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Connect People, Share Knowledge, Improve Care It’s easy to reinvent the wheel, it’s even easier to re-invent a flat tyre ~ misquote, Sir Muir Gray 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, team@juniordr.com Editorial Team Yvette Martyn, Ivor Vanhegan, Anna Mead-Robson, Michelle Connolly, Muhunthan Thillai, Rob Bethune JuniorDr PO Box 36434, London, EC1M 6WA Tel - +44 (0) 20 7 193 6750 Fax - +44 (0) 87 0 130 6985 team@juniordr.com 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 2011. 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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t the beginning of most patient encounters there is a junior doctor. That junior doctor understands far more intimately than anyone else what a patient is experiencing, and can identify what challenges and fears may present along the journey. Often it is the junior doctor who makes the most significant decisions on behalf of the patient, and who has the biggest impact on patient outcomes. So why aren’t junior doctors more involved in the quality improvement process? In some cases there is a lack of opportunity, with audit focusing on data collection instead of being part of a change process. In others there is a lack of time, with rotations being fleeting and support to introduce an innovative idea poor. However, the strength of being a junior doctor lies in rotating through hospitals and communities, and being able to share best practice ideas. At the core of effective quality improvement is the need for collaboration and dissemination of ideas to truly reach a tipping point of change, improving patient care and experience but also job satisfaction for junior doctors. In this quality improvement issue of JuniorDr, co-produced with The Network, we share some ways to run a quality improvement project and offer examples. The Network was established at the end of July 2010 as an online community connecting medical students, doctors and other healthcare professionals to improve the quality of care in the UK and beyond. With over 1,400 members representing clinical, non-clinical and allied health professionals across all grades, up and down the country and internationally, the value of The Network lies in the ability of members to share the quality improvement work that they are doing. NHS professionals have been using Facebook, LinkedIn and Twitter for years now as a medium to communicate and exchange thoughts and ideas. The Network takes social media a step further by providing the latest in case book and blog technology to interact with like minded individuals and explore the innovative ideas of your colleagues. Read our QI section in this issue, then join The Network today at www.the-network.org.uk and explore the endless possibilities of being connected.
Rob Bethune – The Network
Nikki Kanani – The Network
What’s inside 04 09 12 14
LATEST NEWS Animals in training How to run a Quality improvement project QI case studies
15 17 26 30
Learning to Lead Colalife Dr Fairytale Courses and Conferences
TRIAGE
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Tell us your news. Email team@juniordr.com or call 020 7193 6750.
NHS
Doctors think NHS reforms bring more risks than benefits
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he vast majority of doctors are unconvinced of potential benefits of the potential benefits of government plans for the NHS in England, according to an Ipsos MORI poll of BMA members. The survey of 1,645 respondents found widespread concern about plans to increase competition even among the minority of doctors who are generally supportive of the changes. Almost nine in ten (88%) think it is likely that the reforms will lead to increased competition between providers, but only a fifth (21%) believe this will improve the overall quality of NHS care. Two thirds (67%) think closer working between general practice and hospitals would improve the overall quality of patient care but only a third (34%) believe it likely that the reforms will lead to this. In terms of the impact on their own roles, three fifths of respondents (61%) think it likely that the reforms will lead to them spending less time with patients.
“This survey shows that the government can no longer claim widespread support among doctors as justification for these flawed policies,” said Dr Hamish Meldrum, Chairman of Council at the BMA. “While there are widely differing opinions, with many still to decide, there are a number of key issues where the majority have very clear concerns. The government simply cannot afford to dismiss this strength of feeling amongst the group they are expecting to lead much of the change.” Overall the survey suggests that doctors attitudes to the reform fall into three distinct groups: a third (33%) are broadly opposed, around a fifth (18%) are broadly supportive, and just over a third (36%) say they are waiting to see what happens. There are also mixed views about the impact of the proposed system of GP-led commissioning. Two thirds (66%) agree it will increase health inequalities and half (49%) that it will reduce the quality of patient care.
“The government simply cannot afford to dismiss this strength of feeling amongst the group they are expecting to lead much of the change.” Hamish Meldrum Chairman of BMA Council
www.bma.org.uk
NHS
NHS reforms forcing GPs into retirement
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ore than half of GPs planning to retire in the next two years blame the NHS reforms as the reason for them going, according to a major new survey of 18,000 GPs by the BMA. After age, NHS reform was the second commonest reason given for GPs planning to retire in the next two years (56%). According to the BMA, if these results were extrapolated the survey suggests that in the next two years, approximately 6,700 GPs across the UK plan to retire - with approximately 3,700 saying that NHS reforms were a factor in their decision. Dr Laurence Buckman, Chairman of the BMA’s GPs Committee, said: “I’m not surprised, for example, to find
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NEWS PULSE
that two thirds of GPs are worried about how the new consortia will operate when you consider the laissez-faire approach that the government has taken to planning the new arrangements so far.” “Staff are leaving Primary Care Trusts in droves and those that are left are spending their time and energy creating PCT ‘clusters’ instead, without any certainty about their long-term future. In many areas, GPs are being left to get on with it while many of the key questions, such as how groups will be determined geographically, are left unanswered and still not determined by law.” www.bma.org.uk
Other key findings from the survey include: • Respondents believe it is important for other professional groups to be involved in consortia - with hospital consultants and public health doctors the most important and local councillors the least important • Three-quarters of GPs do not believe consortia should be paid performance-related bonuses (often referred to as the ‘quality premium’) for commissioning • Around seven in ten are concerned about the potential conflicts of interest within the Health Bill, both for the impact this could have on their relationship with patients and because of their role as commissioners as well as providers • Approximately two thirds do not think consortia will be appropriately skilled or supported to run the NHS effectively
Medical Students
New training programmes fail to widen diversity in medicine
Knowledge you need in an INSTANT!
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ost new training programmes designed to widen access to medicine in the UK are failing to increase the diversity of medical students, according to a study published in the BMJ. It shows that although historic under-representation of women and of minority ethnic groups has been redressed, a large proportion of medical students still come from the most affluent socioeconomic groups in society. Recent years have seen major initiatives to broaden the demography of the UK medical student population, but it is unclear whether new programmes, such as graduate entry and foundation entry courses, have achieved this. Researchers at the University of Birmingham looked at whether new routes into medicine have produced more diverse student populations. They found that students on graduate entry courses were, as would be expected, significantly older than students on traditional courses and were more likely to define themselves as white (84% v 70%). Two fifths of students on traditional courses declared their parental occupation to be higher managerial and professional compared with 27% of students on graduate entry courses. In contrast, only 23% of students on foundation programmes (where entry is restricted to under-represented groups) defined their ethnicity
as white and only 8% defined their background as higher managerial and professional. However, the numbers of places available on these courses are small. “Evidence of the advantages of increasing diversity is emerging, but the implementation of ‘new’ admission routes to the profession does not seem to be bringing significant change,” say the authors. “In both the US and UK, the most successful programmes to increase student diversification seem to be those based on explicit affirmative action, yet these programmes are not universally welcomed among the public or the profession.” www.bmj.com/cgi/doi/10.1136/bmj.d918
Affordably priced • All the essential facts you need to know • Accessible, easy-to-read, approachable • Clear and simple diagrams • Excellent for review ahead of examinations
Training
Med schools fail to teach necessary legal skills for medicine
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he majority of medical students feel they lack the skills and legal knowledge to challenge poor clinical practice and promote better patient care, according to research published in the Journal of Medical Ethics. The survey of 1,154 UK medical students found that confidence was notably low in the areas of the Coroners Act and working in court room settings. Only in the knowledge areas of consent, assessing mental capacity and confidentiality did students feel confident. “If young doctors do not feel confident, they are unlikely to challenge poor practice or show leadership in promoting better patient care through using legal rules and an understanding of how law relates to and underpins good medical practice,” say the authors.
