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Life and death in the hands of doctors
A THE MAGAZINE FOR JUNIOR DOCTORS
Presenting History JuniorDr is a free lifestyle magazine aimed at trainee doctors from their first day at medical school, through their sleepless foundation years and tough specialist training until they become a consultant. It’s proudly produced entirely by junior doctors - right down to every last spelling mistake. Find us quarterly in hospitals throughout the UK and updated daily at JuniorDr.com. Editor Ashley McKimm, email@example.com Editorial Team Michelle Connolly, Matt Peterson, Muhunthan Thillai, Andro Monzon Newsdesk firstname.lastname@example.org Advertising & Production Rob Peterson, email@example.com JuniorDr PO Box 36434, London, EC1M 6WA Tel: 44 (0) 20 7 193 6750 Fax: 44 (0) 87 0 130 6985 firstname.lastname@example.org 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. © JuniorDr 2009. 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.
t 11am on December 8th convicted murderer Kenneth Biros was executed in the US state of Ohio. For the first time, in a move away from the traditional ‘triple cocktail’ injection, executioners administered a single dose of thiopental sodium - the same drug used in the UK to euthanise pets. Biros was pronounced dead at 11.47am. Ohio had abandoned the ‘triple cocktail’ in September after the botched execution of Romell Broom when the 18 attempts made to find a useable vein failed. Controversially a doctor was called to assist a distressed Broom after he himself had tried to help executioners find a useable IV site. The involvement of doctors in executions remains a contested issue. In our main feature ‘When doctors are expected to kill’ (page 14) Michelle Connolly looks at execution via lethal injection in the US and the arguments for and against medical involvement. Staying overseas, but this time looking at preventing death, ‘Sun, Sea and Surgery’ (page 9) analyses the increasing trend for medical treatment abroad. Last year UK residents spent over £130 million on procedures from hip replacement to valve surgery. Attracting health tourists is becoming a booming industry for developing economies. We look at Thailand where one hospital has installed a Starbucks and pizzeria as part of their ongoing push to attract Westerners. Brits are being wooed abroad in campaigns by organisations such as the Singaporean government which described our ageing population as a ‘great potential to be tapped into’. As the UK struggles to save £20 billion from the NHS by the year 2014 could exporting our patients overseas for treatment be the answer? While you contemplate these dilemmas may the JuniorDr team wish you a relaxing Christmas and a productive start to 2010. Look out for the new bigger JuniorDr with expanded clinical content in March.
What’s inside 04 09 14 18 19 20
“As the UK struggles to save £20 billion from the NHS by the year 2014 could exporting our patients overseas for treatment be the answer?”
Ashley McKimm JuniorDr Editor-in-Chief ST3 Psychiatry
Sun, Sea and Surgery When doctors are expected to kill SECRET DIARY OF A CARDIOLOGY SPR Weekend Ward Escape Batman gets a check-up
Tell us your news. Email email@example.com or call 020 7193 6750.
One in four patients suffer from delay in consultant review
arlier consultant input is needed for emergency patients according to an independent inquiry which analysed the care given to those who died within 96 hours of hospital admission. The report from the NCEPOD (National Confidential Enquiry into Patient Outcomes and Death) found that one in five emergency patients were diagnosed by FY and ST1-3 doctors despite some patients having complex conditions requiring urgent senior input. At night this number increased to one in four. The research found a clinically important delay in the first review by a consultant in one in four patients. The report recommends that clinical need should direct access to consultants: “Consultant advice should be sought according to the patient’s clinical condition, not the time of day,” said Dr James Stewart one of the authors. “Our report states that juniors should have 24 hour access to consultant advice. Juniors should not be timid in seeking senior advice.”
DNAR Orders The inquiry which analysed the care received by over 3,000 patients who died in acute hospitals also found that junior doctors are inappropriately signing one in five DNAR orders. This is despite the GMC stance that a ‘senior medical member of the
Professor Tom Treasure The Chairman of NCEPOD
“Don’t get out of your depth - ask for help. If it’s a ‘do not attempt resuscitation decision get the boss involved in good time.”
team should record fully any advance decision not to attempt to resuscitate a patient’. Junior doctors were also found to be taking surgical consent despite lacking ‘sufficient knowledge’ to inform patients adequately. The report suggests that senior doctors are taking consent and a junior signing but in this case it recommends documenting that the discussion took place. The Chairman of NCEPOD, Professor Treasure, recommends that junior doctors should be better equipped to deal with emergency patients: “For a very sick patient the first and last doctor they are likely to see is a junior - so be prepared to ask the questions, get a plan from the consultant, document it, be sure to update it, and communicate it at handover,” he said. “Don’t get out of your depth - ask for help. If it’s a ‘do not attempt resuscitation’ decision, get the boss involved in good time and make sure the patient and family are in the picture. That way the patient gets the care that’s appropriate for them.” www.ncepod.org.uk/2009report2/Downloads/ DAH_report.pdf Yvette Martyn
Key Stats • 1 in 4 patients (24.9%) had a clinically important delay in their first consultant review. • 1 in 5 emergency patients (20%) were diagnosed by junior doctors during the day. • 1 in 4 emergency patients (25.1%) were diagnosed by junior doctors during the night. • 1 in 5 DNARs (21.8%) were signed by junior doctors.
CARING TO THE END? A review of the care of patients who died in hospital within four days of admission
#ARING TO THE %ND ! REVIEW OF THE CARE OF PATIENTS WHO DIED IN HOSPITAL WITHIN FOUR DAYS OF ADMISSION
‘Academic doping’ could spark routine urine tests for exams
he growing use of smart drugs or ‘nootropics’ to boost academic performance could mean that doctors sitting exams will face routine doping tests in the future, suggests an article in the Journal of Medical Ethics. The non-medical use of methylphenidate and amphetamine is already as high as 25 percent on some US college campuses, particularly in colleges with more competitive admission criteria, according to the authors. “It is apparent that the failures and inconsistencies inherent in anti-doping policy in sport will be mirrored in academia unless a reasonable and realistic approach to the issue of nootropics is adopted,” says Vince Cakic of the Department of Psychology, University of Sydney. Despite raising many dilemmas about the legitimacy of chemically enhanced academic performance, these drugs will be near impossible to ban, says Cakic. Nootropics were designed to help people with cognitive problems, such as dementia and
attention deficit disorder, but students with a looming deadline are using drugs such as modafinil (Provigil), methylphenidate (Ritalin), and amphetamine (Dexedrine) says Cakic. For boosting memory retention, there’s brahmi, piracetam (Nootropil), donepezil (Aricept) and galantamine (Reminyl). To get a bit more get up and go, there’s selegiline (Deprenyl). The impact of these drugs is as yet “modest”, says Cakic, but more potent versions are in the pipeline. “The possibility of purchasing ‘smartness in a bottle’ is likely to have broad appeal to students seeking to gain an advantage in an increasingly competitive world,” he says.
