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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. 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 2012. All rights reserved. Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out JuniorDr.com.
The medicine behind the medals O
n July 27 the world’s greatest sporting event comes to London. As 10,500 athletes from 204 nations compete, an estimated four billion of us will take to our sofas to watch the Games at home. Everything about London 2012 is record breaking - from the world’s largest McDonald’s serving 1,500 at any one time to the 350 tons of vegetables which will be consumed. We’ve collated the most impressive health facts about the Olympics on page 8. No other single sporting event will have such an impact on health. The ambitions for London 2012 from its inception were to provide a national sport participation and physical activity legacy - the first Games ever to have such ideals. The Labour government at the time promised to get one million more adults participating in sport three times a week by 2013 - a target which has been dropped since by the coalition. But with less than two months to the start of the Games, London is heading towards a story of unfulfilled promises and of legacies lost says Professor Mike Weed in our feature ‘Is the health legacy of London 2012 lost?’. Will London 2012 be the first Games to have tried and failed to deliver a national sport participation and physical activity legacy? Read Professor Weed’s view on page 9. As well as the public health impact we bring you the story of the medics behind the medals. Hundreds of doctors are involved in the organisation of the Games and in maintaining peak performance of the athletes. Dr Richard Budgett is Chief Medical Officer to London 2012. We caught up with him before his appointment to talk about sports and exercise medicine in the UK and his role in leading medical cover (page 12). With the world’s greatest sporting event the Olympics also bring a major public health and sports medicine challenge. If you’re one of the hundreds of junior doctors who have volunteered to help provide medical cover for the Games we wish you a fantastic event. Good luck London 2012!
What’s inside 04 08 09 12
LATEST NEWS London 2012 health facts London’s legacies lost?
20 26
Practice in Safe prescribing Courses and Conferences
the medicine behind the medals
TRIAGE
3
Tell us your news. Email team@juniordr.com or call 020 7193 6750.
INDUSTRIAL ACTION
4 in 5 junior doctors vote for a strike on June 21 82% of junior doctors voted for outright strike action in the recent BMA ballot - a higher number that all other branches of practice - published results show. Of 11,113 who replied to the ballot an even higher 92% said they would get involved in industrial action short of a strike. However, turnout among junior doctors was among the lowest of all professional groups at just 39.5%. Industrial action, short of a formal strike, will take place on Thursday 21 June and will involve doctors only providing cover for non-urgent cases. The BMA argues that the latest pension changes will see doctors paying up to 14.5 per cent of their salaries in pension contributions twice as much as some other public sector staff. They will also have to work up to the age of 68 in order to receive their pension. “This is not a step that doctors take lightly – this is the first industrial action doctors have taken since 1975,” said Dr Hamish Meldrum, Chairman of Council.
“We have consistently argued that the Government should reconsider its position, and even at this stage we would much prefer to negotiate a fairer deal than to take action. We are not seeking preferential treatment but fair treatment. The government’s wholesale changes to an already reformed NHS pension scheme cannot be justified.” The BMA has confirmed its intention for further action if necessary after June 21. www.bma.org.uk
What the papers are saying? “Doctor, doctor: why is my GP going on strike? Because a £53,000-a-year pension deal isn’t enough...” May 31
“Thousands of doctors ‘will defy’ the order to strike as they are deeply opposed to action” June 1
“A doctors’ strike puts the ethos of the NHS at risk” June 2
WORKING CONDITIONS
RemedyUK closes after five years
J
unior doctor pressure group RemedyUK has closed citing unsustainable management and leadership as the reason. RemedyUK was formed in 2007 following the mismanagement of the Medical Training and Application Service (MTAS) and exposed unfairness in the matching process and lapses in data security. As well as political lobbying and mounting a legal challenge against the government it succeeded in organising a protest march of 12,000 people to Westminster.
4
NEWS PULSE
In a statement on the RemedyUK website they said: “We are immensely proud of everything that our small committee and 12,000 supporters have managed to to achieve during this time. Remedy was about providing the legitimacy and security to passionate medics who wanted to challenge the views of the establishment.” They expect £2,000 will be remaining from all assets which will be donated to the Medical Benevolence Fund.
www.remedyuk.org
NEW IN 2012
NHS
‘NHS tourists’ owe £40m in unpaid fees
N
HS hospitals in England are owed as much as £40m in outstanding fees for the treatment of foreign nationals, according to an investigation by GP magazine Pulse. Currently, when foreign nationals are not eligible for NHS care they, their insurers or their country of origin is approached for payment. Of the 35 acute trusts who replied to the investigation the average unpaid debt for the provision of care to foreign nationals was £230,000. Extrapolated across all 168 trusts in England it puts the total owed to the NHS by foreign nationals at £40m. St George’s Healthcare Trust in London had the largest outstanding debts, totalling £2m from treatment of foreign nationals from April 2009. Barnet and Chase Farm Hospital was next with £488,000 outstanding. “A high percentage of our patients require lifesaving trauma, neuroscience, cardiovascular or paediatric care. We’re working hard to improve the way we record overseas patients and the debt recovery rate,” said a spokesperson for St George’s. The most inefficient trust in collecting money was Royal Wolverhampton, which collected only 24% of the £419,000 owed, followed by Newcastle-upon-Tyne, which collected 36%.
978-0-415-68003-5
Dr Richard Vautrey, deputy chair of the BMA’s GP committee, said: “Hospital trusts must put in place arrangements that ensure people cannot exploit the system. However, we need to be careful that we are not putting barriers in place that prevent people from getting access to healthcare. It can be quite challenging. It is too simplistic to call it health tourism. The reality is a lot more complex.”
978-0-415-68416-3
www.pulsetoday.co.uk
978-1-85996-264-0
PATIENT SAFETY
1 in 20 GP prescriptions has an error
O
ne in 20 prescriptions written by GPs contains an error, according to a major study of GP prescribing by the GMC. The study of practices in England found that while most errors were classified as mild or moderate, around 1 in every 550 prescriptions contain A serious error which could have resulted in serious harm. The most common errors were missing information on dosage, prescribing an incorrect dosage,
“We will be leading discussions with relevant organisations, including the RCGP and the CQC, and the Chief Pharmacist in the Department of Health, to ensure that our findings are translated into actions that help protect patients,” Professor Sir Peter Rubin Chair, General Medical Council
and failing to ensure that patients received necessary monitoring through blood tests. “We will be leading discussions with relevant organisations, including the RCGP and the CQC, and the Chief Pharmacist in the Department of Health, to ensure that our findings are translated into actions that help protect patients,” said Professor Sir Peter Rubin, Chair of the General Medical Council. A number of factors were found to be associated with increased risk of prescribing or monitoring errors. They included the number of medicines a patient was taking - there was a 16% increased risk of error for each additional medicine. Children and those aged 75 years and older were almost twice as likely to have an error as those aged 15-64 years. The research recommends a greater role for pharmacists in supporting GPs, better use of computer systems and extra emphasis on prescribing in GP training. www.gmc-uk.org
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NHS
Private out-of-hours firms rated worse than NHS providers
P
rivate providers of GP out-of-hours services are more expensive and rated worse by patients than those delivered by not-for-profit and NHS alternatives, according to analysis by Pulse. The study looked at five indicators across 81 out-of-hours services - 32 provided by not-for-profit organisations, 27 in house by the NHS and 22 by private firms. They found that whilst companies often matched the performance of not-for-profit and NHS providers on the National Quality Requirements, under which contracts are monitored, they fell significantly behind on patient satisfaction scores. Private providers were paid an average of £8.11 per head compared with £7.39 for notfor-profit organisations and £9.10 for NHS providers. However, just 59.5% of private services were rated good or very good by patients, compared with 65% for not-for-profit services and 64.7% for the NHS. Harmoni, the country’s largest out-ofhours provider, performed significantly below average not only on patient satisfaction but on key requirements to assess urgent cases within 20 minutes and see them face to face within two hours.
