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THE IMPORTANCE OF RESEARCH 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. Team Leader Matt Peterson, email@example.com Editorial Team Yvette Martyn, Ivor Vanhegan, Anna MeadRobson, Michelle Connolly, Muhunthan Thillai, Anjali Balasanthiran 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, David Cameron, 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 2012. 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.
n the 1940s it was estimated that 81% of men and 39% of women in the UK smoked. Adverts adorned the sides of buses proclaiming the health beneﬁts and attractiveness of this glamorous habit even Eton College made smoking compulsory at one point. Few people believed that smoking had any serious impact on health - and those that did understood it to be a minor inconvenience to the stress-relieving beneﬁts tobacco brought. Then in 1951 Richard Doll and Austin Bradford Hill published their pioneering paper in the BMJ. They studied patients across 20 London hospitals and their research ﬁnally demonstrated that smoking was a causal link in the development of lung cancer. Their work continued over the next three years as they enrolled 40,000 doctors in a study which looked at whether smokers went on to develop lung cancer. They found a direct correlation, and following two further papers the government ﬁnally embarked on a tobacco control policy which dramatically helped to reduce use. Today the number of smokers is under 20% of the adult population - across both men and women. Without the groundbreaking work of researchers, such as Doll, the link between smoking and cancer may never have been discovered.
What’s inside 04 LATEST NEWS 08 PHOTO FEATURE GUIDE TO 09 BEGINNERS RESEARCH 20
28 22 30
Clinical research is critical to the ongoing improvement of health, and many would say should be a key component of the training and activity of doctors. Sadly it is not an integral part of the curriculum for most doctors and often the ﬁrst formal exposure is applying for a PhD. In this issue, with the help of the team from NIHR CLAHRC Northwest London, we’ve produced a Beginner’s Guide to Research. We’ll take you through the routes into research, practical advice for getting research oﬀ the ground as well as tips on sources of funding. We hope you’ll ﬁnd our guide useful no matter what career stage you’re at. Read our guide then search out answers to your questions from our experienced team online at JuniorDr.com.
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INCREASED RISK OF DEATH FOR PATIENTS ADMITTED AT WEEKENDS
atients admitted to hospital at the weekend have a signiﬁcantly increased risk of death within the following 30 days compared to those admitted on a week day, according to research published in the Journal of the Royal Society of Medicine. The analysis of 14.2 million NHS admissions between April 2009 and March 2010 showed that elective and emergency admissions on a Sunday had a 16 percent increased risk of death within 30 days compared to those admitted on a Wednesday. “This study is further evidence that patients admitted at weekends are more likely to die following admission than patients admitted to hospital during the week,” said Dr Andrew Goddard, director of medical workforce at the Royal College of Physicians.
“This study is further evidence that patients admitted at weekends are more likely to die following admission than patients admitted to hospital during the week.” Dr Andrew Goddard DIRECTOR OF MEDICAL WORKFORCE, RCP
“There are many reasons for this, but the two most important are that the patients are more ill and there are fewer doctors available.” These results, from the Quality and Outcomes Research Unit at University Hospital Birmingham Foundation Trust, are consistent with a similar study of 254 not-forproﬁt hospitals in the United States. The Royal College of Physicians says the outcome of this study strengthens the evidence behind their call that any hospital admitting acutely ill patients should have a consultant physician on-site for at least 12 hours per day, seven days a week.
SEVEN DAYS A WEEK WORKING Despite a higher death rate in patients admitted at weekends the overall death rate on Saturdays and Sundays was found to be lower than during the week. For every 100 deaths among patients in hospital on a Wednesday, 92 deaths would occur among similar patients in hospital on a Sunday. “This phenomenon must be due to the way services are organised since, all things being equal, we would expect a similar number of deaths on each day of the week,” said Professor Domenico Pagano, lead researcher in the study.
“It may be that reorganised services providing seven day access to all aspects of care could improve outcomes for higher risk patients currently admitted at the weekend. However, the economies for such a change need further evaluation to ensure that such reorganisation represents an eﬃcient use of scarce resources.” jrsm.rsmjournals.com
GUIDANCE PREVENTING DOCTORS BEING ‘GAGGED’ COMES INTO EFFECT
ew guidance from the General Medical Council which prevents doctors entering into contracts or agreements which stop them raising concerns about poor quality care has come into eﬀect this month. The guidance document, which has been sent to all 240,000 doctors, explains that doctors have a duty to act when they believe patient safety is at risk, or when a patient’s
care or dignity is being compromised. Raising and acting on concerns about patient safety (2012) has been implemented as a result of so-called ‘gag’ clauses which have prevented employees criticising care provided by their employer. “Our guidance makes clear that doctors have a duty to act when they believe patient safety is at risk, or when a patient’s care or dignity is being compromised,” said Niall
Dickson, the Chief Executive of the General Medical Council. “Our new guidance also makes clear that doctors must not sign contracts that attempt to prevent them from raising concerns with professional regulators such as the GMC and systems regulators, such as the CQC.” www.gmc-uk.org
NEW IN 2012
MEDICAL SCHOOL LINK TO WIDE VARIATIONS IN PASS RATE FOR MRCOG
ide variations in MRCOG pass rates appear to be linked to the particular medical school where the student graduated, according to research published online in the Postgraduate Medical Journal. The research looked at ﬁrst time pass rate for doctors who had graduated from UK medical schools for both parts of the Royal College of Obstetricians and Gynaecologists (MRCOG) membership exam between 1998 and 2008. Among the 1335 doctors who took Part 1 and 822 took Part 2 MRCOG during the study period, analysis revealed considerable variations in the pass rate, depending on the medical school the candidate had attended. Doctors who had studied medicine at Oxford had the highest pass rate (82.5%+), followed by graduates from Cambridge (75%), Bristol (just under 60%), and Edinburgh (57.5%) for the Part 1 exam. At the other end of the spectrum, graduates from Southampton (just under 22%), and Wales (18%) had the lowest pass rates. For Part 2, graduates from Newcastle upon Tyne had the highest pass rate at just under 89%, followed by those from Oxford (82%+), Cambridge (81%), and Edinburgh (78%+). Conversely, only around half of those from Glasgow
(49%+) and just over a third of those from Leicester (36%+) passed the written exam. Overall academic performance of the university’s students was associated with the pass rate in Part 1, but not in Part 2, the ﬁndings showed. “Undergraduate and postgraduate medical education are now considered as a continuum in the training of a specialist in all ﬁelds of medicine,” say the authors, but “little consideration is given to the eﬀect that changes in style of learning, the curriculum and objectives of undergraduate education might have on postgraduate performance.”
