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LAST YEAR THEY CRUSHED OUR MORALE, THIS TIME IT’S OUR PAYPACKETS THE MAGAZINE FOR TRAINEE DOCTORS
Presenting History JuniorDr is a free distribution lifestyle magazine produced by doctors for the UK’s Medical Students, Foundation Year Trainees, Specialist Trainees, GP Trainees and Specialist Registrars. You can find us quarterly in hospitals and medical schools throughout England, Scotland, Wales and Northern Ireland, and updated daily at JuniorDr.com. Editor Ashley McKimm, editor@juniordr.com Editorial Team Michelle Connolly, Anita Sharma, Wendy Brown, Muhunthan Thillai Newsdesk news@juniordr.com Advertising & Production Rob Peterson, ads@juniordr.com JuniorDr PO Box 36434, London, EC1M 6WA Tel - +44 (0) 20 7 684 2343 Fax - +44 (0) 87 0 130 6985 team@juniordr.com Health warning JuniorDr is not a publication of the NHS, Gordon Brown, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not necessarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual orientation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash. © Copyright JuniorDr 2008. All rights reserved. Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out juniordr.com.
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n 2007 the MMC scandal led to a massive plummet in junior doctor morale across the NHS. Many disheartened doctors made an exodus overseas and those that remained were forced to endure a future of job and training insecurity. This year the pain continues. As we report in our news section newly qualified doctors are now faced with an effective 20 percent paycut following the loss of hospital accommodation – with no compensate increase in pay. This is despite the pay review “We have body previously using this perk in deciding salaries. remained At the same time that the government agrees an effective paycut for all junior doctors awarding a payrise of remarkably quiet 2.2 percent (below inflation), their regulatory bodies, while teachers, PMETB and the GMC, have hiked professional fees by up to 48 percent. train drivers and It doesn’t end there. From August 2009 European other public Working Time laws will reduce our hours from 56 to 48 hours – as a result our pay will dive further. Not that servants have anyone has questioned why so few doctors are currently made their working within their NHS contracted hours. Doctors are unlikely ever to strike – though we’ve voices known been close in the past. We have remained remarkably – and looking quiet while teachers, train drivers and other public servants have made their voices known – and looking at the at the facts facts we’ve more to complain about than any of them. we’ve more to Perhaps the Department of Health has successfully kept us so demoralised and strained under the recent complain about changes that we don’t have the energy to fight back. than any of Junior doctors and those that represent them have been surprisingly absent over the last few years. This is somethem.” thing we need to change. Over the next few months we will be asking a number of the big players, from the Department of Health to the BMA, what they plan to do about it and we’re giving you the opportunity to put questions to the people influencing your future. Help us by joining the debate at Ashley McKimm JuniorDr.com. JuniorDr Editor-in-Chief
What’s inside 04 10 12 14 17
LATEST NEWS BRIDGE OF DEATH - Suicides at the Golden Gate Bridge
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SECRET DIARY OF A CARDIOLOGY SPR DR FAIRYTALE
Killer Net – Pro-Suicide Websites HOW TO BE A SUPERMEDIC FACING DISFIGUREMENT
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Tell us your news. Email us at team@juniordr.com or call 020 7684 2343.
Working Conditions
nhs
Financial worries as junior docs face “20 percent paycut” • Below inflation payrises • Free accommodation scrapped • Soaring professional fees
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unior doctors are facing a year of massive financial pressure with “unacceptable” pay rises and loss of free accommodation resulting in an effective pay cut of 20 percent for many, say the BMA. The government has confirmed it will impliment in full the Doctors and Dentists Pay Review Body recommendation of just 2.2 percent payrise for junior doctors - half that called for by the BMA in November. GPs will receive an average increase of 0.2 percent per practice. “It is clear that the treatment of junior doctors is completely unacceptable,” says Dr Hamish Meldrum, chairman of the BMA. “This will further outrage a group that has already suffered enough. The loss of free hospital accommodation means doctors graduating from medical school with massive debts will effectively be losing £400 a month – a 20 percent pay cut.” The Doctors’ and Dentists’ Review Body (DDRB) was established to set the pay of doctors and dentists by inviting evidence from a range of sources, including the BMA and the government. Previously the DDRB has cited free accommodation as a reason against increasing junior doctor’s pay. The BMA has requested an urgent meeting with NHS employers to open negotiations with junior doctors. Medical students at their annual conference earlier this month also voted in favour of public protests if NHS employers do not engage in negotiations, or if an acceptable agreement cannot be reached. The low pay award follows figures released by the BMA showing the cost of being a junior doctor has increased by 80 percent over the last seven years while salaries have risen by only 20 percent. In February’s JuniorDr we reported on PMETB’s plans to increase the cost of the Certificate of Eligibility by 48 percent for doctors in non-training posts, and the rise in GMC fees by £100.
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NEWS PULSE
Dr Hamish Meldarum Chairman of the BMA
“It is clear that the treatment of junior doctors is completely unacceptable.”
www.bma.org.uk www.nhsemployers.org
Third of docs on understaffed rotas Junior doctors are being forced to work extra hours without pay because of gaps in hospital rotas, the BMA has found in a survey this month. Almost three in ten (29 percent) of the 432 respondents reported they were working on a rota with at least one vacant post. Although the majority trainees stated that one or two doctors were currently missing, some reported up to five absent colleagues. “It’s fundamentally wrong for junior doctors to be pressured into working excessive hours,” said Ram Moorthy, chairman of the BMA’s Junior Doctors Committee. “This was a problem that employers and the government could and should have foreseen, and it’s unfair that doctors have to prop up rotas without being paid for it.” The BMA believes the problem has arisen due to the inflexibility of the new medical training system introduced last year. It draws attention to a leaked Department of Health memo that stated that trusts may be ‘having problems in appointing to posts which fall vacant throughout the year because the new appointment process has provided trainees to a national timetable’. Many hospital trusts claim they have been unable to find locums to cover for unplanned sickness, particularly in psychiatry and paediatrics. Some hospitals have taken the unusual step of holding locum doctors hired through agencies in extended contracts to ensure clinical cover. The BMA has advised junior doctors to be alert to changes in their rota patterns and has warned the problem could result in increased stress, bullying and harassment. www.bma.org.uk
Training
Call for UK doctors to be licensed nationally
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octors should be licensed through a national examination to exclude regional variations in clinical performance, says a report published in the journal BAC medicine. The recommendation follows analysis of MRCP results of almost 6,000 UK medical graduates from 19 universities which showed strong variation in performance based on medical school. Medical graduates from Oxford, Cambridge and Newcastle universities performed better than average in the three-stage multiple choice and clinical examinations of the MRCP, whereas those from Liverpool, Dundee, Belfast and Aberdeen did least well in terms of their performance. 83 percent of Oxford and Cambridge graduates passed the MRCP Part I at their initial attempt, as did 67 percent from Newcastle. This compares with 32 percent and 38 percent of those from Liverpool and Dundee, a two-fold difference. “The General Medical Council (GMC) has explored the possibility of a national medical licensing examination in the UK, as exists in the US,” said Dr McManus, research team leader. “Our study provides a strong argument for introducing one, as we have shown that graduates from different medical schools perform markedly differently in terms of their knowledge, clinical and communication skills.” As part of the analysis they examined whether differences in medical school pre-admission qualifications could explain the variations, and found that they did so only in part, suggesting that differing teaching focus, content and approaches of the medical schools also play a role. The research also showed that male trainees outperformed their female colleagues on the multiple choice examinations, whereas females performed better on the clinically based PACES exam.
