ARE YOU “HIGHLY RECOMMENDED” OR “BEST AVOIDED?”
I THE MAGAZINE FOR TRAINEE DOCTORS
Presenting History JuniorDr is a free distribution lifestyle magazine produced by doctors for the UK’s Medical Students, Foundation Year Trainees, Specialist Trainees, GP Trainees and Specialist Registrars. You can find us quarterly in hospitals and medical schools throughout England, Scotland, Wales and Northern Ireland, and updated daily at JuniorDr.com. Editor Ashley McKimm, firstname.lastname@example.org Editorial Team Michelle Connolly, Anita Sharma, Grace Bandoy, Muhunthan Thillai Newsdesk email@example.com Advertising & Production Rob Peterson, firstname.lastname@example.org JuniorDr PO Box 36434, London, EC1M 6WA Tel - +44 (0) 20 7 684 2343 Fax - +44 (0) 87 0 130 6985 email@example.com Health warning JuniorDr is not a publication of the NHS, Gordon Brown, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not necessarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual orientation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash. © Copyright JuniorDr 2008. All rights reserved. Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out juniordr.com.
magine choosing a new washing machine. You might consider reading the Which? ratings online, perhaps view a YouTube review or check the seller’s eBay-style score. Now imagine choosing a doctor. It’s not so easy. Try to find similar information and you’ll be struggling. This has led many to argue that patients should be able to choose a doctor in a similar way to choosing a household appliance. On the surface it makes sense. Apart from a name, GMC number and hospital reputation there’s little a cardiac bypass patient will know about their surgeon before he cracks open their chest. Demands from patients’ groups have led to a flood of new government and private initiates with the aim of offering patients more control over who provides their healthcare. This year saw the roll-out of ‘Choose and Book’, a service allowing patients to choose their hospital and appointment from home. We also saw the launch of statistics on surgery survival rates and hospital MRSA data. Privately run websites like iWantGreatCare.org, allowing patients to rate their doctors, have also appeared but leave doctors fearful that the system can be abused and reputations ruined. Despite all these ideas the aim of increasing patient choice is fatally flawed say economists. They argue that a public healthcare system like the NHS will never have or be able to afford a real choice. At best, they say, patients are likely to be overloaded with statistics without any manageable way of using this to guide their care – at worst we’ll be informing them of what’s good and bad about healthcare without providing them any options to change it. But despite the pessimism the onslaught of ratings seems unstoppable. Doctors don’t want to be compared like washing machines and kettles but perhaps we need to embrace it and learn from the feedback – at least this way we can adapt and come ‘highly recommended’. Join the debate on healthcare information online at www.juniordr.com.
“Doctors don’t want to be compared like dishwashers and kettles but perhaps we need to embrace it and learn from the feedback.”
Ashley McKimm JuniorDr Editor-in-Chief
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Doctors fear abuse of ratings website
Fewer working hours could dramatically reduce mistakes
atients are being asked to rate their doctor via the controversial new website iWantGreatCare.org which has been officially launched this month. The site, developed by Dr Neil Bacon, former CEO of Doctors.net.uk, encourages patients to rate their doctor out of 100 in three key measurements - ‘Do you trust them?’, ‘Did they listen to you?’ and ‘Would you recommend them?’. Scores and comments are then available for public viewing and searchable by doctor, specialty and location. Many doctors have already expressed concern the site is open to abuse, however the team behind the site say they have procedures in place to prevent inappropriate and libelous comments: “We have developed iWantGreatCare to provide doctors with a simple, safe way to build up a career-long portfolio of patient feedback. Part of this development work is the ongoing investment in security, to ensure abuse and unprincipled feedback is filtered,” said Dr Neil Bacon, site founder. “Since our launch last month, we have found that most of the reviews of doctors are overwhelming positive and that patients are taking this forum very seriously in writing balanced and accurate reviews of their healthcare experience.”
utting junior doctor’s hours does not compromise patients’ safety and could dramatically reduce mistakes, according to research by the University of Warwick Medical School. The intervention study, the first in the UK and Europe, looked at the impact of a 48 hour EWTD compliant rota on medical errors and patients’ safety over a 12 week period. It found that those on shorter rotas benefited from longer sleep time - 7.26 hours per day compared with 6.75 hours a day on a normal rota – and produced a third (32.7%) fewer medical errors.
Professor Francesco Cappuccio Warwick Medical School
“Patients’ safety was not compromised during the 48hweek rota … if anything we detected a 30% reduction in non-serious medical errors.” “The study not only showed that patients’ safety was not compromised during the 48hweek rota, but if anything we detected a 30% reduction in non-serious medical errors during the experimental rota compared to the traditional rota,” said Professor Francesco Cappuccio, lead researcher in the study. “These results provide some evidence-base to reassure all of us that the widely held belief that reducing the hours would lead to risks to patients is not necessarily true.” The project, funded by the NHS National Workforce Projects, observed 19 junior doctors at the University Hospitals Coventry & Warwickshire NHS Trust over a 12-week period. Nine were studied while working less than 48 hours per week and 10 were on traditional schedule of an average of 56 hours a week. The study did however show a perceived
reduction in overall junior doctor cover by other hospital staff in the study on the shorter rota – something that continues to concern the Royal College of Surgeons. “Feedback from both consultants and trainees has indicated that reduced working hours in surgery will have a detrimental effect on providing continuity of care, with particular anxiety over the need for multiple handover sessions between changing teams of junior doctors,” said John Black, President, Royal College of Surgeons. Issues of compliance The study comes as the BMA released data this month that shows almost half (46%) of junior doctors are still working hours in excess of the new 48 hour working week which will be enforced from August 2009. “The new figures on junior doctor working hours are worrying. Trusts have had many years to prepare for the introduction of the European Working Time Directive and it is of concern that so much remains to be done to bring junior doctors working hours down in line with the rest of the medical profession,” said Mr Ram Moorthy, Chairman of the BMA’s Juniors Doctors Committee. www.warwick.ac.uk www.rcseng.ac.uk
GMC approves new medical schools The Hull York Medical School and Brighton and Sussex Medical School are the latest medical schools to be approved by the General Medical Council to award their own primary medical degree qualifications. There are now 30 university medical degrees recognised in the medical act. New schools must pass the GMC’s thorough assessments before they can award degrees. www.gmc-uk.org
NHS Direct cuts GP workload Three-quarters of callers to NHS Direct (73%) would have attended their GP or A&E if they did not have the service, according to independent research. Almost half (41%) were advised by the helpline to treat themselves, with just 28 percent referred to a GP and 11 percent to A&E. 95 percent of the 4163 callers questionned stated they were satisfied with the service. www.nhsdirect.nhs.uk
Public fear NHS charges Half of the public fear there will be charges for some NHS services within 10 years according to a poll by the BMA. The majority (93%) of the 1000 questionned agree that the NHS should remain free however just 42 percent believe that changes to the NHS in the past decade have succeeded. Commercial companies providing NHS services were opposed by 51 percent of respondents.