Whistleblowing process not working
The Primary Care Foundation said there was too much focus on fulfilling National Quality Requirements, and urged commissioners to also consider patient satisfaction, audits of clinicians and integration of services. Commenting on the results Richard Hoey, editor of Pulse, said: “Private out-of-hours companies have increasingly taken over from the old-style GP co-ops, and yet our analysis suggests the private sector is not only performing worse, but is more expensive.” www.pulsetoday.co.uk
Aptitude test is fairer way to select for medical school
M
6
NEWS PULSE
Working night shifts more than twice a week is associated with an increased risk of breast cancer, according to a long term study published in Occupational and Environmental Medicine. The study of 18,500 women found that night shift work was associated with a 40% increased risk of breast cancer compared with no night shifts. One in ten of the European workforce currently work night shifts. oem.bmj.com
MEDICAL STUDENTS
edical schools which use the UK Clinical Aptitude Test (UKCAT) as part of their admission process reduce the disadvantage faced by those in lower socioeconomic groups, according to a study published in the BMJ. Researchers at Durham University looked at 8,459 applicants to 22 UK medical schools which used UKCAT as part of their admissions process. They found that candidates from underrepresented groups applying to medical schools which relied upon the UKCAT heavily in making their admissions decisions did not suffer significant disadvantage. “Our findings suggest that placing an
Night shifts double cancer risk
increased weight on an applicant’s UKCAT performance significantly reduces the disadvantage faced by most candidates from underrepresented sociodemographic groups,” say the team led by Dr Paul Tiffin. The UK Clinical Aptitude Test (UKCAT) was developed in 2006 and assesses skills such as verbal reasoning and decision analysis. It is designed to ensure that candidates have the most appropriate mental abilities for a career in medicine. At present only around 5% of entrants to medical school have parents from non-professional backgrounds. www.bmj.com
‘Fear of consequences’ is the most common reason (49%) why doctors believe the current ‘whistleblowing’ process is not effective. The survey of 1500 members of the Medical Protection Society also found that where doctors had raised concerns about patient safety less than 40% felt their concerns had been addressed. www.mps.org.uk
Old people smell nicer The smell of old people is less unpleasant and less intense than young and middle-aged people, according to a study at Monell Chemical Senses Center in Philadelphia. The blinded study looked at the odours gathered from pads worn by volunteers for five days. Contrary to popular opinion older people were generally accepted to have more neutral and pleasant smells than their younger counterparts. www.plosone.org
Measles deaths drop 74% Deaths from measles have dropped by 74% worldwide since 2000 according to a report by the WHO published in The Lancet. Total global deaths from the disease dropped from 535,300 in 2000 to 139,300 in 2010 - but still below the 90% reduction target. 40% of all measles deaths in 2010 occurred in India where vaccination rates are among the lowest in the world. www.who.org
NHS
Junior doctors unsupported when dealing with deteriorating patients
A
third of in-hospital cardiac arrests and subsequent attempts to resuscitate could have been prevented, according to the latest National Confidential Enquiry into Patient Outcome and Death report. Better assessment on hospital admission, and recognition and response when acutely ill patients deteriorate could have prevented cardiac arrest and the subsequent resuscitation attempts in a third of cases. The report showed that patient assessment on admission was deficient in 47% of cases, and there were warning signs that the patient was deteriorating and might arrest in 75% of cases. However, the warning signs were not recognised in 35% of those patients, not acted on in 56% and not communicated to senior doctors in 55% of cases. NCEPOD Advisors found a lack of input from senior
clinicians in the 48-hours prior to cardiac arrest. “Senior doctors must be involved in the care planning process for acutely ill patients at an earlier stage, and support junior doctors to recognise the warning signs when a patient is deteriorating,” said report author and NCEPOD Lead Clinical Co-ordinator Dr George Findlay. “The lack of senior input fails patients by both missing the opportunity to halt deterioration and also by failing to question if CPR will actually improve outcome.” The report, Time to Intervene?, calls for improvements in recognition and response to patient deterioration. It also recommends advance decision-making around what care is likely to benefit acutely unwell patients, including do not attempt cardiopulmonary resuscitation (DNACPR) decisions. www.ncepod.org.uk
Top training Down Under Queensland Health, Australia Queensland Health will be recruiting for the 2013 intake of resident medical officers and registrars from Tuesday June 19, 2012.
M130412-1 RMO2013 JrDr
A medical career with Queensland Health includes outstanding salary packages, exceptional training and development opportunities and the dream Queensland lifestyle.
Apply online at
www.health.qld.gov.au/rmo Applications close Monday July 16
NEWS PULSE
7
London 2012 Olympics health F acts and figures
68,000 people are expected to become so intoxicated
Extra-long beds have been ordered for some
taller athletes
they will need
medical intervention
6 condoms per athlete were provided in Beijing 2008 – a decrease from 8 in previous games Four billion people – 2/3 of the world’s population – are
The onsite
McDonalds - the world’s biggest - will seat 1,500
expected to become
TV couch potatoes during the
at any one time
two week event
ancient Greece athletes ate mainly cheese before the games, in London they’ll eat 350 tons In
of
vegetables
and
100 tons of meat
purpose-built polyclinic health
Only three companies will be able
centre will later
to advertise inside the venues
The
converted into a health education centre be
–
McDonalds, Coca Cola and Cadbury
IS THE HEALTH LEGACY OF
London 2012
ALREADY LOST? Will London 2012 be the first games to have tried and failed to deliver a national sport participation and physical activity legacy? Professor Mike Weed, Director of the Centre for Sport, Physical Education and Activity Research (SPEAR) at Canterbury Christ Church University, believes it may be.
Professor Mike Weed Director of the Centre for Sport, Physical Education and Activity Research (SPEAR) Canterbury Christ Church University
OLYMPIC MEDICINE
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F
rom the ambitions of the final bid presentation that secured the 2012 Olympic and Paralympic Games for London, through the legacy promises made in the previous Labour government’s action plan, the sporting, social, cultural and economic development legacies have been referenced many times in Olympic planning. Labour’s legacy action plan and the coalition government’s more recent priorities each appear to give billing to legacies in different areas however, the sport participation legacy is undoubtedly ‘first among equals’ in the minds of the IOC, LOCOG and the UK media. In Singapore in 2005 Lord Coe, Chair of the London Organising Committee for the Olympic and Paralympic Games (LOCOG), secured the 2012 Games for London with a final bid presentation that included a promise to inspire a new generation to choose sport.
“No previous Games has succeeded in raising participation in sport and physical activity.” Yet, as the popular press is fond of reminding us, no previous Games has succeeded in raising participation in sport and physical activity. Systematic review of previous multisport events in the BMJ in 2010 concluded that “the available evidence is not sufficient to confirm or refute expectations about the health of socio-economic benefits for the host population of previous major multi-sport events” (McCartney, et al, 2010). However, this is not the full picture. Whilst it is true that no previous Games has resulted in sustained increases in sport and physical activity participation in host populations, no previous Games has attempted to raise population levels of sport and physical activity participation.