“Structured law teaching is required throughout qualifying programmes, and that this needs to be reinforced and practised in clinical attachments and continuing professional development, otherwise, knowledge and skills, even when acquired, may decay.” Students felt they knew more about the legal principles relating to negligence than to the NHS complaints procedure. The authors suggest more time and emphasis needs to be put on legal skills in the formal medical curriculum and that these need to be practised and honed during clinical training. www.gmc-uk.org/recordings
Order your copy online now www.garlandscience.com
Young docs prescribe more
nHs
Hungover doctors performance affected
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urgeons who drink a lot the day before theatre appear to have impaired skills when performing surgery, according to research published in the Archives of Surgery. The study by researchers at the Royal College of Surgeons, Dublin aimed to determine the effects of previous-day excessive alcohol consumption on laparoscopic surgical performance. They found that compared to the control group those who consumed ‘excessive’ alcohol the previous day displayed worse performance in all three measures - time, errors and economy of diathermy. “In the two studies we showed persistent detrimental performance effects the day after excessive alcohol had been consumed,” they said. “Given the considerable cognitive, perceptual, visuospatial and psychomotor challenges posed by modern image-guided surgical techniques, abstinence from alcohol the night before operating may be a sensible consideration for practicing surgeons.” Part of the study involved 16 medical
students and eight surgeons all going out for a night of dinner and drinks. Half of the students and all of the surgeons were allowed to drink as much alcohol as they wanted until they felt drunk. The other half of the students were not allowed to drink at all. The study found that those who had consumed excessive alcohol the previous day performed their tasks more rapidly during the 9am simulation but with more errors. By 4pm performance had returned to baseline levels. www.archsurg.ama-assn.org
Patients with risk factors for cardiovascular disease are more likely to be prescribed cardiovascular drugs if they see a younger doctor, according to research published in the International Journal of Clinical Practice. According to the study of 1,078 doctors and nearly 10,000 patients, although younger doctors prescribed more drugs this did not result in significantly better control of their patients’ major CV risk factors than older doctors who were more likely to recommend a change in lifestyle. http://bit.ly/lp3TRi
Saving smallpox Smallpox samples stored at the only two labs which continue to hold specimens will not be destroyed for a further three years, according to the latest announcement from the World Health Organization (WHO). The WHO debated in May whether to recommend destroying the only remaining samples held in Atlanta, USA and the other near Novosibirsk, Russia. The USA, Russia and many industrialised nations successfully argued that we need the samples for research. Smallpox was declared eradicated in 1980. www.who.int
Shortage of academics
GMC
New guidelines for videoing and photographing patients
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ew GMC guidance on taking clinical photos and video came into effect on the 9th May with the aim of protecting patients from recordings that invade their privacy. Making covert recordings of patients and using mobile phones to record consultations are two of the areas covered in ‘Making and using visual and audio recordings of patients’. The document sets out what doctors must do when recording patients for any purpose, including treatment, research, education or public media. “Doctors often face a number of dilemmas when making recordings of patients and it can be difficult to strike a balance between supporting training, education and research and protecting the best interests of their patients,” said Ros Levenson, Chair of the GMC’s Standards and Ethics Committee. “The increase in using new technologies, such as camera phones and webcasts, can make this even more challenging. This revised guidance
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NEWS PULSE
A shortage of medical academics is threatening to undermine the UK’s vital clinical research base and leave some medical schools struggling to teach their students, according to the BMA. The number of medical academics fell to around 3,100 in 2010, down from the estimated 4,963 in 2000, according to the Medical Schools Council. They warned that the situation may get worse as universities continue to cut costs. www.bma.org.uk
NHS still sick
should help them make the right decisions.” TV and radio production teams who record patients are also required to be aware of the revised guidance as doctors involved in a programme have a duty to make sure patients’ rights to privacy and confidentiality are properly protected and be satisfied that consent has been obtained. www.gmc-uk.org/recordings
Levels of staff sickness absence in the NHS vary dramatically across the country, with the North of England showing the highest levels, the Audit Commission has found. It found that more NHS staff take sick leave in areas of high deprivation and that junior staff are also more prone to taking time off sick than their more senior colleagues. The report suggested core areas where the NHS could increase staff productivity, improve morale and save £290 million. www.audit-commission.gov.uk
EVERYTHING THAT MEDICAL SCHOOL
DIDN’T TEACH YOU
July 2011
|
704 pp
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978-0-19-960648-1
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£29.95
Available now direct from OUP at
www.oup.com/uk/isbn/9780199606481 or from all good bookshops
www.wellcomecollection.org
he Wellcome Image Awards recognise the creators of the most informative, striking and technically excellent images. This image by Anne Weston is a scanning electron micrograph of the underside of a sticking plaster that has been used to treat a razor blade cut. Red blood cells and thin fibres of the protein fibrin, coloured beige, can be seen between the gauze fibres of the plaster, which is coloured blue-grey. The images are on display in the Wellcome Collection until the 10 July 2011.
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Blood clot on a plaster, by ann weston
Wellcome Image Awards 2011
Used with permission. Wellcome Images; Anne Weston, London Research Institute, Cancer Research UK
Animals
in training Scientific advisor to the government, The Royal Society, claim that virtually every medical achievement in the 20th century relied on the use of animals in some way. Today about 50-100 million vertebrate animals continue to be used for medical experimentation each year. JuniorDr’s Ben Chandler looks at the current use of animals in clinical treatment and their role in medical training.
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watched anxiously as the patient’s saturations started dropping, the monitors shrieking that the oxygen levels were becoming dangerously low. Urgent action was needed before a hypoxic cardiac arrest occurred. Intubation or any other intervention via the mouth or nose was impossible. As the tension levels rose another doctor undertook a procedure often talked about but very rarely performed - a cricothyroid puncture. Using a cannula to enter the airway then ventilating the patient’s lungs with oxygen, the doctor was successful at the first attempt and the oxygen levels rose to a safer level; the immediate threat to life avoided. As the atmosphere calmed an instructor gave extra tips on how to undertake this life-saving procedure. For the ‘patient’ - a live sheep - the morning’s training was far from over. Using animals for any kind of experiment is controversial. The dispute surrounding the use of animals for teaching medical students can be traced back over a hundred years. In the early 1900`s Sir William Bayliss, an eminent physiologist (and the discoverer of hormones) was accused of
cruelty to animals based on a demonstration he gave to a group of medical students. During the experiment he had dissected a dog which the Anti-Vivisection Society claimed was not fully anaesthetised. The dog had also previously been used for
experimentation and both activities were illegal at the time. In the following uproar Bayliss successfully sued for libel. However the Anti-Vivisection Society were not finished with the issue, and following a public donation of funds, proceeded
Animals in Training
9
to commission a statue of the dog. The monument to the little brown dog became a battle ground for the opposing groups and was a target for numerous episodes of vandalism. Events came to a head in 1907 when a large group of medical students marched to the monument intent on knocking it down led to full scale riots. The local council unhappy at the costs of guarding the monument pulled it down three years later. It was not until 1985 that a new version of the little brown dog statue was unveiled and still exists in Battersea Park, London. Animals in simulated training
Until recently trauma training in the USA commonly involved the use of live anaesthetised pigs on which various surgical techniques, such as chest drains and emergency airway interventions, were practised. Following the training session the pigs were euthanised with the aim of avoiding exposure to any pain that may occur. Advocates for the use of live animals claim that undertaking a procedure on a warm creature replicates reality more closely. The muscle tone, feel of tissues and response to intervention reflect the changes seen in a real human patient. Aside from the animal rights issues, critics argue the
differences in anatomy are a huge limitation in the actual surgical experience gained - a view confirmed by at least one clinical trial of candidates learning experience. In the face of mounting criticism from various groups the number of centres in the United States using live animals as part of their Advanced Trauma Life Support (ATLS) training has now fallen to only 11 out of 280 centres. In the UK the use of live animals for medical training is illegal. History of simulated learning
Medical simulators were first used in the 1960s. Over recent years their use has become much more widespread and the technology has evolved greatly from the basic ‘Resusci-Anne’ to the latest ‘SimMan’. Since 2001 the ‘TraumaMan’ system has been approved for trauma training. It has become the most widely used surgical trainer device in the world and over 30,000 clinicians are trained with this device annually. TraumaMan consists of a human-like torso, covered with a pliable ‘skin’. Numerous procedures can be practised on it, including cricothyroidotomy and chest tube insertion. When cut it will mimic bleeding and recent upgrades even allow for integration of focused trauma ultrasound (FAST) scanning into the system. All this technology is not cheap though and a TraumaMan system costs around $24,000 (£15,000 pounds) and to allow optimal use it needs a supply of disposable skins as well. Mannequins have numerous advantages over using animals - they have human anatomical landmarks, give a more reproducible
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Helpful animals
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ot all medical interactions with animals involve painful experiments. Some animals have demonstrated great abilities not only for companionship but to help patients cope with health conditions.