www.biomedcentral.com/bmcmed
Figure 1 - Medical school effects for the Part 1, Part 2 and PACES exams of MRCP(UK) - (Error bars indicate +/-1 SD)
Licence to practise
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Docs still most trusted profession Doctors continue to top the poll of professionals that the public trust the most, according to the latest annual survey commissioned by the Royal College of Physicians. Ipsos MORI polled over 2,000 people as to whether they trusted different professions to tell the truth. 90 percent of the public stated that they trusted doctors, closely followed by teachers at 86 percent. Only one in five trusted politicians and government ministers, however it was journalists and politician who ranked lowest with just 18 percent of the public trusting either of them to tell the truth. Dr Ian Gilmore President of the Royal College of Physicians
“I am delighted that once again the public rates doctors as the most trusted professionals.” “I am delighted that once again the public rates doctors as the most trusted professionals,” said Ian Gilmore, President of the Royal College of Physicians. “This fits with the work we have done, and continue to do, on medical professionalism. With patients having access to an increasing range of facts and figures and other information about their health, it is reassuring to know that the doctor/patient relationship is still highly valued.” Doctors have consistently topped the list of most trusted professions in virtually every year since 1983 when the poll began. www.rcplondon.ac.uk
All UK doctors will require a “licence to practise” by the end of 2009 if they wish to continue to treat patients, says the GMC. They estimate that out of the 240,000 doctors registered with them only 150,000 are in active practice. Any doctor who wishes to practise in the UK will need to hold a new licence issued by the GMC – those who do not may retain registration only. www.gmc-uk.org
Elderly expensive pill poppers Prescribing costs increase six-fold when patients reach 65, according to a study of more than five million patients published in the British Journal of Clinical Pharmacology. The study also found that female patients are 23 percent more likely than men to be prescribed medication. When researchers looked at the average number of drugs patients were prescribed those over 75 had almost eight times as many prescriptions as children under four. www.blackwell-synergy.com/loi/bcp
Parlez-Vous Français? Medical staff should have access to professional interpreters and specific training on intercultural awareness, according to recommendations in a study published in the open access journal BMC Health Services Research. The study of 2,400 doctors in Berlin found that around 20 per cent of doctors were dissatisifed with the course of treatment for non-German speaking patients – double that for those they treated in their native language. www.biomedcentral.com/
Smallpox alive in Scotland The vast majority of Scottish people interviewed on the streets of Edinburgh are unaware that smallpox is extinct, according to a poll sponsored by the Society for General Microbiology. Of the 200 people questionned only 13 per cent were aware that smallpox, which killed 300-500 million people during the 20th century, has been eradicated. Smallpox was declared extinct in 1979 following the WHO’s largest vaccination campaign. www.sgm.ac.uk
NEWS PULSE
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Less space for doctors
Working Conditions
Fears of training quality under EU working limits
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wo-thirds of junior doctors believe that compliance with the 48-hour working week will have negative effects on training, according to a survey by the BMA. The European Working Time Directive will restrict the time junior doctors can spend in hospital to 48 hours a week from 1 August 2009. Currently the limit is 56 hours. Despite the concerns only three out of ten respondents wanted the BMA to lobby for the 48-hour limit to be delayed, with the majority believing that doctors should be protected from working excessive hours.
Seven in ten believed that the number of years junior doctors spend training should be increased to obtain adequate experience. Currently two in five junior doctors (41 percent) reported they regularly experienced a need to undertake training during time off. “The 48-hour limit is coming, and it will have a massive impact,” said Ram Moorthy, chairman of the BMA Junior Doctors Committee. “Our training has to get far better if we’re going to continue to produce the best quality of doctors. We need to look at the possibility of lengthening the amount of time it takes to qualify as a consultant.” www.bma.org.uk
nhs
Female consultants ‘20 per cent less productive’ than men
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emale hospital consultants working in the NHS are responsible for 20 percent fewer patient episodes than their male colleagues, according to study published in the Journal of the Royal Society of Medicine. The research by the Universities of York and Birmingham logged the inpatient workloads of 8284 consultants across ten of the most common surgical and medical specialities. They found on average that male consultants completed 160 more episodes of care each year than their female colleagues. “The difference in activity between male and female consultants was striking and changed little between different medical specialties,” said Professor Nick Freemantle from the University of Birmingham’s Department of Primary Care. “Studies in the US and Canada have shown similar results, but in those systems doctors are paid by fees for service, so lower activity rates may represent a personal choice. It’s harder to know why this difference should exist in the NHS, but it’s a substantial and statistically significant difference across a wide range of medical areas.” NHS data was used by the team to chart the activity of individual consultants. Hospital Episode Statistics data contains details of all admissions to NHS hospitals in
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NEWS PULSE
England, and was linked with more general information about consultants’ age, gender and area of work. The authors did note that the HES data does not measure every aspect of consultant’s work, especially teaching and administration, where women may be more heavily involved. “These data do not show that men are better doctors than women. They do, however, highlight potential differences in the way medical careers develop for men and women in our health service,” added Dr Kamran Abbasi, editor JRSM. “It will be fascinating to explore the underlying reasons for this difference in productivity. Does it mean less is more?”
