After the COVID-19 pandemic had shattered any dream of us going abroad for our elective placement, I thought the best I could do is organise something worthwhile and interesting here in Cambridge. And so, I ventured out to find an elective which would allow me to further my understanding of a certain area of medicine and simultaneously balance clinical time with research.
I spent 5 weeks at the Cambridge Centre for Frontotemporal Dementia and related disorders, which is housed on the Addenbrooke’s site. This was, in part, a calculated decision because not only has cognitive Neurology always been of great interest to me, but my Neurology block was also the most affected by COVID last year so I thought this would be a great opportunity to make up for lost time. The team runs specialised memory clinics for patients suffering predominantly with progressive supranuclear palsy (PSP), corticobasal syndrome (CBS) and frontotemporal dementia (FTD). Given the rarity of these disorders, any other doctor might be lucky to ever meet 1 or 2 such patients in their career, which made this elective an invaluable learning experience. This elective provided me with a great insight into the world of dementias and whilst it was immensely heart breaking to meet patients suffering with these conditions, it was also very gratifying to see how much support is available to these patients and their families.
Despite the unpredictable situation last year, my elective was able to go ahead as my supervisor and I had planned it. The first half of the week was dedicated to clinics. On Mondays, I joined the ‘Disorders of Movement and Cognition’ clinic, which mostly caters to patients with PSP and CBS. The team were very friendly and considerate. They would brief me on each patient beforehand and help me examine patients, to better understand the complex ways in which these patients present and progress. I learnt the difference between rigidity and spasticity, what vertical gaze palsy looks like and how to test for it, and the meaning of more complex signs suggestive of cognitive dysfunction such as agraphaesthesia.
On Tuesdays, the team runs a ‘General Memory Clinic’, where they usually meet with newly referred patients. Unsurprisingly, there was a stark difference between the patients I saw on Mondays and Tuesdays, as patients tended to be at earlier stages of their disease. However, in many ways, the general memory clinic was the most upsetting. Patients and their loved ones were told about their diagnosis - sometimes for the very first time - and invariably wanted to know about ‘how long they have’, ‘what their illness will look like in 5 years’ and ‘the worst they can expect’. You could just see how well trained the clinicians were at answering these questions – telling them the (very often, harsh) truth but at the same time telling them what they wanted to hear - which undoubtedly helped me refine my own skills at breaking bad news. Something I found confusing at first is that the doctors would have conversations about lasting power of attorney, wills, and council funding very early on – maybe even at the first consultation. When directly asked about this, the consultant explained that they introduce these topics early because the application process can be long and strenuous, and often applications are unsuccessful, at which point patients are encouraged to re-apply.
Finally, on Wednesdays I joined the ‘Early Dementia’ clinic which mostly caters to patients with FTD. I met patients at different stages of their illness and saw how they often progress from being very inappropriate and aggressive to being very apathetic and amotivational. Moreover, I assisted in carrying out the extensive cognitive examination, involving the ACE-R test and various other language, comprehension, and memory exercises. I learnt how to interpret results of the ACE-R test, a very useful tool that pinpoints the areas of cognition in which the patient has the most deficit and helps to narrow down the diagnosis. Interestingly, because patients with FTD often develop very challenging behaviours, doctors often focus more on the wellbeing of their carers at later stages of the disease, who take on the extremely physically and emotionally draining job of caring for a loved one that they recognise less and less every day. It is truly impressive how much there is to offer to carers: from therapy, to respite care, to educational classes. In fact, ‘continuity of care’ and ‘caring for carers’ are two themes that feature very strongly in dementia clinics, and I firmly believe that I wouldn’t have been able to get such an incredible insight into these anywhere else. At the end of Wednesday’s clinic, all doctors, nurses, and healthcare and research assistants had a meeting where they discussed all cases of the day and highlighted important learning points. The friendly and supportive environment that prevailed, made it easy for me to ask questions and enhance my understanding of these conditions.
The rest of the week I worked on my project on genetic dementias. In recent years, various monogenic causes of dementia have been identified. As of August 2020, new guidelines have been released outlining which patients are eligible for genetic testing, which we believe are too strict and will hinder access to genetic testing for many patients. In fact, since these guidelines started being implemented, this has become reality for our patients. I was involved in an audit, where we collected data from existing patients at the Cambridge centre for Frontotemporal dementia and related disorders to see just how strict these guidelines are. Indeed, we found that almost 45% of patients who have already been found positive for a causative gene, wouldn’t have met criteria when they presented to clinic – a staggering and very disappointing statistic which can have detrimental effects on patients and their families. My project partner and I presented our findings to the department and received lots of positive comments and useful feedback. We subsequently submitted our paper to the Journal of Neurology and are waiting to hear back. The whole process has been incredibly rewarding and enlightening and has made me more confident in my knowledge, opinions, and presentation skills. I am very passionate about this project as it has the potential to change national policy and give more patients access to genetic testing.
My elective was everything I could have asked for and more. I am very grateful to the team for being so welcoming and for making such extensive efforts to keep the elective running as smoothly as possible. The experiences and knowledge I gained from this elective will stick with me forever and I am positive I will be a better doctor because of it.
Undergraduate student, Medicine
Image credit: School of Clinical Medicine, University of Cambridge