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Patients Don’t Use Official Data When Choosing A Hospital
ost patients rely on their own past experience or that of family and friends when choosing where to go for an outpatient appointment rather than official information sources such as NHS Choices, according to a survey by The King’s Fund. Only four percent said they had looked at the NHS Choices website when choosing a hospital despite two-thirds having internet access. A further 13 per cent used the advice of their GP to judge a hospitals’ performance. “This survey shows there is still some way to
Dr Anna Dixon Director of Policy at The King’s Fund
“This survey shows there is still some way to go before choice is fully embedded in the NHS.”
go before choice is fully embedded in the NHS. Patients recognise that the quality of care is an important factor when deciding which hospital to attend,” said Dr Anna Dixon, report co-author and Director of Policy at The King’s Fund. “However, currently they are not actively comparing hospitals or using performance data to select the highest quality provider, instead they continue to rely on their own experience or the advice of their GP.” Cleanliness, quality of care and the standard of facilities available were the three most important factors that influenced patients’ choice of hospitals. Travel costs and car parking were only seen as ‘somewhat important’. The survey of patients was based on four case study areas across England. It found that 60 per cent of respondents were satisfied with the amount of information they were provided with, 22 per cent did not want any information and 14 per cent would have liked more. www.kingsfund.org.uk
Case Studies in /ŶĨĞĐƟŽƵƐŝƐĞĂƐĞ Complete eBook (978-0-203-856871): £22.00
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GMC updates pandemic guidance
he GMC has updated its guidance for doctors working in a pandemic this month. ‘Good Medical Practice, responsibilities of doctors in a national pandemic’ outlines the standards of practice expected of doctors if their work is affected by an outbreak. The guidance recognises that a pandemic can break out regionally and allows those most affected to work flexibly to provide assistance where it is most needed. Key adjustments include: • An allowance for doctors to work outside their normal field of practice so long as they are able to do so safely. • Doctors running research programmes are asked to consider whether to interrupt them during a pandemic. • Patient care prioritisation will be based on clinical need and on the pa-
tient’s likely capacity to benefit. For example, young people should not be given automatic priority over adults. • No formal duty to report concerns about resources, equipment or insufficient patient services, other than in exceptional circumstances. “Should a complaint be made against a doctor working under the strain of a pandemic, the GMC will take into account the circumstances under which they were working,” said Jane O’Brien, GMC Head of Standards and Ethics. “However, it is important to note that all doctors should be ready to explain how and why they altered their practice if called upon to do so.” www.gmc-uk.org
Patients In US 5 Times More Likely To Spend Last Days In ICU Than Patients In England
atients who die in hospital in the United States are almost five times as likely to have spent part of their last hospital stay in the ICU than patients in England, according to research from Columbia University. The study, which compared the two countries’ use of intensive care services, also found that of all hospital discharges only 2.2 percent in England had received intensive care, compared to 19.3 percent in the U.S. “In England, there is universal health care through the NHS, and there is also much lower per-capita expenditure on intensive care services when compared to the U.S.,” said Dr. Hannah Wunsch, assistant professor of anesthesiology and critical care medicine at Columbia University and lead author of the study. “The use of intensive care in England is limited by supply to a greater degree than it is in the U.S., and there are consequently implicit and explicit decisions regarding who gets those limited services. We wished to examine what different decisions are made.”
60 percent of US medical schools have reported having to deal with unprofessional content posted by their medical students online, according to research published in JAMA. Incidents ranged from profanities about the course and staff, to frank breaches of patient confidentiality on social networking sites and blogs. Most were given an informal warning but three medical schools reported dismissing students after they had posted unprofessional material. www.jama.org
Health gets scarier Eight out of ten (84%) doctors believe the public has become more susceptible to health scares, according to a poll published in BMA News. Examples given included a London specialist registrar in anaesthesia who said pop star Michael Jackson’s death had led to patients expressing concern about the use of the anaesthetic drug propofol. 80 per cent of doctors did not believe the government was doing enough to rebut scare stories. www.bma.org.uk
Errors in elderly treatment Seven out of 10 care home residents are subject to drug errors, suggests research published in Quality and Safety in Health Care. The study of 55 care homes located in West Yorkshire, Cambridgeshire and central London found that drug errors were made in seven out of 10 cases, with the average number of mistakes just under two for each resident. Contributory factors included doctors who did not know the residents, or had insufficient background information. www.qshc.bmj.com
Standardise to stop resistance England currently has one-sixth the number of intensive care beds available per capita that are available in the U.S. The study, published in the American Journal of Respiratory and Critical Care Medicine, also noted that medical decisions in England are generally considered to be the direct responsibility of the physician, rather than that of the patient or the patient’s surrogate decision-makers as it is in the U.S. ajrccm.atsjournals.org
Antibiotic prescribing for respiratory illness should be standardised across Europe to help reduce resistance, say experts in the largest study of its kind published in the BMJ. The EU funded Network of Excellence GRACE project found that antibiotic prescribing for LRTI ranged from 21% to nearly 90% across the EU. There were also marked differences in the choice of antibiotic. Amoxicillin ranged from 3% of prescriptions in Norway to 83% in England. www.grace-lrti.org
Medical graduates ‘poorly prepared’ to become doctors
ewly qualified medical graduates are poorly prepared to work as junior doctors say their senior colleagues, according to the results of a survey published in the Postgraduate Medical Journal. Senior doctors were asked to score how well prepared their FY1 trainees were to work as doctors six months after they had graduated from medical school. Using the GMC ‘five point’ scale for competency the juniors scored below three on 48 of the 70 items. For clinical and practical skills only six of the 20 were above the midway point. “The findings give cause for concern,” say the researchers. “Senior doctors perceived that the undergraduate medical degree had not adequately prepared F1s for practice, especially in clinical and practical skills.” Basic respiratory function tests, prescribing, and more advanced communication skills were some of the areas where juniors performed poorly. They scored well on basic communication skills and how to ask for help, prompting the
authors to wonder whether medical schools had ‘gone too far in emphasising risk management and, perhaps inadvertently, helplessness’. The study at two major teaching hospitals in the East Midlands of England called for more opportunities for ward based experiential learning and for senior doctors to be more explicit about what is expected of FY1 trainees. pmj.bmj.com
MEDICAL STUDENTS TO GET MANAGEMENT TRAINING
edical students are to be offered management training under a new scheme launched by The British Association of Medical Managers (BAMM). BAMMdot will train students who are interested in management careers within the health service, through Begin To Lead - a junior spinoff from BAMM’s acclaimed Fit To Lead training
Professor Jenny Simpson OBE Chief Executive of BAMM
“We’ve seen an increase in interest from medical students who are keen to learn about medical management and pursue careers in clinical leadership.”