Half of junior doctors (54 percent) and a quarter of consultants said the quantity of their office space had declined over the last year, according to the UK-wide BMA poll. Over a third (36 percent) reported this had impacted on their ability to provide patient care with junior doctors most likely to report problems. They warned that the necessity of doctors having to ‘hot-desk’ was putting the confidentiality of their patients at risk. www.bma.org.uk
Docs find tests testing Many junior doctors do not understand basic laboratory tests, according to a survey by the Association of Clinical Biochemistry. They found that out of the 80 doctors questionned almost a fifth would order tests they were not confident in interpreting. Many did not feel confident in laboratory tests such as magnesium, phosphate, parathyroid hormone, urine sodium and osmolality and the short Synacthen test. www.acb.org.uk
PMETB to merge with GMC The Postgraduate Medical Education and Training Board (PMETB) is to merge with the GMC, according to new Department of Health plans. PMETB is the independent regulatory body currently responsible for postgraduate medical education and training. The combination of the two bodies is designed to aid revalidation and licencing of UK doctors. The decision follows recommendations made by Professor Sir John Tooke’s independent inquiry into the MMC reforms last year that the two bodies should be merged. www.pmetb.org.uk
Hospitals to turn green Department of Primary Care. University of Birmingham
“The difference in activity between male and female consultants was striking and changed little between different medical specialties.”
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www.rsm.ac.uk
Professor Nick Freemantle
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Six out of ten NHS trusts are making plans to tackle climate change, according to an NHS Confederation poll. Over half of all trusts were confident that they could reduce energy consumption, however only one in five thought they would be likely to invest in alternative energy or renewable schemes. www.nhsconfed.org
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Wellcome Image Awards 2008
Ruptured Blood Vessel, by Anne Weston
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his colour-enhanced image shows red blood cells leaking out of a ruptured blood vessel. This is due to a mutation in the ephrinB2 gene that causes the blood vessels to be more fragile than normal leading to an increased rate of haemorrhaging. This fragility is due to the inadequate coverage of the vessel by smooth muscle cells. This kind of leaky blood vessel is frequently found in tumours and in certain other human diseases.
images.wellcome.ac.uk
Used with permission from Wellcome Images
MAKING SENSE OF THE ECG Can you make sense of the following cardiac events?
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est yourself and see if you can work out the waves and intervals of the ECG that correspond to the following events: Making Sense of the ECG provides a portable, easyto-read and easy-to-remember guide to the ECG as a tool for diagnosis and management; answering these questions and many more. We have 10 copies of the updated edition of this prizewinning text to give-away! To win your copy, email the correct answers (with your name and contact details) to healthsci.marketing@hodder.co.uk.
Making Sense of the ECG Third Edition 978 0 340 94688 6 May 2008 304pp | PB 220 illus | RRP £17.99
Cardiac Arrhythmias Seventh Edition 978 0 340 92562 1 2006 | RRP £27.99
ECG event
Cardiac event
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Ventricular depolarization
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The period from the end of ventricular depolarization to the start of repolarization
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Total time taken by ventricular depolarization and repolarization
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Ventricular depolarization
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Start of atrial depolarization to start of ventricular depolarization
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Atrial depolarization
(Adapted from Making Sense of the ECG, Third Edition, page 18)
Are you looking for practical guidance on one of the most common investigations? LOOK NO FURTHER! The Third Edition of this prize-winning text has been fully revised and updated to reflect new guidelines on cardiopulmonary resuscitation and other interventions, as well as including many new ECG examples.
Sixth Edition highly commended at the BMA Medical Book Competition • Covers the diagnosis and treatment of all abnormalities in cardiac rhythm and emphasises the problems encountered in daily clinical practice • Includes over 350 ‘real-life’ ECGs of superior quality and a popular ‘arrhythmias for interpretation’ self-assessment section to test your understanding
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ADVERTORIAL
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Bridge of Death — San Franciso’s Golden Gate Bridge is not only known as the most photographed structure in the USA but also for it’s more intriguing title as the most popular site for suicide jumps in the world. Over 1,200 people have travelled to this location to take their own lives since the bridge opened in 1937. In fact, the rate of suicide is rising and, as Denise Oliveri reports, officials are struggling to stop the frenzy.
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he drop from the Golden Gate Bridge is approximately 260 feet. It takes a quick four seconds to drop from the deck of the bridge to the waters below, and at a speed of 75 mph it is almost always an instant death. With such a fast impact many jumpers are convinced they won’t feel a thing, making the idea of suicide more tolerable at this location.
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Suicides at the Golden Gate
1,200 people – number of people who have committed suicide from the Golden Gate since 1937 The Golden Gate Bridge has been a popular jump site for people wanting to commit suicide since the bridge opened in 1937. As of October 2003, there have been approximately 1,200 successful suicide attempts made here1 – a figure that has captured the attention of people worldwide. The latest statistics show there is one new successful suicide attempt made at the Golden Gate Bridge every two weeks. Marin County Coroner, Ken Holmes, reports that 206 people committed suicide by jumping off the bridge from 1997 to 2007. Fifty-nine of these incidents were by San Francisco residents, and made up a third of the total, but others travelled great distances just to plunge to their death at this location.
¾ of jumpers are from outside San Francisco The fall is brutal and violent. For most, death is immediate, but for a few they will land in the water in such a way they do not instantly die but are plummeted below the frigid water to a slow and agonizing death.
Reducing Suicide Attempts One proposal to reduce the number of suicide jumpers at the Golden Gate is to increase the height of the bridge railings, making it more difficult for jumpers to perform the plunge into the waters below. The problem with making higher rails is that they may not be able to withstand the 100 mph winds sometimes seen at this height. Different designs for barriers have been discussed by officials for years, but have met with much opposition from residents who don’t want the barriers in place.
26 survivors Cost has been a major issue for building the barriers, which could cost almost $20,000,000 3. Experts point out that barriers have improved suicide rates at places like the Eifel Tower in Paris and the Empire State Building in New York, but officials worry that these new barriers could cause safety issues for the bridge, especially in the case of high winds.
$20,000,000 – cost of improving barriers
One of fifteen telephones on the Golden Gate Bridge that connect callers to crisis support.
The bridge has suicide hotline phones installed along the path in the hope that those in desperation will make a call in lieu of jumping. Other precautions undertaken are that the bridge is closed to pedestrians at nightfall (with the exception of cyclists who are allowed access by staff through security gates) and beefed up security has been placed along the bridge where staff will patrol and look for any potential jumpers4.
