After the Alzheimer’s Research UK conference I could be forgiven for worrying that in a few years time I might be the only clinician scientist working on dementia in the UK. There were no other clinicians at the PhD day. There were no talks on cognitive testing or psychology. There were no talks on imaging. There was one talk reporting on a clinical trial, but by an Italian speaker.
I may be over-reacting a bit; there were certainly a number of senior clinicians at the conference and I know a fair number of clinical fellows who didn’t come the meeting. I’m told there were more clinically focused talks last year.
But, I’m not the only person who’s worried. The ARUK had no applications for their Clinical Training Fellowship this year and every member of ARUK staff I bumped in to over the three days asked me why there weren’t more younger clinicians getting involved in dementia and applying for funding. Following David Cameron’s announcement about increased funding in dementia we need the next generation of doctors coming through who can carry out clinical research, be involved in the direction of molecular research and bring hard won gains in knowledge to the clinic.
As a medical student and junior doctor it is common to see patients with dementia, but only when treating them for a urinary tract infection/fall/fracture neck of femur/chest infection etc. Seeing dementia for the sake of diagnosing and managing dementia simply does not happen. Junior doctors do not get clinical exposure or experience in picking apart mild cognitive impairment from Alzheimer’s disease, or taking a careful history of behaviour change in frontotemporal dementia, or putting together the eye signs with apathy in progressive supranuclear palsy. Partly this is because some of these diseases are rare, but more importantly these activities happen in clinics and not on general medical or neurology wards. I don’t have an easy answer for this, other than a sea change in training with more exposure to clinics. This will not happen any time soon given the service commitment required in hospital wards.
Maybe there is another way to hook in budding neurologists (I’m afraid I’m not qualified to address psychiatrists or geriatricians). What excites neurologists above all else is making a diagnosis. I enjoy talking to relatives, addressing social issues, designing management plans and palliative care, but diagnosis is what sets apart being a doctor from other healthcare professionals. Diagnosis in cognitive neurology remains an art form, based on the most basic skills of putting the patient and their relatives at ease and asking the right questions, with a good dose of patience. Imaging is only occasionally helpful and further blood tests even less so.
However this art form isn’t taught well, even to neurology registrars. At the Royal Free hospital, I was inspired seeing Jon Rohrer carefully guiding an FTD patient through their history and examination. It took about an hour and I had never seen a history so carefully or thoroughly constructed. It opened my eyes that asking about cognition is a bit more than asking ‘is your memory OK?’. I was lucky enough shortly after to gate-crash Nick Fox teaching London neurology registrars to take a cognitive history. But after a year in the memory clinic in Cambridge, I’m still learning how to do it properly, and I’m sure I always will be.
I’ve deliberately dropped in a couple of names, which neurologists often seem to do when reflecting on their training. This is no coincidence, as in many parts of life we are inspired by people we have worked with and look up to in some way. Therefore as clinical academics at whatever stage, we should be looking to, at the very least, be nice to those trying to climb the career ladder below us. If we want junior doctors to become clinical scientists in dementia, we need to do more and take time to help them navigate the pathway ahead of them. I wouldn’t be doing what I’m doing now if (quite a few) people above me in the food chain hadn’t pointed me in the right direction and taken time to read applications, coach me before interviews, highlight funds and jobs to apply for, and forward me things to read.
And we should be targeting junior doctors at an early stage. The relatively new academic F2 posts (I was actually a guinea pig for these back in 2007!) give us an opportunity to catch juniors who want to get involved in research. It involves a 4 month period of research as part of a rotation alongside other specialities. Some will go on to do Academic Clinical Fellowships, but even those who do not can go on to do small projects and apply for PhDs either at SHO grades or as Specialist Registrars. If we can encourage F2 doctors to spend those 4 months studying dementia, then give them a way to continue that research, they may be bitten by the dementia bug for the long term.
Funding for clinicians to study dementia is available. The question is whether I and my fellow academic clinicians at all stages can inspire more junior doctors in to the field. If not, maybe I will end up as an endangered species as a clinical academic working on dementia in the UK.