JuniorDr Magazine - Issue 08

JuniorDr

JuniorDr.com The magazine for JuniorDrs Issue 8

Return of the body snatchers The shortage of body donors

Saving lives in Sudan Doctors on the front line

Blood, glorious blood

ot eas he e rs lea to ve en fo jo r y

Pl

Warning Last of stock

The history of the red stuff

Presenting History JuniorDr is a free distribution magazine produced quarterly for the UK’s junior doctors. You can find us in hospitals throughout England, Scotland, Wales and Northern Ireland, and online at JuniorDr.com.

Editor Ashley McKimm

When patients start to fight back

Triage

JuniorDr

ST2 Psychiatry

editor@juniordr.com

Editorial Going to work each day as a doctor is a pretty safe event.

Despite the odd patient-acquired chest infection it’s reasonable to expect we’ll be home safely at the end of a long day.

We used to revel in our position near the top of the UK’s drink and alcohol abuse charts, and being at the pinnacle of the suicide ranking - it showed just how tough a career in medicine was.

But no longer. We’re doing pretty well in the health stakes these days - the city boys are outdrinking us and we’re less likely to take our own lives than housewives.

In fact, if you ignore the mess the Department of Health has made with our careers, we’ve never had it better - expect in one area - more patients are fighting back at us.

In our main news story we report on a BMA poll that showed almost a third of doctors had been a victim of a physical or verbal attack in the last year.

This continued abuse of other patients and staff is tolerated because ‘it has always happened’ and the expectation that drunk and disorderly patients deserve treatment whatever the situation.

Editorial Team Mareeni Raymond London

Michelle Connolly London

Hi Wu-Ling Nottingham

Muhunthan Thillai Chelmsford

Thanks to Andro Monzon, Gil Myers, Mun Hong Cheang, Rhona Atkin

Ashley McKimm Editor-in-Chief ST2 Psychiatry

Newsdesk news@juniordr.com Printing partners Witherbys, UK Advertising & Production Rob Peterson ads@juniordr.com

JuniorDr PO Box 36434 London EC1M 6WA Tel - 020 7684 2343 Fax - 087 0 130 6985 info@juniordr.com

Health warning JuniorDr is not a publication of the NHS, Tony Blair, 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. 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.

Patients often think they are entitled to treatment despite their attacks. They’re not. When one in ten doctors have been physically attacked in the last year it’s a situation that has become untenable.

“Patients often think they are entitled to treatment despite their attacks. They’re not.

When one in ten doctors have been physically attacked in the last year it’s a situation that has become untenable.”

We will always have patients who are physically or verbally abusive secondary to their physical or mental health - it comes with the job. However we need the resources to deal with them. Currently only one in ten doctors has access to a secure facility to treat these difficult patients.

As doctors we make a commitment to treat patients with respect - they must do also or should be refused access.

> What’s on the inside Saving lives in Sudan A look at the work of MSF in southern Sudan Page 10

Blood, glorious blood The story behind the red stuff Page 12

Latest News Page 4

The Secret Diary of a Cardiology SpR Page 17

Return of the body snatchers The shortage of body donors Page 14

3

JuniorDr The Pulse

News Pulse Tell us your news. Email the team at newsdesk@juniordr.com or call us on 020 7684 2343.

NHS

Violence against doctors going unreported LONDON One in three doctors has been a victim of a physical or verbal attack in the past year but most do not report it, according to a poll by the BMA. The most frequently stated reason for workplace violence was dissatisfaction with the service, including frustration with waiting times and refusal to prescribe medication. This has doubled as a cause of violence since 2003.

Junior doctors are the most likely to experience violence on the job.

“Ministers have repeatedly stated that there should be zero tolerance to violence of any sort in the NHS. We heartily agree,” says Dr Hamish Meldrum, Chairman of Council at the BMA. “The mechanisms must be there to minimise the likelihood of attacks, to support staff who experience them, and to ensure that anyone who commits an act of violence is dealt with

> Key findings

appropriately.”

Approximately 600 doctors responded to a BMA survey on their experiences of violence in the workplace in the past year. A third had experienced some form of violence - including threats and verbal abuse - and one in ten had been physically attacked. Of these, one in three received minor injuries, and one in 20 was seriously injured.

Aggression tolerated

“Ministers have repeatedly stated that there should be zero tolerance to violence of any sort in the NHS. We heartily agree.”

Dr Hamish Meldrum BMA Chairman

4

Ben, a London GP trainee who is currently working in A&E feels there’s an institutional tolerance to aggression in the NHS: “At the the start of my post I was shocked at how verbally abusive patients are tolerated in our department - particularly drunk or intoxicated patients” he told JuniorDr. “There’s a common conception that patients should be treated no matter what their behaviour ... it’s not just intimidating for the staff it’s also upsetting for many of the other patients too.”

Results of the survey showed higher rates of violence against

female doctors and psychiatrists.

Over half of physicians polled report witnessing violence against other staff members, including nurses and receptionists. http://www.bma.org.uk/ap.nsf/content/violence08?

OpenDocument&Login

> Half of doctors said violence in the workplace is a problem > More than half had witnessed violence against other staff, such as nurses and receptionists > Female doctors are more likely to experience violence in the workplace than males (37% compared to 27%) > Junior doctors are the most likely to experience violence, followed by GPs > Almost two thirds of psychiatrists report that violence in their workplace is a problem, compared with a fifth of surgeons > Most doctors have not received any training in dealing with violent patients > Only one in ten doctors has access to a secure facility in which to treat violent patients

Training

GMC to raise registration fees by £100 LONDON The annual retention fee for full registration on the GMC medical register will rise to £390 per year, taking effect April 2008.

The annual retention fee is the main source of income for the GMC, and is regularly reviewed to ensure that it remains at an appropriate level. It has been frozen at £290 for the past six years, since 2002.

Professor Sir Graeme Catto, President of the General Medical Council said: “It is six years since the GMC put up the ARF. We have

been able to maintain the fee at that level by a combination of rigorous measures to ensure that we have been operating as efficiently, economically and effectively as possible ... This rise is to ensure that the costs of regulation to doctors and to the health service are maintained at an appropriate level.”

Although the fee is set to rise, the GMC will continue to offer a 50 percent discount for doctors on lower incomes. www.bma.org.uk/ap.nsf/content/studentfinsurvey1 7?OpenDocument&Login

JuniorDr

Up to £45,000 in grants will be dispensed by the BMA for international humanitarian work in 2008. Individual NHS teams can apply for up to £3,000 each. “This fund is a reflection of the fact that healthcare is a global issue and provides an opportunity for NHS clinicians to access financial support to undertake work in partnership with health professionals overseas,” says Dr Peter Carter, RCN General Secretary. NHS staff seeking funding for projects should apply to the BMA’s International Department. www.bma.org.uk/ap.nsf/Content/HumanitarianFun d07

BMJ Group acquires OnExamination.com The BMJ Group announced that it has acquired OnExamination.com, the UK market leader in online exam preparation for doctors, medical students and other healthcare professionals. Since its launch in 2000, OnExamination.com has expanded to cover the principal post-graduate exams run by the UK Royal Colleges in medicine, surgery and primary care. It has recently expanded with exam preparation for medical students and nurses and is about to launch a resource for school leavers aiming for a career in medicine. www.bmjgroup.bmj.com

BMA warns of risks with Internet drug purchases A warning to patients about the dangers of buying prescription drugs via the Internet was issued recently from the BMA. The Association wants to work with the government and the World Health Organisation to control Internet sales of medicines. Dr. Hamish Meldrum, Chairman of the BMA Council, said the problem with buying medications via the internet is that patients may not be getting the same drugs, but instead an inactive or dangerous substance. Drugs for the treatment of erectile dysfunction are among those most frequently purchased from Internet sites. Dr Meldrum said: “One of the messages we are trying to get over to the public is of the dangers of [self-prescribing medication without seeing a doctor].” www.bma.org.uk

Working Conditions

Cost of being junior doctor soars, salaries remain low LONDON The cost of being a junior doctor has increased by 80 percent over the last seven years, according to figures published by the BMA. Over the same period, junior doctors’ basic salaries have increased by little more than 20 percent, and supplements paid for antisocial hours have fallen.

Research by the BMA looked at the minimum essential costs borne by junior doctors as they progress through their training.

This includes the compulsory membership of organisations such as the General Medical Council the cost of which has more than doubled to £290 for second year junior doctors.

It also includes the costs of sitting exams - essential if doctors are to progress in their training.

The fee for receiving a certificate of completion of training (CCT)

has trebled since 2000 to over £750.

“In other professions, the employer pays for the benefits of a well trained workforce. In the NHS, junior doctors pay for it themselves. We’ve seen the cost of our training soar over the past seven years, but this hasn't been matched by an increase in our pay, or funding for study leave,” says Ram Moorthy, Chairman of the BMA Junior Doctors Committee.

The BMA is concerned that trainees may soon face additional fees for membership of new bodies overseeing training. It should also be noted that takehome pay has fallen for many junior doctors because of Working Time Directive limits on hours.