SURGEONS AGED BETWEEN 35 AND 50 PROVIDE SAFER CARE
urgeons aged between 35 and 50 years provide safer care compared to their younger or older colleagues, according to a study published on bmj.com. Existing research has found that surgeons reach their peak performance between the ages of 30 and 50 years or after about 10 years’ experience in their specialty but few studies have measured the association between clinicians’ experience and performance. This new study by the University of Lyon reviewed 3,574 thyroidectomies by 28 surgeons and found that patients were at higher risk of permanent complications following thyroid surgery when operated on by both inexperienced surgeons and those in practice for 20 years or more. When thyroid surgery was performed by
surgeons in practice for 20 years or more, the probability of permanent complications increased considerably. Surgeons between 35 and 50 years old had better outcomes than their younger or older colleagues. The authors say their ﬁndings suggest that surgeons’ performance varies over the course of their career and that a surgeon cannot achieve or maintain top performance passively by accumulating experience which raises concerns about ongoing training and motivation throughout a career that spans several decades. www.bmj.com
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WOMEN MORE LIKELY TO BE APPOINTED TO SURGICAL TRAINING
omen who apply for surgical training are proportionately more likely to be appointed than men, according to a paper published in the Bulletin of the Royal College of Surgeons. The study looked at all applicants to surgical training in England and Wales over a two year period. It found that, while 29 per cent of applicants to basic surgical training were women, 31 per cent of appointees were female, suggesting women performed better in the application process than men. Women’s success rate was even greater in higher surgical training: in one year (2008) only 16 per cent of applicants were women, making up 22 per cent of appointees. “Surgery needs the very best doctors and this means ensuring everything is being done to encourage the widest pool of applicants,” said Scarlett McNally, Consultant Orthopaedic Surgeon at Eastbourne District General Hospital and Chair of Opportunities In Surgery. “Given that the majority of those qualifying from medical school are women, to ensure the best possible surgeons in the future it is essential that a surgical career is seen as an attractive choice to both sexes.” The paper also reported an attrition rate, with the 25 per cent of the female applicants for basic surgical training dropping to 15 per
Healthy advice from healthy docs
cent for higher training suggesting that the years of postgraduate training coinciding with the years of child-rearing may be a factor in dissuading female doctors from remaining in surgical training. Surgery remains a profession signiﬁcantly populated by men. Women account for 55 per cent at medical school but only 7 per cent of consultant surgeons. All surgical specialties are very competitive, with only 9 per cent of applicants securing a training post. www.rcseng.ac.uk/publications/bulletin/
FOUR DAYS SHADOWING FOR FY DOCS
ew appointees to the Foundation Programme will undertake a minimum of four days shadowing immediately before starting F1, the Department of Health in England has announced. The new shadowing scheme has been introduced following pilots across England and other parts of the UK. The aim is to reduce the level of stress which many newly qualiﬁed doctors experience whilst also improving patient safety. All foundation doctors appointed in England will spend a minimum of four working days shadowing the F1 job that they will be taking up and completing a trust-based induction.
Fifteen percent of US doctors were trained in low income countries, according to research published in PloS ONE. The study by the Stanley Medical Research Institute found the practice was clinically and economically beneﬁcial to the US but may have a negative impact on the countries of origin. They found that the Philippines had the biggest loss of doctors to the US.
Foundation doctors will be paid for this shadowing period on a pro-rata basic F1 salary and all new F1s have been told they must ensure they are available for at least the last week of July 2012. New F1 doctors in Wales have been required to participate in a paid four day shadowing period for the last few years. Different arrangements exist in Scotland and Northern Ireland and further information will be provided to new F1s in these countries in the near future. www.foundationprogramme.nhs.uk
Doctors who have more healthy habits are more likely to recommend ﬁve important lifestyle modiﬁcations to patients, including eating healthy, limiting sodium intake, maintaining a healthy weight, limiting alcohol and being more physically active. The study by the Emery School of Medicine also found that doctors who exercised at least once a week or didn’t smoke were about twice as likely to recommend the ﬁve interventions. www.heart.org
Blockbuster binge drinking Teenagers who watch a lot of movies featuring alcohol are three times as likely to start binge drinking compared to their peers, according to a study published in BMJ Open. After watching on average 4.5 hours of on-screen alcohol use in the two year study the proportion of teens who started drinking alcohol more than doubled from 11% to 25%, while the proportion who began binge drinking - deﬁned as ﬁve or more drinks in a row - tripled from 4% to 13%. bmjopen.bmj.com
Collision injuries from iPods The number of cases of serious injury sustained while walking along the street wearing headphones for a handheld device, such as an iPod or MP3 player, has tripled in six years, according to research published in Injury Prevention. During the study period, there were a total of 116 collisions - 81 (70%) of which were fatal. In three out of four cases, eyewitnesses said the victim was wearing headphones at the time. injuryprevention.bmj.com
HEAVY ALCOHOL USE ASSOCIATED WITH POORER SURGICAL OUTCOMES
eavy alcohol use one year prior to an operation is associated with longer stays, more days in intensive care and increased return to theatre, according to new research published in the Journal of the American College of Surgeons. The study of 5,171 male patients found patients who score highest on the Alcohol Use Disorders Identiﬁcation Test-Consumption (AUDIT-C) experience longer postoperative hospital stays and more days in the intensive care unit (ICU); they are also more likely to return to the operating theatre within 30 days of a surgical procedure than patients with low AUDIT-C scores. Men with high-risk drinking spent nearly a day longer in the hospital and 1.5 more days in the ICU, and they were twice
as likely to return to the operating theatre compared with low-risk drinkers (10 percent versus 5 percent, respectively). “The ﬁndings from this study indicate that preoperative alcohol screening might serve as an eﬀective tool to identify patients at risk for increased postoperative care,” said Anna Rubinsky, lead author of the study. A previous randomised, controlled trial among patients scheduled for elective colorectal surgery who reported drinking more than four drinks daily found that patients who stopped drinking for one month prior to the procedure reduced their risk for postoperative complications by as much as 50 percent. www.facs.org
HIGH RATE OF RESEARCH FABRICATION IN UK
It’s four a.m.
ore than one in ten (13%) UK based scientists or doctors are aware of colleagues intentionally altering or fabricating data during their research or for the purposes of publication, according to a survey by the BMJ. A further 6% of the 2,700 responses say they were also aware of possible research misconduct at their organisation which has not been properly investigated. “While our survey can’t provide a true estimate of how much research misconduct there is in the UK, it does show that there is a substantial number of cases and that UK institutions are failing to investigate adequately, if at all,” said Dr Fiona Godlee, BMJ Editor in Chief. The study reﬂects previous research among newly appointed consultants in seven UK hospitals. One in ten said they had ﬁrst-hand knowledge of scientists or doctors intentionally altering or fabricating data, and 6% admitted to past personal research misconduct. “The BMJ has been told of junior academ“The BMJ has been told of junior ics being advised to keep academics being advised to concerns to themselves to keep concerns to themselves to protect their careers, being protect their careers.” bullied into not publishing their ﬁndings, or havDr Fiona Godlee ing their contracts termiBMJ EDITOR IN CHIEF nated when they spoke out,” said Dr Godlee.
You’ve been bleeped. You know what to do. But it would be good to get a second opinion – just for peace of mind. That’s exactly what Best Practice provides. A trusted second opinion on the assessment, treatment and management of patients. On call. All day. All night. Just when you need it.
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DIAGNOSE • TREAT • MANAGE • LEARN
AT THE WELLCOME COLLECTION
‘brainbow’ forms from the process of highlighting individual neurons in the brain by using ﬂuorescent proteins. It produces colourful images by randomly expressing diﬀerent ratios of red, green, and blue derivatives of green ﬂuorescent protein in individual neurons. This process has been a major contribution to the ﬁeld of connectomics, or the study of neural connections in the brain. Brainbows form part of ‘Brains’ - a major new free exhibition at the Wellcome Collection until 17 June. It seeks to explore what humans have done to brains in the name of medical intervention, scientiﬁc enquiry, cultural meaning and technological change. Wellcome Collection, 183 Euston Road, London NW1 2BE
Used with permission. Livet and Lichtmann Harvard University.
A BEGINNERS GUIDE TO
RESEA Conducting research as a clinician can be an exciting and rewarding opportunity. Even if you don’t make the next ‘big discovery’, with the right approach, preparation and support you can make new connections and learn new skills which can enhance your clinical practice - and provide signiﬁcant beneﬁts for patients. SECTION EDITORS
This guide to research is produced by selected authors with research experience and covers important considerations from the earliest stage of a research idea to undertaking a career in research.
Dr Anjali Balasanthiran CLINICAL RESEARCH FELLOW NIHR CLAHRC FOR NORTHWEST LONDON
Professor Derek Bell
Read the advice from our experts then join the discussions and ask your questions online at JuniorDr.com.