Sport participation Participation data has merely been examined afterwards to explore whether Olympic and Paralympic Games have passively affected participation levels. As such, and as noted by the authors in their conclusions, the 2010 BMJ review should be interpreted to mean that there is no evidence for an inherent sport and physical activity participation legacy effect, in which benefits occur automatically from hosting an Olympic and Paralympic Games. So what does this mean for London 2012? Was it reasonable to suggest that a sport and physical activity participation legacy could be possible? In short, yes. The lack of evidence for sustained population level effects following previous Games which did not attempt to deliver sport and physical activity legacies is not an indication that such a legacy could not be leveraged from the London 2012 Games. In fact, a worldwide systematic review of the research evidence, conducted by SPEAR for the Department of Health (Weed et al, 2009), shows that there is evidence that mechanisms associated with Olympic and Paralympic Games have had a positive effect on sport participation where specific initiatives have been put in place to leverage such participation. Such initiatives have however not been on a large enough scale to effect population levels of sport and physical activity 10
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participation, hence the lack of evidence for an inherent effect found in the BMJ review.
The Demonstration Effect SPEAR’s review for the Department of Health provides evidence for two mechanisms which could be scaled up to affect population levels of sport and physical activity participation. The first of these is the Demonstration Effect, whereby people are inspired by elite sport, sport events and sportspeople to participate themselves. However, and most importantly, the Demonstration Effect only works with those who are already positively disposed towards sport. As such, it can encourage those who participate a little to participate a little more, or encourage those who have participated in the past to participate again. What it does not do is get those who do not and never have participated in sport to start playing. The problem is that people can feel daunted, they see someone like Kelly Holmes winning double Olympic gold and think that is so far removed from what they feel they could do, that it’s not even worth trying. This is called a competence gap.
A festival effect For those that are not sporty, a second effect can be harnessed; a Festival Effect. A Festival Effect taps into an individual’s sense of community and desire to be part of something bigger than and beyond the sporting competition, and can be leveraged by emphasising the cultural and creative value of the Games, and not mentioning sport at all. This has the potential to reach the less active or even the sedentary, but for it to work, initiatives must be rooted in local cultural and community activities and tap into preexisiting ‘value hooks’ such as family or eco values.
“Population levels of sport participation in England have increased by an average of only 38,000 a year over the last three years.” One example might be the use of the commitment some individuals’ have to green values, which can be matched with the sustainability agenda of the 2012 Games, to get people involved in initiatives that clear and enhance local parkland, thus getting such people active, almost without them realising it.
IS THE HEALTH LEGACY OF LONDON 2012 ALREADY LOST? Getting the message right The key, however, is to ease up on health and exercise messages, and in particular to tone down what might be called ‘finger wagging’, especially where it is directed at the less active and sedentary. Among such people, messages that are overtly about the science of health and exhorting people to become healthier fall on deaf ears, as the less active and sedentary are wholly fed up with being told they are unfit and unhealthy, and so tend to disconnect from the content of such messages. So, armed with this evidence, surely good progress must be being made towards delivering a sport and physical activity legacy from the London 2012 Games? Well, unfortunately not. Evidence from the largest and most robust survey of sport participation habits ever conducted, Sport England’s Active People Survey, suggests that population levels of sport participation in England have increased by an average of only 38,000 a year over the last three years. The problem appears to have been that, although evidence suggests that London 2012 could have boosted the nation’s sport and physical activity participation given the right strategic approach and investment, there is little indication that policy has been based on evidence. Instead, legacy aspirations have been pinned on the hope that there will be an inherent inspiration effect from the Games. The government’s Mass Participation Legacy Plan, Places People Play, focuses almost solely on supply: of facilities, of fields, of leaders, and of opportunities. However, this is not Field of Dreams - there is no evidence to suggest that if you build a sport supply infrastructure, people will come.
sport participation legacy, and that it is not to be trusted because Sport England, who commission the survey, have “singularly failed”. As alternative evidence, Lord Coe suggests that ‘if you speak to [the British Cycling performance director] Dave Brailsford he will tell you he’s got half a million more cyclists than pre-Beijing’.
“The lack of progress towards delivering a sport and physical activity participation legacy from the London 2012 Games is a policy failing.” However, the Active People survey provides official National Statistics, and since 2005 has been carried out on behalf of Sport England by two of the most respected market research companies in the UK, IpsosMORI and TNS-BMRB. Each year it has a sample size exceeding 175,000, which provides accuracy to within 0.2%. The same cannot be said of the anecdotal view of a national performance director, however genuinely-held it may be.
A legacy lost? In contrast to Lord Coe, Jeremy Hunt has not sought to explain the lack of progress towards a sport and physical activity legacy by suggesting that National Statistics are flawed. Rather he has suggested that the wrong legacy target was set by the previous Labour government, which promised to get one million more adults participating in sport three times a week between 2007/8 and 2012/13. This target has now been dropped by the Coalition government because Mr Hunt says that a ‘more meaningful national measure’ is required. However, with less than 50 days to go to the start of the Games, a ‘more meaningful national measure’ has yet to be announced. Consequently, and somewhat conveniently, there is currently no nationally endorsed success indicator against which government policy to deliver a sport and physical activity participation legacy can be judged. With almost no time left to enhance the impact of the 2012 Games on sport participation, it seems that London is heading towards a story of unfulfilled promises and of legacies lost. In which case, London will have the somewhat ignominious honour of being the first Games to have tried and failed to deliver a national sport participation and physical activity legacy.
A lack of progress
Further reading
In short, the lack of progress towards delivering a sport and physical activity participation legacy from the London 2012 Games is a policy failing, in which legacy strategy has not been informed by the available evidence. Nevertheless, a policy failing is not one of the explanations that have been respectively offered by Lord Coe and Jeremy Hunt, the Culture Secretary. Lord Coe has recently suggested that the Active People Survey is not capturing the
McCartney et al (2010). The health and socioeconomic impacts of major multi-sport events: systematic review (1978-2008). BMJ 2010;340: c2369 Weed et al (2009). A Systematic Review of the Evidence Base for Delivering a Physical Activity and Health legacy from the London 2012 Olympic and Paralympic Games. Department of Health.
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The medicine behind In the field of sports medicine there is no greater ambassador than Dr Richard Budgett. He has been the Chief Medical Officer to Team GB for the past six consecutive Summer and Winter Olympic games and is the current CMO to the London Olympics in 2012.
H
is personal achievements in sport include assisting Sir Steve Redgrave to the first of his five consecutive gold medals winning the Men’s Coxed Fours at the 1984 Los Angeles Olympic Games. He is currently Chairman of British Association of Sports and Exercise Medicine (BASEM) and Lead Physician EIS South East. JuniorDr’s Ivor Vanhegan spoke to Richard Budgett about his career and the future of sports medicine in the UK.
What was your general medical training that lead to your career in Sports and Exercise Medicine? After completing my medical degree at the Middlesex Hospital I quickly chose a training path in general practice with a view to going into some form of sports and exercise medicine (SEM). I was a keen rower and wanted to see how I could get involved in sports as a doctor. I completed a diploma in sports medicine which was being offered at that time by The Royal London Hospital. I had previously done some research at the newly opened British Olympic Medical Centre in Northwick Park Hospital during my first year of GP training which had concreted my interest in the field. That led to my continued research interest into fatigue and underperforming athletes which has now become known as ‘unexplained underperformance syndrome’. Initially I split my time 50:50 between General Practice and Sports Medicine but in 2004 I went full time into SEM. I was the Director of Medical Services for the British Olympic Association from 1994-2007. I have also been the Chief Medical Officer with Team GB at the last six summer and winter Olympic Games in Atlanta, Nagano, Sydney, Salt Lake City, Athens and Turin. What aspect of athlete treatment are you involved with: general physical wellbeing or only musculo-skeletal injury? There is an increasing body of evidence to say that the two go hand in hand. Taking a common cold as an example: as well as adequate treatment of the symptoms one must consider isolation from other members of the squad, when and to what extent the individual can return to training and how to implement preventative measures for the future. As a growing specialty we can only base our decisions on presumed best practice and available evidence, however, taking this holistic approach does appear to be working. Certainly more rigorous research in the area is required and we rely on journals such as the British Journal of Sports Medicine to increase the evidence base. What is the current situation of SEM Training in the UK? Things have progressed enormously in the last few years since SEM training officially started in London in February 2007. The training programme currently has 16 places with four ST3 vacancies annually; there are a further 16 ST posts nationwide. The programme runs from ST3 to ST6 with applicants mainly coming from Core Medical Training but also from General 12
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Practice Training posts and ACCS trainees. Now that the specialty is affiliated to two Royal Colleges, has formalised training and is increasing research, I feel the UK has become a leader in SEM and has overtaken the likes of Australia and The United States in this regard.