Doctors lose desire to practice within first year
rainee doctors become disenchanted with medicine within their first year, according to the results of a study by the BMA this month. The survey found that on completion of FY1 just 30 percent expressed a very strong desire to practice medicine - a drop from 54 percent on graduation from medical school. A further third (26%) of trainees rated their desire to practice as either lukewarm or weak almost double that at graduation (15%). Two percent stated they regretted becoming a doctor in the first instance. The survey is part of a 10 year BMA cohort study that will follow the career paths of 435 doctors who graduated in 2006. “Clearly the shambolic handling of MTAS has done untold damage to junior doctors’ morale. Continual government reform has also contributed to the disenfranchisement of
juniors with many feeling undervalued,” said Mr Ram Moorthy, Chairman of the BMA Junior Doctors committee. “Many feel they are not viewed as dedicated professionals who embrace a difficult role, and make decisions of fundamental importance.” It found that four-fifths of those taking part felt their FY1 experience gave them the ability to practice medicine independently. Worryingly however, more than a third of trainees also felt they had been asked to perform tasks during their first year that were beyond their capabilities. Only eight percent of respondents felt confident of automatically obtaining a job after completing their training. The percentage who envisioned working outside the NHS also rose from 66 percent at graduation to 75 percent at the end of FY1. www.bma.org.uk
Student camp out to protest at accommodation loss M
Two-thirds of patients value a convenient appointment over seeing the same GP, according to a survey by Which?. 32 percent of the 1,791 polled by the consumer agency reported that seeing a different doctor was the norm at their practice. Patients over the age of 55 are more likely to want to see the same doctor (75%) while the younger and fulltime workers prioritise convenience.
edical students held an overnight protest in central London on the 18th July against the removal of free hospital accommodation for newly qualified doctors. The event, organised by the BMA, saw almost thirty tents representing all the UK medical schools being erected as part of a campaign calling for the reversal of the policy. It is estimated that FY1 doctors will be £4,800 worse off when the changes come into force this month. “It is a disgrace that the government is adding another financial burden to junior doctors at a time when they are already graduating with average debts in excess of £21,000 - a figure that will rise to well over £35,000 with the introduction of variable top up fees,” said Ian Noble, Chairman of the BMA’s Medical Students Committee. Hospitals were required to provide free accommodation to doctors as part of the Medical Act in 1983. In the past accommodation provision was used as an argument by the Doctors’ and Dentists’ Review Body against larger increases in basic junior doctor salaries.
Convenient appointments over GP choice
Finger Clubbing Riddle Solved by Leeds Medics
he pathophysiology behind finger clubbing, a condition that was first identified over 2,000 years ago by Hippocrates, has finally been explained by researchers at the University of Leeds. The deformity of swollen reddened fingers has been used as an indicator for diseases such as lung cancer, heart disease, hyperthyroidism and GI disorders, but the association was unknown – until now. “We knew that in cystic fibrosis patients who have undergone a lung transplant, their finger clubbing goes away,” said Professor David Bonthron of the Leeds Institute of Molecular Medicine. “The same goes for empyema patients who have had their lungs drained. It suggested that impaired lung function was somehow crucial to finger clubbing – but we didn’t understand how.” The team studied a group of patients with inherited primary osteoarthropathy and finger clubbing. Their findings pointed to PGE2, a compound produced by the body to mediate the effects of inflammation, which is then broken down by an enzyme 15-HPGD produced in the lungs. In the study patients with finger clubbing were found to have a genetic mutation that prevented the production of 15-HPGD. “If you don’t have this enzyme the PGE2 isn’t broken down normally and simply builds up,” said Bonthron. In lung cancer overproduction of PGE2 by the tumour is likely to be the cause of clubbing. The researchers believe Fig. 1 - The classic symptoms drugs preventing the PGE2 like aspirin may be effective in of finger clubbing. Courtesy reducing the painful symptoms of finger clubbing. University of Leeds ©
Med student debt soars with introduction of top-up fees
ew medical students could face debts of £37,000 by the time they graduate, according to the BMA. The introduction of variable top-up fees could nearly double the debt for new students by the time they graduate from the present amount of £20,000. If the government decides to lift the cap on tuition fees in 2010, the average medical graduate debt could “catastrophically” triple to as much as £57,000, says the BMA. In London, where the cost of living is higher, average debts could hit £67,000. “We think it is best for patients and the NHS if doctors represent the society they serve,” says Ian Noble, the chairman of the BMA’s student committee. “But it’s very likely that many able sixth form students, who want to become doctors, will be put off by the idea of such large debts when they graduate. £40,000 or even £60,000 of debt is a huge amount to ask someone that young to take on, particularly because medicine is a less certain career than it used to be.” It could hurt the government’s efforts to entice medical students coming from the lower socio-economic backgrounds, warns the BMA. www.bma.org.uk
Almost two thirds of NHS acute hospital switchboards fail to answer incoming calls within 20 seconds, according to a study published in the JRSM. The average waiting time in the study was 45 seconds, the longest was 18 minutes. Fifty hospitals averaged more than a minute. University Hospital North Durham was the best at around one second, while Bristol Royal Infirmary was worst at 381 seconds. www.rsm.ac.uk
1 in 10 psychiatrists stalked One in ten psychiatrists has been a victim of stalking, according to a survey by the Royal College of Psychiatrists. 10.7 percent of college members reported at least 10 incidents each occurring over at least 2 weeks. Even more, approximately 1 in 3, had experienced stalking behaviours that met the legal definition of harassment. The majority of stalkers were patients (71%) and most were women (59%). http://www.rcpsych.ac.uk
Stabbings cost NHS £3m per year Injuries caused by gun and knife crime cost the NHS in excess of £3 million a year, according to research by the Trauma Audit Research Network. Stabbings accounted for around threequarters of all penetrative injuries, said the researchers based at the University of Manchester, with an average cost of £7,196 per victim. Firearms injuries cost £10,307 per patient. www.tarn.ac.uk
Suicide rate at record low The UK national suicide rate is at its lowest ever level, according to the latest figures from the National Institute for Mental Health. The overall suicide rate in England is 8.3 deaths per 100,000 population – down from a peak of 9.2 in 1995/6/7. The highest rates of suicide continue to be in prisoners, mental health patients and young men aged 20-34. www.nimhe.csip.org.uk
Nursing Quality To Be Based On Compassion
urses will be rated on their level of compassionate care under new plans announced by Health Secretary Alan Johnson this month. The proposal, which aims to develop new parameters to assess the effectiveness and safety of nursing care, will be included in Lord Darzi’s review of the NHS and was welcomed by the Royal College of Nursing. “Nurses across the UK work tirelessly to ensure that patients are treated with dignity, compassion and sensitivity - aspects of care which are so important but rarely measured,” said Dr. Peter Carter, General Secretary of the RCN. “We are delighted that the government has recognised the need to measure quality in nursing care. These new standards are groundbreaking in that they will directly recognise nurses for the kind of care that patients really value.” Standards of nutrition, pain minimisation, handwashing, decreased infection rates and safety on the wards will also be included in the assessment. Nurses at this year’s RCN national congress had requested more recognition for the quality of care they deliver to patients and to be able to benchmark the work they are doing on their ward and compare it with their peers to drive up the quality of care.