CHAIR OF ACUTE MEDICINE, RESEARCH AND DEVELOPMENT DIRECTOR AT CHELSEA AND WESTMINSTER HOSPITAL, DIRECTOR OF NIHR CLAHRC FOR NORTHWEST LONDON
IN THIS GUIDE tResearch: Your First Thoughts
tPatient and Public Views of Electronic Health Records
tRoutes into Research
tEngaging with Statistics in Research
tGovernment Sources of Research Funding
tPatient & Public Involvement in Planning and Executing Research
tNon-Government Sources of Research Funding
tThe Practical Aspects of Getting Research ‘Off the Ground’ tThe Importance of PR & Communications in Conducting Research
tTransferable Skills from Research tApplying the Findings from Research to Beneﬁt Patients tExperiences of a Researcher
GETTING STARTED The ﬁrst step on the research career ladder is to identify a research topic that interests you - which can often be a diﬃcult task. Strategies to help you with this include keeping an interest log or diary, brainstorming ideas (looking for patterns and recurring topics) and approaching local researchers to ﬁnd out what is already going on in your area. Regular reading of the medical literature may also reveal startling gaps in current knowledge that you may be the ﬁrst to recognise! You may then, for example, express an interest in cancer research but which aspects in particular? Do you want to work on a speciﬁc cancer? Do you want to perform molecular or epidemiological studies or do you want to work on cells in culture, animal models or clinical studies? Whilst it is beneﬁcial to be ﬂexible in the topic you wish to study you should aim to deﬁne a topic which is manageable with a small scale focus, with options available for the investigation of your hypotheses. Once you have considered various topics you may wish to approach potential research supervisors whose interests cover the topic you wish to study. Their role will be to assist you in formulating appropriate research questions, guiding you through the design, planning, funding and management of your project. Most large academic institutions run ‘graduate schools’ that can assist you in ﬁnding an appropriate supervisor for your studies. Your supervisor need not be a clinician and many advances in medicine have come about through collaboration with chemists, engineers and others. Remember that the goal of medical research is not only to generate new knowledge but also to become a competent researcher, capable of undertaking independent study in your chosen ﬁeld. Involvement in existing projects may allow you to develop these skills in a supportive environment before progressing to lead your own work. Dr Caroline Patterson, Clinical Research Fellow, Imperial College, London DISCLAIMER: THIS ARTICLE PRESENTS INDEPENDENT RESEARCH PARTIALLY COMMISSIONED BY THE NATIONAL INSTITUTE FOR HEALTH RESEARCH (NIHR) UNDER THE COLLABORATIONS FOR LEADERSHIP IN APPLIED HEALTH RESEARCH AND CARE (CLAHRC) PROGRAMME FOR NORTH WEST LONDON. THE VIEWS EXPRESSED IN THIS PUBLICATION ARE THOSE OF THE AUTHOR(S) AND NOT NECESSARILY THOSE OF THE NHS, THE NIHR OR THE DEPARTMENT OF HEALTH.
A BEGINNERS GUIDE TO RESEARCH RESEARCH METHODS Research methodology, or design, describes how a researcher goes about answering a research question. Broadly speaking, research design in health sciences is either descriptive or empirical (see Fig 1). These diﬀer in philosophy, approach, measurement and purpose. Other considerations include prospective and retrospective data collection. The appropriate choice of study design depends on the research problem you are trying to answer.
For example, if a researcher wishes to discover whether intervention with Drug B will improve mortality rates in elderly patients who have been admitted with an acute stroke, a randomised control trial is entirely appropriate. If, however, the researcher wishes to discover how carers of elderly patients who have suﬀered an acute stroke cope in the community, a questionnaire survey investigating carers’ perceptions is the most appropriate choice1.
Dr John Soong, RCP Clinical Quality Improvement Research & Training Fellow Further information about qualitative research: Mays N, Pope C, Journal BM. Qualitative research in health care: Wiley Online Library, 1996.
FIGURE 1: TRADITIONAL HEALTHCARE RESEARCH METHODS In addition to the traditional medical research model above, new methodology has been recently developed to better cope with the complexities of evaluating the success of interventions in real healthcare systems. These methods are broadly described as improvement science, and come in various ﬂavours including quality improvement, statistical process control, lean, six-sigma and evidence based implementation.
ENGAGING WITH STATISTICS IN RESEARCH Key messages: t Seek advice from a statistician early and often t Don’t underestimate the extent to which a statistician will need to understand the detail of your proposed research in order to advise you eﬀectively; or the time this will take. t “Wisest is he who knows he does not know” - be prepared for the statistical advice you receive to shape the design and implementation of your study t Involve your statistician at all stages of your study
t Consider your statistician in funding applications and publications t Be open minded about the statistical approach required - but also bear in mind the needs of your stakeholders: patients, staﬀ, funders, journals, etc.
for you? Which statistician should you talk to? What should you say? When should you approach this statistician? The way in which you interpret this superﬁcially simple piece of advice could be a key factor in the success of your research project.
Talk to a statistician If you are embarking on a career in health research, you are very likely to hear these words sooner or later, maybe from a colleague, maybe in a lecture, maybe even from a statistician. This is really good advice - but what exactly do these wise words mean
The Science of Statistics Statistics - the science of collection, analysis and presentation of data - is the means by which the hard work of your study will be transformed into meaningful knowledge. You could say that without statistics, your results will be meaningless!
Statistics is a science in its own right, distinct from, but symbiotic with, the other sciences. It is not surprising therefore that navigating through the forest of disciplines, theories and techniques available for the statistical elements of your study will require the skills and experience of a trained statistician. The choice of statistical methods for your study is intimately woven together with the other aspects of your study design. The statistical considerations involved in a study of the implementation of a new diagnostic test will be completely diﬀerent from those involved in a retrospective cohort study, or a double-blind randomised controlled trial … and within each of these broad classes of design there will be myriad factors that may be unique to your study, each impacting on the statistical design … you get the idea. This certainly doesn’t mean that you shouldn’t aspire to having a good understanding of the methods used in your study - just that it is unrealistic to aspire to do it all yourself. Talking to Your Statistician In discussions with a statistician it is important to keep an open mind with regard to the methodological approach whilst a ‘hypothesis test’ may be the appropriate analysis when you are using a random sample to make inferences about a large population, this approach is likely to break down when studying the implementation of an intervention for real in a speciﬁc setting. In that latter case, statistical process control may be a more appropriate methodology to adopt. It is also crucial to bear in mind the needs of your stakeholders: patients, other healthcare professionals, managers, colleagues, funders, journals, etc. Keep Talking But it isn’t enough to talk to a statistician once at the start of a study and then wave goodbye until it’s time to analyse the data. In fact your ﬁrst conversation will inevitably come up with questions that need answering before the work can progress. Once you’ve established the high level plan, it’s time to talk details - will you be sampling or is all the relevant data available? If you are sampling, how will you choose your sample? How big will it need to be? What data will you need to collect? How should you go about collecting it? What is the best approach to storing your data? Answering these questions is as important as deciding
which analysis to use - a t-test is merely a wild stab in the dark if due consideration has not been given to these crucial questions. Also note that some of these questions are far from trivial to answer, even for the most seasoned statistician. You may need to review existing literature, collect baseline data or perform a small pilot study in order to plan your main study well. A good research study will require statistical input throughout the work - from conception to publication and from publication to implementation. This can amount to a substantial amount of work, and this should be reﬂected in any project planning, funding applications, and publication authorship. But do not despair, help is at hand! To mention but a few: your research institution may have a statistics advisory service, your department or group may have dedicated statistical support, there is the NIHR research design service, the list goes on. I hope that the above convinces you ﬁrstly that it is important to “talk to a statistician” about any piece of research you intend to carry out, and secondly that it is important to do this early on (right at the start), in detail (the statistician needs to understand enough about your study to locate and successfully navigate through the right area of the forest), and frequently throughout your work. Further reading and resources: http://www.nihr.ac.uk/infrastructure/ Pages/infrastructure_research_design_services.aspx t D.G. Altman Practical Statistics for Medical Research, Chapman and Hall