The BMA has submitted the figures to the Doctors and Dentists Review Body, which makes recommendations on doctors' pay.

The Pulse

BMA Announces Grants for International Humanitarian Work

“In other professions, the employer pays for the benefits of a well trained workforce. In the NHS, junior doctors pay for it themselves.”

Dr Ram Moorthy Chairman BMA Junior Doctors Committee

www.bma.org/uk

NHS

Docs have no confidence in new NHS database LONDON Most doctors say they have no confidence in the government’s ability to handle confidential patient information safely, according to a poll conducted by BMA News.

Over 90 percent of those who responded to the survey said they were not confident the data on the proposed new NHS patient database would be secure.

The poll follows recent highprofile data losses, including CDs from HM Revenue and Customs containing details of 25 million child benefit claimants and security breaches during last year’s online training recruitment fiasco for junior doctors.

Trainee cardiologist Dr Sally Simmons says she has no faith in security of government information after her personal details became publicly available

during the MTAS breach last year: “I have received no apology from the Department of Health despite writing to the former health secretary [Patricia Hewitt].

I was also affected by the loss of the two child benefit CDs with my bank details on them. Not surprisingly, I have no faith in any form of IT security that this government proposes,” she said.

Over 200 doctors replied to the Doctors Decide poll with nine out of ten (93 percent) reporting that they did not feel in a position to assure patients that their data would be safe.

A further eight out of ten (81 per cent) said they would not want their surgery data stored on the national NHS ‘spine’.

However, Berkshire GP and consultant in family planning Dr Meg Thomas argued the benefits: “This will help with continuity of care and communication between primary and secondary care … There may be a risk but paper records are also going astray. We need to join the 21st century and quick,” she said. www.nhs.uk

5

JuniorDr NHS

The Pulse

High rate of avoidable deaths, despite increased healthcare spending LONDON Approximately 17,000 unnecessary deaths occur per year in the UK, according to a recently released report by the TaxPayers’ Alliance.

“Wasting Lives: A statistical analysis of NHS performance in a European context since 1981” analyses data from the WHO to estimate the number of deaths that could plausibly have been averted by the NHS since the 1980s. The measure used is known as “mortality amenable to healthcare”. The calculations compare the UK performance to that of Germany, France, the Netherlands and Spain.

If the UK were to achieve the same level of “mortality amenable to healthcare” as the average of the other European countries studied, there would have been 17,157 fewer deaths in 2004, the most

recent year for which data is available.

“Thousands are dying every year thanks to Britain’s health service not delivering the standards people expect and receive in other European countries,” said Matthew Sinclair, author of the report and a Policy Analyst at the TaxPayers’ Alliance. “Billions of pounds have been thrown at the NHS but the additional spending has made no discernable difference to the longterm pattern of falling mortality.”

Improvements in mortality rates, relative to European peers, have been made at almost exactly the same rate throughout the Thatcher, Major and Blair governments despite huge increases in spending from 1999 to date.

6

Prostate Cancer linked to Fatherhood

“The NHS should not be a religion, with its structure set in tablets of stone.”

Professor Karol Sikora Doctors for Reform, Report Foreword

Training

Working Conditions

GMC Collects Race Data on UK doctors

PMETB 48% fee increase criticised

LONDON The GMC is attempting to collect ethnicity data on all doctors practising in the UK. With the support of leading medical organisations, it is calling on doctors to provide their details to help the GMC ensure that its processes are fair and transparent.

The data will be analysed to help provide answers to long standing questions, including why international medical graduates are comparatively overrepresented in referrals to the GMC from public bodies (as opposed to individuals).

“We would encourage doctors to provide their details because without such co-operation the GMC cannot ensure and demonstrate that its processes and

LONDON The BMA criticised proposals from the Postgraduate Medical Education and Training Board (PMETB) to increase its fees by up to 48 percent.

Under the proposals, fees for a Certificate of Eligibility would be increased 48 percent for doctors in non-training posts. The fee for junior doctors applying for a Certificate of Completion of Training (CCT) would rise in line with inflation.

“It's hard to see how these rises can possibly be justified,” says Dr Hamish Meldrum, the BMA’s Chairman of Council.

procedures are free from discrimination,” says Dr Hamish Meldrum, Chairman of Council at the BMA. No single organisation holds accurate ethnicity data about the UK’s 40,000 doctors. As the regulator, the GMC needs this information to fulfil specific statutory duties under the Race Relations Act. http://www.gmc-uk.org

A trial of electronic transfer of repeat prescriptions between general practices and pharmacies is currently being rolled out across the UK. Developers hope it will streamline the system making it faster and more convenient for patients - as well as cutting down on prescription errors. The new prescription transfer scheme is to be studied by academics at The University of Nottingham with a research grant from NHS Connecting for Health.

Researchers will analyse the program to determine if it benefits patients and the NHS. www.nottingham.ac.uk

http://tpa.typepad.com/bettergovernment/2008/01/ major-study-on.html

Electronic Prescription Transfer Hopes to Save Time, Money

www.bma.org.uk/

Childless men have a lower risk of developing prostate cancer than fathers, according to an article in the journal Cancer.

Paradoxically, the study also showed that the more children a father has, the lower the risk of the disease. The study found men without children were 16 percent less likely than those with children to be diagnosed with prostate cancer during 35-years of follow up. The analysis also showed that among fathers, there was a gradually reduced prostate cancer risk with increasing number of children. http://www3.interscience.wiley.com/journal/28741/ home

Circumcision not linked to decreased sexual satisfaction Over 98 per cent of circumcised men report the same levels of sexual satisfaction and performance as uncircumcised men, according to an article published in BJU International.

Circumcision is recommended as an efficient way to reduce HIV transmission, but previous trials found conflicting results. “Other studies have already shown that being able to reassure men that the procedure won't affect sexual satisfaction or performance makes them much more likely to be circumcised,” says co-author Professor Ronald Gray from the Bloomberg School of Health at Johns Hopkins University, Baltimore, USA. http://www.blackwellsynergy.com/doi/abs/10.1111/j.1464410X.2007.07369.x

RSMtrainees Prizes open to Trainees Need support in applying for a Specialty training post in 2008?

The Royal Society of Medicine is happy to announce the launch of two new services that will help trainee doctors beat the intense competition for posts this year. Collaborating with the experienced team at Maximize YOUR Medical Career, who helped over 2000 doctors apply for ST posts last year, the RSM is offering the following two new services: 1. ST Application Adviser – an online ST application form evaluation service where trainees can submit their application form online to be appraised and improved within 72 hours • Improve your chances of getting shortlisted • Help in identifying your ‘Unique Selling Points’ • Advice on selection of scenarios that best demonstrate required competencies 2. Interactive ST Interview Workshops – Commencing in February day courses and intensive evening courses • Perfect YOUR interview performance • Approach to common interview questions and effective answers • Interview do’s and don’ts • Each of the key competencies for ST training specifically addressed • Practical interview demonstrations and ample opportunities to improve your own performance For more information on either the ST Application Adviser or Interactive ST Interview Workshops visit www.rsm.ac.uk/STsupport, or phone 020 7290 3856

Meetings for Trainees 23 February Society Course Interactive ST interview workshop

28 February Young Fellows Win the publication game

05 March

29 March

Society Course Interactive ST interview workshop

Society Course Interactive ST interview workshop

15 March

31 March

Society Course Interactive ST interview workshop

Vascular Medicine Section Presenting and writing up your research

19 March

05 April

Society Course Interactive ST interview workshop

Young Fellows Interview Intelligence training day

20 March

For a full list of meetings visit www.rsm.ac.uk/diary

Young Fellows Histopathology training day

Oncology Section Sylvia Lawler Prize Submission Deadline: 26 March 2008 Prize: Two prizes of £500

Young Fellows The John Glyn Audit Prize Submission Deadline: 28 April 2008 Prize: £300

Cardiology Section President's Medal Submission Deadline: 9 May 2008 Prize: Commemoration Medal and £1000

For full details, please visit www.rsm.ac.uk/awards

RSM Young Fellows/Trainee Membership -

The RSM has a graduated membership for Young Fellows, depending on the date of your qualification, starting at just £65 pa.

We also offer a 50% discount on your subscription rate if you are temporarily out of work, enabling you to continue using the RSM training, networking and library to further your career at a lower rate.

Visit www.rsmmembership.org for more information.

Visit www.rsm.ac.uk or call 020 7290 2991

JuniorDr The Pulse

Journal Review Future psychosis predicted by abnormal behaviours in youth NEW YORK Young people who are likely to develop psychosis can be identified in 65 to 80 percent of cases if they have specific combinations of risk factors, according to a study published in the Archives of General Psychiatry.

Predictors of psychosis included deteriorating social function, family history of psychosis combined with a decline in functional ability, unusual thoughts, paranoia, and drug abuse. The team outlined specific survey criteria for each category.

