JuniorDr Magazine - Iss 16 - Spring 2010

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The Politics of health

I 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 Ben Chandler, 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, Gordon Brown (if he is still PM by date of publication), 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 2010. All rights reserved.

Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out JuniorDr.com.

n 2001 Dr Richard Taylor, previously a consultant in rheumatology, became a MP after campaigning on a single issue - saving his local Kidderminster Hospital. He is the only independent MP to have retained his seat for a second term in the house since the 1949 elections.

In advance of your questions to the current and shadow health secretaries (page 9) we asked Richard Taylor for his thoughts on the key issues for the new health secretary after the general election: The next Government must learn from the past not to make further major re-organisations of the NHS especially if these are ill thoughtout, knee jerk reactions to reported crises.

The financial problem can be solved without immediate hospital bed cuts which must not be made to force patients into the community but only after primary care and community services are ready to provide better care. Estimates for possible savings include: • £2bn from self-treatment of minor ailments.

• £6–7bn from increased self-management of long term conditions.

Both of which would only require education of people about how to use their NHS appropriately.

• £2-3bn from implementation of the Better Care, Better Value initiatives.

• Widespread application of the Productive Ward Initiative.

• Increased spending on prevention for future savings.

The problems of short comings in safety and quality of care can be addressed by: • Rigorous emphasis on quality in applications for Foundation Trust Status and registration by the Care Quality Commission.

• Appointment in all trusts of clinical leaders and board members with specific responsibility for safety and quality.

• Greater teaching and awareness for all clinicians of the importance of non-technical skills including teamwork, communication and leadership.

• Convincing patients and GPs of the value of a brief electronic summary care record (SCR). The problems of confidentiality could be solved by giving patients the ownership of their SCR and control of its contents.

• Accepting that the best way of reducing accidents and errors is to learn from them rather than by attributing blame.

• Promoting the normal channels for staff whistle blowers but providing independent support for those who wish to preserve their anonymity or whose expressed concerns have been blocked by their seniors.

Dr Richard Taylor Independent MP for Wyre Forest

Medical Career: • 1959-1961: Registrar Westminster Hospital • 1961-1964: Medical Officer - R.A.F. • 1964-1972: Hospital Doctor - London • 1972-1995: Consultant Physician Kidderminster Hospital

What’s inside 04 09 14 18 20 26

LATEST NEWS

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Medical Courses and Conferences

The Big Health Secretary Debate HAITI EARTHQUAKE: ONE MONTH ON THE MEDICINE BEHIND THE MEDALS CLINICAL REVIEW: UMBILICAL LINT Alice in Wonderland check-up

TRIAGE

3

Tell us your news.

Email team@juniordr.com or call 020 7684 2343.

EWTD

MOST JUNIOR DOCTORS PRESSURED TO WORK HOURS EXCEEDING EWTD O

time to get the formal training needed to do their jobs.

Only half of those questioned reported that they thought that it is possible to train in their specialty whilst complying with the maximum 48 hour week.

“We cannot afford to place the future of the NHS in jeopardy by compromising on the training of tomorrow’s consultants and GPs. It is not sustainable to run hospitals by creating an environment where doctors feel they have to come in during their free time to get training,” said Shree Datta.

ver half of junior doctors have experienced pressure to work additional hours that are not recorded and exceed the EWTD limit of 48 hours a week, according to a new BMA survey.

It also found that one in three of the 1,500 UK junior doctors questioned worked more than 65 hours a week. This conflicts with claims made by the Department of Health in August last year that 97 per cent of the NHS has already met the EWTD requirements.

“The government would have us believe that the 48-hour week has been successfully implemented in UK hospitals,” said Dr Shree Datta, Chair of the BMA’s Junior Doctors Committee.

“Our survey reveals that compliance has only been achieved by pressurising junior doctors into working off the clock.”

58 per cent also reported having been asked to provide emergency cover on at least one occasion with a further 12 per cent of these respondents providing cover on more than ten occasions since August 2009.

Only half of those questioned reported that they thought that it is possible to train in their specialty whilst complying with the maximum 48 hour week.

Dr Shree Datta Chair of the BMA’s Junior Doctor Committe

“Our survey reveals that compliance has only been achieved by pressurising junior doctors into working off the clock.”

The Department of Health dismissed the BMA survey findings: “The majority of the NHS is compliant with the working time regulations. The Department is very clear that we do not support doctors being pressured into working more hours than the legal limit,” a DH spokesperson told JuniorDr.

4

NEWS PULSE

Reduced training Despite DH reassurances on training prior to the implementation of the EWTD in August 2009 half of respondents felt they had missed out on essential opportunities.

Three-quarters had not been able to attend lectures and training days, and six in ten had missed out on supervision and opportunities to complete new procedures.

A further two in five respondents have felt compelled to come into work in their own

“The current system is jeopardising the quality of training given to junior doctors, a development that will inevitably result in poorer quality patient care.”

