sheather, advisor on ethics and human rights to the BMA and MSF. (25.37) Update on covid-19 research, looking at viral particle shedding. (29.24) We’ve mentioned the potential wasted effort in covid-19 research, and Helen speaks to Paul Glaziou, director of the Institute for Evidence Based Research at Bond University, about the waste he’s already seen, and ways in which it could be avoided.

A new podcast from The BMJ, to help GP's feel more connected, heard, and supported. Subscribe on; Apple podcasts - https://bit.ly/applepodsDBI Spotify - https://bit.ly/spotifyDBI Google podcasts - https://bit.ly/googlepodsDBI In our first episode, we discuss the highs and lows of video consultations, and how coronavirus has altered the landscape of business as usual for GPs. How will this change affect our relationships with our patients? How do we cope with frustrating technical issues? Are we more likely to miss a crucial diagnosis if we can’t rely on physical examinations? And, finally, are teleconsultations the future of GP practice? Our guests: Trish Greenhalgh is a former GP of 30 years who is now Professor of Primary Care Health Sciences at the University of Oxford. Trish is a leading researcher on video consultations. Fiona Stevenson is a medical sociologist and researcher based at UCL. She is the co-director of their e-health unit. Deep Breath Out - the Rob Auton Daily Podcast https://play.acast.com/s/robautonpodcast https://www.bmj.com/podcasts/deepbreathin

A new podcast from The BMJ, to help GP's feel more connected, heard, and supported. Subscribe on; Apple podcasts - https://bit.ly/applepodsDBI Spotify - https://bit.ly/spotifyDBI Google podcasts - https://bit.ly/googlepodsDBI This week, our topic is fear: we try to get a better understanding of fear, how it affects all of us as clinicians for better or for worse, and the impact that fear has on the ways in which we approach our patients & practice. Does fear distort our judgement, and increase the likelihood of blundering, or does a healthy dose of fear help to keep us grounded? Our guests: Iona Heath is a former GP and president of the Royal College of GPs. Danielle Ofri is an internist at Bellevue Hospital in New York, and Clinical Professor of Medicine at NYU School of Medicine. She has written several books on topics such as medical error and how doctors’ emotions affect their practice. The Deep Breath Out - The bees of Brockwell Park Surgery https://www.bmj.com/podcasts/deepbreathin

There is no doubt that anxiety levels that clinicians are feeling during this pandemic are high. One military medic believes the current situation is comparable to his experience when posted during British campaigns in Afghanistan and Iraq. Cormac Doyle offers advice on how to deal with high-stress conditions, both in a work and at home, as well as how to negate the future effects of post-traumatic stress disorder. One strategy he supports is using Bilatural Stimulation using music, one example of which called “Strength Within” can be found here shorturl.at/fgrSW.