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Wellcome Collection 2008
Medicine Now Exhibition
he Wellcome’s ‘Medicine Now’ exhibition presents a range of ideas about science and medicine since Henry Wellcome’s death in 1936. It reflects the experiences and interests of scientists, doctors and patients. The exhibition focuses on the body, genomes, malaria, obesity and living with medical science. Each is explored through a range of exhibits from science and everyday life, as well as artistic responses to the issues presented in red ‘art cubes’. For more information on visiting the ‘Medicine Now’ exbibition visit:
Used with permission from Wellcome Images
Making it Crystal Clear: The myth of methamphetamine? In 2006 the UN issued a global warning for a drug that threatened both the developed and developing world. A drug they said would push health resources to their limits. They called it the “biggest drug crisis worldwide”. Two years later methamphetamine is virtually absent from the UK and global use is falling. Ashley McKimm investigates if the fear over methamphetamine was just a myth or if the drug remains a threat to UK healthcare.
ach weekend in the clubs of Vauxhall and Greater Manchester dealers are offering free hits of crystal meth alongside their regular supply of pills and stimulants. Their aim is to get their clients hooked on one of the toughest habits to shake. Meth use on the gay club circuit – which experts feel usually preempts the trends in designer drug use – is already established. A recent study by City University has suggested that one-fifth of clubbers on the London gay scene have tried methamphetamine in some form(1). But despite this and addiction experts warning for years of a UK scourge of meth addicts it has not yet been realised. Outside of the club environment use of the drug remains miniscule explains Victoria Machin, Secretary of the Association of Chief Police Officers Methamphetamine and Precursor Chemicals Working Group: “In the UK virtually every force around the country has reported instances of methamphetamine use but there are no signs of a meth epidemic,” she told JuniorDr. “Its use is still relatively rare in the UK, because we have a significant and profitable market for cocaine and crack cocaine.” John, a London banker and regular on
the clubbing scene, is more certain about the reason: “Clubbers know their stuff. They know about the substances, their side effects and dangers. Crystal meth is shunned on the clubbing scene as people know the risks,” he explained. “Unlike in the US and Australia, drugs such as GHB and GBL are used in preference to meth. It’s easier to make, has most of the positive effects without the addiction problems.” GHB and it’s precursor GBL can be made at home from solvents that are relatively easy to obtain despite government restrictions introduced in 2005.
Hitler’s chocolate Methamphetamine is not a new drug. It was first synthesized by Japanese chemist Nagayoshi Nagai in 1893 and historians have reported that Hitler used intravenous injections to treat depression and fatigue during his final years(2)(3). Use became widespread during WWII when it was distributed to German troops to increase alertness. Chocolates dosed with methamphetamine, known as
“Fliegerschokolade” (“flyer’s chocolate”) were given to pilots to help with nighttime raids. Following the end of WWII methamphetamine continued to be prescribed for medical use around the globe for the treatment of ADHD, obesity and narcolepsy. In the US it was banned in 1960 causing clandestine production and recreational use to soar up until the late 1980s.
The ideal substance For users (2S)-N-methyl-1-phenyl-propan-2-amine is an almost ideal substance. It can be snorted, swallowed, smoked, injected – in fact, it can be almost taken via any route unlike most other drugs. It’s bioavailability also remains high at over 90 percent when smoked. In its most addictive form, when vapourised either in a glass pipe or over aluminium foil, methamphetamine reaches peak blood concentration within seconds producing instant euphoria. According to Drugscope the price of methamphetamine in the UK is around £50 a gram – around the same as heroin(4). Half a gram lasts most users a few days. It gives the same high as crack cocaine
Making it Crystal Clear: The myth of methamphetamine? but instead of lasting just minutes, methamphetamine lasts for up to 8 hours. John who has tried methamphetamine on a number of occasions described it as a much more exhilarating experience than other recreational drugs such as cocaine and ecstasy: “Meth makes you feel like you’ve awoken from a deep sleep all your life. You don’t want to sit still and suddenly want to experience all those things that give you pleasure – and they’re so much more enhanced than ever before,” he said. “The problem arises when you stop. All that excitement leads to a massive low. You’ll spend days mopping around thinking life is worthless – or worse still you won’t be able to sleep and think you’re going mad.” Methamphetamine acts on the noradrenergic, dopamine and serotinergic systems with stimulation of the mesolimbic system causing the euphoria and addictive qualities of the drug. One of the side effects is obsessive behaviour with users performing repetitive tasks such as characteristic skin picking leading to stereotypical sores on the bodies of users.
Most users also experience an irresistible and compulsive sexual urge - one of the reasons why it has become so popular on the club scene. Intercourse is often more aggressive and for longer frequently with the inability to reach orgasm, increasing the risk of sexual trauma and infections. Decreased inhibitions also make it more likely for sex to be unprotected – users are six times more likely to have intercourse without condoms(6).
“Meth labs have been uncovered here - and as with crack, the chances are that the drug will find a level within existing chronic drug using groups and this would present a challenge for existing drug services.” Harry Shapiro Director of Communications and Information, DrugScope
Effects of methamphetamine: • • • • • • • • • • • • • • • • • • •
Euphoria Agitation Diarrheoa Nausea Sweating Insomnia Bruxism Agitation Compulsive fascination Obsessional behaviour Increased libido Weight loss Withdrawal-related depression Psychosis (often on withdrawal) Dopamine receptor downregulation and hypersensitization Visual and auditory hallucinations Stroke Meth mouth Liver damage
SOURCE: EROWID; DRUGSCOPE; ASSOCIATION OF CHIEF POLICE OFFICERS
Fig 1. – Media fears of methamphetamine use
Sudafed and YouTube Newspapers have claimed that a 15-yearold with a chemistry set could cook up methamphetamine from household ingredients by following an instructional video from YouTube. They highlighted that making methamphetamine is relatively simple. The active ingredient is pseudoephedrine – which can easily be purchased in over-the-counter decongestants such as Sudafed. This is heated with red phosphorus and blue iodine – known in the US as the “Red, White and Blue Process”. So concerned were drug agencies about the availability of the constituent ingredients in the US that they introduced the Combat Methamphetamine Epidemic Act of 2005 that limited the amount of pseudoephedrine that can be purchased at one time. In reality, production of methamphetamine is not so safe as it involves flammable and toxic gases which can ignite in explosive form - one of the ways clandestine meth factories are commonly discovered.
Fig 2. – “Meth mouth” as used in US health promotion advertising.