Survivors of the Jump As of 2006, only 26 people are known to have survived the jump and most have died later from internal injuries2. These “survivors” usually land feet first in the water and sustain multiple fractures and damage to internal organs such as ruptured spleens. For most, their first attempt will be their last but in a suprising case a young woman who jumped once and survived in 1988, took the plunge again later that same year and died. For her the attraction of the now infamous ‘Bridge of Death’ was just too much. For more information on the suicide prevention efforts visit the Golden Gate Suicide Barrier Coalition at http://www.goldengatecitizens.com/suicide/info_where.htm. References
1,2. Jumpers: The fatal grandeur of the Golden Gate Bridge. The New Yorker, 2003. 3. “Deadly Beauty.” The Economist, 2006) 4. “Golden Gate Bridge: Bikes and Pedestrians.” Golden Gate Bridge, Highway and Transportation District, 2006
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The Killer Net pro-suicide websites People searching the web for suicide help are more likely to find sites encouraging them rather than offering support, says a study published in the BMJ. Many professionals are now supporting calls for sites like these to be banned in the UK. Michelle Connolly looks at the rise of pro-suicide websites, the people who use them and arguments for their existence.
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ype in some simple suicide-related search terms into four popular search engines and the results will show sites like ‘Alt Suicide Holiday’, ‘Satan Service’ and ‘suicidemethods.net’. Even academic discussion groups are occasionally ‘hijacked’ as a forum for pro-sucicide discussion. ‘Alt Suicide Holiday’ was initially established as a newsgroup in the late 1980s to discuss why suicides increase during holiday periods but has since evolved into a pro-suicide site. Researchers from Bristol, Manchester and Oxford analysed the first ten sites in each search for suicide1. 19 percent were dedicated pro-suicide sites with personal accounts of failed suicide attempts and discussion on the pros and cons of particular methods. Two of the sites went as far as portraying suicide and self-harm in a glamourous light. Nine percent provided information on suicide methods either in a factual, semijocular or completely jocular manner. Sites focusing on suicide prevention accounted for a meager 13 percent.
including copies of suicide notes, death certificates and photographs of the deceased. A report published by the Australian Institute for Suicide Research described three individuals who posted suicide notes on ‘Alt Suicide Holiday’ which read like a pre-suicide diary2. Typically, the individual notified the forum of his intent to commit suicide and enquired of the best method and how to obtain any necessary items. The replies would contain very specific information, for example how to precisely aim a pistol in the mouth for maximum effect. In two cases, the suicides were apparently successful via the use of firearms and selfpoisoning. In the first case, discussion of the suicide on the site centred on whether the encouragement the deceased received was appropriate. The third individual was not successful in his attempt to poison himself with carbon monoxide and was admitted to a psychiatric hospital. Shortly after his discharge he discouraged other forum members from using this method.
Suicide supporters
Unlike Australia, pro-suicide sites are not illegal in the UK, although the Suicide Act (1961) indirectly makes it unlawful to aid, abet, counsel, procure or incite someone to kill themselves. The charity Papyrus, established to tackle youth suicide, said the Act should be amended to make it illegal to publish such information online. In response, the UK Internet Service Providers Association has said it will remove sites but only those deemed illegal. Those
Pro-suicide sites host forums where those taking part in chatroom discussions encourage suicidal people to take their own lives, idolise those who have committed suicide and facilitate suicide pacts. Such discussion is likely to allay the fears suicidal people may have. Memberships of those discouraging suicide are revoked. The sites often describe specific suicides in graphic detail, frequently 12
SUICIDE
determined to circumvent an ISP-enforced ban can at present easily do so by the means of a disclaimer, while still leaving the damaging content accessible. One positive case report highlighted in the Psychiatric Bulletin3 showed how the internet can intervene in potential acts of suicide. It recounted how a woman who had posted a suicide note, and subsequently taken a potentially lethal overdose, was saved after a hacker traced her whereabouts in the UK and alerted the police who broke into her home and took her to hospital.
Sites currently legal References
1. Biddle L, Donovan J, Hawton K, Kapur N & Gunnel D (2008). Suicide and the internet. BMJ. 336: 800-802. 2. Baume P, Cantor CH, Rolfe A (1997). Cybersuicide: the role of interactive suicide notes on the Internet. Crisis. 18: 73-9. 3. Suresh K & Lynch S (1998). Psychiatry and the WWW: some implications. Psych. Bull. 22: 256-257.
Secret Diary of a Cardiology SpR * Names have been changed to try to keep our cardiology SpR in a job - though she’s doing a pretty good job of trying to lose it without our help!
Monday If you’ve been following this column then you’ll know I ended my struggle with research, finished my MD and went back to real work. And don’t worry about Foundation Two, he turned out fine. I’ve spent the last few months writing up my thesis which I handed in successfully and getting back to grips with medicine. The on-calls have been the hardest. During my research I did an angio list once a week but stopped general medicine completely for two years. Now that I’m back I’m doing about one on call a week. Not to mention the obligatory weekends and nights. Re-learning the practical procedures was easier than I thought. The hard part was willing yourself to go and see another confused little old lady with a UTI. By the time you’ve seen your third one in the middle of the night you’re willing to jack it all in and head back to the lab. Anything to save you from another mini mental examination. I spend Monday doing an echo list in the morning and then paperwork in the afternoon. I leave early and spend a couple of hours shopping for shoes before I decide on a pair. I go home and am in bed by ten.
Tuesday Consultant ward round today. I have two bosses. One is a real gentleman, has silvery hair and lets you do all the fun stuff in the angio room. The other is a complete idiot. It’s his ward round today. The juniors look nervous - no doubt they came in early to avoid a repeat of last week’s debacle when Dr. Weston made one of them recite the twenty known cardiac causes of clubbing. The poor kid got about ten which was pretty good going and even more than I knew but the entire ward round stopped as we watched him get humiliated over the rest. The ward round came and went and Weston was not so much quiet as deadly silent. He actually looked at the ECGs, enquired about troponins and made some real management decisions. Before he left he turned and thanked us all for our hard work. We stood at the bed of the last patient, shocked. The cardiac sister muttered something under her breath. I spent the afternoon in clinic seeing post MI patients and trying to persuade them not to have sex until they could at least climb one set of stairs.