programme. It will be organised to fit around students’ existing academic commitments. “With public interest in the management of the NHS at an all-time high, we’ve seen an increase in interest from medical students who are keen to learn about medical management and pursue careers in clinical leadership,” said Professor Jenny Simpson OBE, Chief Executive of BAMM. “We’re looking forward to being able to provide medical students with opportunities and training that will meet their needs exactly, in order to provide insight into management careers within the health service and increase their understanding of clinical leadership, so that, come graduation, they are completely prepared to begin the first steps of their careers.” BAMMdot members will also receive advice, invaluable networking opportunities, regular policy updates and material. www.bamm.co.uk
on our selection of detailed, uncomplicated revision guides for junior doctors
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Wellcome Image Awards 2009
Villi in the small intestine, by Paul Appleton
he Wellcome Image Awards recognise the creators of the most informative, striking and technically excellent images. In this image by Paul Appleton finger-like structures in the small intestine of a mouse have been cropped at the tips and stained with fluorescent dyes to distinguish between different components of the cells. The cell nuclei are blue, while the red stain shows actin,
Used with permission. Credit Wellcome Images.
a protein that covers the surface of each villus. The images are on display in the Wellcome Collection from 14 October 2009 to spring 2010. www.wellcomecollection.org
Not long ago the term ‘medical tourist’ was used to describe unscrupulous patients entering the UK to obtain free treatment on the NHS. Today, in contrast, it is used to describe the thousands of British citizens who flee the long waiting lists to seek private healthcare abroad. JuniorDr’s Michelle Connolly looks at the surge of medical tourists travelling abroad for sun, sea and surgery.
Whether it’s for a hip replacement, valve surgery or a simple rhinoplasty medical tourism is booming. Last year alone some £130m was spent on medical tourism procedures outside the UK. However, Britons are still in the Ryanair league compared to countries like the United States where 150,000 Americans jet off each year for long-haul procedures in countries as far away as India, Thailand, Argentina and Malaysia.
ut the UK is catching up, according to research by analyst Mintel. Their survey suggests that 12 per cent of Britons would consider surgery abroad because of the substantial savings - costing up to eighty per cent less in some cases - compared to private treatment in the UK. Dental surgery is the most common overseas procedure with around 20,000 Brits travelling to favourites such as Hungary and Poland for a better smile at around £2,500 a time.
Cosmetic surgery comes a close second with 14,500 of us shelling out for facelifts, breast augmentation and liposuction at a cost of £50 million each year. Those wishing to skip NHS waiting lists for elective surgery, the most frequent of which are joint replacements and cataract surgery, make up a further 10,000 patients spending £36 million.
Word-of-mouth is one of the main drivers for overseas treatment. International medical facilities are promoting good service and reward schemes to encourage ex-patients to recommend to friends. Jacqueline Wilson, a 48 year old Herefordshire housewife travelled to Gdansk in Poland for tooth veneers after first getting quotes from British dental surgeons. “Poland was nearly three thousand pounds less than the price I was quoted in Harley Street and I combined it with four-day spa holiday too,” she said. “The hospitals were clean, the operation fast and the staff were very pleasant and spoke English. I’d recommend the experience without question.”
Selling surgery Foreign governments and private firms have begun to realise the potential of medical tourism. Brits are being wooed abroad by development agencies such as the Singaporean government’s Singapore Medicine, which describes the UK’s ageing population as “a great potential to be tapped into”. Intermediary brokers are one of the big drivers for overseas treatment in what is a difficult process for potential patients to negotiate themselves. Dipa Jethwa, from the London-based Taj Medical Group, explained how they try to simplify medical treatment abroad for clients: “We liaise with the patient’s NHS consultant to obtain their clinical records. We then arrange flights, visas and their admission to hospital.”
Thailand’s Bumrungrad hospital is the number one international hospital in the world treating some 450,000 medical tourists annually. While the mainstay of treatment is joint replacement operations, Taj Medical is also benefiting from the obesity epidemic. “We are seeing an increase in the number of patients, particularly from the US and Canada requiring gastric banding surgery.” And it’s not just small brokers that are benefiting from the public’s new acceptance of private treatment overseas. High street tour operators such as Thomas Cook have realising the potential and have established partnerships with agencies like Taj Medical. Because of these new medical expectations centres in countries targeting medical tourists are no longer typical hospitals - they are ‘resort hospitals’ with enticing names such as Kuala Lumpur’s ‘Palace of the Golden Horses’. Thailand’s Bumrungrad hospital is the number one international hospital in the world treating some 450,000 medical tourists annually. To accommodate Westerners it has a specially built Starbucks in the reception and a pizzeria upstairs.
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Americans driving the market Americans lead the way in medical tourism partly because of the baby boomer generation and also because of sporadic healthcare cover. With 45 million Americans uninsured overseas treatment is the only way to avoid huge medical debts. Last year, the average healthcare expenditure for a family of four exceeded the total annual earnings of a minimum wage worker for the first time.