How can an interested trainee get involved in SEM? Before making the commitment to something like the diploma I would first suggest immersing yourself in the profession to see if it is right for you. Getting involved in sports medicine in any capacity is always a bonus and assisting as a paramedic doing crowd work is always a good place to start. From there I would highly recommend any of the introductory weekend courses run by BASEM to provide a good idea of what’s involved. What is your role for London 2012? In February 2007 I was appointment Chief Medical Officer for the 2012 games in London. Unusually for me this meant I spent my entire time at the Beijing 2008 Olympic Games more as an observer than actually as a treating doctor. My general remit is to ensure the safe medical care for the athletes themselves, their coaches and auxiliary staff, spectators, dignitaries and anyone else who is present at the Games. The numbers run into the many thousands which presents a logistical challenge. Furthermore, you have to consider that the Games will be spread over 36 sites: the main Olympic Park in Stratford, tennis in Wimbledon, Triathlon in Hyde Park, Rowing in Dorney Lake Eton, sailing in Weymouth, and the football at multiple locations around England, Scotland and Wales with the final in Wembley. In effect we will be setting up a polyclinic within the Olympic Village with MRI, CT, x-ray and diagnostic ultrasound facilities available. There will be some of the country’s top musculo-skeletal radiologists on hand as well as other appropriately trained senior doctors to provide immediate and expert advice. The Homerton Hospital in East
ehind the medals Dr. Richard G. Budgett OBE
MA MBBS Dip Sports Med. FFSEM FISM
London will be the main referral centre for athletes at Stratford, and University College London Hospital for those closer to central London. We have ensured that they will have a fast, efficient and discrete service to fast-track them to the relevant services they require in each of these hospitals to ensure optimum care. The Royal London will be the port of call for major trauma.
You must have come across so many weird and wonderful things given the breadth of your work? It’s the constant variation that makes this such a brilliant career to go into. One particular event I can recall was when I was at the Beijing Games. As I mentioned I was only meant to be there in an overseeing capacity and not as a treating doctor. There was one occasion however, when I was out at the rowing venue which was near the Great Wall of China. The family of an athlete who had recently won a medal were caught in a freak thunder storm and they all sought refuge in one of the towers. Due to bad luck the tower was hit by lightening and everyone inside sustained a mild shock but about three people were affected more severely. Unfortunately, one of those hit was the brother of this athlete who, for reasons better known to himself, had chosen not to wear any shoes. As you can imagine, the lightening was able to pass straight through him and knocked him out cold for well over a minute. As the nearest British medic on hand I saw him 30minutes later and had to rack my brains as how to and manage victims of lightening strikes. I must admit it had been some time since I’d even read up on what to do in such circumstances but am pleased to report that he made a full and uneventful recovery. With special thanks to Lynn Morris, medical administrator at Bisham Abbey.
Suggested Resources London Deanery info for applicants to SEM www.londondeanery.ac.uk/specialty-schools/ sport-and-exercise-medicine British Association of Sports Exercise Medicine www.basem.co.uk Faculty of Sport & Exercise Medicine (UK) – Specialty Training and Diploma information www.fsem.co.uk Voluntering for London 2012 www.london2012.com/get-involved/volunteering/thevolunteer-programme.php
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What makes the
ultimate athlete? As 10,000 athletes arrive in London to compete in 300 different Olympic events what really makes a gold medal winner? Unshakable stamina, round-the-clock training and a life’s dedication to your chosen sport? Or is the likelihood of clinching gold or being left on the starting line already determined by the time we’re born?
I
n the fight for an Olympic gold medal, worth just less than £150, billions are spent to shave milliseconds off competition times. From high-tech swimsuits which reduce water drag to high altitude training which avoids muscle fatigue, sports training has become big business. The Olympics started as a demonstration of the wonder of the human body in the 6th century BC but it is now also a long-term investment business delivering high returns. British athletes winning gold in London 2012 are expected to earn £2 million from subsequent sponsorship deals and commercial partnerships.1
Genetics Despite the hundreds of hours athletes devote to the gym and track training it contributes
less than 40 percent of the maximum power of our fast-twitch muscle fibres. More important for performance is the impact our genes have on the quantity and quality of these fibres. The impact of genetics is most obvious in track athletes. Sprinters who trace their ancestry back to West Africa hold 95% of the best times in the 100 and 200 metres. Middle and long distances runners from Kenya and surrounding regions make up 50% of the best times. West Africa has a surprisingly high dominance of the genes for fasttwitch muscle fibres - particularly the sub-type which is metabolically most efficient. In contrast white athletes have a predominance of slow-twitch fibres more suited for other sporting events. Kenya’s dominance of running is astounding. Runners from Nandi, a small region of green rolling hills at the edge of the Great Rift Valley, despite having a population of just 560,000, win an impressive one in five world championship
References 1. How much is a British gold medal worth? £2m http://www.independent.co.uk/sport/olympics/ how-much-is-a-british-gold-medal-worth-2m-6283727.html 2. Fina extends swimsuit regulations http://news.bbc.co.uk/sport1/hi/ olympic_games/7944084.stm 3. Prosthetics don’t give sprinters an unfair advantage, research suggests http://www.guardian.co.uk/science/2009/nov/04/ prosthetics-athletes-oscar-pistorius
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OLYMPIC MEDICINE
long-distance events - way ahead of any other country in the world. Technology Having the ideal genome for an Olympic athlete may provide a headstart to the podium but without the right technology you’ll still be chasing the pack. At the 2008 Beijing Olympics 25 new swimming world records were set - more than any Olympics except 1976 when goggles were introduced for the first time. The reason? A new full-body swimsuit from Speedo which has since been branded ‘technological doping’ and banned from many international competitions. Of all the records set in Beijing all but one swimmer wore Speedo’s LZR Racer suit. Seemless and water-repellent it reduces drag by nearly 40% compared to a regular suit resulting in a 3% increase in speed - enough to make the difference between last and first place.2 However, at a cost of £500 for the suit, which lasts just 10 races, it’s an expense that leaves many poorer nations at a huge disadvantage. And it’s not just able-bodied athletes who are using technology to their advantage. South African paralympian Oscar Pistorius fought a court battle in 2008 for the right to run against able-bodied athletes. He was banned not because he would be at a disadvantage but because it was feared that his prosthetic legs would actually put able-bodied runners at a disadvantage. It was claimed that he used 25% less energy than other athletes.3 Hard work The good news is that genetics and technology alone do not guarantee a place on the podium. Recent science has confirmed the dual importance of nature and nurture in sporting success. Sport remains a skill requiring intense training and practice - no matter whether you have the genes or technology which might suggest otherwise.
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Focus on Finance - in association with Wesleyan Medical Sickness
What’s happening with your pension?
T
he last 12 months have seen a number of proposed changes to the NHS Pension Scheme, as well as reductions in the amount individuals can save into a pension tax efficiently. Ian Morgan, National Sales Manager at Wesleyan Medical Sickness, looks at the proposed changes to the NHS Pension Scheme and how they may impact junior doctors.
What is happening to the NHS Pension Scheme?