Used courtesy Meth Project Foundation ©
“Meth mouth” has become an infamous side effect of using the drug but the belief that it is caused directly by the corrosive effect of smoking is incorrect. According to the American Dental Assocation it is the result of a dry mouth, poor oral hygiene accompanied by teeth grinding and clenching.(10)
More users than heroin The UN estimates there are 35 million users of methamphetamine worldwide compared to just 11.5 million of heroin(5). More than a third are from the US – despite intense action by the government and drug control agencies. Production of methamphetamine suffered a dramatic surge in the US during the late 1990s, highlighted by the state of Indiana which saw state police uncover 1,260 labs in 2003 compared to just six in 2005. US wide 12,484 labs were seized in 2005 alone(7). Studies have shown a strong correlation between criminal activity and meth use. 58 percent of US Sheriffs named it as the “biggest cause of raising crime rates” and police data has shown it was involved in an 1/8 of all homicides in San Diego(8). In Arizona a school was opened specifically for meth addicted teens to aid their rehabilitation. Today the US Drug Enforcement Agency figures suggest that 80 percent of meth now originates form abroad. Outside the US methamphetamine continues to remains References
endemic in parts of Asia, particularly Thailand and Japan. Elsewhere use was also problematic in inner cities in Australia though it has declined from a peak in the last 1990s. Canada increased the jail sentence to those found supplying crystal meth to life imprisonment. Unlike treatment for heroin there are no available substitutes for methamphetamine. SSRIs have been shown in some circumstances to aid recovery by decreasing craving but not consistently in trials(9). Treatment is via the management of withdrawal symptoms and referral to a secondary drug service.
The Future So far the UK has escaped the pandemic of methamphetamine. Many drugs experts continue their warnings that the UK is just at the beginning of a meth invasion - and the evidence suggests they may be right. In 2006 the UK’s first meth factory was discovered in the sleepy Derbyshire village of Stoney Middleton(11). Since then over
18 further sites of production have been uncovered from London to Devon - something that doesn’t mean we are certain to see a surge o f methamphetamine says Harry Shapiro, Director of Communications and Information, at DrugScope: “The important point to note is that drug cultures are very different from country to country, so there is no inevitability about the UK having a significant meth problem,” he told us. “However meth labs have been uncovered here - and as with crack, the chances are that the drug will find a level within existing chronic drug using groups and this would present a challenge for existing drug services.”
Fig 3. – Crystals of methamphetamine. They can be swallowed, smoked, injected or inserted rectally. Used courtesy of Talk to Frank ©
5. World Drug Report 2007; United Nations (UN) Office on Drug Crime; 18 Jul 2007
Justice, Drug Enforcement Administration, Office of Diversion Control (2006-10-18)
6. Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users; F Molitor, S R Truax, J D Ruiz, and R K Sun; West J Med. 1998 February; 168(2): 93–97.
9. AKAMATSU Yukio et al; Fluoxetine as a potential pharmacotherapy for methamphetamine dependence : Studies in mice; Annals of the New York Academy of Sciences; 2006, vol. 1074, pp. 295-302
3. Doyle, D (2005). “Hitler’s Medical Care”. Journal of the Royal College of Physicians of Edinburgh 35: 75–82.
7. DEA Congressional Testimony, “Drug Threats And Enforcement Challenges”, U.S. Drug Enforcement Administration, March 22, 2007,
10. “Methamphetamine Use (Meth Mouth)”. American Dental Associaion. Retrieved on 2006-12-16.
4. DrugScope street drug trends survey 2007; Druglink; 2007 September.
8. “The Combat Meth Act of 2005: Assessment of Annual Needs - Questions and Answers”. U.S. Department of
1. Bolding G et al. Use of crystal methamphetamine among gay men in London. Addiction 101 (online edition), 2006. 2. Nagai N. (1893). “Kanyaku maou seibun kenkyuu seiseki (zoku)”. Yakugaku Zashi 13: 901.
11. ‘Drugs factory’ found in village; BBC News Online; http://news.bbc.co.uk/1/hi/england/derbyshire/6084016. stm; 25 October 2006
How are your diagnostic skills in obstetrics and gynaecology? W
hen a patient presents to you, it is vitally important to be able to differentiate quickly and correctly between the various diseases to which the presenting symptoms may be attributed. Differential Diagnosis in Obstetrics and Gynaecology: An A-Z provides you with invaluable assistance in this diagnostic process.
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a. What is this condition? b. Give 4 predisposing factors for its development.
Case: 16 year old girl presents with a history of primary amenorrhoea, intermittent abdominal pain and urinary incontinence. What is the diagnosis and how would you manage her condition?
a. What is the diagnosis? b. Which specific organism causes this condition? c. How is the organism identified?
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Bell’s Palsy: Ten things to remember
Bell’s Palsy is named after Sir Charles Bell, a Scottish surgeon.
There is a lifetime prevalence of 6-20 per 1000 cases. Increased incidence is seen with age, diabetes and pregnancy. Right side is affected in 63 percent of cases.
Evolution of Health Care: GPs with Special Interests
ver considered becoming a GP with a special interest? It is a great way to develop your clinical practice. Here’s the who, what, why and how:
The facial nerve is almost entirely a motor nerve and supplies all the muscles of the face and scalp. It also supplies salivary and lacrimal gland, taste receptors of the tongue and the stapedius muscle.
The diagnosis is made on clinical features – facial asymmetry, loss of forehead and nasolabial folds and when the patient smiles, the mouth is drawn towards the normal side. Fluid may escape from the affected side and food may collect between teeth and gums.
The common causes are Herpes Virus type I, Herpes Zoster – Ramsay Hunt Syndrome, otitis media, cholesteatoma and lyme disease.
The prognosis is worse if there are no signs of recovery in three weeks.
Patients should be started on both antivirals and oral steroids (BMJ article Piercy J ,10 minute consultation: Bell’s Palsy, BMJ 2005;330:1,374). There is no universal agreement on this.
However there is agreement that there is more benefit if corticosteroid is started within 48 hrs of onset or at least within one week. Dose – 60 mg Prednisolone for 4 days and tapered for 6 days. Review in 7-10 days and check eye care. Review in 8-12 weeks from the onset.
Aciclovir is more effective in Ramsay Hunt’s syndrome dose of 800mg. Five times a day for five days. If no recovery - refer to facial palsy physiotherapist with a view to trial of eutrophic stimulation.
Patient information www.bellspalsy.org.uk
Who are GPs with special interests?
In 2002 the DH and Royal College of General Practitioners (RCGP) described the role of a GPwSI to “deliver a clinical service beyond the normal scope of general practice, undertake advanced procedures and develop services”. It was anticipated that GPwSIs would work as partners in a management service and would not replace consultants or interfere with access to consultants by local GPs. What services can be offered?
The six specialist areas singled out by the white paper were dermatology, ENT, orthopaedics, urology, gynaecology and general surgery. Since then the role has begun to emerge in almost every field. Who loves GPwSIs?