Research shows that intervention during the early stages of psychosis improves outcomes, but it is not yet clear if even earlier intervention before a psychotic illness develops is effective. http://archpsyc.ama-assn.org/

8

Simulated resuscitation training more effective than traditional means NEW YORK Senior doctors who are trained in critical resuscitation skills on patient simulators become more skilled than those who undergo traditional training, according to an article in the journal Chest.

Although prior studies have already shown that simulation training is effective in imparting such skills, this study sought to demonstrate the superiority of simulation training over traditional methods.

In doing so, researchers found that simulation-trained doctors out-performed their traditionally trained counterparts in 8 of the 11 steps of initial airway management during a simulated scenario of respiratory arrest.

“We weren’t surprised by the skills demonstrated in the simulation-trained residents, although we were quite surprised to see how poorly the traditionally trained residents performed,” said study author Pierre Kory.

“This finding was quite alarming because traditional training or ‘learning by doing’ is how doctors have historically been trained and continue to be trained, around the world.”

Dr. Kory and his colleagues from Beth Israel Medical Centre, USA compared two groups of third-year internal medicine residents; one group received training in initial airway management skills using a computerised patient simulator during the first year of residency while the other group received

traditional “hands on” training.

Researchers found that 38 percent of the simulation-trained residents, compared with zero percent of the traditionally trained residents, successfully resuscitated the mannequin. In addition, the simulation-trained residents performed significantly better in eight of the 11 tasks of initial airway management.

“Patients should have the peace of mind of knowing that their treating physician could save their life, should they suddenly stop breathing,” said Alvin V. Thomas, Jr., President of the American College of Chest Physicians.

“Simulation training can provide efficient and effective learning in not only airway management, but in a number of areas where critical skill is required.” http://www.chestjournal.org/

“This finding was quite alarming because traditional training or 'learning by doing' is how doctors have historically been trained and continue to be trained, around the world.”

Dr Pierre Kory Beth Israel Medical Centre

Suppressed anger linked to early death Couples in which both partners suppress their anger during conflicts die earlier than members of couples where partners express their anger, according to a University of Michigan study. Researchers looked at 192 couples over 17 years. When both spouses suppressed their anger at the other when unfairly attacked, earlier death was twice as likely as in all other types. “If you bury your anger ... and you don't try to resolve the problem, then you’re in trouble,” says Ernest Harburg, lead author. http://www.sph.umich.edu/

Healthy lifestyle adds fourteen years to lifespan People who adopt four healthy behaviours - smoking cessation, exercise, moderate alcohol intake, and a diet high in fruits and vegetables - live on average an additional fourteen years of life compared with people who adopt none of these behaviours. The study, published in the open access journal PLoS Medicine, is based on a lifestyle survey and death rates of 20,000 men and women.

The increased longevity was unrelated to body mass index or social class. medicine.plosjournals.org/perlserv/?request=getdoc ument&doi=10.1371/journal.pmed.0050015

Meat-heavy diet increases risk of metabolic syndrome Healthy adults who eat two or more servings of meat a day increase their risk of developing metabolic syndrome by 25 percent compared with those who eat meat twice a week, according to research published in Circulation: Journal of the American Heart Association. Fried food is also to blame, says to Lyn M. Steffen, coauthor of the study.

Dairy products appear to offer some protection against metabolic syndrome. The findings emerged from an analysis of dietary intake by 9,514 participants in the Atherosclerosis Risk In Communities (ARIC) study of which nearly 40 percent had three or more risk factors for metabolic syndrome. http://circ.ahajournals.org

Finger length ratio may predict osteoarthritis NOTTINGHAM People whose index finger is shorter than their ring finger are at higher risk of osteoarthritis (OA), according to a study published in the journal Arthritis and Rheumatism.

The results suggest that people whose index finger is shorter than their ring finger are up to twice as likely to suffer from the condition, which is the most common form of arthritis.

“The underlying mechanism of the risk is unclear and merits further exploration,” said Professor Michael Doherty, lead researcher.

Index to ring finger length ratio (referred to as 2D:4D) is a trait known for its differences between the sexes. Men typically have shorter second than fourth

digits; in women, these fingers tend to be about equal in length.

Researchers at The University of Nottingham conducted a casecontrol study of over 2,000 patients to assess the relationship between the 2D:4D ratio and the risk of knee and hip OA. Their findings suggest that having a relatively low index finger to ring finger ratio raises the risk for

developing OA of the knee, independent of other risk factors and particularly among women.

“The 2D:4D length ratio appears to be a new risk factor for the development of OA,” said Professor Doherty. “Specifically, women with the ‘male’ pattern of 2D:4D length ratio - that is, ring finger relatively longer than the index finger - are more likely to develop knee OA.” Smaller 2D:4D ratios have intriguing hormonal connections, including higher prenatal testosterone levels, lower oestrogen concentrations, and higher sperm counts. Reduction in this ratio has also been linked to athletic and sexual prowess.

The Pulse

JuniorDr

http://www.interscience.wiley.com/journal/a rthritis

HIV Subtype Determines Virulence LONDON People infected with HIV in Thailand die from the disease significantly sooner than those with HIV living in other parts of the world, according to two studies published in the journal AIDS. According to the researchers, the shorter survival time measured in the studies suggests that HIV subtype E, which is the most common HIV subtype in Thailand, may be more virulent than other subtypes of the virus.

The median time from HIV infection to death for the Thai men was 7.8 years compared to 11 years for HIV positive men living in North America and Europe.

The survival rate for the Thai men was also lower than studies of similar populations living in lowand middle-income countries in sub-Saharan Africa where subtypes A, C, D and G circulate.

However, the shorter survival after HIV infection among persons in Africa infected with subtype D was similar to the survival among the Thai men.

“The fact that [patients] in Thailand had similarly shortened survival compared to persons in the U.S. and Africa-except those infected with subtype D virusessuggests that viral subtypes D and E may be more virulent than many

“ Viral subtypes D and E may be more virulent than many other viral subtypes.”

other viral subtypes,” said Kenrad E. Nelson, MD, a senior author of both studies and professor in the departments of Epidemiology and International Health at the Johns Hopkins Bloomberg School of Public Health.

“If we could understand better the virulence characteristics of these viruses, we might learn something more about why those with HIV infection progress to AIDS, usually many years after they are infected.” www.thelancet.com/journals/lancet/article/P IIS014067360761232X/

Dr Kenrad Nelson Senior study author

9

JuniorDr Features

Saving MSF has been operating in southern Sudan since 1983 working in hospitals, clinics and through mobile teams. Here GP Simon Burling who has been positioned as a "flying doctor" in southern Sudan talks about his role.

> Role of MSF in Sudan In hospitals, clinics and through mobile teams, MSF staff provide basic health care, in-and-outpatient services, surgery, nutritional, maternity and ante-natal care. Our teams also provide treatment for HIV-AIDS, tuberculosis, kala azar and sleeping sickness.

In addition to providing primary and secondary healthcare, MSF teams in southern Sudan are on hand to respond to disease outbreaks and natural disasters. 2007 saw MSF launch a large-scale response to a meningitis outbreak, as well as treating people for cholera and measles.

I first went on mission with the medical humanitarian aid agency MSF in 1999. Nine years later, and having worked in Somalia, southern Sudan and Congo, I am now back in southern Sudan, working with MSF for nine months as a “flying doctor”.

In over twenty years of brutal warfare between Sudan’s southern states and the government in Khartoum, an estimated two million people died. Ground and aerial attacks on towns and villages killed people directly, while others perished from exposure, thirst, malnutrition, epidemics and a host of preventable diseases. Since a 2005 peace agreement, tens of thousands of Southern Sudanese people are returning to their homes after decades in exile, hoping that their suffering can finally draw to a close.

But this is one of the least developed places on Earth; southern Sudan is more than twice the size of Great Britain and has virtually no roads - and those that exist are mostly rutted tracks that become impassable in the rainy season. There is virtually no health care and in most of the region walking for days is the only way to get to the precious few health posts that actually exist.

The job I have a great job, in part

10

because I do not have a typical day. My day to day work is alongside the clinical staff, helping them to gain new skills and provide some insights into the cultural aspects and as to what is feasible in southern Sudan. There is very little infrastructure and the majority of the population we work with has had little or no education. It can be difficult for staff to manage stock in the pharmacy or to work out the proportion of an injectable drug to be given.

My job involves providing support to the international medical staff (doctors, nurses, midwives) and the national staff teams in four of the projects that MSF runs in southern Sudan.

These four projects, provide primary health care to around half a million people. This "primary" health care not only covers outpatients, immunisation, antenatal care but also inpatient care, tuberculosis, feeding of malnourished children (both inpatient and ambulatory), kala

g lives in Sudan azar, maternity care and in one site, surgery.

Each project has one doctor, although there is also a general surgeon in the surgical site. This means that we need someone with a wide range of skills which is increasingly difficult to find in the West. We do not want specialists, but someone who can treat malnourished children, a case of cerebral malaria, stabilise trauma cases prior to referral (which depends on having two dry landable airstrips in the wet season and may mean a patient dies awaiting transport), deal with obstructive labour (normal deliveries tend to happen at home and we only see the problems), run a TB programme, a routine OPD and deal with the occasional hysterical patient. All this in an environment of 40 plus degrees heat, living in mud and thatch huts, with basic food and with a bunch of other international staff that you have probably never met

before I also do assessments and help set up new aspects of the programme, for example, investigating reports of a kala azar outbreak, working with our water and sanitation department for a hepatitis E intervention, restarting a TB programme and establishing VCT and STI clinics.