In March, the government published its final proposals for the new design of the public sector pension schemes in England and Wales, including the NHS Pension Scheme (NHSPS). A bill will be introduced in the next Parliament, with the aim of implementing it in 2015. The main changes to the scheme will be:
55, although early retirement is likely to result in a reduced pension. You can take your NHS pension before your State Pension Age. • Employee scheme contribution rates will increase by an average of 3.2%. These increases are being introduced over three years from April 2012. Higher earners will see a 2.4% increase in contributions. Do these changes affect pension rights already earned?
No. All pension rights earned in the NHSPS up to April 2015 will be unaffected and you can access it in full at your current normal pension age. What other changes should you be aware of?
• It becomes a career average scheme for all members. Hospital doctors’ pensions are currently based on their final salary while GPs already have a career average scheme. This type of scheme means you build up a ‘slice’ of pension each year of your service, based on your salary in that year. That slice – and future slices – will be revalued each year in line with the increase in the Consumer Price Index (CPI) rate of inflation, +1.5%. On retirement, the total accumulated ‘slices’ make up your pension pot. • There will be an accrual rate – the amount of pension you build up each year – of 1/54th (1.85%) of pensionable earnings. This is very similar to the 2008 Scheme (1/60th or 1.67%). • The normal retirement age will fall in the line with the State Pension Age – currently between 65 and 68. However, members will retain the option to retire after
From April 2012, the Lifetime Allowance, the total amount of benefits that can be drawn from pensions without tax penalties being applied, reduced from £1.8 million to £1.5 million. At this stage in your career this sounds like a lot of money, but over a 40 year career which is likely to include promotions, you may find yourself impacted by changes in the Lifetime Allowance, especially if you also save into a personal pension. This could influence how you build your pension and you might need to consider other savings products such as ISAs to run alongside your pension for retirement planning. In April 2011 the Annual Allowance, that is the total amount you can save into your pension each year with tax relief, fell from £255,000 to £50,000. The likelihood of exceeding the Annual Allowance will be determined primarily by the yearly increase in your NHS pension and also if
you contribute to a private pension plan or pay additional voluntary contributions. What will happen if doctors build up more in their pensions than the limits allow?
Exceeding your pension allowances can be very costly – if your pension accrual over the year is more than the Annual Allowance of £50,000 and you do not have any unused Annual Allowance to carry forward from the previous three tax years, you’ll be taxed on the additional amount at your marginal rate, which will likely be either 20% or 40%. These changes sound complicated, how can doctors be sure of their particular situation?
Wesleyan’s Financial Consultants are regularly briefed by our technical experts about all the changes affecting the NHS pension scheme and retirement savings. Combined with their in-depth understanding of the medical profession, they will be able to help you understand your individual circumstances.
The above information does not constitute financial advice. If you would like more information or need specialist financial advice, call Wesleyan Medical Sickness on 0800 358 6060 or visit the website at www.wesleyan.co.uk/doctors.
Specialist financial services for doctors • Savings and Investments
• Mortgages
• Retirement Planning
• Motor, home and travel insurance
• Life and Income Protection
Motor, home and travel insurance is arranged by Wesleyan for Professionals.
0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk Wesleyan Medical Sickness and Wesleyan for Professionals are trading names of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Limited is wholly owned by Wesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham B4 6AR. Telephone calls may be recorded for monitoring and training purposes.
16
FINANCE
WIN an iPad
Your chance to WIN a new 32GB Apple iPad 3G*. Wesleyan Medical Sickness specialise in providing tailored financial advice to medical professionals. Our iPad competition is exclusive for medics. To enter visit www.wesleyan.co.uk/ipadcompetition *Terms and Conditions apply. See entry form for details. Model shown for illustration purposes only and may differ from actual prize. Wesleyan Medical Sickness is a trading name of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Ltd is wholly owned by Wesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham, B4 6AR. Telephone calls may be recorded for monitoring and training purposes. HD-AD-15 (02/11)
Medicolegal Advice - in association
Ready, set, go!
How junior doctors can contribute to the Olympics The term good Samaritan stems from the bible – a person who gratuitously gives help to those in distress. During the Olympics, foundation doctors cannot apply to be medical volunteers; but you can provide assistance by way of a good Samaritan act. Charlotte Hudson explains
T At the 2008 Beijing Olympic Games there were a total of 22,137 medical encounters with staff, journalists, visitors and athletes.
he Olympic Games is just around the corner and more than 5,000 doctors have already offered their services as medical volunteers to work at the event, to attend to the millions of spectators, press and associated workers who will be present. Foundation doctors who were hoping to volunteer as so-called Games Makers have been turned away, however, as they are not eligible to volunteer in a medical capacity. Dr Iain Barclay, Head of Medical Risk and Underwriting at MPS, said that MPS has been approached by a number of foundation doctors who were hoping to volunteer, but unfortunately, owing to statutory restrictions, F1 and F2 grade doctors are unable to work at the Olympics as it is not an approved practice setting. However, this does not mean that should a medical emergency arise that foundation doctors should not provide assistance by way of a good Samaritan act.
What is a good Samaritan act? A good Samaritan act is one where a doctor provides medical assistance, free of charge, in a bona fide medical emergency where they are not on duty. Foundation doctors may attend the Games as spectators, and assisting a fellow spectator would be an example of such an act.
What should you do? When called into action whilst off duty, you must remember to: • Only intervene if the situation is an emergency
18
with the Medical Protection Society
• Assess your own competence in handling the situation – eg, you may be under the influence of alcohol – and proceed accordingly
Whilst London 2012 is a once in a lifetime experience, the medicolegal risks remain the same as any other clinical encounter. By following the above advice, you will not only safeguard yourself against the risks, but you will contribute to making the • Make a full clinical record after treatment, yourfor con-articles.qxd:MPS Checkup 12/2/10 10:05 Page 1 About and MPSgive info 2012 Olympics a safe and enjoyable event. tact details to the appropriate official. Read Olympic Dilemmas in the latest issue of MPS Casebook – http://www.medicalprotection.org/uk/casebook-may-2012/ If you encounter a situation that would normally be beyond your olympic-dilemmas. competence, you may still be able to help. There will be millions of people at the Games and any situation that is beyond your competence may still benefit from your input, to a degree. For example, you can use your clinical skills to: • Take a history • Make an examination to reach a preliminary assessment • Give an indication of the likely differential diagnosis and suggest options for the management of the situation pending arrival of support. In the unlikely event that legal proceedings follow a good Samaritan act, MPS members are tentitled to apply for assistance, no matter which country the legal proceedings are commenced in; this is important as many spectators will be drawn from around the world.
About MPS
MPS is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world. We actively protect and promote the interests of members and believe that education is an integral part of every health professional’s development. As well as providing legal advice and representation for members, we also offer workshops, conferences and a range of publications designed to aid good practice. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.
MPS Members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.
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.
19
Practice in safe Junior doctors are more likely to make prescribing errors than their more senior colleagues and a major reason for this may be that junior doctors seem to know less clinical pharmacology than they used to1, 2. Whether this may put patients at risk is the subject of numerous studies in the NHS and overseas3-5.