Guide Dogs Although references to dogs helping guide visually impaired people can be found in texts dating back hundreds of years, the first modern training scheme for guide dogs appeared in Germany during the first world war to aid veterans injured during battle. Over the next 40 years the idea caught on throughout several other countries. Guide dogs take around 8 months of training and there are
animals in training
learning experience and they are much more portable, allowing courses to be run almost anywhere, without the need for animal facilities. Doctors against animal use
Some of the most vocal criticism of animal use in medical education comes from doctors in the form of the Physicians Community for Responsible Medicine (PCRM). Founded in 1985, the organisation has 9,000 doctors in its membership. As well as opposing animal experimentation it also promotes vegetarianism. The PCRM exerts pressure on numerous universities and hospitals using email based campaigns to highlight ongoing animal cruelty. John Hopkins Medical School is one of PCRMs current targets. Regarded as one of the top medical schools in the US it remains one of the only medical schools where live animals are used for teaching. During the students surgical placement they have the opportunity to attend a surgical skills session using live anaesthetised pigs. The session offers students the chance to suture wounds and operate on various organs, however pressure is now mounting on the university to abandon this practice. In February this year a criminal complaint was filed with the state attorney claiming that the university ‘should be held criminally liable for cruelty to animals’ and requesting an investigation to halt the live animal component of the school’s medical student curriculum. Two former students along with the PCRM were behind the action. Dr John
around 4500 in service in the UK. Two guide dogs in the USA were credited with saving their owners lives in the 2001 attacks on the World Trade Centre with both leading their owners down 70 flights of stairs to safety.
Seizure alert dogs Trained to help look after their owner following or during a seizure, by either alerting helpers, getting the phone or even by stopping their owner from falling. Some dogs may even develop the ability to recognise signs that their owner is about to suffer a seizure.
Psychiatric Service Dog Dogs that are trained to recognise symptoms of psychiatric
problems such as hallucinations, and give companionship to people suffering from diseases such as schizophrenia.
Hearing dog Trained to recognise certain noises, such as alarms, sirens or even somebody calling their owners name.
Monkey Helpers Capuchin monkeys have proved to be suitable as companions for mobility-impaired patients. Capuchin monkeys are a suitable size and with a playful nature and ability to undertake practical skills that other animals would not find possible.
Pippin, spokesperson for PCRM is quoted at the time as saying that “animal use at Johns Hopkins is inhumane and violates Maryland’s anti-cruelty statute”. Despite being faced with this criticism the director of surgery at John Hopkins University has so far refused to withdraw the pig based training lab. Military service
Trauma and surgery are not the only specialities that use live animals for training procedures. In the US live ferrets have been used in paediatric training programmes for practising tracheal intubation, and live rabbits for paediatricians to learn chest tube insertion. Pressure is mounting on all of these hospitals to stop such practices. As more medical schools and hospitals stop using live animals in trauma training the focus has shifted to the US military and its use of live animals. As recently as 2009 the US military were using 8,000 live animals a year for training during which the animals would suffer severe injuries for medics to cope with. Other animal use within military training includes the use of monkeys exposed to chemical agents to observe the clinical signs and response to treatment. The PCRM has obtained videos of this practice via freedom of information acts and posted them on the internet, increasing public awareness.
shown no signs of distress or pain during the procedures. Seeing this type of training first hand left me with mixed feelings. Using live animals for surgical training is illegal in the UK and my description of the experience is based on time spent overseas. Anaesthetising a sheep to allow training is extreme and requires serious justification. However some procedures and the stressful circumstances in which they may be needed cannot be replicated as well on a mannequin and a live anaesthetised animal may provide the best learning opportunity. The sheep used for this training was also used to provide blood for the microbiology
Strange medical products from animals
W
ould you ever consider injecting a product taken from a pig’s intestine into a patient then reversing its effects with a syringe full of fish sperm? Believe it or not these are just some of the wacky products we use in everyday medicine. Ben Chandler takes a trip to the pharmaceutical zoo, to uncover some of the strangest uses of animal parts he can find.
The experience
Pigs
Our ‘patient’ died at the end of the training session. It was given a lethal injection by the attending veterinary anaesthetist having
Pigs have the misfortune of having similar sized organs to humans and being readily available. Porcine tissues are already used throughout numerous fields of medicine and the humble pig is felt to be one of the best candidates for future production of organs for transplant into humans. Among the many porcine derived products include:
Animal Assisted Therapy A wide range of treatments based around spending time with animals. Recent evidence has suggested that spending time in “animal assisted therapy” may help with treatment of autism, and it is often undertaken to help with many other ailments. Although many types of animal have been used, some of the most common include horses (hippotherapy), dogs and dolphins - and even elephants.
Heparin - One of the oldest drugs still in current use, heparin was initially extracted from dogs liver. Controversy was sparked in the USA in 2008 when a number of patients suffered adverse effects from heparin with numerous deaths. When the drug was traced back to its sources it was discovered that some of the heparin was extracted from pig intestines on small unregulated farms in China. A potentially extremely expensive lawsuit is ongoing.
The new Brown Dog by Nicola Hicks, erected in Battersea Park in 1985
department and following euthanasia it was used for surgical training and research. As new working time directives curtail the amount of time spent in training for junior doctors, exposure to true emergencies is reducing and high quality emergency training becomes more important. More acceptable alternatives already exist for much of the training that is done on live animals. As simulator technology continues to evolve the use of live animals will be increasingly difficult to justify but in the mean time some continue to argue that the UK is ignoring an important educational resource too soon.
Insulin - Although newer insulin formulations are human insulin, porcine insulin is still available. It only differs from human insulin by a single amino acid - another example of how genetically similar we are to pigs!
Pig skin - Aside from being a key ingredient in pork scratching production, pig skin is also used in some special wound dressings.
Maggots Observers noted over a hundred years ago that maggots did a great job of cleaning wounds and that soldiers who had maggots in their wounds seemed to be more likely to survive. The invention of penicillin stifled interest for a while but with the advent of drug resistant bacteria maggots are back.
Leeches Another medieval sounding treatment that is also making a comeback. Leeches have been used for over 3,000 years and modern medicine still finds them useful. Historically leeches were used to treat many ailments but today their use is mainly in plastic surgery to extract blood from swollen grafts. Unlocking the components of leech saliva has also given a new range of anticoagulant medications.
Salmon Possibly the most surreal use of an animal product. Protamine sulphate is derived from salmon sperm and it is used to reverse the effect of heparin. It is associated with some nasty side effects when injected.
Bees Honey has been used as a medicine for thousands of years, and recently has been shown to have antibacterial properties. It may even be a useful weapon against MRSA.
Animals in Training
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How to run a Quality (whilst working full time as a junior doctor) Establish a team This is crucial, you cannot do it alone. Most of us do four or six month placements and this is often not enough time to run a project. Get a team of 6-10 people who can rotate whilst running the project throughout the year and you’ll find things much easier. You’ll need as many pairs of hands as possible as good data collection is crucial and you need to make this easy and feasible for yourself. You can often get by with a little help from your friends but working in a team also makes it fun and gives you immediate motivation as your colleagues and friends will hold you to account.
Effecting change in the NHS as a junior doctor can be a daunting experience. With limited power, influence and time it can seem an almost impossible task. Yet, as a junior doctor we get a unique insight into how we can improve patient care. In this article The Network’s Rob Bethune offers a few helpful suggestions that can help facilitate change.
for Improvement. I will describe it in more detail below using a current F1 quality improvement project as an example, but the diagram below shows the outline - make your aim, measure the thing you are trying to improve and then run a series of tests of change (the plan-do-study-act cycle).
As junior doctors we are in a unique position to see the problems and affect the solutions. Develop a structure to the project It is useful from the outset of the project to set specific targets. This will help focus your mind and enable everything to be done by the end of the year. Below is an example of a timeline for a series of Foundation One projects in the South West - one of which is described in a bit more detail later. The collaborative feature of this timeline is particularly important. If there are other groups in your hospital running quality improvement projects then make sure you have collaborative sessions with them. This will help all of you to learn from each other as well as providing motivation and support. The Model for Improvement There are a multitude of tools for improving quality of systems (Lean and Six Sigma are examples) but the most tried and tested model for healthcare is The Model 12
Management
Profound knowledge is often underestimated. We see problems on the surface and think solutions are obvious and often we just go ahead and implement them. These simple change efforts are often unsuccessful because we do not really understand the system we are dealing with. Once we have this knowledge then the changes are usually clear. Remember H.L. Mecken’s words ‘For every problem there is a solution, simple, elegant - and wrong’. We have to be able to show that our solutions do make a difference so we plot our data on a run chart. In our example project the team collected data on how many jobs were being completed on a weekend (they sampled this data) and plotted the initial data before any tests of change on the graph below. As you can see they did this on five separate occasions to ensure the accuracy of their data.
FIG 1 - The Model for Improvement
Aim What is it you want to improve? It is really important to carefully define this at the start to help you develop a deeper and more profound understanding of the system. Our example project was trying to improve the effectiveness of weekend handover. They wanted 95% of jobs that were handed over to the weekend team to be completed by Monday morning. Measure ‘Data, data, data’ goes the drumbeat of a quality improvement project. Without it you will not be able to see if your changes are an improvement - but more importantly by getting really good data you will develop profound knowledge that will allow you really see what needs changing.