t J.M. Bland An Introduction to Medical Statistics Oxford t B.R. Kirkwood and J.A. Sterne Essential Medical Statistics Blackwell t D.J. Wheeler Making Sense of Data : SPC for the Service Sector t Grafen, A; Hails R. Modern Statistics for the Life Sciences. Oxford. Dr Tom Woodcock, Principal Information Analyst/Statistician, NIHR CLAHRC for Northwest London
A BEGINNERS GUIDE TO RESEARCH PATIENT AND PUBLIC INVOLVEMENT IN PLANNING AND EXECUTING RESEARCH “The more you engage with customers the clearer things become and the easier it is to determine what you should be doing” - John Russell, former Vice President of Harley Davidson Motor Company Industry has long accepted that it is crucial to think about and engage with customers when designing or creating products. It is easier to think this way when company proﬁts relate directly to customers purchases, but perhaps more diﬃcult to think this way in the NHS, where care is free at the point of access. But in the NHS it has long been accepted that for care to be eﬀective it must be delivered in a more patient-centred way. And it is this ideal that should be the centre of your research. Engaging the end
user, be they staﬀ, patients, members of the public, carers or families is crucial to ensure your research leads to useful improvements and change for healthcare. This goes beyond involving people in a randomised controlled trial, to engaging the right people in the whole research process. A CLAHRC-funded project, evaluating a quality improvement framework to improve antibiotic prescribing in hospitals (AQIP), found value in engaging the right type of people in the right way. Local and national patient advisors were crucial members of the project team and continued to raise awareness of the project in other settings, thereby reaching a wider audience than the project initially intended. Similarly, OMERACT, an international network aimed at improving outcome measurement in rheumatology, gained new insights as a result of patient involvement. Novel outcomes such as fatigue were identiﬁed by patient groups and incorporated
into the research agenda. This was followed by substantial qualitative work demonstrating the importance of fatigue in rheumatoid arthritis and the development of powerful instruments for measuring fatigue. It is apparent that engagement of the right people at the right time in both these case studies added value which would otherwise not have been realised, or would have taken much longer to achieve. For practical information about patient and public involvement in research, visit the INVOLVE website (http://www.invo. org.uk/) or Research Design Service, London (http://www.rdslondon.co.uk/Patient--Public-Involvement.aspx) Meerat Kaur, Associate Programme Lead for Patient and Public Involvement, NIHR CLAHRC for Northwest London
r e w fo lin d No ted Me ) p ce by ed ac ing bM x u de (P in
Over 3,000 cases to view
Explore and contribute it to the world’s largest repository of case reports Become a BMJ Case Reports Fellow today and you can submit an unlimited number of cases and access all published content. For an Institutional Fellowship and free trial, email firstname.lastname@example.org. Personal Fellowships available for £115 + VAT. For more information visit casereports.bmj.com/site/about/becomeafellow.xhtml
THE PRACTICAL ASPECTS OF GETTING RESEARCH ‘OFF THE GROUND’ The early stages of the research process will vary according to factors such as the type of research and the research unit. Despite this, there are some broad tasks for most new researchers. t Start communicating eg: supervisors, research colleagues, potential collaborators clinical staﬀ, university, local research networks, PPI experts, statisticians, hospital/
medical school’s research ﬁnancial advisor t Consider logistics eg: working space, storage facilities, lab/equipment/software training, stationary, data storage, good clinical practice training t Get reading eg: research papers, local guidance, requirements for ethics, R&D and higher degree registration t Get writing eg; initial assessments, research protocol, participant leaﬂet, GP information sheet, informed consent form, grant applications, project plan, Integrated Research Application System [IRAS] - an online application form incorporating ethics, MHRA and Research
and Development (R&D) and other applications (ﬁgure 2). Remember to leave plenty of time. This is not an exhaustive list and some examples may not apply to you. Your supervisor(s), local R&D department and research colleagues should be able to provide local guidance. Ask if you are not sure! Dr Anjali Balasanthiran, Clinical Research Fellow, NIHR CLAHRC for Northwest London and Imperial College and Dr John Dixon, Clinical Research Fellow, St George’s Hospital, London
FIG 2: SUMMARY OF GAINING NHS PERMISSION FOR RESEARCH (AN EXAMPLE FROM CHELSEA & WESTMINSTER) Aligned to the recommended NIHR processes and reproduced with kind permission from the Research & Development Support Ofﬁce at Chelsea & Westminster Hospital NHS Foundation Trust.
A BEGINNERS GUIDE TO RESEARCH THE IMPORTANCE OF PR, COMMUNICATIONS AND NETWORKING IN CONDUCTING RESEARCH Meetings, emails, phone calls, texts; these are things we do every day to communicate with each other, yet may be the ﬁrst to be forgotten when starting a research project. Conducting a piece of research requires help via the most unexpected sources. In our experience, convincing people to ﬁll out a questionnaire was the most taxing aspect, making it necessary to obtain help from as many diﬀerent people as possible. For example, getting to know the receptionists at the GP practices led to the questionnaire being integrated into the checking-in system at the desk. This proved to be quite eﬀective and demonstrates the beneﬁts of
networking - it even doubled our recruitment numbers on consecutive days! Although sometimes time consuming and occasionally expensive (with the amount of chocolates given out!) we couldn’t have reached the number of questionnaires ﬁlled out without being friendly and using a bit of charm. You never know who might be willing to help and you will never ﬁnd out without putting in the eﬀort. Sarah Hancox & Joshua Wolrich, Medical Students and Investigators on ‘Patient & Public Views of Electronic Health Records’ (study supported by the Wellcome Trust)
CASE EXAMPLE : PATIENT & PUBLIC VIEWS OF ELECTRONIC HEALTH RECORDS A study was conducted to obtain patient’s views on the use of electronic health records for healthcare and research. Recruitment exceeded expectations and 5336 patients ﬁlled in the study questionnaire across Northwest London. Below, the researchers highlight some factors they feel contributed to their success and made working on the study a rewarding experience: t Prior to launch, the questionnaire was piloted with patient and public involvement networks. Revisions were made until all participants found the questionnaire clear and concise. t Ample time was left for communication with frontline staﬀ in order to raise the proﬁle of the study. The message was spread using formal correspondence, informal visits, departmental meetings, posters and trust bulletins. t A one week induction period was invested in ensuring all researchers were clear about the aims of the study and the importance of research in the ﬁeld. t During recruitment, researchers always ensured they introduced themselves to staﬀ in the clinical areas and observed the way patients moved through the department. t Close monitoring of recruitment statistics (electronic spreadsheet and whiteboard) provided a clear idea of progress as well as areas for improvement. Regular meetings were held to discuss problems and share success stories and tips. Networks were developed. t A Gantt chart was used for project management, clearly demonstrating deadlines. t Motivational charts were used and goals were set. t Researchers scheduled time for socialising in order to keep fresh and motivated! Study supported by the Wellcome Trust. Dr Anjali Balasanthiran, Clinical Research Fellow, NIHR CLAHRC for Northwest London and Imperial College
ROUTES INTO RESEARCH The route into research has traditionally been convoluted and unclear. More deﬁnite routes are now being established. For example, if you decide early on that you wish to be a clinical scientist, you can now undertake an intercalated MB PhD at undergraduate level. For more information visit - www.academicmedicine.ac.uk/careersacademicmed/medstudents/mbphd.aspx For those medically qualiﬁed and at the early stages of their specialty training, NIHR Academic Clinical Fellowships are specialty training posts that incorporate
academic training into the rotation, with 75% of the rotation devoted to specialty training and 25% devoted to research (ﬁgure 3). It is a structured platform to allow for the development of academic skills and experience that will support a candidate’s future application for a Research Training Fellowship (eg PhD). For more information: www.nihrtcc.nhs.uk/intetacatrain/acfs Another option is to undertake a postgraduate degree in translational medicine or clinical research. These courses beneﬁt from being fairly ﬂexible in nature: part-time whilst in specialty training or full-time outof-programme; at postgraduate certiﬁcate