Ongoing conflict Although there is a peace agreement, the border areas are disputed and are scenes of ongoing conflict. The division of the oil revenues is not transparent and withdrawal of troops is behind schedule. Although none of these were the trigger for this evacuation; this time it was a local revenge shooting between two different subclans of the population we work with. One man was killed and three were injured, including one of our senior clinical staff. He was brought in when I was on call on New Year's Day. He had been carried for 6 hours, having been shot twelve hours previously.

There are no ambulances and it was too dangerous for people to go and collect him until the gunman had left. Although the bullet transversed his pelvis, he seems to be only left with a foot drop and no visceral damage.

Over the last few weeks tensions have built up with more shootings and revenge attacks.

Features

JuniorDr

Some of our other senior clinical staff have had to disappear for a time as they are high valve revenge targets. Indeed the first day after the first shooting we had lost three quarters of our OPD staff and that is not a pleasant situation with a full OPD after the holidays. Triage, innovation and high frustration tolerance are a must.

Meningitis Other plans include training some of the national staff in anaesthetics in the newly opened surgical site. We are also entering the meningitis season and a large epidemic is "overdue". Small outbreaks occur each year but there was a significant increase in 2007, with 12,570 cases and a CFR of 6%. We have emergency preparedness plans and stocks for this, as well as for the other outbreaks we see, particularly measles (a major killer) and cholera. We also expect that there will be an increase in malnourished children this year, as large amounts of sorghum (the staple crop) was destroyed by flooding. There will be a longer hunger gap and already some staff are asking for payment in the form

A woman has a one in eight chance of dying during childbirth.

of food as opposed to money.

It can be exhausting with long hours and on call duties with incredibly sick people and a heavy reliance on your clinical skills without fancy investigations - eg no blood chemistry, no X-rays, but the work is incredibly satisfying. It is very clear that we work in some of the most neglected parts of the world, away from media attention and that if MSF was not there, there would be no health care at all. However, it is the most stimulating and satisfying job and the ability to help the person in front of you and make a real difference to their life, even saving it, is immensely rewarding. I have and you can truly say that you make a difference.

You can find out more about the work of MSF in Dafur and other projects around the world at www.msf.org/unitedkingdom

11

JuniorDr Features

Blood, glorious blood After William Harvey demonstrated his theory of the circulation of blood in 1620 scientists struggled for nearly 300 years to perfect the transfusion of blood to humans. Today the national blood service collects 2.5 million blood donations each year. Professor Pete Moore, author of ‘Blood and Justice’, takes us on a journey back to the origins of blood transfusion.

Fifteen years ago I taught physiology. One of the more memorable practical classes involved a couple of buckets of ox blood. Laced with heparin, it was subjected to a series of ‘experiments’ by often palefaced undergraduates.

But they were great experiments. Blood gave us an opportunity to play with a living organ, with a fluid that displayed many different properties, some simple some complex.

While some students were squeamish, few attributed this to a belief that they were handling the very life of the slaughtered animal.

Wind back a few centuries and the situation would have been very different.

First established in preChristian Greece, life was seen by some to contain blood, by others to be the very stuff of life itself.

There was a simple observation that proved the case - let it out and the person’s life left their body.

This was so well established that trying to bleed a person became one of the main criteria for determining death - cut into a vessel and if no blood comes out, there is no life left inside.

The Circulation of Blood The seventeenth century saw the first glimpse of a new concept of blood. Arguably it started with William Harvey’s 1620s realisation that b l o o d m u s t

12

(Courtesy - Library of Medicine, USA)

> William harvey first demonstrated the circulation of blood using a deer

circulate around the body. He made a few rough and ready calculations of the blood flow through the heart and realised that this was too great to be sustained by a one-way passage from the heart to the extremities.

Looking for inspiration he turned to Aristotle who had come to similar conclusions from his local river. The water must be part of some great cyclic activity, Aristotle reasoned, otherwise such was the flow that the mountains would soon run out of their supply.

Like the presumed water cycle, Harvey reasoned that blood flowed to the extremities in the arteries, and in some way ‘condensed’ into the veins before returning to the heart. He was also convinced that a circular system was in operation as he saw this sort of motion in the stars of the heavens. The God who created had obviously ordained that circles were good.

His reasoning may have been flawed, but the conclusion was correct.

The 1650s then saw anatomist and astronomer Christopher Wren

inject solutions into this circulating stream of fluid.

Maybe, he surmised, this would be a good way of distributing medication through the body. His one attempt in a human, involved borrowing a friend’s servant and injecting opium into him. The man slumped to the floor. Wren was disappointed, as he felt he had only just started the experiment, and was fairly sure the wretched servant was feigning his faint in order to go home early.

Robert Boyle and colleagues then took up the trail, investigated the physical properties of blood and searched for any medical benefits that could come from manipulating it.

Jean Baptise Denis Into this steady progress of early scientific endeavour, stepped a 26 year old Frenchman. Jean Baptise Denis was keen make a name for himself and thought that pioneering a cure-all treatment would be a good way to achieve it.

Transfusing blood seemed a pretty good possibility.

His theory was confused, but incorporated the idea that if a (Courtesy - Library of Medicine, USA)

> The first successful human to human didn’t take place until 1818

person was unwell, then their lifeblood was damaged. Draining this diseased fluid and replacing it with blood from some healthy donor should restore health.

He borrowed some ideas from the English workers, made a few attempts at transfusing blood between animals and then launched into medical applications. On 15 June 1667 Denis connected a sick teenage boy to a lamb. While Denis was thrilled that the boy made a rapid recovery to good health, this was probably due to the fact that the boy’s physicians abandoned him and no performed the standard treatment of blood letting.

All the same, Denis was convinced that the technique was a success and transfused sheep’s blood into a paid volunteer – again with apparent success. His next two patients however died, and Denis found himself in court accused of murder.

Not having to go through at 21st century ethical approval system may have meant that he could stride ahead rapidly, but when things went wrong it left him distinctly exposed.

It would be 250 years until science caught up and anyone made a concerted effort to transfuse blood again. We may have moved away from believing in the mystical properties of blood, but in one aspect Denis was right transfusing it can indeed support sick and injured people and as such restore their health.

Pete Moore’s ‘Blood and Justice’ is published by John Wiley.

ISBN 0470848421.

JuniorDr Features The recent expansion of medical training in England has resulted in a shortage of bodies for the education of medical students and for research.

While the numbers of people donating body organs has increased, the number of people leaving their whole bodies for medical science has fallen since 2000.

Michelle Connolly finds out more from Dr Jeremy Metters, HM Inspector of Anatomy.

Over the last five years the number of bodies donated in England and Wales has fallen from 670 to 600. In contrast, the number of medical schools has increased by eight, and 15 new postgraduate anatomy departments have opened to improve the anatomy training of surgeons. In this time the number of new medical students has increased to over six thousand a year.

JuniorDr spoke to Dr Jeremy Metters, HM Inspector of Anatomy, about this threat to our anatomy teaching.

Why do you think there has been a fall in the number of cadaveric donors to medical schools?

Since 2000, the number of offers of cadaveric donation has fallen, mainly for three reasons: firstly, Alder Hey and Bristol played a role. In light of those scandals, many people withdrew their intention to donate their bodies, directly citing these scandals. Secondly, from 2001 onwards, if a person was diagnosed with dementia, their body could no longer be used for teaching purposes. Thirdly, if

14

Return of the body snatchers

people had MRSA, they could no longer donate their bodies.

Annually, 600 people wish to donate their bodies to medical science and considering that each year some 260,000 people die in the United Kingdom, this isn’t a great deal. The percentage of people donating their bodies to anatomy teaching would be greater if the public knew how to donate.

The office of the Inspector of Anatomy has to be particular in what type of cadaver is accepted.

Donations below 60 years of age are declined, unless the patient is ill and likely to die soon, because it’s not worth the bureaucracy.

Demand for cadavers has also risen since 2000 because the number of medical schools and the number of students at those schools has increased by 20 percent. Demand will increase even further because surgical reconstruction procedures which were banned as part of the Anatomy Act 1984 are now lawful under the Human Tissue Act 2006.

It was ok for trainee orthopaedic surgeons to excavate the upper end of the femur in a cadaver but it was unlawful for the trainee to insert a prosthesis. It took 22 years for this

bizarre caveat to be addressed, simply because it’s very difficult to obtain parliamentary time.

Do you believe anatomy is still best taught on cadavers?

Yes. All medical schools with the exception of Peninsula say that cadavers are the best means by which anatomy should be taught.

The use of cadavers is very expensive. Does the cost-benefit ratio of anatomy teaching on cadavers still warrants its continuation?