FIG 2 - Run-chart
The plan-do-study-act-cycle (PDSA) Now you have your background data collection and a deeper and more profound understanding of the system (weekend handover in our case) you are ready to make some changes. These are done in the form of a PDSA cycle. The PDSA cycle is as simple and intuitive as it sounds; come up with a plan, trial it out on one day, study the effect and act upon the result. One of the keys is to trial
Improvement Project What is quality? A
the change over a short time period in one area. If it works you can spread it but if it doesn’t and needs refining then you can do that easily. If you implement your idea widely from the beginning (as we have seen so often in healthcare!) and you get it wrong it is expensive both in terms of time and resources to undo it. Make your first tests small. In our example (see the next run chart below) they did several PDSA cycles, improving the handover sticker in the notes as well as unifying the Excel spreadsheets used to pass the information on. Through a series of small scale changes
with continuous data collection the effectiveness of weekend handover increased dramatically (and for the managers out there this was free!). Improving the systems in which we work is crucial to improving the care we give to our patients. As junior doctors we are in a unique position to see the problems and affect the solutions. Rob Bethune, Surgical Registrar, Severn Deanery Acknowledgements. Izzy Mark and Joanne Hooker and the rest of the weekend handover group at North Bristol NHS Trust, for their data.
FIG 3 – Run chart example
lthough ‘quality’ is discussed widely in many professions and industries, (the word is included some 360 times in Lord Darzi’s much cited NHS Next Stage Review Final Report1), it remains a slightly evasive concept. The focus on quality has been apparent in healthcare for much of the 20th century and is both political (used by different professions to advance their particular interests) and subjective (dependent on who is assessing it and what values and consensus are used). The popular definition of quality in healthcare that now dominates was produced by the Institute of Medicine and Committee on Quality Health Care in America (2001); this portrays safety, effectiveness, patientcenteredness, timeliness, efficiency and equity as the six ‘pillars’ of quality in healthcare. Simply evaluating quality represents just one end of the quality continuum which includes quality assurance, and quality improvement. The latter, popularised by a number of quality improvement evangelists in the late 20th century (such as W.E. Deming and Philip Crosby), had its roots in managerial and industrial sectors before being applied to healthcare. Perspective is also important: a key distinction is that between patient quality and professional quality. In the former, the patients’ perception of a service could be deduced by counting complaints, or rating service attributes for example. When professional quality is considered, the professionally assessed needs of patients represent the standard which should be met. So, whether you are trying to measure it, assure it, or improve it, quality in healthcare is a slippery but increasingly relevant force for improvement.
Management
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QI Case Studies Unnecessary blood testing What was the problem?
Fast track protocols are now well established for elective surgery, and early discharge is becoming the vogue. This removes the need for additional blood tests (C reactive protein and coagulation screens) in the early post operative period as ‘screening’ tools in place of bedside assessment. However, these are requested frequently and unnecessarily, imposing extra burden on busy pathology labs, and at significant cost. What changes did you make?
An intervention was designed through Pathology and IT, with consultant approval. We introduced a notification on the computerised blood requesting system to remind surgical house officers of test indication, and to make
recent results quickly accessible before requesting serial tests. We also provided junior doctor education. How did you demonstrate any differences you made?
We collected a prospective database of 114 patients under surgical specialties over two months and performed audit, intervention, and closure of the cycle. We demonstrated a significant 54% and 56% reduction in requesting of CRP and coagulation screens respectively. This did not affect safety: average length of stay did not differ significantly (3.7 and 3.6 days respectively), and 10.5% had complicated recoveries in both groups.
coagulation panel = £8.34. Based on 57 patients/month, this infers potential savings of approximately £36,000 per year. This improves accuracy for detecting complications by reliance on clinical examination and reduces burden on pathology labs. Indeed, this offers significant cost savings through a front line intervention without compromise in patient care. What lessons have you learnt that could help others?
Established practice can be changed through simple intervention. This achieves significant improvement, and IT provides an effective instrument to realise this change.
What are your conclusions?
Dr Anish N Bhuva, F2 Doctor Hillingdon Hospital
Hospital costs of CRP= £5.37;
F1 Doctors Making Better Discharge Summaries Aims:
95% of discharge summaries to be of high quality and be completed within 24 hours of patient discharge by the end of our F1 year. Objectives:
Responsibility for discharge summaries often falls to Foundation Doctors. We recognised the importance of this communication with primary care in patient safety. By studying the system and process of producing discharge summaries, and engaging everyone involved (from ward clerk to GP), we sought to improve this part of our jobs and serve our patients better. Methods:
We divided our project into Quality and Timeliness. To evaluate Quality we devised a 12-part questionnaire that was completed online by a GP and a Consultant using a 5-point rating system. Using data from IT managers, Timeliness was
assessed by comparing the Cerner ‘time of discharge’ with the time the electronic discharge summary was completed. We met regularly to create rolling data logs, monitor progress and discuss the next innovation. Solutions:
• Feedback from local GPs on what constitutes a high quality discharge summary was distributed to our Foundation colleagues. • We collaborated with IT managers to improve the electronic discharge summary system. • All discharge summaries were read by a team Consultant. • We asked juniors to involve seniors in the discharge summary process by specifically asking on the ward round, ‘the diagnosis/differentials’ and ‘details of follow-up’. • We made sure Registrars had log-in details for the discharge summary system to spread responsibility for com-
For more case studies and to post your own visit
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MEDICAL STUDENTS Improving Care
pletion and ensure operation notes were entered. Conclusions:
The percentage of discharge summaries being sent out within 24 hours of discharge increased from 35% to 90%. The overall rating of quality in our discharge summaries improved by 26%. • We learned that whilst systems are often imperfect as Foundation Doctors we are in a prime position to identify problems and implement change. • We learned the importance of engaging clinical and non-clinical colleagues, from GP’s to ward clerks, to facilitate improvement. • We took away a sense of pride that a small group of Foundation Doctors could make a significant difference to the care our organisation provides. Dr Dermot Mallon and Dr Andrew Hamilton, Musgrove Park Hospital
at www.the-network.org.uk.
Learning to lead
FROM JUNIOR DOCTOR TO CONSULTANT
Many of the challenges facing new consultants in the emerging NHS lie in the realm of leadership and yet junior doctors often report feeling unprepared to lead. The time when the sole function of a doctor was to provide clinical care has passed.
A
s a junior doctor you can develop your leadership competencies by being proactive and consciously assuming greater responsibilities around leadership activities; the Medical Leadership Competency Framework provides a range of practical examples of opportunities for learning and development. Establish clinics, participate in management meetings and volunteer to undertake additional leadership responsibilities; closely observe selected role models in order to identify effective leadership behaviours; attend a postgraduate leadership course so as to gain exposure to unfamiliar scenarios and new theoretical models and identify your personality and leadership styles by completing selfassessment questionnaires. Additional opportunities for leadership development, both pre- and post the transition to consultant grade are outlined below and learners are encouraged to blend learning opportunities. Each development tool and method has its own advantages and disadvantages and the right approach will depend upon individual and organisational circumstances and goals.
Opportunities for leadership development
• Action learning - working as part of a small group of peers or an ‘action learning set’ to address real life problems, develop solutions and take action • Coaching - a time-limited, goal-orientated, one-to-one developmental relationship based on real work issues • Developmental work assignments - learning from ongoing work initiatives and integrating these experiences with each other and strategic organisational imperatives • Mentoring - a long-term, open-ended, one-to-one developmental relationship in which a senior colleague supports the personal and professional development of a junior colleague • Leadership within a team - motivating team members, leading through change, confronting poor performance, delivering results (by achieving objectives) and encouraging and supporting the professional development of team members • Networking - creating interdependent and often mutually beneficial relationships;
• Self-directed learning - taking responsibility for finding, managing and assessing one’s own learning eg. basic internet research, reading leadership books and journal articles, attending and contributing to networks and forums • Shadowing - provides opportunities to observe and understand an unfamiliar part of a system without being required to act • Workshops and masterclasses - timelimited learning sessions focused on specific topics which provide opportunities to gain up-to-date information, develop particular skills and to share learning; workshops delivered by experts in their field are called masterclasses Developmental experiences are likely to have the greatest impact when they can be linked to or embedded in your ongoing work. You should adopt a cumulative approach to learning, considering basic concepts and local systems early on in your training and complex concepts and wider systems when more established. Regular, accurate and honest appraisals, grounded in the Medical Leadership Competency Framework, can offer insight into your leadership strengths, abilities, gaps and developmental needs as you progress in your career. Seize opportunities to reflect, individually and with colleagues, and
to promote deep learning as a means of realising positive changes in your thinking and behaviour. When confronted by a new leadership framework or approach it is helpful to ask “how does this apply to my situation” and “how can I do things differently in the future?”. A significant temptation for a newly appointed consultant is to accept every leadership role and opportunity that is offered; this approach, however, is an inappropriate use of resources, limits teamwork and team development, fails to foster the skills of others and may increase levels of stress. Conversely over-delegation risks establishing unrealistic expectations and stretching individuals beyond their competencies to the detriment of patient care and team well being. Dr Michael Hobkirk Michael is the Lead Consultant for Chichester Child and Adolescent Mental Health Service and the Specialist Advisor for Leadership Development at the Royal College of Psychiatrists. Reference NHS Institute for Innovation and Improvement, Academy of Medical Royal Colleges (2010) Medical Leadership Competency Framework, 3rd edn. http://www.institute.nhs.uk/images/documents/ Medical%20Leadership%20Competency%20Framework%203rd%20ed.pdf (accessed 30th April 2011).