Patients love them because they receive a more rapid, closer to home and holistic approach. PCTs love them because they provide a cost effective service. Governments love them because it keeps patients and doctors happy – for that reason they support the idea and the number is expanding. Why become one?
Award for researcher in general practice
ony Avery, Professor of Primary Care at the University of Nottingham’s Medical School, has been awarded the RCGP John Fry Award recognising him as one of the best researchers in general practice. He was described as “quite simply one of the best researchers we have had in general practice” by RCGP Honorary Secretary, Dr Maureen Baker. Professor Avery is currently involved in the £750,000 study of a new electronic transfer system for repeat prescriptions which is being rolled out across the NHS.
As a GPwSI you enjoy better career satisfaction as well as raised self esteem. How do I become a GPwSI?
You must have a postgraduate degree or diploma in the specialist service. The DOH/RCGP guidance recommends that GPwSIs should also receive regular training and undertake CPD. A GPwSI is an experienced GP as well as being competent in a particular field so it is unlikely to be an option for a newly qualified GP. You can find out more about GP careers and opportunities from the RCGP website (www.rcgp.org.uk) or BMJ careers (www.bmjcareers.com), and you should consider joining the National Association of Sessional GPs www.nasgp.org.uk
Animal in the United Research Kingdom: The Facts Why do I need to know about animal research? Medical students need to know the facts about animal research as they will be directly or indirectly involved with it during their career. They need to know the relevant laws, decide where they stand ethically and explain what is involved in animal research to patients in an objective way. In 1998 academics involved in teaching medical ethics and law in UK medical schools produced a consensus statement on what should form the core curriculum(1). Medical research was one of the agreed themes, however a later study in 2006 found that five medical schools felt that medical research ethics was covered poorly and two medical schools felt that it was not covered at all(2). This article aims to give the plain facts about animal research that medical students need.
just 0.14 percent (Fig .1). Chimpanzees, orang-utans and gorillas have not been used in animal research in the UK for over 20 years since their use was banned when the Animal Specific Procedures Act was introduced in 1987(5). In 1989 parliament endorsed the Code of Practice for the housing and care of animals used in scientific procedures. The Codes of Practice state “all experimental animals shall be provided with housing, an environment, at least some freedom of movement, food, water and care which are appropriate to their health and well being”(6). Codes for individual species of animal give specific guidance on factors such as temperature, bedding and nesting material, food and water, animal accommodation and environmental enrichment. For example pairs of mice are required to have a minimum floor area of 300 square centimetres, which is just under half the size of a closed JuniorDr Magazine.
What animals are used in animal research? In the UK the Animal Specific Procedures Act of 1986 regulates What is animal research used for? Of the three million scientific procedures in 2006 that used aniexperimental and other scientific procedures on animals protected mals, 37 percent were classified as the breeding of laboratory aniby the act including all living vertebrate animals and one species of mals (Fig 2). This includes the breeding of animals with genetic octopus. Immature forms of mammals, birds and reptiles are also defects by manipulating germ cells, or embryos, and the subsequent protected from half way through gestation, as are fish, amphibian breeding of the genetically modified animals. and octopi vulgaris from when they become capable of independent The use of genetically modified animals has more than quadrufeeding. Invertebrate animals, such a fruit flies and worms are not (3) pled in the UK since 1995, most used are rodents (88%) with fish protected . It is not known where the dividing line falls between (4) and amphibians making up the remaining 12 percent(3). Fundamensentiency and non-sentiency among animals . tal biology and medical research, such as researching the actions of A regulated procedure is described as any experimental or other a hormone, accounted for 32 percent of the procedures in the UK scientific procedure that has the effect of causing an animal pain, in 2006 (Fig 2). Developing new treatments for diseases, including suffering, distress or lasting harm. Pain, suffering, distress and lastresearch into ways of improving medical equipment such as incuing harm are defined as any material disturbance to normal health. bators, accounted for 21% of the procedures. Safety testing of nonGiving anaesthesia and analgesia are therefore also regarded as regumedical products accounted for 4 percent of the procedures applied lated procedures. to animals in 2006 – testing of cosmetic ingredients and products In 2006, just over three million regulated procedures were applied to animals in the UK however the total number of animals on animals has been banned in the UK since 1998(8). used in research was less as How is animal research animals sometimes have regulated? more than one procedure Animal research in most applied to them. 2006 saw countries in the world is the number of procedures regulated either by statureach more than 3 million tory controls or by an ethfor the first time in 15 years ical committee. The UK is due to increases in the use of (5) the only country to operate mice and fish . both regulatory systems in Mice, rats and other parallel. The statutory conrodents make up the largest trols outlined in the Anipercentage (83.3%) of the mal Specific Procedures Act animals to which regulatFigure 1. Pie chart showing the percentages of different animals that 1986 are administered by ed procedures are applied. procedures were applied to in the UK, in 2006 the UK Secretary of State at Monkeys, such as marmothe Home Office(3). Home sets and macaques, make up (5)
Office Inspectors visit research establishments on average fifteen recorded 29 infringements of the Animals Specific Procedures Act times a year to ensure the Animal Specific Procedures Act is adhered – 17 of which were self reported or reported by the establishment. to, with visits mainly unannounced(7). The licence holders to blame for the most serious infringements volThe Animal Specific Procedures Act requires that animal pro- untarily surrendered their licences(7). cedures take place in research institutes or companies which have appropriate animal accommodation and veterinary facilities, and What more is there to know about animal research? have gained a Certificate of Designation. These are issued to indiAnimal research and testing is not legally required for fundaviduals who are responsible for the research institute, or company, mental biological and medical research and it is a legal requirement meeting the Home Office Code of Practice on facilities. The animal to ensure there is no alternative research method available. Organiprocedures must then be sations such as the Europecarried out by people with an Centre for the Validation sufficient training, skills and of Alternative Methods and experience as shown in their the National Centre for the personal licence. To obtain a Replacement, Refinement personal licence individuals and Reduction of Animals have to attend compulsory in Research (NC3Rs) in the accredited training coursUK are researching alternaes. Procedures must, howtives to animal testing(4). ever, be part of an approved There is no conclusive research, or testing proanswer about the translatgramme, which has been ability of animal models to given a project Licence. Projhumans, or how alternatives ect licences are also issued to such as organs grown in culindividuals and contain proture, mathematical modFigure 2. Pie chart showing the percentages of animals used in tocols outlining each indiels, computer simulation, different areas of research in the UK, in 2006 vidual experiment(3). or microdosing compare Schedule 1 of the Anito animal models. Animal mal Specific Procedures Act research in the UK is differrefers to appropriate methods of killing for individual species at ent to animal research internationally, but is not isolated from it; specific stages of development. Animals must be killed in a desig- the same ethical debates around animal research occur all over the nated establishment and officials have the power to revoke licenc- world. This aim of this article was to present the facts about anies and certificates if work is not authorised or if the conditions of mal research in the UK in an unbiased way. It is up to each of us as the licence or certificate are not met. Serious offences can lead to medical students to undertake our own cost benefit analysis based fines and imprisonment. In 2006, the Home Office Inspectorate on the facts. (5)
References (1) Consensus Group of Teachers of Medical Ethics and Law in UK Medical Schools. Teaching medical ethics and law within medical education: a model for the UK core curriculum. J Med Ethics 1998; 24: 188-192. (2) Mattick K, Bligh J. Undergraduate ethics teaching: revisiting the consensus statement. Medical Education 2006; 40: 329-332. (3) Home Office. Guidance on the operation of the animals (scientific procedures) Act 1986. Available at: http://www.archive.official-documents.co.uk/ Accessed: 19/03/08 (4) Dr Hadwen Trust. Frequently Asked Questions. Available at: http://www.scienceroom.org/
Accessed: 19/03/08 (5) Home Office. Statistics of scientific procedures on living animals. Great Britain. 2006. Available at: http:// www.homeoffice.gov.uk/ Accessed: 19/03/08 (6) Home Office. Codes of Practice. Available at: http://scienceandresearch.homeoffice.gov.uk/ Accessed: 19/03/08 (7) Home Office. Animals (scientific procedures) Inspectorate Annual Report 2006. Available at: http://science.homeoffice.gov.uk/ Accessed: 19/03/08 (8) Research Defence Society. Animal Research Facts.