Yes, and it is actually not that expensive. At each of the thanksgiving services, students are incredibly grateful for their 'silent teachers', who provide them with the most incredible textbook.

Indeed, some medical students recently wrote “our silent teachers provided us with a text that no book can duplicate, no lectures can match and no computer could simulate”.

Would you donate your body?

Yes, in due course but being on the National Organ Donor Register is more important. One cannot be on both registers, since the maintenance of life is more pertinent. A lady today stipulated

that her body be used only for research purposes, and not for teaching. But her wishes cannot be guaranteed, as we cannot forsee what type of research will be conducted at the time of death and whether her body will be of use.

We also cannot guarantee intending donors that medical schools will accept the body.

Schools must run checks that can preclude donation, which is very distressing for the family, particularly if it was “Granny's last wish”.

What are the motives commonly cited when people wish to donate their bodies?

People often donate if they benefited in some way from medical care. There is also a strong desire to help future generations.

There are about 600 donations per year; there would be more but many cadavers are lost via post mortems.

What happens to donated bodies?

Provided there is a consent form, or a donation request in the Will, the person in possession of the body - usually the next of kin, will contact the medical school,

who will then ask questions about the death. This is to ensure there are no conditions which preclude donation (post-mortem examination, severe deformity, hepatitis or dementia). The school will then accept the body for “anatomical examination or research” but by law for no longer than a period of three years. Body parts are allowed to be separated but they must be brought together when the body is cremated or buried within three years of death.

The donor is free to withdraw their consent at any time. Under the Anatomy Act 1984, the next of kin was allowed to halt donation. This will no longer be lawful under the Human Tissue Act 2006. Most donors take the view: “I don’t mind what you do with my body after I’ve gone”, and express this in their donation forms.

A brief history of body donation Before the Anatomy Act 1832, the only bodies available for anatomy teaching were those of executed criminals. The shortage of bodies in the early 19th century led to the practice of “grave robbing” - in those days medical schools asked no questions. The most infamous grave robbers were Burke and Hare, who committed murder to meet demand for cadavers at Edinburgh medical school.

Similar events in London led to the Anatomy Act 1832, which allowed the use of bodies of paupers or of unclaimed bodies to be used in the dissection room.

Until after World War II, most of the bodies were from those who had no relatives to pay for the funeral. It wasn't until the 1960s when people actually started bequeathing their bodies to medical science. The Anatomy Act 1984 tightened the legal controls on body donation.

However, Section 4(3) continued to allow the “person in possession” to permit donation, where there was no evidence that the deceased objected.

There followed a decline the the willingness of medical schools to accept bodies when the deceased had not expressed a wish to donate. By 1990, all donations followed the written consent of the donor. Since 2000, all anatomy departments in UK medical schools have refused to accept bodies unless it was the expressed wish of the deceased during life.

Collagen corpses

Features

JuniorDr

In today's celebrity culture, where looks are becoming more and more central to a person’s confidence, the desire to fit into a set mould is ever increasing.

But how far will the beauty and medical industries go to fulfil the demands of such an image conscious public? Sinem Ayman highlights how fears have been raised about the origins of collagen for implants.

In the constant pursuit of ‘forever youth’ collagen injections have become the UK’s treatment of choice, second only to botox.

Collagen itself is a compound found in abundance in skin, bone and muscles and serves as scaffolding to strengthen and support these organs. In the beauty industry it is used to smooth out wrinkles and bolster lips but unfortunately treatments have to be repeated as the effects are not permanent.

The collagen used in the UK is originally sourced from cows, pig and human skin and these samples are grown for up to ten years in laboratory conditions. In all cases the collagen is highly purified and sterilised before being converted into an injectable form ready for use in humans.

Collagen crime Last year however, The Guardian newspaper uncovered that collagen in some UK clinics had been sourced from a Chinese firm which has been extracting collagen direct from the skin of executed Chinese prisoners.

Shockingly, according to reports from agents at the company this practice is quite ‘normal’.

Bar the ethical concerns of this collagen, there are also major health risks to

consider. Transmission of disease especially blood-borne viruses, such as hepatitis and vCJD, are possible - although there are no records of this happening. An inquiry by the Department of Health has reported cases of acute allergic reactions to contaminated collagen injections causing scarring and disfigurement.

Regulation As collagen products are not strictly classed as either medicines or cosmetics they bypass any current regulations. This anomaly is being reviewed at present by the European Commission but any legislation is several years away.

Mr Douglas McGeorge, president of the British Association of Aesthetic Plastic Surgeons (BAAPS) emphasised the importance of consumer awareness: “Stories like these only reinforce the advice given by BAAPS that patients should always see reputable surgeons who have a proper training in aesthetic procedures and who are properly qualified to give good and appropriate advice,” he said.

“The hope is that the forthcoming changes in the regulations will eliminate the fringe clinics offering poor advice and questionable treatments with inferior products.”

They also hope that patients will be more proactive in questioning where and how the constituents used in their procedures have been obtained. www.guardian.co.uk/science/2005/sep/13/med icineandhealth.china

15

JuniorDr Features

Most people, with the exception of fishermen and extreme animal lovers, will be disgusted by the thought of maggots crawling onto their skin. You can instantaneously conjure up an image of a rotting body plagued with flesh-sucking creepy crawlies. In fact, myiasis is the very term given to the ‘infestation of live humans and animals with dipterous larvae which feed on the host’s dead or living tissue, liquid body substances or ingested food’. But as Amilia Youkhana explains, despite its ickiness, maggot debridement therapy (MDT) could be a significant part of the management of chronic inflammatory processes such as wounds, ulcers, burns and even necrotic tumours.

Chronic wounds and skin ulcers have always been difficult to treat. One important example is that of diabetic foot ulcers that frequently result in amputation.

Numerous observations of soldiers at war in past centuries have shown that wounds accidentally infested with maggots not only healed quicker but also appeared to protect the host from acquiring septicaemia. Since the late eighteenth century, studies of controlled, sterile management of infected wounds, abscesses and osteomyelitis with MDT had been successful and popular until the introduction of antibiotics and aseptic techniques in 1940’s, where it was used only as a last resort. Interest in the little creatures has once again grown recently because of the emergence of antibiotic resistant microorganisms - MDT can reduce the risk of acquiring an MRSArelated illness.

Certain species of larvae, particularly the green bottle blowfly (lucilla sericata), feed on necrotic tissue only and don’t invade internal organs or break away from each other. They provide a useful method of removing necrotic tissue that would normally impede new tissue formation. They also release exudates containing certain

proteolytic enzymes and chemicals such as allantoin, ammonia and calcium carbonate that act as antimicrobial agents and possibly as growth factors to encourage wound healing. Some believe that the physical effects of the crawling maggots and sucking of debris and bacteria also assist in these processes.

“The latest technological instrument in the surgeon’s tray can be bought from your local angling shop.”

It is recommended that between five and ten maggots are used per centimetre squared of wound and up to 1000 maggots can be introduced into the wound at any one time. They are kept in place via hydrocolloid dressings (double layered and designed to allow oxygen in and exudates and debris out) and are usually left for three days. A number of applications may be needed depending on severity of the wound and the amount of necrotic tissue removal desired. MDT is mostly used on chronic, external, non life-threatening wounds, where other interventions have failed, and has even been

successfully used for necrotising fasciitis and other situations where surgery would have been risky.

Candidates should be chosen with care. Those with a purulent, sloughy, skin lesion that is resistant or not completely responsive to treatment will benefit from MDT. It can be used alone (important when costs need to be kept minimal) or supplementary to medical or surgical treatment.

Although studies are difficult to accurately evaluate and compare, it has been observed that in 80-95 per cent of cases most or all debridment is removed via MDT. There is substantial evidence to advocate the use of larval therapy in chronic leg/pressure/venous stasis ulcers, diabetic foot wounds, traumatic and post-surgical wounds and even burns or necrotic tumours. MDT is simple, costefficient, effective and rapid, without any known side effects aside from itching/tickling sensations felt by some patients. It is becoming more and more popular in hospitals across the globe, and as our knowledge increases, will probably open the doorway to more unconventional forms of medical treatment.

(1) "Myiasis: The Rise and Fall of Maggot Therapy", D. Morgan, Journal of Tissue Viability , 1995, 43-51, 5(2)

Pros • Simple and fast.

• Cost-effective, especially in third world countries.

• Decreases chronic wound healing time and efficiency • Eliminates odour of necrotic tissue.

• Reduces morbidity and mortality by preventing infection of the wound.

• An alternative to medical/surgical methods that have failed or are unsuitable for the patient.

• No side effects reported apart from slight physical discomfort.

Cons • Disgust/revulsion/other psychological distress.

• Pain/tickling/itchiness.

• Fear of maggots escaping/ burrowing into skin/maturing into flies (in fact, this is not true as mature larvae need to leave the wound to turn into pupae and then adult flies).

• Potential allergic risk (although none has been reported thus far).

• Require an experienced clinician to select and sterilise the right species of maggots.