T
he British Pharmacological Society has taken steps to try of debate but it is likely that a combination of written and OSCE and remedy this with a dedicated prescribing exam, which at assessment will be used widely until the national prescribing examithe moment is optional. Medical schools examine prescribnation is universally implemented. ing in the final clinical years and some NHS Trusts now formally The implications for student learning and assessment before the Foundation years and beyond are significant. As safe prescribtest junior doctors’ prescribing skills6. ing stresses patient assessment and review alongside a firm grasp of The teaching of safe prescribing varies across the UK but prothe pharmacology and interactions of common medications, it is grammes of didactic lectures in clinical pharmacology, pharmacoimplicit that junior doctors completing drug charts on the wards kinetics and pharmacodynamics seem to have been abandoned by know their patients and update themselves of their patients’ progmost UK medical schools in favour of problem or case-based teachress day by day or, in some instances, hour by hour, depending on ing comprising vertical themes throughout the medical degree; the clinical problem. where, although the teaching and learning approaches are effecFrom a practical perspective, keeping up with a patient’s progtive, teaching hours may be too few and poorly structured to be ress is yet another challenge in a modern healthcare system where truly effective7. The result is that it is becoming increasingly rare to one junior doctor may not be the main prescriber for a patient as encounter a junior doctor who really knows how drugs are metabopatient care is shared amongst specialists, lised and how they work. e.g. the pain or palliative care teams. DocExactly how harmful interactions arise, tors now work in shifts and the daily ward therefore, remains a mystery until more Only 20% of doctors round where the drug chart is reviewed detailed study at membership level. Hardconsistently prescribed may be supervised by doctors also rotating ing8 devised assessments on clinical pharsafely through shifts. macology topics essential to a junior docThe Medical Schools Council worktor’s working knowledge comprising ing group on safe prescribing has put together eight competencies extended matching questions and unobserved structured clinical expected of foundation year doctors9: examinations to simulate real clinical scenarios where failures in appropriate prescribing might result in real harm to patients. 1. The ability to establish a drug history These scenarios included prescribing anti-coagulant drugs with 2. The ability to plan therapy for common indications antibiotics, post-operative analgesia, insulin, treating diverticulitis 3. The ability to write a safe and legal prescription and an exacerbation of COPD. Only 20% of doctors consistently 4. The ability to appraise critically the prescribing of others prescribed safely, 50% of doctors had variable, middling scores and 5. The ability to calculate appropriate doses 30% consistently prescribed poorly with lethal errors in some cases. 6. The ability to provide patients with appropriate information about their medicines Learning and assessment 7. The ability to access reliable information about medicines As we try to simulate the clinical environment in undergraduate 8. The ability to detect and report adverse drug reactions teaching, we have shifted emphasis away from the study of individual drugs or families of drugs and moved towards scenarios that demand Below you will find examples of questions used to prepare stua working knowledge of how to assess a patient’s need for pharmacodents for final exams and, more importantly, the Foundation years. therapy depending on their medical history and clinical state. We aim to provide some basic science amidst clinical priority but We ask medical students to consider whether a patient needs fluid would argue that what we really need to equip our students and resuscitation or electrolyte correction while prescribing intravenous junior doctors is effective training on the ward, in the classroom, fluids? How much fluid should be prescribed before the patient is online and ready access to formularies and a familiarity with clinreassessed and the blood results reviewed? What analgesia should be ical guidelines10-13. If students can get used to these before they prescribed for a patient with acute large bowel obstruction? What qualify their practice as doctors may be considerably easier. should be done about the patient’s regular medical and INR of 5.6? Test your knowledge Prescribing without really assessing the clinical situation is, and should be, impossible. To this end, problem and case-based learning You admit a 75 year old gentleman with abdominal pain duris invaluable, but the volume of cases needs to be significant and if ing your surgical on-call. The patient has a metallic heart valve in this cannot be achieved in teaching sessions in the clinical classroom situ and is, therefore, on lifelong warfarin therapy. On examination or in practice on the wards then medical students need resources to the patient’s abdomen is soft with left iliac fossa tenderness and practise and learn from. Exactly how all aspects of prescribing are no overt signs of peritonism. A diagnosis of acute diverticulitis is examined in the final years at medical school remains the subject made. On checking his blood tests you note he has an INR of 6.5. 20
Safe prescribing
prescribing
Fig. 1-3
Question 1: What should be the target range for his INR? A. 2.0 – 3.0 B. 2.5 – 3.5 C. 3.0 – 4.0 D. 3.5 – 4.5 E. 4.0 – 5.0
D. Stop warfarin therapy E. Stop warfarin and administer 1mg vitamin K intravenously The answer is E.
Warfarin should be stopped until his INR is therapeutic. Giving a low dose of vitamin K allows for his INR to be lowered, without totally reversing the effects of warfarin so that he can remain anticoagulated on warfarin. If he had a diverticular bleed, reversing the The answer is C. INR would have to be weighed up against preventing life-threatening haemorrhage. A is the target range for long term therFresh frozen plasma (containing clotapy for atrial fibrillation and mitral stenoting factors) may be used to correct INR 30% consistently sis with embolism. C would be the tarin cases of haemorrhage or when INR prescribed poorly with get range for recurrent DVTs and metallic must be rapidly corrected. lethal errors in some cases heart valves. Patients who have bioprosVitamin K is a cofactor required for the thetic heart valves without atrial fibrillasynthesis of prothrombin (factor II) and tion do not require anticoagulation. If they have atrial fibrillation, factors VII, IX, and X within the coagulation cascade. Vitamin K a history of systemic embolism or those with intra-cardiac thromconverts the glutamate in vitamin K dependent proteins to gamma bus, a target INR of 2.5 should be achieved. carboxyglutamate. A series of oxidation and reduction reactions then occur which finally convert the chemical back to vitamin K, Reference: which is known as the vitamin K cycle. Humans are rarely deficient 1. Keeling et al. British Committee for Standards in Haematology Guidelines on oral in vitamin K as it is continuously recycled in cells. anticoagulation with warfarin – 4th edition. Br J Haem 154 (3): 311-324. Synthetic vitamin K is phytonadione. After oral administrahttp://www.bcshguidelines.com/documents/warfarin_4th_ed.pdf Page 1 tion of vitamin K blood coagulation factors increase in 6-12 hours; 2. 2.8.2. Oral anticoagulants: British National Formulary http://www.bnf.org/bnf/go?bnf/current/2791.htm within 2 hours after parenteral administration. Full effect may take up to 24 hours.
Question 2: From the options below what is the single most appropriate management of his INR? A. Continue warfarin and give 1mg vitamin K intravenously B. Continue warfarin therapy as he is not actively bleeding C. Give fresh frozen plasma
Question 3: The next day the patient develops brisk rectal bleeding. He becomes tachycardic and hypotensive and his haemoglobin falls from 14 g/dl on admission to 9 g/dl. In terms of correcting his INR which ONE of the following is most appropriate action to take?