The medical tourism industry is worth $100bn – growing at 15 - 20 per cent per year Source: Ernst and Young
Howard Staab, a 56 year-old carpenter from North Carolina has become the industry’s poster boy. His local hospital demanded a $50,000 deposit from him for a mitral valve replacement before warning him that the cost of treatment could rocket to $200,000. He got change from $10,000 for a pig valve in New Delhi - and also a trip to the Taj Mahal. Differences in doctor’s salary partly explain why such considerable savings can be made. The average salary of a US family doctor is $161,000, compared to just $35,000 in India.
India With four doctors for every 10,000 people, compared with 27 in the US, India is hardly a healthcare model to be copied.
Cost comparisons The average procedure in India is one-tenth of the cost in the US. Singapore is a more expensive destination but the savings are still large - a liver transplant which costs $300,000 in the US is just $150,000 in Singapore. Partial hip replacement
• India $4,500 • US $18,000 Full hip replacement
• India $3000 • US $39,000 Orthopaedic surgery
• India $4500 • US $18,000 Knee surgery
• India £8000 • UK (Private) £20,000
Gall bladder surgery
• India $7500 • US $60,000 Figures are approximate. They do not include travel and accommodation costs.
Yet India is now seen to be leading the world as a medical tourism destination - with the finance minister calling for the country to become a ‘global healthcare destination’. Efforts have been made to improve infrastructure to help smooth the arrival and departure of medical tourists. Import duty on medical equipment has been slashed and the government has introduced a special medical visa which permits tourists to stay in the country twice as long as before. As a result India’s medical tourism industry is set to balloon to $2 billion by 2012, according to a joint report by the consultancy McKinsey and the Confederation of Indian Industry.
Effect on the NHS Many expected the boom in medical tourism to lead to a reduction in UK private healthcare prices - instead the effect has been largely an efflux of medical tourists. Fiona Harris, head of personal markets at BUPA, the UK’s largest private healthcare provider, denies that their business is threatened by the boom in medical tourism: “Sometimes BUPA customers will seek treatment abroad where it is not available in the UK; in these cases we meet the equivalent UK costs of the treatment.”
Social costs Often the last thing a patient planning an operation overseas considers is the affect on the local community but it’s one of the key concerns that objectors raise. Many fear an internal brain drain whereby doctors leave small rural practices to work in better equipped urban centres that cater for medical tourists. Anil Maini, director of corporate development at the Apol-
“Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less than they earned in the West.” Anil Maini. Director of Corporate Development. Apollo Hospitals Group, India.
lo Hospitals group - India’s largest medical tourism organisation - doesn’t deny this is the case: “There is an internal brain drain but there are enough doctors available to serve both rural and urban populations,” he says. “Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less, than they earned in the West.” There are many who believe medical tourism hails the beginning of a much broader overhaul in the world’s healthcare systems - the advent of medical outsourcing. Outsourcing means that it won’t be the patient who decides to travel for treatment, it will be your insurer or government who sends you abroad to save money. Just as manufacturing and call centre operations were relocated to countries such as India healthcare is likely to follow. References Burkett L (2007). Medical tourism. Concerns, benefits, and the American legal perspective. J. Leg. Med. 28: 223-45.
An honest mistake? Cutting a few corners or embellishing a training application might seem harmless, but it could leave you in hot water, says Sara Williams When applying for jobs, many young professionals openly admit that they have exaggerated achievements on their CVs, relaying similar justifications: “But everyone does it, don’t they?” This could land a junior doctor in a lot of trouble. In the BBC’s Apprentice, Lee McQueen famously landed the top job despite lying on his CV, but Dr McQueen would not have been so lucky. All doctors are expected to be truthful and medical regulators take evidence of any dishonesty very seriously, whether it be making false claims about qualifications and experience to get a job, plagiarism or signing fraudulent certificates.
Lying on applications The pressure of on-call commitments, combined with the everincreasing competition for training posts, may lead some individuals to take “short cuts” when completing their application forms. However, trusts would usually consider dishonesty on an application form as a disciplinary matter, which could subsequently lead to termination of a doctor’s contract of employment. If a doctor intentionally makes a false representation in order to gain a financial advantage, he or she may be guilty of a criminal offence under the Fraud Act 2006. In the 2007 GP application process, the GMC saw a number of cases where junior doctors were accused of plagiarism on application forms. This led to sanctions ranging from warnings through to erasure from the medical register. Many of the doctors involved had reproduced material from websites, with others being found to have copied from their colleagues.
Scenario ST1 Dr T is in the second week of his surgical training. Following a successful cholecystectomy, Dr T is delegated the responsibility of writing up the operation notes from the surgery. He gets to work immediately, but in his haste he forgets to write up the postoperative instructions for hourly urine output monitoring, and continues to work through his list of patients. A few hours later the patient experiences problems so he visits her again, and finds that there has been no monitoring of urine output. He realises the mistake on the records. Dr T alters the records to include what he had previously omitted. Dr A, a registrar, saw Dr T alter the record. Dr A confronts Dr T about his actions, but Dr T pleads with him not to say anything. Dr A calls MPS for advice. A medicolegal adviser suggests that Dr A raise the matter with Dr T’s consultant or supervisor. Dr A does this, and Dr T receives advice and a warning from his consultant, who addressed it as a training issue. If his actions were to be repeated, Dr T could face disciplinary action.
Survival tips If you are uncertain, double-check your work with a senior. Take steps to verify what you are saying. Never sign a form unless you have read it and you are absolutely sure that what you are saying is true. Probity means being honest and trustworthy, and acting with integrity.
Why is dishonesty such a danger to doctors?
Be honest about your experiences, qualifications and position.
Good Medical Practice advises that you must be honest and trustworthy when signing forms, reports and other documents. It also requires you to make sure that any documents you write or sign are not false or misleading. This means that you must take reasonable steps to verify the information in the documents, and must not deliberately leave out anything relevant.
Be honest in all your written and spoken statements, whether you are giving evidence or acting as a witness in litigation.
You may encounter families who don’t want certain information visible on the death certificate, but you have a legal and professional obligation to complete the certificate truthfully.
Assume that all records will be seen by the patient and/or others, eg, GMC, the courts.