Maggots - Taking the bite out of wounds 16

Names have been changed to try to keep our cardiology SpR in a job - though she’s doing a pretty good job of trying to lose it without our help!

Monday If you’ve been following this column then you’ll know that I had a dilemma last time - well two dilemmas actually. The first involved the job offer for a year in Montreal to convert my MD into a PhD and continue the research that I had been doing into cardiac myocytes. This was actually more tempting than you would think - a year of skiing would have been perfect. The other dilemma involved James, the cardiac surgeon that I had been seeing for four months. He wanted me to move in with him.

I thought long and hard about it over the course of a weekend (and a few glasses of Merlot) and decided it was time to change my life around. I wasn’t getting any younger (as my mother kept reminding me) and didn’t want to keep from doing the things that mattered to me most. And so I declined the offer of a PhD, finished my MD and returned to clinical medicine. And I dumped James as he was a bit of a sissy.

Monday involved a clinic and some paperwork before going home for an early night.

Tuesday Another clinic this morning where I saw post MI patients. I love explaining the things they can and can’t do and get most fun from explaining how long they should abstain from sex. To be honest, looking at some of my chain-smoking overweight cardiac patients I often feel they should abstain for a bit longer - for everyone’s sake. The bad thing about research is that you lose touch with clinical work. Aside from a weekly angio list I hadn’t done any acute takes and so even looking at a clinic chest x-ray I have to spend a few extra seconds before coming to a decision.

I have a quick lunch and partake in the joys of a ward round in the afternoon. The inpatients are pretty light for some reason and we move round the beds swiftly. I have two Foundations who keep insisting on referring to me as a Specialist Trainee. I have reminded them more than once that I like to be called a registrar.

Foundation Two is a quiet Asian girl with long black hair and soft voice. Foundation One is a large rugby playing Welsh boy who seems to know nothing at all about medicine let alone cardiology.

After telling him off several times in my nicest voice I give up and tell him to take a break. He doesn't understand the sarcasm in my voice and so thanks me gratefully before promptly disappearing.

I spend the evening working at home as I need to hand in my MD thesis this month.

Wednesday I have my angio list this morning. Actually, it’s a list for Douglas who is my nice consultant. A near retirement gentleman with white hair and a quiet voice, it was he who encouraged me to go for the MD. He usually hangs around somewhere in the department but generally lets me get on with it. I perform four procedures during the session, one of which is a stent which is placed in perfectly. I wrap up and meet a colleague for a leisurely lunch.

The afternoon is spent reviewing a few inpatient echos and I leave early enough to have a shower, change and be at a bar with some friends by seven. I drink a little too much and we spend the evening complaining about the men (or ex-men) in our lives. I get a taxi home and collapse into a bed a little after one am.

Thursday Unusually for me I have a slight headache and feel reasonably grotty by the time our ward round starts. This is the once a week shame game led by my other boss, the nasty one. He particularly delights in making Foundation One squirm. He used to go for me too but the good thing about my recent research is that I think he’s a little scared of me especially since last week when I quoted a New England paper on cell death after cardioversion to prove that he was wrong about a patient. Anyway, I try to help Foundation One out as much as possible but some of the holes he’s dug for himself mean he’s on his own at times. Afterwards I try to give him an encouraging word and even Foundation Two chips in but he remains glum.

I spend the afternoon reviewing jobs from earlier in the week and then find myself at a loss with nothing to do. I

decide to leave early again and spend the rest of the afternoon looking for a new handbag. It’s the first shopping I’ve indulged in for over a month and it feels pretty good. I get through a big chunk of my thesis by nine and then call it a night as I settle into bed with a glass of Merlot and a book about Afghanistan that I never seem to be able to finish.

Features

The Secret Diary of a Cardiology SpR

JuniorDr

Friday I’m on call today (but thankfully not at the weekend) so start early. The good thing about the system here is that my team are with me and although Foundation Two is diligently seeing patients from the box, Foundation One has called in sick. I wonder how much of yesterday’s humiliation got to him but luckily we have enough juniors to cope with the workload.

I spend the morning putting in a chest drain on a palliative lung cancer patient, excluding meningitis with an LP and making an elderly pneumonia comfortable.

Shortly after two I get a fast bleep from resus. I walk in and find the casualty middle grade over the bed of a large white male.

He tells me that it’s a junior doctor with a suspected overdose and his GCS is dropping. I walk over to the bed and for a second the I think it’s Foundation One. It wasn’t.

I calm myself and then start work. His airway starts to occlude and I tube him. An anaesthetist turns up and takes over. The head of ICU turns up and the two of us spend an hour stabilising him before transferring him upstairs.

Later, I finish my shift and go up to see him. Around the bed are two people who I presume are his parents. Nasty and nice bosses are here too, deep in conversation with the ICU consultant as they pour over his charts. I look over and see that his blood pressure is dipping despite the aggressive inotropes going in through multiple lines.

Back home I call Foundation One just to check how he’s doing.

He’s fine.

17

JuniorDr

Education

SURVIVAL GUIDE to ST interviews

in association with

How can you make an impact in your interview? Some candidates have an innate ability to sell themselves well, but many find it more difficult and are in search of a magic formula that will give them the job they seek. Forget the miracle cure; there is only one recipe for success: preparation.

Secret guide to nurses

What makes a good candidate?

Good candidates display a wide range of attributes, but they always have 3 things in common:

Nurses are not just evil people who bleep you in the middle of the night to sign a chart - they are also friendly, thoughtful and have lots of chocolate. A nurse should be your best friend as a junior doctor. Nurse Tracey Maher tells us why.

A good structure Many candidates have good content; they say all the right words but they fail to impress the panel because the information is not structured. As a result, the interviewers fail to follow the arguments presented and good scoring opportunities are missed.

Make sure that your answers contain three or four distinct points which you can develop in turn, and not a long rambling novel.

A personal approach Candidates have a tendency to waffle or "theorise" about topics.

Questions on leadership contain a lot of buzzwords such as "vision", questions on governance get answers discussing "frameworks", etc. This sounds very theoretical and does not allow the candidate to demonstrate that he/she understands these concepts on a practical day-to-day level. Rather than theorise and focus on buzzwords, bring examples from your daily experience.

Lateral thinking and maturity Think about the range of issues that each question addresses. For example, dealing with a difficult

colleague does not just mean reporting the issue to a senior colleague; there is also a human and communication side to it.

When you describe your teaching experience, do not limit yourself to the letter of the question; as well as your formal and informal experience of teaching, you can talk about the methods that you have used, courses you have attended, feedback that you have received and your future plans for teaching.

How to prepare It is crucial that you do not rush into mock interviews too early.

There are hundreds of possible questions, but they all boil down to 10 or 15 themes. Take four or five questions from each theme (teaching, difficult colleague, etc) and brainstorm them. Then see how you can structure your answer using 3 or 4 bullet points. Look at what you do every day and see how your experience can be used to enrich your answers. Take your time! Once you have done all that, then you can start practicing.

Attending a course can also help, but make sure that it has a small number of participants. With a small number of participants, you can discuss good and bad answers and obtain personal feedback on your own technique.

ST INTERVIEWS EFFECTIVE PREPARATION ISC Medical offer a wide range of products to help you with your ST interview, including: Frequent courses with small numbers Comprehensive ST interview guide (downloadable) One-to-one coaching 20% OFF for MDU members

www.iscmedical.co.uk 0845 226 9487

18

You may be familiar with the creatures who scuttle up and down the wards, some smiling, others snarling. The younger ones as a rule are slim and attractive, the older variety tend to be haggard and curvaceous. There is even a male variety these days, commonly referred to as the ‘failed medic’.

Junior doctors are generally fearful of them and rightly so. The wrath of the consultant can be nothing compared to the stares and sniggers of an army of these creatures. Unless treated with care, you’ll never find that cannula, or those notes - you will be running around like a headless chicken to the amusement of everyone.

This curious species can usually be identified by their uniform and their harassed manner.

They are often found clutching a bed pan, eating biscuits and chocolates or gossiping in the corner of the ward.

‘They’, ladies and gentlemen, are nurses. So what is their problem? Quite simply - you!

The history History has not always been kind to nurses, they are greatly misunderstood. In the nineteenth century they were referred to as ‘attendance’, who kept the ward in order, the patients clean and obeyed the doctor’s orders. Today, nurses are a profession in their own right, yet you lot often get confused thinking they are a subservient branch of medicine.

This mistake on your behalf causes a few noses to be put out of joint.

Wound care, infection control and manual handling are just a few nursing specialities which seem to make medical students smirk. If you are guilty of sniggering at this list then perhaps you have never

seen a patient die from pressure sores, or MRSA. On a less drastic note, you will appreciate the manual handling skills of a nursing team when faced with an obese patient who needs to be turned, or rolled, or stood up in order to be examined.

“Nurses are also the people who can ensure your path to consultancy is smooth.”

As well as having their own realms of expertise, nurses are also the people who can keep you out of trouble and ensure your path to consultancy is smooth. That wrongly written dose, or that missed vital sign could equal disaster if not spotted.

We’re nice ... really!