Safe Prescribing
21
Practice in safe prescribing A. Continue warfarin as the risks of stopping warfarin are too great B. Stop warfarin immediately C. Stop warfarin and administer platelets D. Stop warfarin immediately, give 1mg vitamin K intravenously E. Stop warfarin immediately, give 10mg vitamin K intravenously F. Stop warfarin, give fresh frozen plasma and Prothrombinex G. Stop warfarin, give fresh frozen plasma, Prothrombinex and 1mg vitamin K intravenously The answer is G. As vitamin K will take 24 hours to take full effect, fresh frozen plasma should be given as it corrects coagulopathy rapidly. Infusions of large volumes may be problematic, however, in terms of how fast they can be given and ready availability. In this situation, as surgical resuscitation and intervention proceeds haematological advice should be sought and Prothrombinex administered (25–50 IU/kg) as it is effective (depending on dose) within 15 minutes. Prothrombinex is a freeze dried preparation of all vitamin K dependent clotting factors (factors II, VII, IX and X). The plasma half-life of individual clotting factors is: • Factor II • Factor VII • Factor IX • Factor X
40-60 hours 3-6 hours 16 – 30 hours 30 – 60 hours
Reference: Keeling et al. British Committee for Standards in Haematology Guidelines on oral anticoagulation with warfarin – 4th edition. Br J Haem 154 (3): 311-324 http://www.bcshguidelines.com/documents/warfarin_4th_ed.pdf Page 6
Question 4 Complete the drug chart for this gentleman at admission. His previous medical history includes hypertension for which he takes 2.5mg enalapril twice daily and furosemide 40mg once a day. See
drug charts Fig 1-6. Comments: 1. The patient details include a unique identifier such as hospital number or date of birth. 2. Allergies need to be documented correctly. Rash or anaphylaxis are allergic reactions, nausea is not; withholding effective medication from patients who have not had an allergic reaction or adverse event related to the drug should be avoided. 3. Date and sign all entries, keeping your name and contact number legible. 4. Prescribe all regular medication in addition to new medication you start on admission. Any medication you choose to discontinue that the patient usually takes at home, document on the drug chart, explain your changes to the patient, and inform the GP on discharging the patient. 5. You are allowed to consult the British National Formulary (BNF) at all times. Get used to using this on the wards and online. 6. The duration of a course of antibiotics should always be specified. You may decide to change your mind and curtail or prolong the course. In that case you can make changes to the chart again but don’t let this stop you from writing the initial limits of the course. Changes should be clearly labelled. Do not write over an original prescription. 7. There is a 10% approximate cross-reactivity between cephalosporins and penicillins in penicillin allergic patients but as this is based on structural similarities of the molecules, the cross-reactivity is greatest in first generation cephalosporins. Cephalexin is a first generation cephalosporin14. 8. A patient with bowel obstruction and heart disease will not necessarily have normal saline infused at a rate of 125ml/hr. The key is to check how much the patient needs and adjust the rate of fluid with regular review rather than prescribing
Fig. 4-6
22
Safe prescribing
multiple bags of fluid from the outset. Conversely, not prescribing enough fluid and leaving this for a doctor unfamiliar with the patient is always a pitfall. Try to make sure that fluid prescription follows clinical assessment of volume status (clinical signs of dehydration or overload, chest Xray findings, central venous pressure or non-invasive and invasive measures of cardiac output) and renal function and electrolyte results. 9. Try to write up fluids at rates of ml/hr rather than 6 hourly or 8 hourly.
Over 2,500 cases to view
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References: 1. Doman T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. An indepth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. Final Report EQUIPstudy. GMC UK 2010 2. Ross S, Loke Y. Do educational interventions improve prescribing by medical students and junior doctors? A systematic review. Br J Clin Pharmacol 2009; 67(6): 662–670
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
3. Tobaiqy M, McLay J, Ross S. Foundation year 1 doctors and clinical pharmacology and therapeutics teaching. A retrospective view in light of experience. Br J Clin Pharmacol 2007; 64 (3): 363-372
casereports.bmj.com
4. Aaronson JK. A prescription for better prescribing. Br J Clin Pharmacol 2006; 61(5): 487-491 5. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002; 359 (9315): 1373 – 1378 6. Kidd L, Shand E, Beavis R, Taylor Z, Dunstan F, Tuthill D. Prescribing competence of junior doctors: Does it add up? Archives of Disease in Childhood 2010; 95(3)219 - 221 7. O’Shaughnessy L, Haq I, Maxwell S, Llewelyn M. Teaching of clinical pharmacology and therapeutics in UK medical schools: current status in 2009. Br J Clin Pharmacol 2010; 70(1): 143-148 8. Harding S, Britten N, Bristow D. The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardized clinical cases. Br J Clin Phamacol 2010; 69 (6): 598 – 606 9. Outcomes of the Medical Schools Council Safe Prescribing Working Group, November 2007 10. E-Learning for Healthcare – Safe Prescribing http://www.e-lfh.org.uk/projects/ safe_prescribing/index.html 11. Prescribing practice at onExamination from BMJ Learning http://www. onexamination.com/self-assessment/prescribing-for-students 12. BNF prescribing resource at onExamination from BMJ Learning http://www.bnf. org/bnf/go?bnf/current/204259.htm 13. Keeling et al. British Committee for Standards in Haematology Guidelines on oral anticoagulation with warfarin – 4th edition. Br J Haem 154 (3): 311-324 14. Campagna et al. The use of cephalosporins in penicillin-allergic patients. A literature review. J Emerg Med 2012; 42 (5): 612-20
Authors Nadia Bukhari BPharm MRPharmS PG Dip FHEA Clinical Lecturer, MPharm Student Support Manager & Pre Registration Co-ordinator, UCL School of Pharmacy Ali Sameer Mallick MBBS BSc MRCS (DOHNS) Academic Clinical Fellow ENT Surgery, Nottingham University
Night sweats? It’s four a.m. You’ve been bleeped. You know what to do. But it would be good to get a second opinion – just for peace of mind. That’s exactly what Best Practice provides. A trusted second opinion on the assessment, treatment and management of patients. On call. All day. All night. Just when you need it.
For the best in clinical decision support tools, visit bestpractice.bmj.com
Seema Biswas MSc FRCS General Surgeon, Health Delegate, British Red Cross DIAGNOSE • TREAT • MANAGE • LEARN
Making the best of it in
Sierra Leone FY2 Dr Mikey Bryant is in Sierra Leone with healthcare charity Mercy Ships. He has been volunteering in a children’s clinic for a year in a country where one in five children don’t live to see their 5th birthday. In this regular column he gives us an update on his experience.
T
Across
1 Of Nirvana’s Nevermind album; mood stabiliser (6) 3 1990s alternative rock band featuring Brian Molko; sham medical intervention (7) 5 Inherited defect in G6PD causing red blood cells to become sensitive to broad beans (6) 7 Type of wine specifically linked to Marchiafava-Bignami syndrome (3) 9 Gout of the foot, especially the big toe (7) 11 Summer fruit; aneurysm at junction of
posterior carotid with internal carotid, or of anterior communicating with anterior cerebral or bifurcation of middle cerebral artery (5) 12 Lowermost element of the backbone (6) 13 Kanner’s syndrome (6) 15 Billroth operation (11) 17 Anaesthetic agent used as party drug; NMDA antagonist (8) 18 Either corner of the eye (7)
Down
1 Political party; sequence of actions by which the baby and afterbirth are expelled from the uterus at childbirth (6) 2 In research, the tendency of a rater to overestimate a subject’s response based on prior assumptions; a popular video game series featuring cybernetically enhanced super-soldiers (4) 4 Furuncle (4) 5 Fever of low intensity or short duration (9) 6 Many or multiple; the one who puts the kettle on (4) 8 The acute form of this condition often present with erythema nodosum and polyarthralgia (11) 10 His incision is made in the right side of the abdomen, paralleling the thoracic cage, for cholecystectomy (6) 14 Bandage wound spirally around an injured limb (5) 16 Single photon emission computed tomography (5)
You can find the crossword solution by searching for ‘crossword answers’ at www.juniordr.com Compiled by Farhana Mann
24
HOSPITAL MESS
oday looks to be a fairly quiet day by our standards, there are only about 50 patients in the waiting area. Things soon turn hectic, though. Within minutes of me sitting down to check e-mails and sort out a few other things after the triage, a baby is rushed into my room, carried in by one of the nurses. “Dr Mikey, look dis pickin not blowing fine!” she says, with panic written across her face. The baby is definitely breathless, the telltale signs of the stomach being drawn in under the ribs giving an obvious clue to the pneumonia underlying the baby’s breathlessness. I manage to get the baby on our only working oxygen machine and we give a stat dose of ceftriaxone, thankfully on oxygen the baby’s saturations creep back up to a reassuring 97%. I try to get a bit of peace from the tornado of chaos swirling around as the patients are triaged to explain to the mother that the baby is going to need to be admitted overnight so we can keep an eye on her. As soon as I say the word “admit”, she starts crying inconsolably, chunky tears streaming down her face and landing in a sad little puddle on the dusty floor. I’m a bit taken aback, I know my Krio is far from perfect but I was sure she had understood what I was saying about how the child will most “She took the child to a government likely get better in a cou- hospital a few days ago and wasn’t ple of days. The situation allowed in without a bribe” really is not that bad at the moment and the baby seems to be getting better. One of the nurses eventually manages to get through to her on a deeper level, doing a far better job of using the standard “Ideas, Concerns, Expectations” model that we are all taught in medical school than my limited Krio will allow. It turns out that she took the child to a government hospital a few days ago and wasn’t allowed in without a bribe, which she couldn’t afford. She explains that she spent her last 1000 leones (15 pence) on transport money to get here and has nothing to left to give. I feel a certain amount of pride in the nurses working here as Jestina explains that we don’t take bribes and reassures her she has done the right thing in bringing the child here. Once she understands that we really are a free hospital, she relaxes hugely, the way a boiler decompresses after turning the safety valve on. Soon the baby is on oxygen and has a bed, and mum looks much happier. The whole experience sets me thinking that evening about the ideal of free health care and how for so many that is still just an ideal. In a country where nurse’s salary is less than £100 each month, some desperation and need for money is understandable, but ultimately the children here so often pay the price. Read Mikey’s blog online at www.juniordr.com
Writing in the Notes ment age will Extending retire patients at risk
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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:
Apple
45p Chicken and chips
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Caroline McD ouglas GP Trainee , Oxfordsh ire
eded to stop
les ne More than GMC ru gagging
at doctors C guidance th M G gh ou lth A hen they to speak out w ed w lo al be t mus is being fety or dignity sa nt tie pa ve belie e is a long good start ther a is ed is om pr com g doctors dance preventin ui ‘G go to way ss 24; p4). es into effect’ (I m co ed gg ga g bein a culture will do little in s le ru e es th y Sadl d loyalty for their jobs an ar fe s or ct do re whe p all othues seems to trum ag lle co or ni se to tion is likely ing this percep ng ha C . es su is er y statutory impact than an er rg la a ve ha to guidance. eld Name withh
ogy, London ST4 Cardiol
‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.