Falling under this category is the requirement for any junior doctor to inform the GMC if they have accepted a caution, been charged with a criminal offence, or if they have been found unfit to practise by a professional body anywhere in the world. It also includes the requirement to take up any post that has formally been accepted. Whilst it is clearly best to avoid any suspicion altogether, if you do find yourself being accused of plagiarism or dishonesty, it is important that you contact MPS to obtain advice at an early stage. The earlier we are involved, the better the chances of mitigating any damage to your career.
You must be open and honest with any financial arrangements with patients and employers, insurers and other organisations or individuals.
Useful links GMC, Good Medical Practice (2006) paragraphs 56-76 – www.gmc-uk.org/guidance/good_medical_practice/index.asp BMA, – www.bma.org.uk/ap.nsf/Content/mafees~cremation?OpenDocume nt&Highlight=2,death,certification MPS, Playing fast and loose with the truth, Casebook (Vol 17, No 1) – www.mps.org.uk
MPS professional support and expert advice 24-hour medicolegal emergency advice line Medicolegal publications – Casebook and New Doctor Risk Management materials including medicolegal booklets
Online resources including factsheets and case scenarios Educational support through discounts with leading publishers Largest international defence organisation
For more information call 0845 718 7187 Or visit www.mps.org.uk The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.
When doctors are expected to kill – administering a lethal injection At exactly 11pm on the 21st September 2006 forty-eight year old Clarence Hill was strapped to the table at Starke Prison, Florida. The warden gave the signal and a cocktail of lethal drugs was pumped into his veins. At 11.12pm the ECG flatlined and Hill was pronounced dead. Hill’s execution went ahead despite his lawyers arguing that the lethal injection is inhumane. Many doctors in California agree and believe the method of lethal injection, supposedly painfree, does cause the condemned pain and should be banned.
key point in the debate for death by lethal injection occurred when California postponed executions indefinitely after doctors refused to participate. They became opposed after a judge’s ruling stated that doctors would have to physically intervene if the condemned person appeared to be in pain.
Doctors would therefore have been expected to tell prison officials whether the prisoner needed more sedation, or possibly even to administer more drugs. “Any such intervention would be medically unethical,” the anaesthetists replied in a statement. “As a result, we have withdrawn from participation.” Lethal injections were suspended as a result. Michelle Connolly looks at the role doctors for JuniorDr.
What’s legal? Lethal injection under United States federal law states that ‘the punishment of death must be inflicted by continuous, intravenous administration of a lethal quantity of an ultrashortacting barbiturate in combination with a chemical paralytic agent until death is pronounced by a licensed physician according to accepted standards of medical practice.’ In it’s simplicity lethal injection simulates a medical procedure - the intravenous induction of general anaesthesia.
The procedure Once the prisoner has been strapped to the table the arm is swabbed with alcohol. Two 14-gauge catheters, the largest commercially available, are inserted, one in each arm. The second is a backup, in case the primary IV. fails. Both catheters are flushed with heparin to prevent clots forming inside.
All condemned prisoners are given the opportunity to make any final statement they wish, and then, on the warden’s signal the drugs are administered. Sodium thiopental (at 14 times the normal dose) is used to induce anaesthesia, pancuronium bromide is the substance used to paralyse the respiratory muscles and potassium chloride is administered to induce ventricular fibrillation. Even without inducing VF death would still follow by asphyxiation. Death typically takes 8-10 minutes and is pronounced
INVOLVEMENT OF DOCTORS The American Medical Association (AMA) specifically condemns the involvement of doctors in state-sanctioned executions. It cites eight acts constituting direct involvement:
1 2 3 4
Administering lethal drugs Maintaining injection devices Supervising technicians Prescribing lethal drugs
5 6 7 8
Selecting intravenous access sites Inserting IV lines Monitoring vitals Pronouncing the prisoner dead
“Even more surprising was that in 43 percent of cases in those four states levels were consistent with consciousness.”
on asystole. A coroner then signs the death certificate and the procedure is complete. With the IV lines, a cardiac monitor and a medical doctor on standby the execution room is not dissimilar from an acute medical ward. The direct telephone line to the Department of Justice in Washington is perhaps the only giveaway - the President is the sole authority able to grant last-minute clemency.
‘Inhumane execution’ The claim of the lethal injection being the most humane form of capital punishment, is disputed by many. Leonidas Koniaris, professor of surgical oncology at the University of Miami, Florida, writing in The Lancet, suggests evidence that judicial execution by these means is not as humane as death penalty proponents have claimed. Researchers obtained post-mortem toxicology reports from four of the 36 states killing prisoners via lethal injection. The results indicated that levels of sodium thiopental were lower than those required for surgical anaesthesia. Even more surprising was that in 43 percent of cases levels were consistent with consciousness. Determining consciousness levels in prisoners who are paralysed and who will not be resuscitated is both difficult and debatable. This lack of certainty has however prompted the American Veterinary Medical Association to ban the use of neuromuscular blocking agents, such as pancuronium bromide, when putting animals to sleep.
The involvement of doctors The involvement of doctors varies considerably with 35 of the 38 death penalty states that rely on lethal injection allowing doctors to participate, and 17 states requiring it. Participating
“The worst toxicology reports were obtained from states that employed teams qualified only at technician level.”
doctors are required to ensure that the Eighth Amendment of the US Constitution, which prohibits ‘cruel and unusual punishment’ is upheld. It was a doctor who pushed the syringe in Illinois’s first lethal injection execution and in Nevada, doctors are required to examine the condemned for good venous access and to prescribe the fatal drugs. Some states, such as Illinois and South Dakota, have attempted to de-medicalise the death penalty with laws decreeing that the assistance of death does not constitute medical practice. South Dakota’s death penalty statute states that “any infliction of the penalty of death … may not be construed to be the practice of medicine.”
The argument for medical involvement Despite the reluctance of medical professionals to involve themselves many feel their presence is essential for the welfare of the prisoner. Each step of the execution procedure from the dosing of fatal drugs to the pronouncement of death ideally requires a medical practitioner. Where doctors are unavailable these tasks are performed by trained ‘technicians’ but as Koniaris and his team point out the worst toxicology reports were obtained from states that employed teams qualified only at technician level. Death row inmates often have poor vascular access as a result of intravenous drug use or obesity and it is here that the skills of doctors are particularly useful. In Georgia one of the three doctors present in the execution chamber during procedures is an expert in vascular access. Many also use the argument view that healthcare personnel transform the executions from a terrifying to peaceful environment alleviating pain or giving the illusion that pain is being alleviated.