level or up to a full masters. They expose trainees to both theoretical and practical aspects of research and increase the attractiveness of a candidate when applying for research training fellowships. If you intend to continue clinical work during your time in research consider carefully how this will impact on your research time. Also note that if you would like your time in research to count towards your total training time this should be agreed prospectively by the deanery. Dr John Soong, RCP Clinical Quality Improvement Research & Training Fellow
FIGURE 3: ACADEMIC TRAINING PATHWAY (THE NATIONAL STUDENT ASSOCIATION OF MEDICAL RESEARCH, NSAMR)
A BEGINNERS GUIDE TO RESEARCH GOVERNMENT SOURCES OF RESEARCH FUNDING The Government currently funds health related research through two main routes, the Medical Research Council (MRC) and the National Institute for Health Research (NIHR). In 2010-2011 the Medical Research Council received £682 million from the Department of Innovation, Universities and Skills and the National Institute for Health Research (NIHR) received £992 million from the Department of Health. The MRC supports research across the biomedical spectrum, from fundamental lab-based science to clinical trials, and in all major disease areas. The NIHR supports NHS, social care and public health research. The role of the NIHR is to develop the research evidence to support decision-making by professionals, policy makers and patients, make this evidence available, and encourage its uptake and use. NIHR research covers the full range of interventions, including pharmaceuticals, biologicals, biotechnologies, procedures, therapies and practices, for the full range of health and healthcare delivery such as prevention, detection, diagnosis, prognosis, treatment and care. Both the MRC and NIHR provide opportunities for young doctors to get involved with research and have established career paths to support development of clinical academics. MRC Career Path and Funding Options Clinical research training fellowship: Up to three years support for clinically qualiﬁed, active professionals to undertake specialised or further research training. Doctoral Studentships: The MRC funds postgraduate research training through studentships. They do not provide funding to students directly; prospective students should contact the institution at which they wish to study Clinician scientist fellowship: To enable outstanding clinical researchers to consolidate their research skills and make the transition from postdoctoral research and training to independent investigation. Jointly funded clinical research training fellowship: Opportunities for additional clinical research training fellowships through collaborations with Royal Colleges and Charity funders. Senior clinical fellowship: Prestigious award for clinical researchers of exceptional ability. For further information see www.mrc.ac.uk/Fundingopportunities/index.htm NIHR Career Path and Funding Options NIHR Integrated Academic Training Programme: An integrated academic training scheme for junior doctors to enable them to combine academic and professional training. Two main schemes make up this NIHR-funded pathway: Academic Clinical Fellows (ACFs) and Clinical Lectureships (CLs). Funding is provided for some 250 ACFs and 100 CLs for doctors: t An Academic Clinical Fellow provides a protected period of predoctoral research training (25% WTE) with the remaining time spent undertaking specialty training. Fellows prepare themselves for a subsequent period of PhD training that may be funded by NIHR or other major research funders (see routes into research). t A Clinical Lectureship is an early postdoctoral award that splits time equally between research and clinical training. t In-Practice Academic Fellowships for fully qualiﬁed general
practitioners (GPs) and dental GPs with only limited research experience, but who can demonstrate potential as future clinical academics. NIHR Trainees - PhD studentship opportunities t NIHR-funded PhD students based mainly in NIHR Biomedical Research Centres (BRCs), Biomedical Research Units (BRUs) and Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). t Trainees are supported through approved training programmes oﬀered by NIHR Schools. NIHR Fellowship Programme Four levels of fellowship are oﬀered covering four career stages from PhD training through to establishment as an independent researcher: t NIHR Doctoral Research Fellowships t NIHR Post Doctoral Fellowships t NIHR Career Development Fellowships t NIHR Senior Fellowships For further information see http://www.nihr.ac.uk/faculty/ or http://www.nihr.ac.uk/Lists/Research%20Training%20Awards/ awards_current.aspx Dr Julie Reed, Health Foundation Improvement Science Fellow and Head of Research Strategy for NIHR CLAHRC for Northwest London
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NON-GOVERNMENT SOURCES OF RESEARCH FUNDING Your local R+D ﬁnancial advisor will be able to advise you on any potential study costs involved and suggest sources of funding. Some are listed below: 1. Commercial/Pharmaceutical companies - often sponsor early phases of drug trials and will pay full economic costing (i.e. staﬀ salaries and building overheads). Usually several centres will be involved in the same trial. Amount: often >£100K. 2. Professional bodies (e.g. Medical Royal Colleges) - will often fund small projects to small-scale fellowships lasting 12 months. Don’t forget to apply to international bodies (e.g. European and US Societies). Amount: £1-100K. 3. Disease-or-specialty-speciﬁc charities (e.g. Diabetes UK, Kidney Research UK) -provide a range of fellowships and other smaller grants. Amount: £5K-150K. 4. Local (hospital) charities - usually fund small studies or top-up more substantial grants. Amount: usually £5K maximum. 5. Non-medical research charities - rarely
fund medical research, although there are some exceptions (e.g. Bill and Melinda Gates Foundation). 6. The Grants register - is a reference book available in most libraries that is a comprehensive guide to worldwide professional and postgraduate funding. It is important to check the relevant funding body’s website regularly because most will hold ﬁnding applications only once or twice per year. Further information t Your Local R&D oﬃce will often be able to provide an up-to-date list of local, national and international funding opportunities. t Medical Research Council. www.mrc. ac.uk/fundingopportunites t NIHR www.nihrtcc.nhs.uk t Wellcome trust www.wellcome.ac.uk t BMA Research grants web page www. bma.org.uk/about_bma/awards_grants/ ResearchGrantsOther.jsp t The Grants Register
APPLYING THE FINDINGS FROM RESEARCH TO BENEFIT PATIENTS Research plays an extremely important part in the development of new treatments and technologies for use in healthcare and also provides a greater understanding of patients’ needs and experience. However, the transfer of research knowledge into care is slow at best and absent at worst. For every £100 spent on research only £1 is spent on implementing the ﬁndings of the research to improve patient care. Cooksey2 identiﬁed two gaps in the translation of research in to healthcare. The ﬁrst gap is between the translation of biomedical knowledge to innovations, the second gap lies between the generation of innovations and their inclusion in the standard delivery of care. The National Institute of Health Research, directly funds research within the NHS and aims to create a world class infrastructure in the UK for the comprehensive development, testing and implementation of innovations that beneﬁt patients. The NIHR funds a range of programmes including Biomedical Research Centres and
Dr John Dixon, Clinical Research Fellow, St George’s Hospital, London
TRANSFERABLE SKILLS FROM RESEARCH Aside from clinical and technical skills, here are just a few of the other skills you may develop/hone during your time in research. These skills are likely to boost your conﬁdence, enhance your practice and make you more appealing to potential employers. t Problem-solving t Independent thinking t Self-directed learning t Project management t Time Management t Negotiation t Assertiveness t Resource Management
t Adaptability t Presentation t Statistics t Ethics t Critical Analysis t Systematic review t Informed consent t Self awareness
t Networking t Communication t Team working t Creativity t Stress management t IT
For tips on incorporating your research experiences into your CV as well as general medical CV writing skills see: http://careers.bmj.com/careers/advice/view-article.html?id=3043 Dr Anjali Bala, Dr Caroline Patterson, Dr John Soong
REFERENCES 1. Crowe M, Sheppard L. Qualitative and quantitative research designs are more similar than different. Internet Journal of Allied Health Sciences and Practice. 2010;8:1-6. 2. Cooksey D. A review of UK health research funding. 2006 [http://www.hm-treasury.gov.uk/d/pbr06_cooksey_ﬁnal_ report_636.pdf]
What is your role within the NIHR CLAHRC for Northwest London? I am a clinical research fellow but whilst my main role is working on my postgraduate research project (see below), I have also been fortunate enough to get involved with several parallel projects. CLAHRC has also oﬀered me the opportunity to gain experience in quality improvement through research strategy meetings and learning events. Collaborations with non-clinical and clinical experts have made me challenge some of my views and helped me gain an appreciation for different perspectives.