Summary • Leadership is a key component of your professional development and an ongoing process • Reflect upon your leadership competencies and learning needs using the Medical Leadership Competency Framework as a guide • There are numerous informal and formal opportunities for leadership development; • Strike a balance between taking on new roles and delegating work to others.
MEDICAL Improving STUDENTS Care
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Agents for change Junior doctors rising to the quality improvement challenge
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he past 10 years have seen a strong focus on increasing the quality of healthcare in the NHS, with billions of pounds invested in improving the services provided to patients. This investment has resulted in wide scale improvements, such as the large reductions in waiting list sizes and rates of hospital acquired infections. In 2008, the 60th anniversary year of the NHS, Lord Darzi’s NHS Next Stage Review titled ‘High Quality Care for All’ described quality in three dimensions to help define excellent healthcare. These three dimensions are patient safety, patient experience and clinical effectiveness. Coupled with this challenge it is estimated that the NHS must save £20billion equivalent to 20% of its current annual budget - over the next four years so that it can afford to pay for these new services. As such, cost has now switched from simply being a financial issue to now being an ethical issue that affects all those who work in the NHS. Improving from the frontline Faced with arguably its toughest challenge yet the NHS has been looking to find those people with the skills, knowledge and expertise already working in the system to meet this challenge whilst also maintaining standards and improving quality. Understanding that there are 55,000 junior doctors currently working in the NHS and that junior doctors lead 80% of ward based activity (Tooke Report, 2007) there has been growing recognition of the increasingly important need to engage junior
doctors in building a more efficient and sustainable NHS. One such initiative is Agents for Change - a partnership established under the leadership of the NHS Medical Director at the Department of Health and the BMJ. Its purpose is to engage and enable junior doctors to lead from the frontline to improve the quality and safety of care provided to patients. Agents for Change works in collaboration with a number of partners to help junior doctors gain the skills to improve their local care for patients. In the past, these organisations have included the National Patient Safety Agency, the King’s Fund, the NHS Institute for Innovation and Improvement and the NHS Confederation. Last year Agents for Change held two national conferences, the first focussed on safety improvement, and the second on quality. In addition to formal conferences, Agents for Change also run a series of seminars and workshops. Most recently, ‘Junior Doctors: Innovating from the front line’, was held at the 2011 NHS Innovations Expo at the Excel Arena in London. These seminars engaged junior doctors through showcasing inventions by award winning young doctors and outlined methodical approaches with which to improve healthcare systems. Agents for Change conferences have also attracted international interest. In November 2010, ‘Agents for Change: collaborating for quality’, a pioneering event – the first to bring together junior doctors and senior managers to explore more effective methods of working together - was streamed live on
the internet and watched by a large number of international medical students. As a direct result of this conference, Agents for Change launched the publication of the ‘7 key recommendations for how junior doctors and managers can collaborate to improve quality’ at the International Forum on Quality and Safety in Healthcare, in Amsterdam, April 2011. This contained the agreements arrived at by the 200 senior managers and junior doctors who contributed to the conference. Engaging Patients, Improving Care Agents for Change is currently planning its next series of events beginning on the 4th November 2011 with the ‘Engaging Patients, Improving Care’ conference in partnership with the Health Foundation. This event will place patients at the very centre of the quality improvement process with junior doctors working in partnership with patients to help shape and improve the delivery of healthcare. The conference will also include a series of Quality Improvement Masterclasses which will provide further context of the changing environment within the NHS. To find out more about Agents for Change and to register for forthcoming conferences and events, please visit agentsforchange.bmj.com. Ahmad Moolla, Agents for Change
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MEDICAL STUDENTS Improving Care
How to reduce child mortality Could Coca-Cola and Facebook have found the answer? One of the great pleasures in life is knowing that you can buy a bottle of Coke virtually anywhere in the world. So why is it, that if Coca-Cola can reach the remotest villages on the planet, children are still dying from inadequate distribution of simple medical treatments?
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pproximately 20% of children die in Africa before their 5th birthdays from preventable diseases such as dehydration or diarrhoea – a mortality rate that has not significantly changed in three decades. But this may be all about to change. Children in developing countries will soon have local direct access to essential medicines through a transformative initiative called ColaLife. ColaLife founder Simon Berry had the idea of using the Coca-Cola distribution network as a means of getting much needed supplies out to the people that really need them. The ColaLife ‘AidPod’ fits between bottles in crates and is designed to carry essential medicines such as oral rehydration salts. This is sold wherever coke is - in every market, shop and at every street corner - for the price of an egg, it will be transforming access to medicines for those most in need. Starting with a blog post and then a Facebook group called “Let’s talk to Coca-Cola about saving the World’s Children” Colalife soon had over 15,000 friends. And Coca-Cola heard: just three months after putting the idea live on the internet, meetings were set up with leading executives in the company and the idea of ColaLife will now become a reality later this year. Hearing about the campaign on-line, a group of students from King’s College London went to meet Simon at an Innovations talk at the Royal Society of Medicine. Five weeks later the team of 15 flew out to Uganda to lead the largest research project for ColaLife to date. Collectively travelling over 1000km by bicycle to ensure the most rural communities were reached, 656 mothers were interviewed, 62 schools were visited and every Coca-Cola sales point enroute was mapped out and the stock in all 16 health clinics in the Northern region was recorded. With enough data and feedback to make the final tweaks to the design and business model, funding has now been secured to run
Photo by Tielman Niewoudt.
the first ColaLife pilot in Zambia this year. However, this is just the beginning: “The success of the pilot will pave the way for us to repeat and scale this project throughout Africa and the developing world,” says ColaLife founder Simon Berry. Soon, local people will be able determine the contents of the AidPod’s that arrive in their communities and be empowered to treat their own children. Maybe then, we will be able to curve the mortality trend and not lose another child from easily preventable diseases simply because life-saving medicines were not available. To find out more or to follow the campaign visit www.colalife.org Claire Matthews, 3rd Year Medical Student King’s College London
“ColaLife is a really imaginative, practical and worthwhile project which aims to help save people’s lives.” Hilary Benn MP Photo by Tim Dench. Simon Berry. Photo by The Rugby Times.
MEDICAL Improving STUDENTS Care
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Improving Care
Doctors advancing D
APS (Doctors Advancing Patient Safety www.daps.org. uk) is an organisation set-up at the beginning of 2009 to empower junior doctors in making improvements in patient safety and care within their clinical environments. DAPS has over the past two years extended its activities to include a website, a student safety forum, a publication for reporting errors and its most innovative activity to date, the Improvement Programme. The Improvement Programme took place on the 21st January 2011 where seven junior doctors from the UK travelled to Lahore, Pakistan to work with seven junior doctors there to carry out quality improvement projects. The programme was organised under the auspices of DAPS and the Government of Punjab which is the largest of the four provinces of Pakistan. The team was allocated to carry out its work in Services Hospital, which is located in Lahore and is the main tertiary centre within the local area. Services Hospital is a government hospital but also has an allocation for private patients.