Available at: http://www.rds-online.org.uk/ Accessed: 19/03/08 Gemma Natasha – fourth year medical student, The Peninsula Medical School, Barrack Road, Royal Devon and Exeter Hospital, Wonford, Exeter, EX2 5DW. Philip Young – Vandervell Lecturer at the Peninsula Medical School, Clinical Neurobiology, Institute of Biomedical and Clinical Science, Peninsula Medical School, St Luke’s Campus, Exeter, EX1 2LU. Competing Interests: None declared
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State-of-the-art simulated operating theatre opens
new state-ofthe art operating theatre has opened at Imperial College this month at a cost of £500,000 to aid training of surgeons, anaesthetists and operating assistants. The ‘Surgical Operating Suite’ (SOS) is a replica of a modern operating theatre complete with the latest surgical devices and instruments. Instead of a real patient on the operating table there is a computerised mannequin physiologically similar to a human and controlled by an operator behind a two-way mirror. “Operating theatres are becoming very complex with a range of different technologies from robots to diathermy devices,” said Professor Lord Darzi, who holds the Paul Hamlyn Chair of Surgery at Imperial College. “What we’re trying to do is equip all of those who use the operating theatre with the basic principles of team-building, leadership and communication.” Interactions between the surgical team are recorded using cameras and microphones during the procedure which can then be played back and analysed later in debriefing sessions. The SOS, part of the Department of Biosurgery and Surgical Technology at Imperial’s St Marys’s campus, is one of the few training theatres to integrate surgery, anaesthetic and nurse training. “When we talk about surgical excellence, people often think first about the technical performance of the surgeon. And that of course is important. But communication, teamwork and leadership are just as essential,” said Sir Roy Anderson, Rector of Imperial College London. “Without a group of people who work together like a well-oiled piece of high-tech machinery, any operation is at risk from human error.”
The Video Journal of Psychiatry www.vjpsych.com
Revise on the move with free psychiatry lectures you can download to your iPod. Includes CPD seminars and modules applicable to most papers of the UK MRCPsych exams.
Mental Health Leaflets for Patients www.rcpsych.ac.uk/mentalhealthinformation. aspx
A collection of printable education leaflets for patients from the Royal College of Psychiatrists. Invaluable for ‘take-away’ information it also includes useful patient support organisations.
Developed by a psychiatry consultant this site contains a impressive collection of printable MRCPsych revision notes, practice questions and PDA tools. Indispensable for all trainees.
Institute of Psychiatry Podcasts www.iop.kcl.ac.uk/podcast/?id=64&type=artist
An archive of lectures, debates and mental health updates from the Institute of Psychiatry in podcast format. Great for keeping updated with the latest developments on the move.
Hyperhighs Neuroanatomy Tutorials www.youtube.com/profile_ videos?user=hyperhighs&p=v
Over 30 neuroanatomy video tutorials covering gross brain anatomy, neural pathways and cranial nerves. Makes this complex field easily understandable.
www.imperial.ac.uk For more key websites in psychiatry - try
MEDICAL STUDENTS TECHNOLOGY
Dr Google will see you now
magine a world where patients are in control of their health information. Where they can browse their own lab results online, view prescriptions from their pharmacy and transfer medical records to and from hospitals at the click of a mouse. This is the world of healthcare as imagined by Google. Launched to some controversy in the US last month Google Health aims to revolutionise the way patients manage and share their medical information. The idea is so revolutionary that industry experts branded it the most important product from the firm since the iconic search engine was launched in 1997. The idea is simple - patients store and manage all their health information in a Google web-based account, then chose with whom and when to share it. It’s like the new NHS network but with patients in charge and without the £20 billion pricetag. Google Health is free.
transfer your electronic medical records and link your account to lab results so you can browse them at your leisure. Lastly add your pharmacy, upload your prescriptions and get text message reminders to take your medications. But Google Health is not just about putting medical records back in the hands of patients. It’s about empowering them to do something with it. If they don’t understand a complicated term they simply click through to a ‘trusted’ Google explanation. Google also allows users to interpret basic clinical tests and browse potential diagnoses. When patients need to chose a new doctor or order an investigation it is as simple as Googling it from their health account. After checking the feedback from other patients and choosing a provider a single click allows them to share their medical files.
Simple yet sophisticated It is also remarkably easy to use. You can enter your health conditions, medications and allergies in just a few minutes. Then, assuming your hospital is participating,
Confidentiality But the launch hasn’t been without controversy. Privacy rights organisations are concerned about who Google will share this information with and how secure it is. Google insists they’ve implemented their toughest privacy measures to date including secure links to participating hospitals but that is unlikely to re-assure everyone.
Google aims to generate revenue from advertisements displayed on the Google Health pages similar to it’s search engine. It’s also an area Microsoft is keen to exploit having launched a similar HealthVault service earlier in the year. To date UK users can only add their own records as Google Health does not provide any links to institutions outside the US at present. It is unlikely the service will have such dramatic impact on this side of the Atlantic due to our small private health sector. One thing is for certain - Google is planning to revolutionise healthcare just like it revolutionised internet search. Patients are back in charge and they’ve changed doctor. Dr Google is their new favourite physician. www.google.com/health www.healthvault.com
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Secret Diary of a Cardiology SpR * Names have been changed to try to keep our cardiology SpR in a job - though she’s doing a pretty good job of trying to lose it without our help!