What area of research are you working on, and how did you get interested in it? Knowing myself, I appreciated early on that I would be happiest working on a practical, patient-facing project. I chose to work on stress hyperglycaemia, a common and under-diagnosed condition, often
A BEGINNERS GUIDE TO RESEARCH Units, which aim to bridge the ﬁrst translational gap through new innovations and advances in medical care from basic clinical and biomedical research. A recent addition to the NIHR family of research programmes includes the Collaboration for Leadership in Applied Health Research and Care (CLAHRC). The aim of the CLAHRCs is to close the second translational gap in delivering research evidence into everyday practice. Nine CLAHRCs have been established across England receiving over £88 million of government funding. The CLAHRC for Northwest London was established in October 2008. The CLAHRC for Northwest London’s vision is that patients experience a seamless journey with consistent delivery of the highest quality evidence based care achieving this by developing a systematic and scientiﬁc approach to the implementation of evidence based care that is generalisable and transferable across health economies. Key components of the CLAHRC for Northwest London approach are: t Understanding care from the perspective of patients and carers through engaging patients and public with the design and development of care
t Bringing research more rapidly into everyday practice, utilising rapid-cycle research, improvement methodologies and rigorous evaluation of clinical and cost eﬀectiveness t Adopting industrial standards of quality in the NHS through utilising information to drive evidence based implementation and support evidence based practice t Increasing staﬀ capacity for research and implementing change and improvements across professional and organisational boundaries. The CLAHRC for Northwest London is conducting improvement driven research in 18 diﬀerent clinical areas ranging from managing Sickle Cell in primary care to increasing referrals to mental health services and improving compliance with NICE standards from COPD in acute care. Stuart Green, Public Health Information Oﬃcer/Research Fellow, NIHR CLAHRC for Northwest London & Dr Julie Reed, Health Foundation Improvement Science Fellow and Head of Research Strategy for NIHR CLAHRC for Northwest London.
INTERVIEW: EXPERIENCES OF A RESEARCHER associated with poor outcomes. The study design is prospective and observational and patients are recruited from the acute assessment unit (AAU). This area of research ﬁts in very well with my training as it covers aspects of Diabetes, Endocrinology and General Medicine. I became interested in it after lots of reading and chatting with colleagues and supervisors. The oﬃce whiteboard was useful for brainstorming ideas! I am also an investigator on a multicentre randomised, double-blind trial. I got involved in this after making contact with various experts in the ﬁeld of stress hyperglycaemia and expressing an interest.
there is plenty of work to keep me going! I try to keep it varied and interesting as sitting at a desk can sometimes be tricky when you are used to pacing the wards all day! Desk-work may include literature review, data analysis and entry, telephone followup of recruited patients, grant applications, aﬃliated projects supporting CLAHRC, or work on the outcomes of research (posters, presentations, papers etc). I also attend courses which complement my research and training eg: statistics, academic writing, speciality training days and have regular meetings with supervisors and collaborators. There are also plenty of opportunities to get involved in undergraduate teaching.
What does a typical day entail for you? A typical day for me would start with checking AAU for patients who may be suitable for my study. Often I will do this with our research nurse. If recruitment is successful, then study procedures typically take up most of the day. If I do not recruit, then
What do you enjoy most about your work? It is great to feel as if you are becoming an ‘expert’ in your ﬁeld and are contributing, even in a very small way, to knowledge which may beneﬁt patients.
What keeps you awake at night? Deadlines and missed opportunities!
What has surprised you most about doing research? How willing patients are (when approached nicely) to take part in research, even when they know it will not necessarily beneﬁt them directly. What advice would you give to junior doctors thinking about getting involved in research? Whilst there are many positives to research, it may initially be a challenge to adapt to a non-clinical environment and work in a selfdirected manner. If possible, try to vary your days to keep refreshed and motivated and allow plenty of time for everything. Keep good people around to talk to and inspire you. Dr Anjali Balasanthiran
CLINICAL RESEARCH FELLOW NIHR CLAHRC FOR NORTHWEST LONDON
CAREERS IN ORAL AND soft tissue work in A&E - and given the number of soft tissue injuries that present via A&E, a signiﬁcant number of these will be referred to maxillofacial surgery. Being on-call is not just about admitting and clerking patients, you actually get to treat them too unlike many specialties. For a specialist trainee the scope of surgery is broad and diverse (see table 1) and operations can range from a 12-hour head and neck cancer free ﬂap to advancing a patients mandible and maxilla - both are complex and engaging and you acquire a unique surgical skillset.
What do maxillofacial surgeons actually do? It may sound like a cliché, but think of the face and ask what a maxillofacial surgeon can’t do! It isn’t only teeth and maxillofacial surgeons aren’t all just dentists (although yes, you do need a medical and dental degree to start speciality training). As a junior trainee you will spend your on-call shift seeing facial trauma. That includes suspected fractures, soft tissue injuries and dento-facial infection. Maxillofacial surgery is one of the few specialities where you are able to undertake a wide array of
Is maxillofacial surgery right for me? The face is a ‘high stakes’ surgery and anatomically complex. These technical and aesthetic concerns make oral and maxillofacial surgery (OMFS) both a challenging and rewarding speciality. You may be a Medical Student, Foundation Doctor, or a Core Surgical Trainee considering ST applications - but all the usual tactics still apply. Speak to trainees and registrars already committed to the speciality. The Junior Trainees Group of the British Association of Oral and Maxillofacial Surgeons is an invaluable resource1; email a committee member, join the group, or attend their annual conference. If you are a medical student reading this then speak to your local hospital OMFS team and get some exposure. As a Foundation or Core Trainee you should ‘try before you buy’. Within your
Head and Neck Cancer Surgery
Removal of tumours and subsequent tissue ﬂap reconstruction
Craniofacial Deformity Surgery
Correction of congenital or acquired facial deformity e.g. Cleft Lip/Palate, to improve function and quality of life
Management of soft and hard tissue injuries/tumours of craniofacial structures
Surgery of the teeth, jaw, temporomandibular joints, and related facial soft tissues
Diagnosis and treatment of medical conditions of the oral cavity
Surgery to enhance facial aesthetics and improve quality of life
(adapted from the British Association of Oral and Maxillofacial Surgery website1)
hospital introduce yourself to the lead Consultant and arrange to spend some time in the department. Medical school special study modules or trainee taster days/weeks are also great for this. An up-to-date article (Tahim et al.) lists all the above and more, describing the various avenues of learning more about OMFS as a career2, and the online OMFS trainee journal Face Mouth & Jaw Surgery is an excellent source of information3.
How do I get into Maxillofacial Surgery? If you like what you see then the Trent, Northern and Oxford deaneries all oﬀer Foundation jobs in OMFS, and the London and Northern deaneries oﬀer Core Training posts. As most Senior House Oﬃcer positions in OMFS are ﬁlled by dental graduates, departments are always willing to employ enthusiastic medical graduates. You may choose to take a year out after Foundation or Core training and get real OMFS job experience as this will always be helpful in future dental school or ST application interviews. If your decide to pursue OMFS then options for dental school will soon begin to occupy your thoughts. Currently there are several four-year postgraduate courses available, with only one 3-year course oﬀered by King’s College London. However, please note that the length of Dentistry degrees is under review by the EU and may be subject to change (always check the UCAS website). Although a considerable time commitment, returning to university is a unique opportunity to step oﬀ the surgical career escalator and spend time gaining OMFS experience, beeﬁng up you CV and pursuing other extra-curricular activities. Touching base with a local OMFS unit during this time is crucial; they can oﬀer you on-call shifts, projects and help you keep a foot in the door. Unfortunately, all the pros listed above are overshadowed by the recent rise in university tuition fees. A second degree is now a major ﬁnancial burden. Previously students were able to obtain NHS bursaries to pay one or two years tuition, however this commitment has not yet been conﬁrmed for the raised fees. Either way get ready to do plenty of locum shifts and be a poor student again! It’s fair to say that the training pathway for OMFS is complex, changing and very confusing (ﬁgure 1). If you have completed
MAXILLOFACIAL SURGERY? Foundation Training only, but have been able to pass your MRCS and gain OMFS experience, then you are eligible to complete Core Training competencies in one year and proceed to Specialist training4. ST applications are now centralised and run out of the Severn Deanery, with two annual recruitment rounds. Compared to its competitive surgical counterparts of Plastic or Neurosurgery, the odds in OMFS are currently very favourable. Be sure to read the person speciﬁcation well in advance to help tailor you CV5.