69p
Royal Cornwall Hospital, Truro
Munch-tastic at,
Leaving the FY sh
Dear Editor, Finally, a shadow ing scheme has in place for ne been put w trainees ‘Fou r days shadowing for FY do cs’ (Iss 24; p6). I remember when I started my PRHO jobs an d we were literally thrown on the ward with out knowing any practical sk ills or even whe re to find venflons. It was sp ectacularly unsa fe and terrifying for both ne w house officers an d patients. Glad to see thin gs have finally ch anged.
Good for your health but not your pocket at,
Hinchingbrooke Hospital, Cambridgeshire
Playing chicken with your cash,
£4.85
Royal Free Hospital, London
Finger-lickin good at,
£2.48 Toothpaste
Basildon Hospital, Essex
Tell your dentist about,
£2.49
Manchester Royal Infirmary, Manchester
Keep on brushing at,
£1.65
Ninewells Hospital, Dundee
Next issue we’re checking the cost of an apple, chicken and chips and a tube of toothpaste. Email prices to hospitalconfidential@juniordr.com
Queen’s Medical Centre, Nottingham 42” TV with Sky Digital, 10 PCs with Internet Access, a plasma information screen, a modern kitchen, two snooker tables and a Fussball table. Complimentary tea, coffee, toast, newspapers and magazines are provided daily and there’s a lunchtime snack bar selling sandwiches, soup, jacket potatoes and snacks, solely for the use of doctors.
JuniorDr Score:
★★★★✩
HOSPITAL MESS
25
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.
Medicine
MRCP part 1
Mon 20
AUGUST
5
£810
days
Manchester
5
£695
3
£549
5
£695
4
£595
4
£595
2
£680
Hammersmith Medicine
Tue 28 AUGUST
Fri 31
AUGUST
Hammersmith Medicine
Mon 3
SEPTEMBER
days
days
days
London
London
London
MRCP Part 2 Hammersmith Medicine
Hammersmith Medicine
Mon 2 JULY
Mon 29 NOVEMBER
days
days
London
London
MRCP paces
Sat 9 JUNE
Sat 9 JUNE
Sat 23 JUNE
Fri 14
SEPTEMBER
Sat 22
SEPTEMBER
Sat 22
SEPTEMBER
Sat 29
SEPTEMBER
26
EVENTSDR.COM
days
2
Ealing
£600
days
Manchester
2
£680
4
£1499
4
£1499
days
days
days
2
Ealing
London
London
£820
days
Manchester
2
£680
days
Ealing
Got an event to add? Do it free at EventsDr.com
MRCPch Part 1
Sat 9 JUNE
Wed 26
SEPTEMBER
2
£820
days
Kingston
3
£549
days
London
MRCPCH Clinical Skills
Sat 29
SEPTEMBER
Sat 6
OCTOBER
2
days
2
days
£820
Hillingdon
£820
Kingston
Hammersmith Interview Course Interview preparation for all grades by interview experienced Consultants 21st July 1st September 6th October 10th November 8th December You wouldn't go into an exam without revising to be as well prepared as possible. The same applies to an interview! But an interview is not an exam - there is no pass mark. It's a competition, and you need to beat the competition by being properly prepared - on the Hammersmith Interview Course.
Your career depends on it
More information & booking on website
Surgery
www.medicalcommunicationskills.com
MRCS Part B Hammersmith Medicine
Mon 2 JULY
Fri 14
SEPTEMBER
Sat 22
SEPTEMBER
Sat 29
SEPTEMBER
4
£595
2
£365
days
days
2
London
Cardiff
£300
days
Liverpool
2
£820
days
London
07906 191 616 Supported by the Medical Protection Society
Leadership, Management & Personal Development Training Courses you should know about!
Psychiatry
Consultant Interview Skills (Includes access to online resources)
MRCPsych CASC
Insights Intensive - Understanding the Implications of the White Paper
SPMM Course
Superego Cafe
Sat 28 JULY
Sat 28 JULY
2
days
2
days
£650 London
£595
Manchester
3-day Clinical Management & Leadership Management Excellence for Junior & Middle Grade Doctors Communication Skills for Junior & Middle Grade Doctors Foundation Course in Leadership & Management for FY Doctors
Others Leadership
View all courses at:
Leadership Masterclass for Health Professionals
Thu 21
www.medicology.co.uk/juniordr
JUNE
2
days
£588
Management Excellence for Junior & Middle Grade Doctors
Wed 27
1
£234
SpR Management for Doctors
Wed 11
SpR Management for Doctors
Wed 1
JUNE
JULY
AUGUST
London
day
Manchester
2
£599
days
2
days
London
£599 Oxford
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EVENTSDR.COM
27
MEDICAL PROTECTION SOCIETY PROFESSIONAL SUPPORT AND EXPERT ADVICE
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n Members can talk to highly qualified and experienced medicolegal specialists whenever they are faced with a legal orethical problem relating to their clinical practice n We focus solely on the needs of members, so they always receive the best advice n Specialist medicolegal advisers are available to speak to 24/7, 365 days a year n A dedicated team will provide the advice members need at each stage of their case MPS is the world’s leading medical defence organisation, putting members first by providing professional support and expert advice throughout their careers.
Members
can find out more about the support we provide by visiting: www.mps.org.uk/JuniorDr
Non-members
can sample some of our support and publications by registering their details at: www.whymps.org.uk
Dr Priya Singh MPS Medical DIrector
T: 0845 718 7187 E: info@mps.org.uk W: www.mps.org.uk/JuniorDr The Medical Protection Society Limited – A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS, UK. 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.