Monday If you’ve been following this column you’ll realise that I’m nearly at the end of my training. In fact, this time next year I should be a consultant. I spend most of Monday morning’s clinic thinking about this. Instead of concentrating on telling people not to have sex after their heart attack and giving them advice about cutting out red meat I was on autopilot. I found myself worrying about what sort of consultant I would end up as. Would I be in a big brash London teaching hospital or somewhere quiet in the countryside? Would I continue my research? I’d already spent 2 years doing my MD but decided somewhere along the way that I didn’t really want to continue that. I did a little paperwork during the afternoon but went home early. I spent most of the evening ignoring text messages from David, a surgical consultant I’d been seeing. David was good looking, nice enough but still very definitely married. And with children. Apparently he was separated but a friend told me she’d seen him with someone, possibly his wife, out at dinner last week. I hadn’t returned his calls since then. Instead I crawled up on the sofa with a John Grisham novel and a large glass of Merlot. I went to bed early.
Tuesday On-call today. I actually enjoy the acute side of general medicine but can’t stand the mundane stuff. The little old ladies with UTIs, the annoying young men with chest pain. I review patients all morning and find myself snapping at one, telling him that it’s not our fault that his asthma is playing up and he’d better stop smoking if he ever wants a normal pair of lungs. It’s the truth but even I find myself shocked at the way it comes out. I see a few sick patients in the afternoon including a seventeen year old with terminal leukaemia. He was under paediatrics until a few months ago but for some reason that I don’t understand, they’ve turfed him over to adult oncology. I spend ten minutes arguing with the bed manager. He tells me that I have to send him to a hospice. I tell him that unless he finds an acute bed immediately he’ll need to find someone else to hold the SpR bleep as I’m driving him myself to another hospital. He relents and I dose up the morphine syringe driver and send the patient and his family on their way. I go home straight after work and crash into bed immediately. I decide that whatever I do end up doing, I don’t want it to involve general medicine on-calls. I’ve had more than enough of those.
Wednesday I have an angio list this morning. I’m at the stage now where Douglas, my boss, lets me get on with it myself. I know he’s probably in the building but he’s slowly moved away over the past year from hovering outside the room, to his office, to somewhere else. He’s on his mobile though. The cases are straightforward but I have difficulty getting femoral access with one and have to use the radial which I don’t like. One of the stent insertions is a little tricky. I stop daydreaming about my future and start concentrating on the patient. It slips in. After lunch I do a quick ward round and a couple of echoes. I have a paper to finish for submission but I keep putting it off. I shelve it till next week and leave early, taking in a shoe shop on the way home. I meet up with a couple of friends for our regular weekly drinking session and end up in a cocktail bar that I know all too 20
well. I dance late into the night then catch a cab home. I check my phone and find 3 missed calls from David. I toss the phone into my clothes bin and collapse into bed.
Thursday In addition to my hangover we have a consultant ward round this morning with Weston, the not-so-nice boss. The juniors have spent a while straightening things up on the ward and the round goes remarkably well. Weston is in a good mood - I think his divorce settlement is coming through favourably for him. I spend the whole time at the back of the team, trying not to throw up. I manage a salad and a litre of water for lunch and find myself feeling better by the afternoon. David calls again and for some reason I answer it. I mumble something about being too busy to return his calls last week and end up agreeing to go out for dinner. We meet in a Spanish tapas bar in town and everything goes well through the Sangria and olives. By the time the patatas bravas turn up I start questioning him about his wife. At least he doesn’t bother lying and simply tells me that they were meeting to talk about the divorce settlement. I’m not sure whether to believe him or nor but find myself trusting him again as we work our way through a third jug of Sangria. He ends up back at my place.
Friday David left early. I haven’t been round to his flat yet and I wonder if it’s because he doesn’t have one and really still is with his wife. I think about this all through my ward round in the morning. Even my FY1, who is normally very dopey, can see that I’m not giving it the best of my attention - particularly when I ask for the troponin results twice on the same patient. I have a quick lunch and spend the afternoon in the registrar’s office. Everyone else is away and I get to finish off the paper and submit it online. I go home and make myself dinner. I’m on-call all weekend and need to relax tonight. As I sip a glass of Californian Merlot I find myself deep in thought again. I think about David and then my job and where I want to be next year. Wherever it is I need to choose wisely as it could dictate where I spend the rest of consultant career. I know that I don’t want to continue in general medicine but to do pure cardiology means I would probably have to stay in a teaching centre - something I promised myself I’d never do. Still, there could be worse things than working all hours of the day doing angios and earning half a million a year. Besides, I don’t have a family to worry about. I think about this as I pour myself another glass.
Focus on Finance - in association with Wesleyan Medical Sickness
Income Protection: Why Bother? As you know illness and injury can affect people at any stage of their life. It’s a difficult time and one when you shouldn’t have to worry about finances. However regular bills don’t get cancelled out by sickness. Have you thought how you would cover outgoings, such as accommodation fees or loan repayments, in that situation? You may think that NHS sick pay would be enough to survive on but it won’t replace 100% of earnings. There is always going to be a financial shortfall that needs to be filled, which is why you should consider income protection. Do I really need Income Protection?
Income protection provides important cover at every stage of your career and the need arises even before you fully qualify. According to the British Medical Association, the average debt of a graduating medical student is £37,000 - higher than the basic annual salary of a foundation house officer. If you fell ill at this stage you would be especially vulnerable financially as debt repayments won’t just disappear. In addition, NHS sick pay for medical professionals in the early stages of their career starts at very low levels, increasing gradually over the years. For example, in the second year of service you are entitled to just two months full pay, followed by two months half pay. This only covers basic salary. It doesn’t include many of the other elements that can significantly boost your regular take-home pay, such as salary band uplift. You may therefore find yourself living on less than half your regular take-home pay. Income protection policies, on the other hand, are generally based on your full earnings and not just basic salary. Once NHS sick pay ceases you would be entitled to statutory sick pay, which runs for 28 weeks. After that, you could be entitled
to State Incapacity Benefit, although the criteria are quite strict and the short-term higher rate is currently £75.40 a week. What should I look for when buying cover?
There is a wide range of income protection products available. Here are some of the key points you should consider: • Your own specific needs and circumstances. You may have alternative ways of covering loss of income such as through savings or a partner’s earnings. You should take this into account when deciding exactly what level of cover you need under a policy. • Own occupation definition. ‘Own occupation’ means that the policy benefits will be paid if you are unable to carry out your specific job due to sickness or injury. Some income protection products offer an ‘any suited occupation’ definition, which means they won’t pay out if you can’t do your own job but could do other types of work based on your knowledge and experience. This is obviously less desirable as you have studied, trained and worked hard to get where you are. • Deferred period. All policies have a set amount of time from the date you are in-
capacitated, after which income payments will start to pay out. You can opt to defer income payments for the amount of time that suits your situation, up to a maximum of 52 weeks. For example if you receive full NHS sick pay for two months, a deferred period that kicks in after this might be appropriate. In general, the longer the deferred period the cheaper the policy. • Guaranteed insurability option. This will enable you to increase your cover, for example on the birth of a child, without the need for further medical evidence. Most income protection plans typically pay out until you return to work, are no longer suffering from a loss of earnings, reach the maximum age for the policy or die. With careful planning, income protection can help you maintain the level of income you received before sickness or injury. You should take professional financial advice to ensure you find the right cover for you.