Opportunities within Maxillofacial Surgery As a young expanding speciality there are great opportunities for academic and career fulﬁlment. Oral cancer is one of the most prevalent cancer types with evidence of an increasing incidence in the UK6. The survival rate has not improved in the last 20 years, as largely patients still present late because of poor awareness on their part and delayed diagnosis by other clinicians7. These statistics are ﬁnally getting the attention and research dedication they deserve there is great scope to undertake practice changing clinical research. Perhaps more than other surgical specialities there is the opportunity to practice OMFS abroad in developing countries. Charities such as Facing Africa or Mercy Ships treat facial conditions from clefts to noma and are always willing to recruit keen trainees to assist in projects abroad. OMFS is exciting, expanding and engaging; and those willing to take a leap of faith and invest in a degree in dentistry will ﬁnd the job opportunities and satisfaction a just
Medical School - 5-6 years
Foundation Year 1 Foundation Year 2
reward. If this article has sparked your interest then take the time to read and discover more about OMFS as a career, and the training pathway. KARL PAYNE, RORY O’CONNOR, NABEELA AHMED
REFERENCES http://www.baoms.org.uk/page.asp?id=84 Tahim A, Awal D. What resources are available for undergraduates considering a career in Oral and Maxillofacial Surgery: A review. Face Mouth Jaw Surg 2011; 1(2): 71-175 Face Mouth & Jaw Surgery. www.fmjs.co.uk http://www.mmc.nhs.uk/pdf/PS%202012%20ST3%20 OMFS1.pdf http://info.cancerresearchuk.org/cancerstats/mortality/ cancerdeaths Doobaree IU, Landis SH, Linklater KM, El-Hariry I, Moller H, Tyczynski J. Head and neck cancer in South East England between 1995-1999 and 2000-2004: An estimation of incidence and distribution by site, stage and histological type. Oral Oncol 2009; 45(9): 809-14 Rogers SN, Vedpathak SV, Lowe D. Reasons for delayed presentation in oral and oropharyngeal cancer: the patients perspective. Br J Oral Maxillofac Surg. 2011 Jul;49(5):349-53.
Core Surgical Training year 1 Core Surgical Training year 2 (CT3 OMFS themed)
SHO post in OMFS - 1 year
Dental School - 3-4 years
Specialist Training (OMFS) ST3-ST7 +/- Fellowship
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THE QUACK GUIDE S
hiv Chopra is a member of Wesleyan Medical Sickness’ Advisory Board. He is currently in his ﬁrst year as a Core Surgical Trainee in London, working at the National hospital of Neurology and Neurosurgery. As if that wasn’t enough, Shiv is also the owner and creator of ‘The Quack Guide’, the UK’s ﬁrst and only independent guide to foundation hospitals for students and junior doctors. In this interview, he talks about the challenges of building a successful medical career while still ﬁnding time to run a successful not-for-proﬁt business.
WHAT HAS MADE IT SO SUCCESSFUL?
Having great relationships with every foundation school manager, the UKFPO (United Kingdom Foundation Programme Oﬃce) and doctors across the UK, has been vital, as has making sure our information is up to date. It allows Quack to provide a hassle-free way to ﬁnd out about a foundation hospital and its surroundings, meaning students don’t have to spend hours researching, which is not ideal when you have ﬁnals looming. And, of course, we wouldn’t be so successful without the dedicated team of Quack-a-holics! WHAT ARE THE CHALLENGES OF RUNNING A NOT-FORPROFIT BUSINESS?
WHAT IS QUACK?
In 2007 the way junior doctors were recruited changed from a local recruitment scheme to a national one. This meant ﬁnal year students had to rank all regions of the country in order of preference without any knowledge of the hospitals and surrounding areas. The fear in the back of every medic’s mind was that they could end up working in a hospital they had never been to before and with no family and friends nearby. Recognising these concerns, I tabled a motion to the national BMA conference to hold an expo or provide more information on all hospital sites, but this was not possible. So, together with a few friends from other medical schools, we created our own guide - The Quack Guide a free magazine sent to all medical schools in the UK. Two years later we went online and have just launched our new site. It is oﬃcially endorsed and supported by the medical school heads and foundation schools, and is written by junior doctors with ﬁrst-hand experience of the areas they are living in, providing testimonials and advice about living and working in the area and much more. It is a non-proﬁt website and is free for all students and junior doctors to use.
The biggest challenge is ﬁnding the right balance to keep my sanity. I’m currently a core surgical trainee and I have to complete DOPs, CEXs, TABs and many other three letter abbreviated assessments throughout the year to stay above water. Alongside all of this is my family, extra-curricular activities and Quack. There aren’t enough hours in the day! Last year I recruited people to help with Quack and was inundated with CVs from keen photographers to doctors who just wanted to express their views. The ﬁnance of the company is a real challenge too, especially as I want to keep the company free for people to use. This has been at a cost and I have had to invest a lot of my personal junior doctor wage into updating and promoting the site. I hope that through sponsorship and partnerships with interested companies I can maintain a free Quack guide in the future.
3. Form a team of people who can help in all areas of the business from the website to marketing 4. Be committed to the project for the long term. Businesses need to be constantly refreshed and updated so you need to be willing to commit the hours needed for a successful venture. WHAT NON-MEDICAL SKILLS DO YOU NEED TO RUN YOUR OWN BUSINESS AND WHAT HAS HELPED YOU FINE TUNE YOURS?
1. Haggle for the best process 2. Some basic accounting skills and being good with spreadsheets is vital 3. Go on a web design course or teach yourself so you are not always paying someone for the basic things you can do 4. Network with everyone to know your market, potential sponsors and competitors 5. Be prepared to ﬁne tune your knowledge the hard way - through trial and error and learning from mistakes. There is no book on this. WHAT HAS THE WHOLE EXPERIENCE TAUGHT YOU?
There is no ‘I’ in team and no success without ‘U’. WHAT ARE YOUR FUTURE PLANS FOR ‘QUACK’?
To have coverage of all hospitals, not just foundations training Trusts, and even information on working at sites around the world and advice on speciality training. I’d also like to create a mobile ‘app’ and produce some Quack merchandise. WHAT ARE YOUR GREATEST AMBITIONS?
WHAT ADVICE WOULD YOU GIVE OTHER DOCTORS WHO WOULD LIKE TO PURSUE THEIR OWN BUSINESS INITIATIVES?
1. Do your homework 2. Speak to people who have set up their own business
I’d like Quack to be the ‘Lonely Planet’ of guides for medical staﬀ and to keep helping my fellow peers through initiatives such as Quack. I’d also like to see Arsenal win the Champions’ League in my lifetime! Visit Quack at www.thequackguide.com
For more information or for specialist ﬁnancial advice contact Wesleyan Medical Sickness on 0808 100 1884 or visit the website at www.wesleyan.co.uk/doctors.
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Medicolegal Advice - in association
A ‘COPY AND PASTE’ The temptation to lift someone else’s work from the internet can be overwhelming when struggling to meet a deadline, but the risk is simply not worth it, says Charlotte Hudson lagiarism is a serious academic oﬀence, and one that has been around for centuries. Shakespeare allegedly stole most of his historical plots from Holinshed, and Oscar Wilde too, was repeatedly accused of plagiarism. Educational institutions are clamping down on the act of plagiarism - passing oﬀ someone else’s work as your own. Academic staﬀ are more commonly using a variety of online resources, such as anti-plagiarism software, to check the content of all submitted work.
academic work, including when conducting research, and take eﬀective action if they have concerns about the honesty of others t Be honest and trustworthy when writing reports and logbooks, and when completing and signing forms t Be honest in CVs and all applications and not misrepresent their qualiﬁcations, position or abilities t Not plagiarise others’ work or use their own work repeatedly in a way that could mislead.