Oxygen masks were being re-used from one patient to another with minimal effort of sterilisation between use despite the fact that the previous patient may have been suffering from active respiratory tuberculosis. Collaborating for safety The first and second days of the programme were largely dedicated to introductions, forming three groups which would carry out the intended quality improvement projects and engaging in a walk-round of the hospital with the intention of looking for areas in which there were potential hazards in patient care. After highlighting a number of areas the team decided to focus on three particular areas of care which they developed over nine days. The first group focused on two specific infection control issues 18
MEDICAL STUDENTS Improving Care
which they had found sorely lacking. The first was hand hygiene and the second was the reuse of oxygen masks. The team observed that there was little or no adherence to simple hand-washing by either staff or patients which was particularly serious given the high patient load as well as the vast number of relatives who were allowed in the ward to act as attendants to the patients due to low nursing staff levels. Oxygen masks were being re-used from one patient to another with minimal effort of sterilisation between use despite the fact that the previous patient may have been suffering from active respiratory tuberculosis. The group made a number of positive interventions which included organising the allocation of alcohol wash to each ward, producing an educational leaflet about infection control for doctors and nursing staff, designing posters for patients and staff about the importance of hand-washing and assigning a house officer on each unit to act as the lead for infection control. The second group focused on the resuscitation trolleys in the hospital, which were not being used for their designed purpose. The vast majority of them were being used as general pharmacy stores and others were placed in inaccessible locations, which was of great concern given that there were five cardiac arrests per day on the medical wards. The aim of the team was to redesign the trolleys so that they functioned as a crash as well as an emergency trolleys. They designed a bespoke tray, which was used to hold medications in slots in contrast to the free-floating medications in the drawer. Testing their new tray against the old system demonstrated that the time taken in obtaining four emergency medications was halved. The group also designed a checklist which was to be checked on a daily basis. The third group focused on discharge medications. At least 50 percent of patients in Services hospital were found on survey to be illiterate and so there was a question over medication compliance. Discharge letters were either handwritten or typed in English and given the illiterate population, comprehension of the medications was extremely limited. The group designed a new medication discharge form which used symbols to represent the different times of the day. Surveying this form with the patient demonstrated that there was much better understanding of the symbols, which would naturally lead to an increase in compliance.
Future planning All three groups made a presentation on the penultimate day to the rest of the hospital which was extremely well received - with some of the local consultants expressing an interest to further take up the work. The team also had the opportunity to take a day out of the programme to see some of Lahore’s historic sights as well as visiting the famous Wagah border between India and Pakistan to watch the changing of the guards ceremony. After the departure of the British doctors the Pakistani doctors have continued to make improvements in their clinical environment and continue to stay in contact through a Facebook group.
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Over 2,500 cases to view
Explore and contribute to the world’s largest repository of case reports The programme was an extremely useful venture with the feedback being unanimous as to its role in promoting quality improvement and empowering junior doctors to take it up. DAPS is due to run the programme again in January 2012. If you would like to participate in the programme in January 2012, please contact info@daps.org.uk Imran Qureshi Specialist Registrar in Medical Microbiology & Virology Founder of DAPS
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 consortiasales@bmjgroup.com. Personal Fellowships available for £126 inc. VAT. For more information visit casereports.bmj.com/site/about/becomeafellow.xhtml
casereports.bmj.com
Writing Case Reports For most junior doctors their first experience of publication will be writing a case report. BMJ Case Reports Editor-in-Chief, Seema Biswas, offers some advice on perfecting your write-up.
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riting up a memorable case with your team is a valuable learning experience. It is the opportunity to research more about a case, search the medical literature, look up and compare clinical guidelines, ask probing questions about the pros and cons of management decisions and, most of all, assert your point of view in the medical literature. As evidence based medicine standards go case reports are level 5 evidence (below clinical trials and case series) but case reports do have their place. We learn from our discussion of cases we manage every day. It helps to discuss unusual presentations, complex symptoms, ethical or practical challenges, near misses, pitfalls and how complications may present and are dealt with. The debate is an educational one and case reports are an ideal educational resource for real case based discussion. A common perception is that only rare or novel cases are worthy of publication. In fact, we learn far more from common cases that present in an unusual way or common management pathways that meet an impasse or result in an unexpected outcome. My advice for writing up a case are to find one with valuable educational lessons for junior doctors or medical students. The patient may be someone you meet as a student or junior doctor, or a patient you looked after on a medical student elective. Take any clinical pictures you need to illustrate your points and then write-up the case using the following structure: Summary: Try to project the lessons of value and points of interest so that these are immediately apparent to someone reading your report. You may choose to type this section last as your report takes shape but this will be what captures the attention of your audience. Background: This is essential information that sets the scene and explains why certain symptoms or complications may have arisen during the course of illness. Case presentation: For most of us this is frequently the easiest section to begin writing. This is an outline of everything that happened to the patient from the time of presentation to discharge. This is ideal for you to type as you are most likely to have completed most of the case note entries 20
Careers
yourself and merely need to consult your notes. Be sure to include all relevant results and write these in full using internationally recognised units explaining any abbreviations, e.g. “The patient was hypotensive with a blood pressure of 130/80 mmHg and had developed neutropenic sepsis with a WCC, white blood cell count, of 2.1 x 109/l” Investigations: This is where radiological images illustrate your results and good pictures are extremely effective. Differential diagnosis: Rather than listing these, what is crucial is to demonstrate is how differential diagnoses were formed and diagnoses excluded as the patient was worked up. Clinical reasoning is fascinating as an entity in itself, but case reports are a brilliant opportunity to demonstrate how diagnoses are teased out through clinical problem-solving. This is where case reports really come into their own and earn their place amongst the medical literature. Treatment: As an editor, the best case reports present the case, investigations, diagnosis and treatment as an honest and reasoned process where management decisions are explained clearly. Clinical judgments and treatment plans, therefore, make immediate sense, especially to a doctor of a different specialty. Outcome and follow up: These give the clearest idea of the progress of a case. All too often this is neglected as inpatient teams may be disconnected from outpatient care. This information is crucial, however, and tracking a patient’s progress after discharge is, of course, excellent practice for the inpatient team. Discussion: There is no need for the discussion to be a summary of all the literature about a particular clinical problem. Focus on points that make the case notable and where lessons can be learned; this may be a mechanism of injury, a pitfall in the interpretation of investigations, the suitability of appropriate clinical guidelines, necessary departures from these guidelines or their adaptation in a particular scenario, the management of challenging complications … there are innumerable possibilities! Learning points and take home messages: These are essentially your final conclusions and serve to crystallize your
“Writing up notable cases is both an educational and career ‘no brainer’.”
thoughts on exactly why you think this case is of value and what we can learn. You may find this very effective in focusing your thoughts when you begin typing the case report. The patient’s perspective: This may be a most enriching contribution. I would urge you to involve patients in the process from the beginning as this is likely to result in a well-rounded account and the process of obtaining consent for images and publication is rendered more meaningful. As an editor, it is often writing style or grammar that fail to do justice to a case report. A well-written case with clear learning points is likely to be published. In modern medical portfolios where publication is essential for job applications and continued professional development writing up notable cases is both an educational and career ‘no brainer’.
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Focus on Finance - in association
An interview with Professor Professor Parveen Kumar is an influential figure in the medical profession. You may know her as co-editor of “Kumar and Clark’s Clinical Medicine”. She is also a Professor of Medicine and Education and Consultant Physician and Gastroenterologist, as well as President of the Royal Society of Medicine and a member of the Wesleyan Medical Sickness Advisory Board. We caught up with Professor Kumar at the Royal Society of Medicine and got her views on everything from coping with student debt to the importance of having fun! Why did you go into medicine? One of the reasons I decided medicine was a great career is that it combines science with caring for patients – both of which I was passionate about and still am. Medicine has so many facets and also gives you an enormous choice of jobs within the speciality. Ultimately, it’s very fulfilling and certainly helped me to achieve what I wanted to do with my life.
How did I get into teaching? I just love to teach. There are so many different ways of teaching depending on where you are, for example, on the wards or in out-patients. Students learn in different ways and part of the excitement of teaching is to find the correct method, level and interests of the students. Medical students are such resilient people – they’re very bright and very motivated. They also ask the most penetrating questions which sometimes make you think ‘well actually I never really thought about that!’
The best tip I can give to doctors is to work hard, be honest and show humility. I’m always impressed with the different activities that medical students do in their day to day lives. Some of the students I have met are doing all sorts of things, including raising hundreds of thousands of pounds for RAG every year. Some of my students are doing a lot of charity work here and abroad in their holidays and I really admire their ability to juggle lots of activities.
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FINANCE
What was the inspiration behind writing Kumar and Clark Clinical Medicine? When I was a medical student there was this textbook which was so difficult to follow – it was verbose, ambiguous and unfocussed. I used to read a paragraph and think ‘should I be giving this drug or should I not give it?’ – an important distinction if it was a life or death case! I promised myself that when I “grew up” I would write the definitive textbook. Well, I think we got pretty close. It came about when Dr Clark, who was my supervisor for my research at the time, heard that I’d agreed to write a chapter for a new textbook that was being compiled. He suggested that we should write a new book as I had ‘gone on and on about it for so long’ and offered to help. Two-and-ahalf years later, having worked every weekend, holiday and spare moment, we actually produced the first edition of Kumar and Clark’s Clinical Medicine. We never thought that we would still be writing it over 20 years later; it is currently in its 7th edition and is used around the world. A humbling thought but also a great responsibility in keeping it up to date.