The argument against Firstly doctors argue that they were not asked whether they agreed with the medicalisation of the death penalty prior to its re-introduction in 1976. Many doctors oppose the execution process on ethical grounds. The president of Georgia’s medical school, in a letter to the prison warden, condemned the involvement of doctors saying their presence in the chamber ‘compromised their relationship with the inmate population.’
When doctors are expected to kill – administering a lethal injection
More significantly in June 2006, the American Society of Anaesthesiologists sent letters to its 40,000 members urging them to ‘steer clear of any participation in execution.’ Missouri officials then sent nearly 300 letters to anaesthetists in the state and in Illinois to ascertain their ‘willingness to participate in execution’. To date not a single recipient has said they would so it seems the Society’s call is being heard. In a further development the following month North Carolina’s state medical board banned doctors from participating in state executions.
Choosing to participate Despite what appears as widespread reluctance by the medical profession to participate in lethal injections many doctors are still willing to assist in state execution. An American Medical Association survey found that 19
percent would inject lethal drugs and 41 percent said they would perform at least one of the eight acts (see table)2. Many individuals balance their clinical responsibility against their duties to society and agreed to their involvement. Many also wanted to provide a ‘painless’’ death and were concerned with the expertise of the technician-level staff. In a case that caused particular furore among the medical profession, the governor of Kentucky, who is a doctor, signed the death warrant of a prisoner with an IQ of 74. Executive counsel John Roach said Dr Fletcher did not violate the American Medical Association guidelines and that in signing a death warrant, he is in ‘no way participating in the conduct of an execution’. Doctors still refuse to be present in the execution room in California. Their role in administering lethal injections across the United States is still uncertain - but executions continue in the other states.
Starke Prison, Florida Death Row Cells A Death Row cell is 6x9x9.5 feet high. Florida State Prison also has Death Watch cells to incarcerate inmates awaiting execution after the Governor signs a death warrant for them. A Death Watch cell is 12x7x8.5 feet high.
Last Meal Prior to execution, an inmate may request a last meal. To avoid extravagance, the food to prepare the last meal must cost no more than $40 and must be purchased locally.
Contact When a death warrant is signed the inmate is put under Death Watch status and is allowed a legal and social phone call. While on Death Watch, inmates may have radios and televisions positioned outside their cell bars. Florida Department of Corrections
Starke Prison, Florida Execution Room Picture: Florida Department of Corrections
Refrerences Koniaris LG, Zimmers TA, Lubarsky DA and Sheldon JP (2005). Inadequate anaesthesia in lethal injection for execution. The Lancet. 365: 14121414. Groner JI (2002). Lethal injection: a stain on the face of medicine. BMJ 325: 1026-1028. Farber NJ, Aboff BM, Weiner J, Davis EB, Boyer EG, Ubel PA (2001). Physicians’ willingness to participate in the process of lethal injection for capital punishment. Ann Intern Med. 135: 884-888.
History of the lethal injection Junior doctors: agents for change Monday 7 June 2010 Hilton London Metropole Hotel, London Lethal injection was first considered in 1888 by a New York doctor writing in the journal Medico-Legal. Initially this was not for humane reasons but to rob the prisoner of the hero status which was attached to hanging. He suggested the injection of 6g of morphine. The idea didn’t catch on and New York state introduced the electric chair instead. In the UK the British Royal Commission on Capital Punishment looked into lethal injection back in the 1950s but following pressure from the BMA decided against it. Lethal injection in its modern form was the brainchild of Stanley Deutsch, an anaesthesiologist at the University of Oklahoma. In response to the state senator’s 1977 request for a cheaper alternative to repairing the dilapidated oak electric chair, Dr Deutsch recommended barbiturate as a ‘rapid, pleasant way to bring about unconsciousness’ followed by a muscle relaxant to bring about an ‘extremely humane’ death. Texas became the pioneering state for lethal injection as a form of capital punishment. It was doctors who watched as the drugs were pumped into the veins of a 40 year old African-American. He was dead within minutes and the procedure was deemed a success. Since then over over 700 men and women have been executed by lethal injection in the USA alone.
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Secret Diary of a Cardiology SpR Monday If you’ve been following this column then you’ll know that Douglas, my boss and mentor, recommended I take a Fellowship overseas before settling down as a consultant. He suggested Melbourne but I chose California. That was how I ended up cramming my face full of ultra low fat skinny blueberry muffins at 6am every day as we started rounds. It’s also how I ended up spending Friday mornings on the beach learning how to surf. Not a bad life. Monday was pretty dull. James (think Hawaiian surfer dude) was the attending on the wards. He is surprisingly meticulous for someone who wears faded jeans and an Aloha shirt and makes sure that all the patients have plans for the week. I spend the afternoon doing an echo list before finishing some paperwork and heading home for an early night. My apartment has a great view of the Pacific but it also has ‘Showtime’ which is a combination of Sky Movies, cable and every other type of great TV, so I end up spending the night drinking a glass of Californian red and watching seasons premieres of shows I have never heard of.
Tuesday Angio list this morning. The attending in charge is Suzie, a young woman not much older than myself, and like all the cardiologists here she is pretty meticulous. Perhaps the constant fear of litigation is what drives them. Everything is heavily supervised, especially the complicated case that we start with. There is a window on the second floor with a small gallery and a professor talks through what I’m doing with a group of medical students. The case goes smoothly and we soon start another and then another. The pace of work is frantic but unlike back home everything seems to run exceptionally smoothly. The assistants and nurses are eager and willing to help, the equipment is always ready and in perfect working condition, and the computer systems to help us do our job are first rate. I guess this is what it would be like if they privatised the NHS.