Wednesday Angio list this morning where everything went smoothly until the last case. It was a simple angiogram to examine the vessel anatomy but I had trouble getting into either femoral. After a while I gave up and went for a radial which is something I hated doing but it worked in this case. It made me remember that as much as I thought I knew, there was still a lot to learn and at this stage in life it was still good to know that there was a consultant around if I ran into difficulty. I spend the afternoon reviewing a few ward patients and doing a couple of echos. I finish my paperwork and leave by seven meeting up with a few friends for a drink which soon turned into five. We lamented the lack of our love lives and the difficulties in our careers. We were all medics and so inevitably spent most of the evening complaining about our consultants. I took a cab home and collapsed into bed around two.
Thursday It is my RITA or yearly interview today. In order to celebrate (or commiserate) I took the day off. I woke up early and spent the morning ensuring that my log book was up-to-date. The interview started at twelve and most of it was pretty boring. Ticking off the log book, making sure I had attended some of the teaching sessions - the usual form filling exercise. We then got onto the subject of my career and what I was doing with my life. I explained that although I had enjoyed my MD I hadn’t decided what I wanted to end up doing. Academic work or being in a DGH. Cardiology alone or general medicine. Interventional work or standard stuff. The truth was that I hadn’t decided. I left with the advice that I had better decide by next year. As the interview committee had passed me, which they were always going to do, I celebrated by going shopping. Twice in one week was a lot. I came home early, called my parents and spent the rest of the evening watching American television and drinking merlot - which would have been a lot more pleasant if I had someone to share the bottle with. I got into bed early and fell straight asleep.
Friday I’m on call today. The morning was spent reviewing a couple of ward patients. I had a quick lunch and then decided to give some teaching on cardiac failure. The medical students seemed to be falling asleep and luckily the arrest bleep put us all out of our misery. I bumped into Weston towards the end of my on call. I wasn’t surprised that he was in late, no doubt checking on one of his private patients. I was however surprised when he offered to buy me a coffee in the canteen. Things were slow so I agreed. As he started into his cup he explained that his wife was leaving him and that was why he’d been so quiet all week. For some reason I’d assumed he was on his third or fourth wife. Maybe he was but he was obviously cut up about this one. I tried to offer a few faint words of advice but this was one area where I probably knew even less than him. He smiled wryly and told me not to worry, he’d be back to being a bastard next week. His words, not mine. Later that night, as I sipped on another glass of Merlot, I contemplated my career choices. Cardiology was always going to be tough but now that I was nearly at the end of my training, I had to decide what to do next. Whatever it was, I would probably spend the rest of my life doing it. I wasn’t sure what I wanted but I did know one thing for certain. I didn’t want to end up like Weston.
DIARY
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How to become a
SUPER MEDIC Step 1 – Suck up with style When your consultant can’t distinguish you from a RTA victim that’s been trailed through an articulated lorry sideways, there’s a problem. “Image is everything,” says Deborra Radcliffe, a professional image consultant. “Looking smart and dressing professionally can actually make you appear more intelligent than you actually are.” “For men, wear a shirt and tie that complement each other with the same colour shades,” suggests Radcliffe. If you’ve less colour sense than a blind patient without a guide dog then high-street chains such as Next and Debenhams sell pre-packaged matching combinations. “Shirts with cufflinks will improve your ranking but only if you wear a jacket or white coat on top,” she advises. Pokemon ties are only acceptable if you’re doing paeds … or if your consultant has the mental age of a five-year-old. If you’re a woman, forget the skirt advises Radcliffe. “Women who power dress are taken more seriously,” she says. For woman who have a soft voice and mild manner wear darker colours to appear more confident. “Students who already ooze confidence should choose paler shades to help you take advantage of your womanly side - it will make you appear more in touch with the patient’s perspective.” Make sure your shirt or white coat is cleaned and ironed. For men who undergo anaphylactoid reactions in contact with electric irons you can now get crease-resistant materials.
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MEDICAL STUDENTS
You get castrated by the consultants, nagged by the nurses and made to look stupid by the other students. “But, it doesn’t have to be this way,” you tell yourself. You should have the consultants begging at your feet, nurses under your power and be the top student on the firm. You should be a “SUPERMEDIC”. Here’s how.
Step 2 – Supercharge your CV Unless you want a job as a GP in the Outer Hebrides you’re going to be up against some tough competition when you qualify. House jobs at the major London teaching hospitals on medical firms are more highly sought after than free food at the Grand Round. So how can you make sure your CV gets more attention than a cardiac arrest? You’ll be judged not just on your academic record and progress reports but on your other achievements. Many medics will have an intercalated BSc or additional qualification, so make sure you’re in this group - check out our intercalated course guide online. Getting your name published in one of the journals is the second top tip. Most intercalated degrees offer the scope for students to produce a research paper, alternatively try offering your services to a research team in your medical school. If you don’t think you’re up for writing clincal papers get involved with JuniorDr or traumaroom.com by emailing the team.
Step 3 – I’m only a medical student A man collapses in the frozen vegetable isle at Sainsbury’s. Everyone stands and stares … until your best mate points at you and shouts, “He’ll know what to do he’s a trainee doctor.” Panic sets in. What do you do? … prop up his head with a bag of frozen peas and hope for the best? It’s a scenario many students find themselves in before they qualify. We get trained in how to identify Klienfelter’s syndrome and palpate breast lumps but first aid, the activity in which we could actually save lives, is rarely practised. If you don’t know your ABCs from your LFTs then it might be time you went on a first aid refresher course. Most medical schools offer these annually as part of the course, alternatively St. John Ambulance LINKS societies operate in most universities. To find out details of your nearest group send an email to info@links.sja.org.uk.
New charity launched to help fund student doctors in Africa
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Step 4 – Past Paper Pointers Medical students are inherently lazy. A quality that doesn’t disappear once you get to slap ‘Dr’ in front of your name – or Dean for that matter. Like us, the big boys who run our universities like to take shortcuts whenever they can and this includes setting exams. By simply rewording, or blatantly copying and pasting previous questions the exam setter saves themselves enough time for an extra round of golf. More importantly it gives you the opportunity to pick up extra marks. Armed with reams of past exam papers some students can become notoriously secretive about their past paper stash. Hunting them down is a valid exam revision activity and a great excuse for a night down the union after a hard day of hitting the books. This is where all those ‘friends’ you inadvertently made in the drunken haze of freshers week have their use. If your friends have no papers, or you simply have no friends, don’t despair. You’re likely to find at least a few years worth of exam material in the library, on the web or from tutors (if you beg hard enough). Failing that all universities set similar exam questions and formats (especially those that make up the University of London board) so there’s plenty of opportunity to hunt down at least a few papers at other uni’s too.