EPORTFOLIOS, ESSAYS AND CVS
The GMC has speciﬁc advice on this issue in Medical Students: Professional Values and Fitness to Practise. It states that in order to demonstrate that they are ﬁt to practise, students must: t Be honest, genuine and original in their
It is not just essays that medical students/junior doctors need to worry about; CVs and job applications are also checked for plagiarism. On the internet an array of websites now exist oﬀering students custom-made personal statements and essays,
for quite a hefty fee. These sites promise that they are 100% plagiarism-free, but last year nearly 30,000 university applicants sent in personal statements that Ucas’ “similarity-detection service” ﬂagged up as copied (source:TES Newspaper). Even the personalised essays, which are guaranteed to be unique, come with a number of risks. By presenting someone else’s work as your own it is likely that you would be in breach of any plagiarism policy at any university. And there is also the chance that your tutor, who is probably clued up on your writing style, will spot the signs that your essay hasn’t been written by you. Other areas where foundation doctors may ﬁnd themselves in diﬃculty with plagiarism include ePortfolios, CVs and postgraduate academic work. An article on Medscape News Today says that the reason students are asked to write essays is because this is most likely
with the Medical Protection Society
CULTURE to demonstrate their ability to analyse and communicate complex material: “All of these are essential skills for the budding clinician or medical academic. Therefore, you need to show you can perform these tasks, and a gift for navigating the net and a facility for copying and pasting, is not the solution even if it a useful means to that end.” i
PROBITY Furthermore, the GMC takes the global issue of probity very seriously, and an allegation of plagiarism would undoubtedly raise
CASE STUDY Mary was in her F2 year and the deadline was looming for her application for a specialty post. She began to panic, but then remembered that her house mate Dave had applied the previous year, and he had given her a copy of his form at the time. By coincidence Mary wanted to apply for the same specialty, and Dave got his ﬁrst choice last year. Worried about running out of time
questions about your probity. Probity means being honest and trustworthy, and acting with integrity. Your actions as a medical professional should be ethical and should uphold the reputation of the profession, helping to maintain public conﬁdence in it. Never pass oﬀ anyone else’s work as your own. If you do use other people’s work, for reference purposes ensure that it is properly attributed and identify any direct quotes appropriately using quotation marks. Ensure that you are familiar with local policies and guidelines in relation to referencing
and not contemplating the consequences, Mary used Dave’s application form and got it in before the submission deadline. While waiting to hear whether or not she had been shortlisted, she was contacted by her educational supervisor who presented her with a copy of her application, and Dave’s from the previous year - Mary was accused of plagiarism. Most colleges and deaneries use anti-plagiarism software to catch out doctors who try to pass oﬀ others’ work as their own.
academic work. If in doubt, don’t be afraid to ask for help - it could be your future career that you are jeopardising. The message in this article is: do not risk your professional reputation and career by “copy and pasting” your way to the top. There are a lot of pressures and temptations in modern life that may tempt you to cheat and take the easy route - but in truth, the only person you are cheating is yourself. i
Marcovitch H, Plagiarism and Medical Students. Where the boundaries lie, Medscape News Today, accessed 16 February 2012
OUTCOME Realising the seriousness of the situation, she withdrew her application and successfully reapplied the following year. Mary put her career on the line just to save a little time - was it worth it? Read more about plagiarism in an article by Dr Jayne Molodynski, Whose work is it anyway? - www.medicalprotection.org/uk/new-doctor/june-2011/ whose-work-is-it-anyway.
About MPS MPS is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world. We actively protect and promote the interests of members and believe that education is an integral part of every health professional’s development. As well as providing legal advice and representation for members, we also offer workshops, conferences and a range of publications designed to aid good practice. 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.
MPS Members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.
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Assessed by Gil Myers
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) 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
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...” Laryngitis - 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 - most 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
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on English Dear Editor, elief your article I read with disb EWTD ‘Most ying with the pl m co ls ita sp ho pliant’ (Iss 23, w EWTD com no s ta ro ng ni ai tr but I think you they might do r pe pa n O ). p7 y junior doctor essed to ﬁnd an pr rd ha be ill w s per week and under 48 hour k or w es do ho w as required. If atutory breaks gets all their st d and we end strike goes ahea the BMA vote to be a lot of jobs rule’ there will up ‘working to completed. which will go un HELD
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:
4 x AA Batteries
Royal Hampshire Hospital, Winchester
Time to recharge at -
Kingston Hospital, Kingston
NAME WITH LONDON
Hot chocolate (small) Good news from
Dear Editor, Finally some go od news! It seem s the never ending tide of increasing fe es and annual charges from the Royal Col leges, BMA and GMC has started to turn ‘GMC cuts fees for all doct ors’ (Iss 23, p4 ). I calculated that last year I paid over £3,500 in fees and exam charges and that’s withou t all the extra courses and trai ning. ALEX WARD ST4, PSYCHI AT
Don’t let your batteries go ﬂat at -
Burns your wallet as well as your mouth at-
Royal Free Hospital, London
Lucky chocolate is good for you at -
Luton and Dunstable Hospital
Packet of tissues
Expensive enough to you weep at -
Whipps Cross Hospital, Leytonstone
Prices not to be sneezed at -
Frenchay Hospital, Bristol
Help us help the
23; p6) tors for hire’ (Iss Your article ‘Doc record 90% ere has been a th at th ts es gg su ctors going number of do e th in se ea cr in eelance’ but recently gone ‘fr e I’v . e’ nc la ee ‘fr ect it’s a simce - and I susp oi ch of t ou t no ors. There any junior doct m r fo y or st r ila e for us at gh jobs out ther ou en t n’ is y pl m but one si not complaining I’m t. en om m at th to me is that come apparent be s ha at th g in th xible workset-up for this ﬂe the NHS is not for the NHS able workforce ing. We’re a valu em. help us help th but they need to PTA
AVINASH GU NDON GP LOCUM, LO
‘Writing in the notes’ is our regular letters section. Email us at email@example.com.
Next issue we’re checking the cost of an apple, chicken and chips and a tube of toothpaste. Email prices to hospitalconﬁdential@juniordr.com
PRINCESS ALEXANDRA, HARLOW Sky HD on 42in High Def plasma, wireless 16Mb broadband, leather sofas, lava lamps. 3 computers in separate computer room: 2 for all access broadband. Kitchen with dishwasher, microwave, basic food bread, tea, coﬀee, biccies etc usually topped up. Separate chill out/quiet room (with a few old sofas!). £10/month.
WEEKEND WARD ESCAPE TO
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.
Plaza de Toros de Las Ventas - Whether you 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.
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.
BULFIGHTING AT PLAZA DE TOROS DE LAS VENTAS
KEY ATTRACTIONS Palacio Real - Arguably the most impressive building in Madrid with fantastic gardens which are perfect for a spot of lunch. There’s 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’s 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.
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 t POPULATION - 2,905,100 t LANGUAGE - SPANISH t CURRENCY - EURO t MADRID IS EUROPE’S HIGHEST CITY (2,100 FEET) PALACIO REAL
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$8#&9%.!#1-&:%,& > Meetings on major health and medical topics of the day > A forum to meet colleagues > Recognition and cash awards for distinguished work > A website with your own address. Visit www.mja-uk.org > Professional advice when you need it Wish to join? For more information visit www.mja-uk.org
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THE MEDICAL COURSE AND CONFERENCE DIRECTORY
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s doctors we hate scouring the web to ﬁnd where and when we can attend the next exam revision course, training event or conference.
We think they should all be in one place - which is why we launched EventsDr.com as part of the JuniorDr network. We’re aiming to build the most comprehensive database of medical events. Below you’ll ﬁnd just a selection of the full listings at EventsDr.com.
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