Wednesday Early rounds again and then a morning of teaching. The students here really know their stuff and some of their questions leave even me thinking for a moment before I can compile an answer. After lunch I see some ward patients and spend an hour catching up on emails. I go out with some of the other residents in the evening and we hit a couple of bars in the centre of town. My colleagues don’t usually drink a huge amount and I find myself getting blank stares when I suggest a third round. Still, they all buy into it and we end up moving onto a gothic club where we look decidedly out of place. The bouncers laughed at us when they let us in and most of the patrons keep out of our way but we end up dancing all night and I crash back in my flat sometime around 2am.
Thursday I feel decidedly unwell as we start rounds a mere four hours later but I look significantly better than some of my colleagues who don’t stay out late very often. It takes several coffees and a double bacon roll (the lady in the canteen looks at me as if I’m mad when I order 18
* 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!
this instead of the skinny muffin everyone else is having) before I feel better. After lunch I leave the building with Suzie and we go downtown to the weekly inner city clinic that the hospital runs as part of its charity outreach programme. Most of the patients have standard stuff but towards the end we find a man in his forties who is really sick. He has no cardiac history but has been getting chest pains and shortness of breath for a few weeks and is now in crushing pulmonary oedema. Suzie looks anxious when he tells us what we already know - that he doesn’t have any health insurance. We tell him that he has to get checked into a hospital and suggest the local one where they will look after him immediately. He doesn’t want to pay for an ambulance so a friend agrees to drive him there. After clinic, I go out for dinner with Suzie and we talk about his case. If he had turned up in the UK he would have had a battery of blood tests, a chest x-ray, an echo and a cardiac MRI within an hour of setting foot through the door. If we had found something stentable the chances are that we would have done an angio tonight and sorted it out. By tomorrow morning he would have been in coronary care eating a skinny blueberry muffin like everyone else.
Friday Wave rounds today which means surfing at dawn for the whole team. We meet for breakfast in a hut on the beach and sit in our usual corner table as we do a paper round of our patients. As we talk, Suzie walks to the juice bar to order some more drinks and makes a call on her phone as she does. When she comes back she tells us that the man from yesterday died early this morning. It turns out he did get to the hospital but aside from an ECG and some blood tests he didn’t have much else as they were too stacked up with patients. He arrested a couple of hours ago and they couldn’t revive him. There’s a silence after she finishes as we all look at each other. James explains to the students that based on the clinical story he may have died anyway but as he does so he gives Suzie and I a look that says otherwise. My six months are nearly up and as I reflect on this in my apartment that night. I wonder which system I’d rather practice in. The NHS has many faults but, like the army, they leave no man behind. However, what’s the point in training to be a cardiologist in the developed world if you can’t treat some of your patients in the best possible way using the best technology? Is it better to treat all your patients to a good degree or treat some of them to a fantastic degree whilst leaving some of them with nothing? I’m not sure that I know the answer to that any more.
Weekend Ward Escape to
MADRID With bullfighters, women who dance clapping metal cymbals and huge 30 inch plates of paella there’s no doubt Madrid sees itself as a macho city. Hardly a place for a relaxing weekend away you may think. Wrong, Madrinos also have a strong reputation for enjoying themselves ... you just have to let them take the lead. Where to stay? Like any capital city staying in Madrid is expensive. Visiting at the weekend does let you take advance of reduced rates when all the business travellers have left. Try the centrally located Petit Palace Arenal (Calle Arenal) approx £60 a room. If you’re still waiting for your paycheck you could try the Barbieri Internation Hostel (Calle Barbieri), just a short walk from the centre, which offers double rooms from under £30. Or if you’re planning a really special weekend away you could splash out on Hotel Santo Mauro (Calle Zurbano) - the choice of residence for the Beckhams at £250 per night.
Eating Tapas will become addictive whilst in Madrid. Pop into a bar, order a drink, and nibble the night away with the locals - it’s how they can stomach drinking until the early hours of the morning. The top tapas treats can be found at Juana la Loca (Plaza Puerta de Moros) or Alhambra (Calle Victoria) which offers a more lively experience with heavy music and a younger crowd.
For a more sedate sit-down meal consider La Viuda Blanca (Calle Campomanes) which offers a modern take on Spanish cuisine.
Key attractions Palacio Real - Arguably the most impressive building in Madrid with fantastic gardens which are perfect for a spot of lunch. There are 3,000 rooms to the Royal Palace, many of which you can wander through. El Teleférico de Madrid - This is a 10 minute cable car ride that departs from the park behind the Royal Palace. It’s a great way to see the city from afar and also ends at a welcome restaurant.
Prado Museum - This is Madrid’s most popular tourist attraction and claims to have a higher concentration of masterpieces than anywhere else in the world. At any time there are 1,500 works of art on display out of an impressive collection of 9,000. Parque del Retiro - Retiro means retreat and is the most popular park in Madrid. With a large lake, monuments and shaded areas it’s the perfect place to relax after stomping around the Prado which is conveniently situated close to the main entrance.
Nightlife Plaza de Toros de Las Ventas Whether you are amazed or are appaled
by bullfighting it’s certainly a big part of Madrino culture and increasingly popular. Tickets can cost from a few quid to over fifty depending on where you sit in this massive 25,000 seater stadium with the action kicking off from 7pm. Casa Patas (Casa Canizares) - Flamenco is the other great Madrino passion and certainly worth an evening’s viewing. Casa Patas offers one of the more authentic experiences. Entrance is approximately £25 and includes a complementary drink. Find the full Madrid guide at JuniorDr.com
Key facts • Population - 2,905,100 • Language - Spanish • Currency - Euro • Madrid is Europe’s highest city (2,100 feet)
Assessed by Gil Myers
t is a dark winter’s night at my surgery and the last appointment of the evening. The clinic is deserted and cost-saving measures have meant that only a single flickering light remains on. Suddenly, creeping from the shadows of the waiting room, a dark figure emerges. Dressed almost totally in a form-fitting reinforced suit with his head covered in a frightening mask I can make out the outline of a man - or possibly something more supernatural. At first he says nothing, then quietly, somewhere between a whisper and a threat, his voice rasps “Doctor, I have an itch...”