edic-to-Medic is a new initiative that aims to encourage UK doctors and medical students to directly sponsor their counterparts in Malawi, and was launched in the London this month. The programme guarantees to pay the £90 per year tuition fee of 20 trainee doctors in Malawi, selected on the basis of financial need and academic potential, for a full year. Doctors and medical students in the UK will sponsor an individual student, and will receive regular updates from that student on their progress. “Malawi has just one medical school located in Blantyre, its largest city. Despite government subsidies, it still costs students £90 a year to study and many cannot afford this,” says Dr Kate Mandeville, a SHO at Imperial College Healthcare NHS Trust who founded the program. “I hope by setting up this programme we can increase the number of doctors graduating every year and make real improvements to the healthcare of ordinary Malawians.” Malawi College of Medicine also faces difficulty recruiting academic teachers especially in the preclinical years. It is hoped that Imperial College students will have the opportunity to enhance their skills by assisting with teaching in Malawi during their summer holidays. The programme, administered through the International Medical Education Trust, also has plans to extend the scheme to postgraduate level in an aim to stem the tide of doctors leaving the country once they have completed their undergraduate studies. It is hoped that specialists could sponsor trainees in the same specialities, providing a supplementation to their local salary and thereby removing some of the incentives to leave Malawi to work in a more developed country.
www.imet2000.org/medictomedic
New disability guidelines for med schools
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ew guidance on accessibility for disabled medical students has been issued by the GMC this month. ‘Advising medical schools: encouraging disabled students’ aims to remove barriers to potential student who previously may have ruled out a career in medicine. It highlighted measures already taken by the eleven medical schools associated with the partnership including provision of hearing loop systems, specially modified stethoscopes and linking microscopes to CCTV screens for use in laboratory work.
www.gmc-uk.org/education/
MEDICAL STUDENTS
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The Ten Commandments for the Management of Controlled Drugs The objective of this checklist is to make sure that the systems in place for the management of controlled drugs (CD) are compliant with the requirements of the current legislation and are applied by all members of the Primary Health Care Team. 1. Ordering
There must be a system in place as to who will be responsible for ordering (named person), how will the order be placed and where will the drugs be ordered from. Requisitions for schedule 2 and 3 CDs must be in writing (not computer generated), be signed by the prescriber, must state prescriber’s name, profession and address, must specify the total quantity of the drug and the purpose of its use e.g. for practice use. A wholesaler or pharmacy supplying CD to a prescriber must be satisfied that the request is genuine, e.g. an original document not a faxed or electronically transmitted prescription. 2. Invoice
The invoice relating to the transaction must be retained by the practice for 2 years. 3. Authority
There must be clear guidelines as to who is authorised to collect the controlled drugs - also how the drugs will arrive at the practice and who will deliver the stock must be known before hand. 4. Responsibility
One designated person within the premises must take overall responsibility of storage. Where the drugs are stored, who has the access to the storage, does the cabinet comply with the safe custody regulations and where are the keys kept must be known at all times by the designated person. The CD container should only be opened by the designated person who remains ultimately accountable for CD’s management. 5. Doctor’s bag
A doctor’s bag is a locked bag, box or a case for home visits. This should be kept locked at all times except when in immediate use. Bags containing CDs should not be left in a car over night or left unattended for long periods of time. Each doctor is responsible for the receipt and supply of CDs from their own bag.
GP Editor:
Dr Anita Sharma (GP Oldham, Chadderton)
6. Administration
Any CD that is administered by a nurse/nurse independent prescriber or nurses acting under the direction of a nurse prescriber must be recorded in the nurses and patient’s notes stating the medicine, dose administered, the date of administration, the method and the person who administered it. The same rule applies for a doctor or a trainee doctor. 7. Register
All health care professionals who hold schedule 2 CDs must be kept in a CD register. The register must be bound, must have the name of the drugs, entries must be made in ink and made on the day of the transaction. No cancellations or alteration is allowed. Any correction made must be signed and dated at the bottom of the page or in front of the correction made. 8. Destruction
Health Care professionals and service providers are not allowed to destroy schedule 2 or 1 CDs from their stock without destruction being witnessed by an authorised person. The drugs returned to the GP by the patient’s carer or relatives after the death of the patient must not be reissued or used to treat other patients. All destruction must be entered into the CD register and must have the signature of the person who witnessed the destruction and the professional destroying it, (two signatures). 9. Incident
Any incident relating to CD should be reported and shared. All GPs whether salaried, full time or part time, are legally obliged to complete an annual self declaration form and send it to the PCT. 10. Update
All professionals involved in the use of CDs must attend an updated course every 3 years or earlier if there are material changes to the legislation.
www.cgsupport.nhs.uk/downloads/Primary_Care/controlled_drugs_in_the_community.pdf
New RCGP Tool for GP Research
Practice managers fear private sector
A new assessment tool to make research easier, quicker and simpler for GP practices has been launched by the RCGP. ‘Research Ready’ is a web-based programme aiming to help GP practices assess their ability to carry out quality research including making sure the practice is aware of its reponsibilities with conducting studies. A database of research is also designed to prevent practices beginning research which is being conducted elsewhere.
Private sector providers pose a serious threat to the quality of general practice and patient care say 68 percent of practice managers, according to a study by journal Management in Practice. Many fear the private sector could cherry pick the most lucrative treatments leaving the NHS funding costly, unprofitable remainders. A further 40 percent also believe their surgery buildings are not fit for purpose.
www.rcgp.org.uk
www.managementinpractice.com
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GENERAL PRACTICE
Facing disfigurement Founded in 1992 by James Partridge, Changing faces is the UK’s charity providing emotional and practical support to people with disfigurements. It was established after James suffered severe burns in a car accident, aged just eighteen. As he told JuniorDr’s Michelle Connolly it was a life-changing event that forced him to rethink everyday life and drastically reconsider things he had previously taken for granted.