Nurses are actually quite nice too - treat them well and with respect and you’ll be offered the odd chocolate, have a shoulder to cry on when medical life is not a bed of roses, and when you hang up your white coat at the end of the day, have some drinking partners.

But old habits die hard.

Despite this invaluable lesson, things will not change overnight.

Nurses will continue to think of you as an arrogant bunch, and enjoy paging you in the middle of the night to write up a bag of fluids, and you will continue to reprimand nurses for sloppy care, and find it funny that they have to wipe bottoms.

But amidst the traditional conflicts, remember, they are your comrades.

A successful relationship with the nursing team can not only save lives, but make ward life a lot more fun!

JuniorDr

Lanzarote

Features

Weekend ward escape to the

There’s a myth that the Lanzarote locals coined the slang “Lanza-grotty” to keep rowdy tourists away from this year-round sunshine island.

Lanzarote however, is more ‘art’ than ‘all-day English breakfast’ and an ideal choice for a long relaxing weekend ward getaway.

Getting there Despite being a Spanish island Lanzarote lies closer to Africa situated just 100 miles off the Moroccan coast on the same latitude as the Sahara desert.

Flying time is a little over 4 hours from London.

For flights check out ThomsonFly, Monarch or the other package operators for cheap lastminute deals. Alternatively BA offer direct flights from many UK airports with Easyjet are launching an new route from Gatwick this March.

Car hire is highly recommended to allow you to experience the extreme island landscape and visit the more remote villages. Alternatively, taxi’s on the island are cheap and coach tours to the main attractions operate from the major resorts towns year-round.

Where to stay?

The two main tourist resorts on the island are the low-rise developments of Puerto del Carmen and Playa Blanca on the south coast. Both are relatively inoffensive with only a splattering of ‘all-day English breakfast’ cafes and beer guzzling Brits making them a good base for those without a car.

Try the cheap and cheerful Atalaya Apartments in Puerto del Carmen for a good location and access to the beach at £50 per apartment per night (+34 902 50 53 50). For a more luxurious 5-star experience the Princesa Yaiza Suite Resort Hotel in Playa Blanca at £140 per night offers a spa and uncrowded beach (www.princesayaiza.com).

For a more exclusive and individual experience try the very private Lagomar guesthouse with seaviews over lava craters and access to an eccentric underground

cave bar (www.lag-o-mar.com).

Eating Lanzarote cuisine is similar to that on the Spanish mainland but you’ll find excellent fresh seafood most commonly served grilled.

There’s a small number of local dishes including salted potatoes in a hot local ‘mojo’ sauce.

Try Caserio de Mozaga (www.caseriodemozaga.com) in San Bartolomé which is recommended for perfect Canarian grilled fish and local produce.

Another great Canarian restaurant with a modern twist is La Tegala in Mácher (+34 928 524 524). Here you can sample Tapas style dishes and enjoy a fantastic panoramic view of the volcanic landscape.

Key attractions Timanfaya National Park - This massive 20-square-mile site of lava and volcanic craters is spectacular and the island’s top attraction. After the tour you can refuel the with food cooked directly off the volcanic surface.

Jameos del Agua - Designed by the islands most famous architect, sculptor and resident, César Manrique, this site contains a subterranean garden, restaurant, pool and concert hall built into a network of volcanic caves.

Reserve a table in advance.

Fundación César Manrique Understand the island’s world famous artist, architect and sculptor who worked with the likes of Andy Warhol.

The pics Find the full Lanzarote guide at JuniorDr.com.

Key facts > Population - 130,000 > Language - Spanish > Currency - 1£ = 1.31 Euros

Clockwise from top left Satellite view of Canaries with Africa to the left; Jameos del Agua; Timanfaya National Park; Lanzarote’s volcanic coast; Tapas

19

JuniorDr

The Corpus Callosum corpus callosum (call o sum) is the largest connective pathway in a human brain connecting the left and right cerebral hemispheres.

Get your neural input to junior doctors. Advertise here. Speak to Rob at JuniorDr on 020 7684 2343.

Courses and Events

RSMmeetings

Applied Clinical Ethics (ACE) 6 x 1-Day Professional Training on Saturdays at Imperial College London 8 March 2008 5 April 2008

Meetings for Trainees 14 March Obstetrics & Gynaecology Section Herbert Reiss O&G Trainees Prize

09 May Young Fellows Teaching skills day

05 April Young Fellows Interview Intelligence training day

05 June Young Fellows Histopathology training day - First years only

18 - 19 April Cardiology Section Acute coronary syndrome

31 March Vascular Medicine Section Presenting and writing up your research and thesis 02 April Urology Section Clinicopathology meeting

12 June Ophthalmology Section Trainees' prize meeting

24 April Young Fellows Histopathology training day

16 June Cardiology Section Heart muscle disease

25 April Urology Section Rare urological cancers

For further information please contact Marie Blythe on (+44) 020 7290 3846 or young.fellows@rsm.ac.uk

The course is intended for hospital doctors, surgeons, general practitioners, nurses, managers and members of clinical ethics committees. No experience of academic medical ethics necessary. Limited places available.

Directed by Dr. Daniel Sokol, Lecturer in Medical Ethics and Law, St George’s, University of London and Honorary Research Associate, Imperial College London.

Details: Ulrika Wernmark +44(0)20 7594 6886; cpd@imperial.ac.uk CME/CPD approval sought

www.imperial.ac.uk/cpd/ace

Medical Interview Skills GPST: Daily courses between 25 Feb and 9 Mar ST: Weekly courses all year round Consultant: Weekly courses all year round One-to-one coaching & CV service also available.

SMALL NUMBER OF CANDIDATES ON EACH COURSE FREE EMAIL FOLLOW-UP UNTIL YOUR INTERVIEW

www.iscmedical.co.uk 0845 226 9487

Visit - Conference and Revision Course Listings

Journalism

Finance

Financial Management Mortgages

7 June 2008 28 June 2008

The UK's first part-time course in applied clinical ethics, designed specifically for practising clinicians. Taught by leading authorities in the field, including Prof. Raanan Gillon, and experts in medical law and conflict resolution. Covers key issues in clinical ethics and methods of case analysis.

Find a revision course at JuniorDr.com

Est. 1982 Accountancy

26 April 2008 17 May 2008

A member of The Capitax Group

Financial Planning

Mortgages

Property Investment

Independent Advice Tax Private Practice Accounts Acting exclusively for the Advance up to 125% * medical profession 5 x plus 1 x Income Tax Planning 4 x Joint Income Peripatetic Consultations Let 2 Buy 2 Let ** Clients throughout the UK Investment Properties Contact: Terry W Ievers: 0870 240 4562

Email: mortgages@capitax.co.uk or tax@capitax.co.uk website: www.capitax.co.uk YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP RE-PAYMENTS ON YOUR MORTGAGE.

Capitax Financial Management is an appointed representative of Personal Touch Financial Services Limited which is authorised and regulated by the Financial Services Authority. There will be a fee for mortgage advice. The precise amount will depend upon your circumstances but we estimate it to be £195.00 *Higher lending charges may apply.

Tax Planning is not regulated and **Buy to Let mortgages may not be regulated by the FSA.

The Medical Journalists’ Association brings together medical writers, the media, health professionals, and health charity workers. > 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

Courses and Events

Think you can write revision questions better than the examiners?

We’re a US publisher ready to take the UK medical revision market by storm! Join our team writing the best revision questions and answer books available for all specialities. If successful you’ll get your name on the book and you’ll get paid. Think you’re good enough? Email us at team@studydr.com

20

JuniorDr Employment

Enrich your career. Enhance your quality of life. Practice medicine in rural British Columbia, Canada.

Variety and challenge, the chance to make a difference in people’s lives, a lifestyle most people only dream about – just a few of the advantages enjoyed by BC’s rural physicians.

With its natural beauty, recreational opportunities, clean air and affordable housing, British Columbia offers a quality of life that is envied around the world.

Create your future in rural British Columbia. Competitive compensation and benefit packages include signing bonuses, relocation travel, fee premiums, retention bonuses and continuing medical education assistance.

For more information and to register, visit our website. Our experienced recruitment consultants can help you match your skills and lifestyle interests to the many exciting opportunities available.

Register today: www.healthmatchbc.org Please note: Specialists with postgraduate training from the UK or Ireland must hold the CCT/CCST or equivalent from the UK Higher Specialist Training Authority (Medicine or Surgery). Family Physicians/ General Practitioners must have a minimum of 2 years of approved and accredited post-graduate training.

Health Match BC is a province-wide physician, registered nurse and pharmacist recruitment service funded by the Government of British Columbia, Canada.

AUSTRALIA AND NEW ZEALAND Our client hospitals have vacancies for 2008 – variable start dates available, some as soon as January. Australia and NZ offers a unique and fantastic environment to work as a doctor. Good orientation programmes are on offer and junior doctors are highly valued and appreciated.

Beat the Winter Blues

Talk to us about finding the best job in the right location for you, and the right support and expertise to move internationally.