What in your view are the challenges facing young doctors? There are of course many different challenges. A key one for students these days is the huge debt they might have, which can be as much as £35,000. This figure will certainly rise with the increase in university tuition fees. Not only do students have large debts but they have less time to earn money because they don’t have as much spare time or the same amount of holidays as students in other courses. As they progress in their career, doctors may get married and have children so they will have a
huge number of financial commitments as well as trying to learn to be a good doctor.
What can young doctors do to alleviate these challenges? There’s a lot to think about and clearly they need to take advice where they can. I think in terms of their education, obviously young doctors should work hard but also they should play hard because it’s important to have a good work/life balance. There’s a worry now that some young doctors might not find a job. In the past doctors always had ready made positions but now there may not be a job in a particular speciality or it may require a young doctor to relocate, which can be very difficult if they have a family. I really think this is an area where doctors will need good advice.
It’s important to have fun; if you’re not having fun then forget it and leave. Medicine is difficult enough anyway and if you have fun you’ll hopefully have a super career, I have certainly enjoyed mine and still do - even at my ancient age! One other thing young medics should consider is joining member organisations. The Royal Society of Medicine is a great institution (I would say that, wouldn’t I, as I am President!) that runs lectures on all sorts of topics. It also provides young doctors with a strong support network and an opportunity to mix with consultants or retired members who can offer the wisdom of their experience.
with Wesleyan Medical Sickness
Parveen Kumar The British Medical Association is another good organisation. It looks after the professional and personal needs of doctors and can help with legal advice if required.
How did you get involved with the Wesleyan Medical Sickness Advisory Board? I was very honoured to be asked to be part of the Wesleyan Medical Sickness Advisory Board. It’s a great organisation and offers a fantastic service to doctors of all ages across all specialities. I wish I’d had Wesleyan when I was a medical student because they give you strong financial advice as you move from being a medical student to becoming a junior doctor and then a consultant. There are always going to be financial headaches so it’s useful to have someone to talk to that understands the specific challenges doctors face and can provide real help.
What would be your top career tips for a successful medical career? The best tip I can give to doctors is to work hard, be honest and show humility; I abhor arrogance. If you make a mistake own up to it; it’s part of becoming a better doctor. Of course you must have the knowledge and this does mean hours of study and seeing patients. The second tip is to ask for help as there
is no point bottling it up because it will not help a situation. There are times when young doctors may be struggling due to work pressures or they feel that their job is not going as well as they would like. They mustn’t be afraid to ask for advice - there are lots of people who can help.
Finally, it’s important to have fun; if you’re not having fun then forget it and leave. Medicine is difficult enough anyway and if you have fun you’ll hopefully have a super career, I have certainly enjoyed mine and still do - even at my ancient age!
The above information does not constitute financial advice. If you would like more information or need general financial advice, you can call Wesleyan Medical Sickness on 0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk
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FINANCE
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Medicolegal Advice - in association
An inconvenient truth
MPS is often contacted by doctors who are surprised that their attitude and behaviour outside the clinical environment has called their fitness to practise into question. Sara Williams shares the story about what happened to Isla when her deanery discovered a serious black mark on her record.
I
sla is now an F2 in Aberdeen. A few years ago, during her final year at medical school, Isla got into some trouble on a night out with friends. She was celebrating getting her final results, so had spent most of the day in the pub. By midnight she was a tad worse for wear so decided to go home. On the way to hail a taxi she spotted her now ex-boyfriend outside a nearby club kissing another girl. Isla saw red and leapt at them, shouting and screaming. A police car spotted what was going on and before Isla knew it she had been arrested and had to spend the night in a cell. The following morning Isla was allowed to leave without charge, but had to later accept a fiscal fine for breach of the peace. Isla wanted to put the incident behind her so did not declare the incident on her GMC application. She already had an F1 job and her CRB check had already come back fine. Isla had a fantastic F1 year and she fully registered with the GMC, but the incident came back to bite her in her F2 year. Another CRB check flagged up the incident and she was formally disciplined by her hospital, who also informed the deanery and the GMC. The GMC discovered that she had failed to declare her fiscal fine on either of her applications to the GMC. Isla was then called to a fitness to practise hearing. MPS stepped in to represent Isla at the GMC and she was given a formal warning that would stay on her record for five years. She also faced significant difficulties at her trust, where she could easily have been dismissed for her failure to accurately complete the job application. Isla learnt the hard way and her F2 year was marred by her dishonesty. According to Dr Chris Godeseth, Medicolegal Adviser at MPS, the GMC takes probity very seriously. He says: “Unfortunately, a number of medical students and junior doctors will find themselves in a situation similar to this. Although medics are famed for their “work hard, play hard” ethos, they must be aware that their 24
behaviour outside the clinical environment, including that displayed in their personal lives, may come under scrutiny from the GMC. Doctors’ behaviour at all times must justify the trust the public places in the medical profession, so there is a similar requirement placed on students.” In this case, Isla failed to declare her caution to the medical school, the GMC, or the trust for whom she had already agreed to work as an F1. All students applying to join the GMC register need to complete a “Fitness to Practise declaration”; she was
dishonest in hers. While there may not be a strict requirement to declare these issues to your medical school, they will often come to light through the CRB checks performed in later years. But trying to hide or ignore the issue will only make things worse. Dr Godeseth adds: “The GMC takes any failure to disclose evidence of criminal behaviour very seriously, and often treats this as evidence of dishonesty. If the GMC calls your practice into question it can lead to suspension, which could mean you do not complete medical school at the same time as
with the Medical Protection Society
“Although medics are famed for their ‘work hard, play hard’ ethos, they must be aware that their behaviour outside the clinical environment, including that displayed in their personal lives, may come under scrutiny from the GMC.”
About MPS info for articles.qxd:MPS Checkup
12/2/10
10:05
Page 1
About MPS other graduates from their medical school.” It really is very important that new doctors who find themselves in this situation are open and honest. It’s often very embarrassing or difficult to do this, but favourable to any initial mistake being compounded by taking the wrong approach with the medical school, your trust or the GMC. This case features in one of a series of podcasts exploring fitness to practice cases for junior doctors and medical students. Access them here: www.medicalprotection.org/uk/ advice-and-publications/podcast
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.
www.mps.org.uk The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.
25
Assessed by Gil Myers
Medical Report
I
Batman
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...”
Down
Across
1 Structure forming framework of the mouth and where teeth attach (3) 4 ___ foot is an infection of the tissues and bones in the feet causing chronic inflammation (6) 6 Any tumout relating to cells of the nervous system (7) 7 Hit from Nicole Scherzinger; any substance that irritates, damages or impairs functioning of body tissues (6) 9 This suture technique is used when closing contaminated wounds and wounds associated with tissue necrosis; made late (7) 13 A streak or line (5) 15 Localized form of scleroderma, plaques in the skin without internal sclerosis (8) 16 Fancy word for swallowing (11) 17 Yellow pigment of corpus luteum (6) 18 This type of association was described by Freud; no cost (4) 1 Annoying person (usually male); sudden contraction of a muscle in response to a nerve impulse (4) 2 Vibrations or
tremors in part of the body, that can be detected by palpation fo auscultation (8) 3 When belonging to a policeman, this is plantar fasciitis (apparently) (4) 4 Diseased, pathological (6) 5 Analysis of variance between groups, statistical procedure (5) 7 Tumour containing sandlike particles; typical of ovarian cancer (8) 8 Do this e.g. for a table if you want to guarantee it; extra volume of air one could breathe in or out if not breathing to limit of his capacity (7) 10 Pes ______ : flat foot (6) 11 Absence or marked impairment of will power, e.g. in schizophrenia (6) 12 ‘Crushing’ this nerve was formerly a treatment option in tuberculosis (7) 13 Apoplexy; you may do it to cats for example (6) 14 Disease of rapid onset or severe symptoms (5) You can find crossword solution searching for ‘crossword answers’ www.juniordr.com Compiled by Farhana Mann
26
HOSPITAL MESS
the by at
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 - 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 Save our NHS! sue (We Dear Editor, s in your last is ct fa e th by ed p9). The I was amaz figures; Iss 20; d an s ct Fa S d of. I’m love our NH e should be prou w ng hi et m so t if the NHS truly is ur facts from bu yo t go u yo re agement not sure whe budget on man its of 3% ds rew LansUK only spen in the USA And % 17 to d se I was also costs as oppo ning so much. ai pl m co be t oyed by the ley shouldn’ people are empl 23 in e on at the streets staggered th all get out on ld ou sh e w special to NHS. Maybe r NHS - it is so ou ve Sa d. di like students as everyone. Karen Thom
W
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:
Packet of Malteasers (37g)
king out
Dear Editor, I’ve had to take some time off work recently fo health reasons. It has been a st r ruggle managin process - neverm g the ind dealing with my fears over w my colleagues hat and the senior staff might thin pleased to say k. I’m that generally I was treated with seriousness and the respect that w as appropriate. didn’t mean it Th is was an easy pr ocess but it ce wasn’t as bad as rt ai nl y my initial fears and apprehensi I think if more ons. people like Hel en Burt (A pers al view; Iss 20 on; p15) were op en about their it would help stories educate the rest of us and hope persuade us no fully t to carry on w orking under fe disclosing our ar of problems. I’m hoping to go ba work soon and ck to I just wanted to congratulate H for having the co elen urage to tell he r story.