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veryday since his accident people have stared at him and appeared uncomfortable and embarrassed when in his company. Ridicule on the street was common and he has even been turned away from restaurants. But James gradually discovered ways of managing other peoples’ unkind reactions. Since then he has brought help to other people affected by disfigurement through Changing Faces. How did you personally deal with your disfigurement? I didn’t adjust to the positive until I could deal with the disfigurement. I coped with the nervousness and avoided all social interaction. It was like going back to school having to learn how to react all over again. Then I became proactive and learnt how to reach out to others if they are not going to reach out to me. Of which achievement are you most proud? It would be the disfigurement support unit at Frenchay hospital in Bristol – Outlook. It’s the only one of its kind that acts as a central referral unit, whether from cancer treatment or Bell’s palsy, offering patients access to psychologists. Regarding peoples’ attitudes it was a massive boost to have the Disability Discrimination Act (DDA) amended to include disfigurement. This makes it unlawful for companies to discriminate against people with disfigurement, however greater clarity is required as ridicule is not recognised in the Act. Unfortunately despite the act, discrimination persists. People may be overlooked for promotion and I know of one exceptionally well-qualified teacher who was turned down for the job solely on his looks - however it is difficult to prove that it was because of disfigurement that he didn’t get the job.
Harassment from other colleagues also occurs in the workplace. People phone us in tears saying they’ve been called ‘scarface’ and other hurtful names. Employers need to implement anti-bullying policies but we know that bullying is unfortunately a fact of life.
Changing Faces’ vision is to create a better and fairer future for people who have disfigurements to the face, hands or body - whatever the cause. The ultimate goal is to enable everyone to face disfigurement with confidence. Changing Faces employs a team of specialists who offer counselling and a range of practical strategies to children, young people, their families and adults with disfigurements, to enable them to manage public reactions and succeed in every part of their life. It also offers a consultancy and training service to health professionals. Why did you establish Outlook? In the mid 90s there was a package of psycho-social interventions called the Changing Faces approach which was centered around the development and maintenance of self esteem. Amongst the NHS community at that time there was interest from plastic surgeons and dermatologists. In several journals we argued that such care should be part and parcel of routine care provided to patients within the NHS. Psychosocial help is a highly cost-effective intervention that complements the surgery. People doubted that this type of therapy would be of benefit so it’s fantastic seeing that it does. Some interventions that were developed at the Outlook centre are now being used in Soweto, South Africa to help similar people out there. Tell us more about your programme for people with disfigurement We use an acronym, SCARED, to represent other people’s attitudes towards people with disfigurement. S is for staring, which happens daily to someone with a disfigurement. C is for curiosity. People ask, “What happened to you?” A is for anguish. It’s not
SURGERY
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the scars that hurt, it’s the reactions that do. R is for recoil. People sometimes leave the room as they do not want to be in the presence of someone who looks different. E is for embarrassment. People don’t know how to ‘deal’ with a disfigured person - they feel awkward. D is for dread. In people who have been diagnosed with cancer others don’t know what to say. Is it a key goal of yours to have a psychologist on every surgical team? The teams of doctors looking after patients with cleft palate have a psychologist as a core member. Such patients are routinely assessed for psychosocial issues. At St Thomas’ in London, the dermatology department is close to having a psychologist on the team. There are some thirty burns units around the country but psychological care is very patchy. At present the National Burns Care Group is working to provide routine clinical assessment but in other injuries resulting in disfigurement, the care is less sophisticated. Do you support people who have become disfigured after botched plastic surgery? Yes. We provide a factsheet detailing legal advice and compensation. The pressures on people to look good have become so great that it’s no wonder they have surgery. We do not blame them and completely understand. They needed a better assessment and information - then they would not have made the decision to have surgery. How does Britain’s care for people with disfigurement compare with other countries? Britain is at the forefront of healthcare for people with disfigurement. Sporadic health insurance cover in the United States, especially amongst poorer people, means it’s difficult for those with disfigurement to get the holistic help, which we’ve shown to be so useful. Do you support face transplantation? In principle we are in favour of all advancements in facial healthcare, we are also pro-stem cell research, however the patient must be extremely well informed of all the psychological issues of receiving someone else’s face. In spring 2003 we
reviewed the evidence for face transplantation and felt at that time it wasn’t viable. Even now we continue to have doubts over the benefits and risks and have stipulated 15 conditions that we feel must be met.
Changing Faces Achievements • Launched disfigurement life skills programme • Creating the world’s first disfigurement support unit within the NHS • Established the Centre for Appearance Research at the University of the West of England • Successfully lobbied for disfigurement to be covered by the Disability Discrimination Act in 1995
Do you think people with disfigurements are represented fairly in the media? The image of people with disfigurement needs to be normalised – at present we’re portrayed as victims. Documentaries about disfigurement rely too much on voyeurism. If there was a newsreader with a disfigurement this would go a long way towards normalising the condition. People never thought you’d see a black newsreader and now our most famous newsreader is black! So progress can be made. For more information on helping patients with facial disfigurement you can visit the Changing Faces website at www.changingfaces.org.uk
Theatre sessions cancelled due to failing instrument cleaning centres
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urgery theatre sessions across England are being cancelled because equipment is damaged or delayed by outsourced private decontamination centres, warns the Royal College of Surgeons. A survey of over 250 surgeons has revealed widespread frustration and concern of the scheme which is being rolled out across the NHS. Two-thirds of respondents said they were unhappy about the availability and condition of instruments sent for sterilisation away from the hospital. “This is yet another example where something that looks good on paper in Whitehall
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SURGERY
gets rolled out across the country without adequate professional consultation and proper piloting,” added College President Bernard Ribeiro. “The NHS needs the best decontamination service possible.” Previously all hospitals sterilised equipment and repaired on-site but NHS Trusts are being encouraged to outsource to private sector companies. The Royal College of Surgeons report that their members find that too much is coming back late or going missing and sensitive, expensive tools are being broken. As a result operations are cancelled or abandoned – occasionally
when patients are already anaesthetised and prepared. “Patients should be concerned to learn that operations they need are being delayed because vital tools are not available,” said Professor Richard Ramsden, who collected the evidence and is an ENT surgeon. “This preliminary study indicates that surgeons working with on-site instrument cleaning facilities are getting a better service, enough to warrant an urgent reassessment of what’s best for the NHS.” www.rcseng.ac.uk
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Junior doctors and obtaining consent for unfamiliar procedures