Register today www.genevadoctors.com - freephone UK to NZ 0800 051 6743, medical@genevahealth.com

Wavelength International are looking for Junior Doctors with a desire to travel, for a variety of excellent training positions in coastal, city & country locations.

The combination of world class healthcare & unique range of lifestyle options makes Australia & New Zealand a great career move.

WAV342

Make the move to Australia & New Zealand

9LHZ KRVSLWDO FRQWUDFWV RQOLQH 9LHZ YDFDQFLHV RQOLQH DW

Our dedicated team give career & salary advice, assist with registration, migration & relocation.

Jobs in Medicine, Surgery, A&E and O&G 6, 9 & 12 month contracts Refer a friend & earn $500 Flight Centre or House of Fraser gift voucher

ZZZ MFM FR XN 7KH 3UHPLHU 'RFWRUVĂ” $JHQF\

&RYHULQJ DOO VSHFLDOLWLHV DFURVV (QJODQG 6FRWODQG ,UHODQG DQG :DOHV

&DOO (PDLO LQIR#MFMORFXPV FR XN

Apply today – you'll be surprised what's out there!

Call Rebecca (NZ jobs) or James (Aust jobs) on 0709 236 2513 or email rebecca@wave.com.au or james.hill@wave.com.au

21

JuniorDr The Mess

Dr Fairytale (B.H.S, M.&.S, R.S.V.P.) General Practitioner to the Stars

Medical Report - Mr Peter Pan

Antisocial personality disorder An ASPD is recognisable by Mr Pan’s disregard for social rules and norms, impulsive behaviour and indifference to the rights and feelings of others. Mr Pan claims, when talking about previous violent actions, “I forget ‘em after I kill ‘em”.

This statement is worrying enough by itself but coupled with his immature and narcissistic behaviour he should really be investigated by a forensic psychiatry team. Should he be allowed to remain at large in the community he may well put the lives of all his “Lost boys” in danger.

Dwarfism Described as “The boy who would not grow up”, Mr Pan is accused of having control over his stature but most forms of human dwarfism are caused by genetic disorders of cartilage or bone development. The accusation is a clear example of the social prejudice which exists against extreme shortness. It may reduce social and marital opportunities, employment options and is associated with low self-esteem. This may explain why Mr Pan is keen to spend time with children in a fantasy world where he is respected and considered mature and all-powerful.

"Accidentally" Poisoned Mr. Pan reports he is the only known person who is able to speak the Fairy language of “Bells”. He claims to have the ability to “Imagine things into existence” and create “doors to place people in Nowhereland”. Mr. Pan is described as: “clad in skeleton leaves and the juices that flow from trees”. It is well known that certain naturally occurring substances, when applied to the skin, or inhaled, cause powerful entheogenic experiences including intense visual hallucinations, euphoria and true hallucinations (perceived extensions of reality). It is not known if any of these grow in “Neverland” but some likely plants include: Salva divinorum, also known as Magic Mint, a Mexican plant used by Mazatec shamans; psilocybin mushrooms, commonly called “magic mushrooms”; or Anadenanthera peregrina, a native South American tree which

Assessed by Dr Gil Myers

contains DMT.

22

An unresolved Oedipal Complex leading to Paraphilia Mr Pan desires for a mother figure. He has conflicting feelings for Wendy, Tiger Lily, and Tinker Bell, who could be said to each represent different female archetypes - which could all possibly hint at a Freudian interpretation. When Mr Pan is introduced to the adult Wendy, now married with a daughter, he breaks down and cries. Mr Pan claims Jane, Wendy’s daughter, asked him to take her with him to Neverland and to let her “be his new mother” which he joyfully accepted. What followed in his description was: “we fly off together with Wendy sorrowfully looking off after us”. Another interpretation would be a kidnapping, child endangerment and grooming.

Ethical advisor Getting an article published in a peer-reviewed journal As junior doctors keen to push the boundaries of medical knowledge and further your careers, you may want to publish in peer-reviewed journals.

A blank ‘publications’ box on that Specialty Training application form can be disheartening. No doubt many of you have tried - and some succeeded - in getting audits or case reports published. The harsh truth is that most will be rejected, either because of poor quality or insufficient contribution to the field. The writing tends to be clumsy, error-ridden, and my medical statistician colleague assures me the statistics are generally shaky. In brief, if you’re going to do it, do it properly.

If you’re new to the publication game, get an able team together. Have a literate friend on board and, if statistics are involved, seek a statistician. It is also wise to team up with someone with a long list of publications in the same or similar field.

“My own advice is to offer potential helpers co-authorship rather than asking them for a favour. They will review the manuscript more meticulously.”

They will know the required standard and can also help with the presentation of the manuscript, including the all-important cover letter explaining why the journal should bother considering the manuscript at all. As a reviewer, I take a very dim view of sloppily prepared manuscripts. No matter how much one protests that it is the content that matters, these imperfections will not put reviewers in a good mood.

My own advice is to offer potential helpers co-authorship rather than asking them for a favour. They will review the manuscript more meticulously. At least, they should. If your

consultant or senior colleague’s name will appear on the final submission, they must justify coauthorship by contributing significantly. There are criteria for authorship and these must be met.

Do not let yourself be exploited.

Similarly, if you feel you have contributed sufficiently to warrant authorship, then speak up. I know of one junior doctor who, as a medical student, was left out of a research paper in Nature despite conducting much of the empirical work. She regrets her silence to this day.

Finally, I encourage you to write articles about your own ethical experiences as junior doctors. Do not restrict yourself to audits and case reports. There is a real need for junior doctors' perspectives on ethical issues.

Many medical and medical ethics journals would be delighted to receive insightful and well-written pieces on the ethical challenges of being a junior doctor. These can be first-person accounts of a moral dilemma or more formal examinations of an ethical issue.

For example, I am currently working with an F2 on how to deal with racist patients. So think about your own experiences in the last few weeks, and put pen to paper.

Dr Daniel Sokol is a Lecturer in Medical Ethics at St George’s, University of London, and Director of the Applied Clinical Ethics (ACE) course at Imperial College, London.

There are four MPS bursaries for junior doctors to attend ACE 2008, starting in March.

E-mail daniel.sokol@talk21.com for details.

Medical Ethics and Law - Surviving on the Wards and Passing Exams Sokol and Bergson £14.95 ISBN 0954765710

JuniorDr

Suicide factfile

The Mess

Hospital

Suicide Rates Ranked by Country

1. Lithuania (38.6 per 100,000) Lithuania has maintained it’s morbid ranking at the top of world suicide rates since the fall of Soviet rule in 1990. More people kill themselves each day in this tiny Baltic county with a population of less than 4 million than die in road traffic accidents.

When your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular column of the best and worse hospital essentials you’ve reported -

Small hot chocolate (takeaway)

Lithuania’s rise to the top has been blamed on the rapid increase in alcohol consumption during the 1980s - a similar trend to that seen in Finland. Researchers also suggest that the increase may have followed changes in law which make it is possible for each citizen to obtain a handgun legally for self-protection.

Suicide by firearm is now one of the most common methods.

18.

(35.1 per 100,000)

3.

Russia (34.3 per 100,000)

9.

Japan

45.

(24.0 per 100,000)

11.

Sri Lanka (21.6 per 100,000)

13.

Finland

80p

WOW!

£2.15

Cheap enough you can discard the crusts at Bronglais Hospital Aberystwyth

LOW!

Cuba

£1.45

Banana

(13.9 per 100,000)

Shop staff are bananas at Royal Free Hospital London

WOW!

55p

United States

Let the monkeys know about University Hospital Of North Durham

35p

China

LOW!

(11.0 per 100,000)

60.

Remember, chocolate is good for you at Newham General Hospital London

It’s not just the cheese causing nightmares at St Thomas' Hospital London

(18.3 per 100,000)

28.

£1.80

Toasted cheese sandwich

UK

Next issue we’re checking the cost of photocopying one A4 sheet, a Mars bar (64g) and a can of Sprite. Email prices to team@juniordr.com.

(7.0 per 100,000)

93.

(31.7 per 100,000)

Data from the World Health Organisation (1996-2007)

Jamaica (0.1 per 100,000)

Which mess is the best?

Belarus

WOW! LOW!

Trends in suicide in a Lithuanian urban population over the period 1984–2003 Abdonas Tamosiunas , Regina Reklaitiene , Dalia Virviciute and Diana Sopagiene BMC Public Health 2006, 6:184doi:10.1186/1471-2458-6-184

2.

Burns your wallet as well as your mouth at Royal Free Hospital London

> Papworth Hospital, Cambridgeshire

What it’s got “The Doctors’ Mess is in the Education Centre near the canteen - it’s a bit tiny, but there are comfy seats, a nice big TV, newspapers and a kitchenette with a toaster, a fridge and a microwave. Tea and coffee are provided, but don't use the Education Centres green crockery unless, for whatever reason, you want to wind them up. A small room off the mess has at least two computers that can check e-mail and another that can run various CAL programmes. They’ll insist on teaching you how to use CAL.” JuniorDr Score - 2/5

23