2 Kidnap; moving a limb or other body part away from the midline (6) 4 Terminal organ of the lower limb; 12 inches (4) 10 High potassium (13) 11 Lobe of the brain behind the frontal; contains sensory cortex and association areas (8) 14 Whitish crescent shaped area at the nail base (6) 15 Group of mammals considered by some as vermin; ulcer associated with basal cell carcinoma (6) 17 Itching (8) 18 What you aim for; red blood cells with central staining, a ring of pallor, an outer rim of staining e.g. in liver disease, thalassaemia and sickle cell disease (6) 21 Coldplay classic; this fever is an infectious disease of tropical Africa and Southern America transmitted by Aedes mosquito (6) 22 Rod shaped bacterium (8) 24 Name associated with the plantar reflex (8) 25 Flat circumscribed area of skin or an area of altered skin colour (6) Down:
1 Name associated with paradoxical rise in JVP with inspiration (8) 3 Purified cardiac glycoside extracted from foxglove (7) 5 Fourth cranial nerve (9) 6 Proton pump inhibitor; ‘Losec’ (10) 7 Paediatrician’s name associated with testing a drop of blood to exclude phenylketonuria (7) 8 FK506, immunosupressant discovered by the Japanese (10) 9 His syndrome is rheumatoid arthritis with pneumoconiosis; treated with steroids (6) 12 Inflammation of the wall of a vein (9) 13 This ligament forms the floor of the inguinal canal (8) 16 Cell type of carcinoma of the bronchus with darkly staining nuclei and scanty indistinct cytoplasm; in porridge (3) 19 satellite of Saturn; first cervical vertebra; collection of maps (5) 20 A rare and relatively benign form of muscular dystrophy of pelvis-girdle type with better prognosis than Duchenne’s dystrophy; Wimbledon’s youngest men’s singles winner (6) 23 Disease associated with spirochaete Borrelia burghdorferi; sounds like a citrus fruit (4)
You can find the crossword solution by searching for ‘crossword answers’ at www.juniordr.com.
Compiled by Farhana Mann
No-one should have to live with a voice that hoarse without seeking medical help. Although there are many causes for this dysphonia, inflammation of the larynx would be the most obvious - likely due to a simple viral infection or overuse of the vocal cords. I would recommend a combination of gargling, menthol inhalation, air humidifiers and simple rest. If the problem persists I will make a referral to our local voice therapist Dr Joe Kerr.
Erythropoietic porphyria Perhaps the main reason for “Batman” only appearing at dusk is photosensitivity to sunlight. In all cutaneous porphyrias, photosensitivity presents as bullous eruptions occurring on sun-exposed areas. The recommended treatment is actually prevention by avoidance of sunlight and use of sun-protective clothing. A firm diagnosis could be made by testing for porphyrins in plasma, urine, and stool; which would be elevated to levels higher than those in other porphyrias. This would however necessitate Batman removing his uniform which in itself would be a difficult task.
Histoplasmosis Quite why this “Batman” chooses to spend the majority of his time in a cave teeming with bats is beyond the limits of this consultation. However, it is common knowledge that bats carry various diseases including rabies, the Hendra virus and Ebola. What is less well known is that their excrement, called guano, has the fungus histoplasmosis capsulation present in a high enough quantity to cause histoplasmosis - an infectious disease caught by inhaling the spores. Around 10 days after exposure many sufferers complain of flu-like symptoms including dry cough, headache, impaired vision and muscle pains. Some cases, however, are more serious often resembling tuberculosis and can be fatal without treatment. My recommendation would be to have the whole cave fumigated and install better ventilation.
Attachment Disorder While obtaining a family history I uncovered that during his early childhood both Mr and Mrs “Batman” were murdered. It is well known that failure to form normal attachments to primary care giving figures in early childhood can lead to problematic social expectations and behaviours - particularly emotional dysregulation, self-endangering behaviour and hyper-vigilance. Although treatment is difficult in these cases, a narrative-therapeutic approach may allow “Batman” to open and explore other aspects to his personality rather than sticking to this Dark Knight persona.
Writing in the Notes charade
e swer for but th Dear Editor, has a lot to an an m on ip t Sh gh d ou ol Har l system br trusive appraisa We know that increasingly in ac eejerk re tion. kn a is s es iln ev Shipman would by his aisal methods pr ap t en rr cu n in your artiunder t doctor. As show ea gr a d te ra en s properly in have be to use portfolio ng ili fa s ss nt lta su often a pointle cle (Con ) appraisals are p5 til 14 s un Is e ls tim sa apprai matter of cise. It’s only a appraisal system box-ticking exer ho ows the w le sh e an m ip Sh r anothe d casts even mor nsive charade an pe H ex D er e th th t ra n’ a to be ic. Should inds of the publ ove rather than doubt in the m n gs we ca impr in th e th on be focus er? ve no control ov the things we ha Anonymous
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:
Fish and chips
Ask for fish fingers instead at:
Bristol Royal Infirmary, Bristol
Expect them to be wrapped in newspaper at:
Barnet General Hospital, London
y SpR Surger
le stick reportin
Dear Editor, In your article (Most surgeons do not report ne dle stick injuries eIss 14 p6) you no te that only a qu ter of surgeons arreport needle st ick injuries. My experience of ha own ving had at leas t two (that I’m of!) is that I rega aw are rded them as lo w risk and wou have taken antir ld no t etrovirals. This judgment was on a good know based ledge of the risk s of transmission blood borne in of fections. Repor ting them is te and inevitably dious means being co rralled into m ing with occupa eettional health. A better way forw is improved ed ard ucation of doct ors to allow th make their own em to risk assessment rather than wai for them to repo tin g rt. Harry Crosse n ST4 General Med, Notting ham
How to spot a fres
esher to add to Dear Editor, way to spot a fr l na tio di ad an I’ve ot a fresher Iss 14 sue (How to sp is st la e th in t have to spend your lis e students who th r fo ok lo to ’s lst balancing a p14). It es each day whi ur ct le in s ur e other hideous eight ho os, Aldi or som sc Te in b jo e so prohibitopart-tim medicine is now in ng ni ai Tr . ce ts off and forcworkpla any good studen m g in tt pu s it’ ion by slaving ry that ise their educat om pr m co to rs edical training ing othe . Isn’t it time m bs jo e im -t rt pa aching? away in e nursing and te lik st ju ed is id is subs Alicia Patel udent Medical St
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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.
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Published on Dec 26, 2009
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