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was tempted to remove the slide on ‘consent and the trainee’ in my presentation on informed consent. Too obvious, I thought. Surely everyone knows that consultants should not ask junior doctors to obtain consent for an unfamiliar procedure. All the published guidance states this simple rule. Last week, however, I met several Foundation Year 2 doctors from different teaching hospitals who felt bullied into obtaining consent for complex procedures. They were suffering in silence. A recent study on the consent practices of senior house officers (SHO) in Ear, Nose and Throat departments in the United Kingdom showed that over 80 per cent of SHOs are routinely responsible for consenting patients. The authors found considerable variation in the complications mentioned by the SHOs for five common operations, including tonsillectomy, septoplasty and total thyroidectomy. It is possible, the authors conclude, that SHOs ‘are not taught about the specific risks of procedures before being expected to obtain informed consent’. There are two possible solutions to the problem. One is to ensure that junior doctors do not obtain consent for procedures which they cannot perform themselves. It would be a blanket rule: senior clinicians must obtain consent for the procedures themselves. Supporters of this argument will say that juniors cannot possibly answer many of the questions posed by patients (“what is the likelihood of this complication happening?”, “what are the performance figures here?”). “If I were a patient about to undergo neurosurgery”, they might add “I would want the surgeon himself to consent me, not some well-meaning but out-of-his depth SHO”. They might also argue that junior doctors’ fear of being asked difficult questions may,
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HOSPITAL MESS
consciously or not, adversely influence the way in which consent is obtained. They may rush the ethically crucial part “are there any questions you would like to ask me?” or provide evasive, uninformative or even incorrect answers. The other solution is to allow junior doctors to obtain consent, but with certain safeguards in place. One may be a preliminary discussion with the consultant, in which the latter would tell the junior doctor about key facts. Another may be the use of standardised, pre-written consent forms, already in use in some trusts, which would clearly mention relevant information about the procedure (visit http://www. orthoconsent.com/ for examples of such forms). Ideally, junior doctors would observe their seniors obtaining consent on several occasions prior to doing so themselves. Aside from practical considerations of time, supporters of this option will note the importance of getting junior doctors to learn this crucial skill before they become registrars. Whatever the guidelines say, the reality is that many junior doctors are still asked to obtain consent for unfamiliar procedures. Senior clinicians must appreciate the dangers of this practice, both ethical and legal. Junior colleagues should try to speak out against the most egregious violations, however difficult this may be. They may as a group decide to raise the issue with relevant authorities, such as the Medical Director or Clinical Governance manager. Good patient care is not limited to wellperformed medical procedures, but includes obtaining high quality, rather than mediocre, consent. Daniel Sokol is a Lecturer in Medical Ethics and Law at St George’s, University of London. daniel.sokol@talk21.com
Medical Report
Tintin
Growth hormone deficiency – An initial diagnosis have taken this referral from Claude Cyr, a professor of medicine at Quebec’s Sherbrooke University asking for some differential diagnoses. Professor Cyr has already hypothesised that: “Tintin never aged during his 50-year career because the repeated blows he took to the head triggered a growth hormone deficiency. This intrepid Belgian reporter has suffered 50 significant losses of consciousness during his many adventures. I hypothesise that Tintin has growth hormone deficiency and hypogonadotropic hypogonadism (a disorder of the pituitary gland) from repeated trauma. This could explain his delayed statural growth, delayed onset of puberty and lack of libido.” Although this opinion appears on the surface to be valid, it fails to take into account some of his other symptoms.
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Psychogenic amnesia People have described Tintin as ‘a well-rounded, yet open-ended character, noting his rather neutral personality - sometimes labelled as bland’. In fact, even the name ‘Tintin’ remains a mystery and whether it is a first name or a surname is unknown. It may not actually be his real name, but rather a pseudonym that the character uses to protect his identity. At this point it is worth considering his early upbringing. Tintin was raised by his mother who died of illness when he was a child. He never knew or met his father, whom Tintin believes to be dead. Early trauma is thought to be a major risk factor for Psychogenic amnesia, a disorder characterized by abnormal memory functioning in the absence of structural brain damage or a known neurobiological cause. Here, a patient can
Assessed by Gil Myers
When 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:
lose their autobiographical memory and personal identity even though they are able to learn new information and perform everyday functions normally. Professor Cyr points out there is a history of head injury, however these symptoms were present prior to these.
Photocopying (A4 sheet)
Save the rainforests and re-use the original at:
10p
Whipps Cross Hospital, Essex
Make extra for your friends at: Hookworms & Iron-Deficient Anaemia Tintin shows growth deficiency, pale skin and thinning hair. At times he has remarked about the bright lights (Tintin in Tibet) and has often felt faint (Tintin - The Blue Lotus). This could clearly be a result of this simple but untreated condition. Because it tends to develop slowly, adaptation occurs, and the disease often goes unrecognised for some time. Iron deficiency anaemia can be caused by parasitic infections, such as hookworms, with the intestinal bleeding leading to faecal blood loss and iron deficiency. In his travels it is likely that Tintin would have been exposed to such parasite given that they are rife in Sub-Saharan Africa (Tintin in the Congo) and India. Craniopharyngioma A rare, usually suprasellar, neoplasm that develops from the nests of epithelium derived from Rathke’s pouch (an embryonic precursor of the anterior pituitary) and grows very slowly along the pituitary stalk. They usually are classified as benign and comprise 9 percent of all paediatric brain tumours - occurring in children between 5 and 10 years of age. On light microscopy, the cysts are seen to be lined by stratified squamous epithelium with keratin pearls. The cysts are usually filled with a yellow, viscous fluid that is rich is cholesterol crystals. This would account for a reduced growth hormone release. It is much like the original diagnosis made by Professor Cyr but sounds much more medical and uses some great long words. An Addendum As a side-note, Tintin is remarkable in that he is apparently devoid of sexual or romantic feeling. In the last adventure a female, Martine Vandezande, flirted with Tintin and appeared to ask him out on a date towards the end but nothing ever happened. He, however, describes Snowy, a Wire Fox Terrier who travels everywhere with him, as “having a bond that is deeper than life”. This would not impact on his growth but it may necessitate a detailed psychosexual history - including fantasy exploration - and a psychiatric referral.
5p Mars Bar (64g)
Belfast City Hosptial, Belfast
Helps you work, rest and save money at:
40p
Mile End Hosptial, London
Don’t do it! Think of the calories at:
55p Sprite (330ml can)
Royal Free Hospital, London
Fizz-tastic prices at:
55p
Royal Free Hospital, London
Better stick to the water fountain at:
60p
Royal Free Hosptial, London
Next issue we’re checking the cost of a cup of tea (small), a minipack of Rice Krispies and a tube of toothpaste (smallest). Email prices to team@juniordr.com.
Withybush General Hospital The mess is based in the ground floor of the hospital and provides TV with freeview, fresh bread and milk, tea and coffee, butter and jam for toast, cooled water, computer with internet access and access to results and the newspapers daily, including Sunday papers.
JuniorDr Score: 3/5
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