Helen ST3 Psychiatr y
Safety is common
60p
Queen Elizabeth II, Welwyn Garden City
Lighter than your average chocolate snack at:
49p
nery Western Dea FY1, North
Thanks for spea
Choc-olotta money at:
Toothpaste (100ml)
Royal Bournemouth, Bournemouth
Enough to give you a toothache at:
£3.19
Royal Edinburgh Hospital, Edinburgh
A tooth sparkling price:
£1.49 4 x AA Batteries
Crosshouse Hospital, Ayrshire
Stick to a wind-up model at:
£4.99
Whipps Cross Hospital, Leytonstone
Time to recharge at:
£2.99
Crosshouse Hospital, Ayrshire
Next issue we’re checking the cost of sausage and chips, a ball pen and one pint of milk. Email prices to hospitalconfidential@juniordr.com
sense?
far behind the read just how to d ke oc sh I was s compared to to working hour s rd ga re ith w hours has little US are in US working n tio uc ed (R ; p6). It seems Europe training; Iss 20 d an ty fe sa ther it’s safe effect on are debating whe es ne ai tr S U at eek when the bizarre th s from 90 per w ur ho ng ki or w ly any member to reduce under 60. Sure ng ki or w e ar on sense would rest of us ounce of comm an ith w ic bl ating at the of the pu a surgeon oper ng vi ha at th nd n’t be safe. understa eek certainly ca w ur ho 0 11 a my end of Sanjay Swa
mingham Locum GP, Bir
‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.
Trafford General Hospital, Manchester The Mess has a newly decorated lounge, which includes a television and snooker table. Adjacent to the mess, a quiet area for study is available with PC, printer and Medline Search facility and CD-ROM texts (a laptop and CDROM can also be borrowed). The doctors also have their own dining area where Barbara the waitress serves breakfast and lunch. In the restaurant foyer vending machines sell snacks, drinks and chilled foods. The latter may be reheated in the adjacent microwave ovens.
JuniorDr Score: ★★✩✩✩
HOSPITAL MESS
27
Get your neural input to junior doctors. Advertise here. Call us on 020 7684 2343.
Journalism
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The Medical Journalist’s Association brings together medical writers, the media, health professionals, and health charity workers.
From little acorns mighty oaks grow
> 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
To make sure your career grows strong and true, and always on an upwards trajectory, join:
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Acute Medicine “The most important body championing the cause of acute medicine” SAM member, 2011
To join or to find out about the many benefits SAM members enjoy visit www.acutemedicine.org.uk or email sam@rcpe.ac.uk.
Recruitment
2012 Specialty Training Recruitment Get Ready The provisional timetable for Round 1 and Round 2 recruitment is as follows: CT/ST1 Round 1 - August/September 2012 intake • Applications open on 25 November and close on 9 December 2011 • First offers issued by 9 March 2012 ST3+ Round 1 (and readvertised CT/ST1 posts) - August/October 2012 intake • Applications open on 17 February and close on 5 March 2012 • First offers issued by 25 May 2012 Note: Round 1 includes recruitment to run-through specialties and CT2 for most of the uncoupled specialties. The exception is Anaesthesia - where CT2 posts will be advertised with ST3 recruitment.
Set... Visit the SMT website over the summer for more information on the application process. Subscribe to the SMT e-Newsletter via the website for the latest updates.
Go!
http://www.scotmt.scot.nhs.uk
28
CLASSIFIED
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Is there a life outside the NHS?
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Considering a year or more abroad?
Global Destinations and Career Advice
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Experience Experience Satisfaction Drama
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Junior Doctors – Christchurch NZ You’ve always been the type to challenge yourself - always up for adventure; keen to do more, see more, achieve more. And it’s a philosophy that applies to every facet of your life...work, play, whatever comes your way. So that said, there’s simply no better way to stay true to yourself – and to truly maximise your career and quality of life, than to join us at Canterbury District Health Board. Imagine it now...living in Christchurch, in New Zealand’s stunning South Island. With the ocean a couple of minutes away, and snow-covered mountains a couple of hours away, you’re literally in the middle of life at its best. Then there are the professional advantages. The variety, training and opportunities you’ll have at our leading tertiary hospital are world-class, so your medical career is set for serious enhancement. If you’re a qualified Junior Doctor looking to ramp up your career and really enjoy life, we can make it happen. To learn more about this unique opportunity, and to apply, visit
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Queensland Health will be recruiting for the 2012 intake of resident medical officers and registrars from June 21, 2011. A medical career with Queensland Health includes outstanding salary packages, exceptional training and development opportunities and dream Queensland lifestyle.
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Apply online from Tuesday June 21 www.health.qld.gov.au/medical/rmoinfo.asp Applications close midnight Monday July 18 or apply now for the Basic Physician or ICU Training Pathways
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29
THE MEDICAL COURSE AND CONFERENCE DIRECTORY
A
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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Mon 30th Aug (5 days)
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£650
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£1395
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£1395
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£600
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£325
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£450
Bristol
Hammersmith Medicine
Mon 5th Sep (5 days)
Fri 9th Dec (3 days)
Leadership, Management & Personal Development Training Courses you should know about!
Thurs 5th Jan (5 days)
MRCP 2 Hammersmith Medicine
Hammersmith Medicine
Mon 4th Jul (4 days)
Mon 31st Oct (4 days)
MRCP Paces Sat 11th June
Consultant Interview Skills (Includes access to online resources)
(2 days)
Insights Intensive - Understanding the Implications of the White Paper
Sat 18th June
3-day Clinical Management & Leadership
(2 days)
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Wed 1st June
Communication Skills for Junior & Middle Grade Doctors
(4 days)
Foundation Course in Leadership & Management for FY Doctors
Thurs 9th June (4 days)
View all courses at:
Sat 11th June
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(2 days)
Sat 18th June
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Win Over A £1000’s Worth Of Training!
3 Day Clinical Management & Leadership Course worth £699+VAT! Advanced Communication Skills e-Learning course worth £275+VAT! Just register your details to enter!
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30
(1 day)
EVENTSDR.COM
Sat 4th June (2 days)
Emergency medicine Sat 6th Aug (2 days)
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Forthcoming
courses MRCP 1
Sat 13th Aug (2 days)
£450
Bristol
22-26 August 9-11 September
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MRCP 2 PACES
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Superego Cafe
Sat 11th Jun (1 day)
£345
London
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19-22 September London 24-25 Sept’ Manchester 26-29 September London 1-2 October Manchester 3-6 October London
MRCPCH 1 5-10 September 28-30 September
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MRCPCH 1 Wed 1st June (3 days)
Mon 5th Sep (6 days)
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Surgery MRCS B Sat 17th Sep (2 days)
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Others Leadership & Interview Skills Wed 8th June Management Excellence for Junior & Middle Grade Doctors
(1 day)
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Wed 13th July (3 days)
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Number 1 for Medical Interviews & Applications Courses in small groups for a more personal approach We offer a range of medical interview courses and services to optimise your chances of success at medical interviews
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31
MEDICAL PROTECTION SOCIETY PROFESSIONAL SUPPORT AND EXPERT ADVICE
Supporting you throughout your career MPS understands the importance of giving members access to a reliable, high quality service, and a range of educational services designed to meet your needs.
The best protection
MPS Educational Services
MPS members have access to a wide range of benefits designed to help with the legal and ethical problems that can arise from professional practice.
We have developed a range of highly rated publications, workshops, conferences and e-learning resources to help promote good medical practice and minimise the risk of clinical mishaps. More than 4,000 doctors in the UK have already benefited from attending an MPS workshop. www.mps.org.uk/education
Medicolegal advice – available in an emergency 24/7 Legal representation – first-class specialist legal advice and representation Media relations – help with adverse publicity We encourage members to get in touch on 0845 605 4000 if they are in any doubt over a medicolegal issue.
Working overseas? MPS has over 270,000 members in more than 40 countries. If you are planning to work overseas we can usually help.
For more information Visit www.mps.org.uk Call 0845 718 7187 Email member.help@mps.org.uk The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.