The above information does not constitute financial advice. If you would like more information or need general financial advice you can call Wesleyan Medical Sickness on 0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk
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or reasons of National Security, ‘Mr Smith’ would not give me his real name. However, he informed me that he was “On Her Majesty’s Secret Service”. He was of slim build, blue-grey eyes, a “cruel” mouth and short, black hair. There was a faint scar of the Cyrillic letter “?” on his hand – which he informed me came from Russia “with love”. On the surface, he appears to be a healthy, attractive man. However, ‘Mr Smith’ has a number of dangerous vices that may seriously affect his life, namely smoking, drinking and sexual intercourse. He is a life-long smoker, at one point reaching 70 cigarettes a day. In the past he has attempted to cut back himself, as this was affecting his job and that cigarettes were clearly a “Licence to Kill”. In the past, he was sent to a health farm because of his boss’s concerns about his habit. ‘Mr Smith’ smokes a blend of Balkan and Turkish tobacco with a higher than average tar content called “Morland Specials”. I attempted to advise ‘Mr Smith’ about his habit but he only replied, “Doctor, No. You only live twice”. ‘Mr Smith’ drinks alcohol to excess. His intake, since I have known him has been of 317 drinks of which 101 are whisky, 35 sakes, 30 glasses of champagne and a mere 19 vodka martinis (which he claims are his favourite). ‘Mr Smith’ feels that drinking was an important part of his job (working at Casinos, Royal engagements, etc) and that alcohol gave him inner peace – eloquently described as a “Quantum of Solace”. It was not only the amount of alcohol that is a concern, but also his food consumption. I have advised cutting back on both but he refused saying only that he would “diet another day”. As well as smoking and drinking, ‘Mr Smith’ claims to have had “pussy, galore”. He clearly indulges in meaningless affairs, mostly one night stands, with virtually every woman he encounters. He doesn’t seem concerned about STDs – sleeping with one woman despite her “Octopussy”. This may explain why he reports some genital itching and “Thunderballs”. A major concern I had for ‘Mr Smith’ was of heavy metal poisoning. At various points he referred to his Goldfinger, his Goldeneye and to “The man with the Golden Gun” – which I presume to be a euphemism. Gold poisoning, like all very metals, causes headaches, irritability, insomnia and depression. In fact, ‘Mr Smith’ did feel that “The World Is Not Enough” which would suggest a low mood was present. This type of poisoning can affect vision so I would suggest a referral to an ophthalmologist “for his eyes only”. In conclusion, I have informed ‘Mr Smith’ that if he continues to behave in this manner he will be “living daylight” hours in a medical ward and, while “diamonds are forever”, his health is not and that I would be prepared for him to “live and let die” without an intervention.
Writing in the Notes
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sion Infectious profes
where DeborDear Editor, terested to learn in ry r ve be ld I wou nsultant’ did he ional image co ss fe r ro pe ‘p Su e, A iff cl ome ra Rad le ‘How To Bec tic ar e ur th yo r ss fo ro ac ls research In many hospita . 4) p1 s, tie 9, to ss (I Medic’ ies have lead n control polic certainly white county infectio garments and ed ev sle ng lo e extracts from jackets, The following ar . ed al nn ba g in coats be l Trust, “Medic in my Hospita y ’ lic w po bo el rm e ifo th low the un adopt a ‘bare be to le d se ab vi pt ad ce e ac staff ar e no longer e “White coats ar preciate that th approach” and n”. Whilst I ap or w gbe t su I no t ay us m and m in cheek ed to be tongue the article is suppos appropriate to is s on dres ce vi ad y an at gest th audience! on Trust NHS Foundati Fiona Legge upon Tyne Newcastle T, EN in F2
hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular column of the best and worse hospital essentials you’ve reported:
Cup of tea (small)
Bring your own teabags at:
St Mary’s Hospital, London
Dose up on those antioxidants at:
45p Rice Krispies (mini-pack)
Homerton Hospital, Newham
Time to start skipping breakfast at:
Royal Free Hospital, London
Snap-tastic prices at:
get it right first ti
Dear Editor, I would like to propose an alte rnative reason w ‘male consultant hy s completed 16 0 more patient ep sodes per year ithan their fem ale colleagues’ p6). It is simpl (Iss 9, y because femal e consultants ge diagnosis right t the first time and do not need to patients on mul see tiple occasions. Probably becaus are not thinking e we about Ronaldo’s transfer from M Utd during clin an ic. Female cons ultant Name withh eld (for her safety)
fake Dr Fairytale is a Fairytale be Dear Editor, essing that Dr pr ite qu is it ible. I have I think quickly as poss as C M G e th M&S and reported to cations in BHS, ifi al qu at th ts of our esteem severe doub ed to treat any ifi al qu m hi e e GMC regisRSVP mak t appear on th no es do he d mpsons epiheroes an ewed every Si vi y dl ou pr g not once has ter. Havin n confirm that ca I ed uc od pr ould like to sode ever a doctor so I w d te si vi on ps m cient clinical Homer Si to make a suffi le ab as w he know how examination. Dr Nick Riviera GP, Springfield
‘Writing in the notes’ is our new regular letters section. Email us at email@example.com.
Toothpaste (small tube)
Axminster Hospital, Devon
Tell your dentist about:
Princess Royal Hospital, Hull
Keep on brushing at:
Royal Free Hospital, London
Next issue we’re checking the cost of Coca-Cola (500ml bottle), chocolate flapjack and a banana. Email prices to firstname.lastname@example.org.
Queen’s Medical Centre, Nottingham 42” TV with Sky Digital, 10 PCs with Internet Access, a plasma information screen, a modern kitchen, two snooker tables and a Fussball table. Complimentary tea, coffee, toast, newspapers and magazines are provided daily and there’s a lunchtime snack bar selling sandwiches, soup, jacket potatoes and snacks, solely for the use of doctors.
JuniorDr Score: ★★★★✩
is Back In addition to the wide range of colours already available, 3M is proud to announce an extention to the range ®
of popular 3M™ Littmann Black Edition Stethoscopes. A Littmann Black Edition stethoscope has always been a symbol of elegance and professionalism, being manufactured to the same high standards as all Littmann stethoscopes. The new Black Edition 3M™ Littmann® Cardiology III Stethoscope Paediatric and adult, two tuneable diaphragms. Converts to a conventional stethoscope by replacing the small diaphragm with a rubber ring. Other colours The new Black Edition 3M™ Littmann® Classic II SE Stethoscope Classic bell and diaphragm design. Other colours
Buy online at
3M and Littmann are trade marks of the 3M Company © 3M Health Care Limited 2008