The Department of Health are continuing to monitor the training situation a spokesperson said: “There is no evidence that junior doctor’s training is being compromised. We are aware of junior doctors’ concerns around their training, which is why the Secretary of State asked Medical Education England to review the impact of EWTD in light of the directive.”

The European Working Time Directive was implemented in August 2009 which limits doctors working hours to 48 hours a week, with a choice for doctors to opt out of the scheme if they wish to work more hours. www.bma.org.uk www.dh.gov.uk

Yvette Martyn

NEW MICROBIOLOGY TEXTBOOK

Regulation

GMC creates online virtual hearing room

T

he GMC has launched an online virtual hearing room this month to support doctors attending a fitness to practise hearing.

The initiative will allow doctors to visit the reception area, tour a hearing room and view who else may be present, such as the medical and lay members of the panel.

Clicking on one of the 12 different different characters will offer an explanation of who they are and what role they play in the hearing.

“We hope that this initiative will offer some peace of mind to all those who are called to give evidence at our hearings, and that the opportunity to familiarise themselves with the process and the look and feel of a hearing will help to demystify it,” said Paul Philip, the GMC’s Director of Standards and Fitness to Practise.

“The vast majority of doctors do a good job in often difficult circumstances but attending and giving evidence in a hearing can be a daunting process for members of the public and doctors alike. We hope that this initiative will offer some

peace of mind to all those who are called to give evidence at our hearings.’’

From April 2011, the adjudication of fitness to practise cases involving doctors will transfer from the GMC to a new body called the Office of the Health Professions Adjudicator (OHPA).

It is being created to ensure clear separation between the investigation of fitness to practise cases and the process of determining whether a professional’s fitness to practise is impaired.

The virtual hearing room can be viewed at: www.gmc-uk.org/static/media/virtualhearingroom/ main.html

Dr Natasha Behl

Working conditions

RCS calls for Passports for Doctors

A

‘passport’ scheme for doctors who work with children is needed to avoid treatment delays caused by the Home Office’s new Vetting and Barring rules, according to the Royal College of Surgeons.

The government ‘Vetting and Barring’ scheme – implemented in October 2009 – requires all paediatric doctors to have full CRB clearance before starting work at a new NHS Trust.

Current backlogs in the CRB system mean that this process is taking up to three months, leaving NHS Trusts unable to provide shortnotice cover for annual or sick leave.

The scheme also restricts specialist surgeons to work within one trust, providing no flexibility to assist colleagues with rare or urgent operations. The RCS raised fears that this is causing children to wait longer than necessary for access to treatment, with cancellation of unstaffed clinics and lists.

Richard Collins, Vice President of the Royal College of Surgeons, describes the current system as a ‘time-consuming bureaucratic process’: “It is absolutely right that there should be robust checks for anyone who works with children, but there needs to be some common sense to ensure patients don’t suffer. The NHS needs flexibility to enable surgeons in specialist fields to undertake operating lists in other Trusts, often on an ad hoc basis.”

It presented a proposal to the Department for Health in November recommending an immediate passport-style system of ‘mutual recognition’ where doctors who have had CRB clearance with one trust are automatically cleared to provide locum cover across the entire NHS if required. www.rcseng.ac.uk

Microbiology: A Clinical Approach is a new and unique microbiology textbook for health science students studying microbiology. It is clinically relevant and uses the theme of ŝŶĨĞĐƟ ŽŶ ĂƐ ŝƚƐ ĨŽƵŶĚĂƟ ŽŶ͘ dŚĞ Ŭ ŝŶĐůƵĚĞƐ ŝŶŶŽǀĂƟ ǀĞ ĐŚĂƉƚĞƌƐ ŽŶ ĞŵĞƌŐŝŶŐ ŝŶĨĞĐƟ ŽƵƐ ĚŝƐĞĂƐĞƐ͕ ĂŶƟ ďŝŽƟ Đ ƌĞƐŝƐƚĂŶĐĞ͕ and bioterrorism not seen in other textbooks.

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Podcasts on professionalism

revalidation

GMC releases most comprehensive outline of revalidation yet

T

he General Medical Council has set out the most comprehensive statement yet on revalidation, with proposals on how it will work, when it will be rolled out and what doctors and employers need to do.

It has also launched a major consultation on the proposals and poses 20 key questions for those who will be affected in order to help shape the process. The consultation concludes on June 4.

The statement makes clear that revalidation is on its way but there will be no big bang approach to its introduction - instead there will be a phased implementation following extensive piloting to ensure that it is proportionate and practicable.

“As doctors, we are among the most trusted of all professionals. We have to ensure that this trust in doctors continues to be justified.

For the past 150 years, the GMC has sought to provide assurance through the register of medical practitioners,” said Professor Peter Rubin, Chair of the General Medical Council.

“It remains one of the most robust and well used registers anywhere in the world.

Professor Peter Rubin Chair of the General Medical Council

“As doctors, we are among the most trusted of all professionals.

We have to ensure that this trust in doctors continues to be justified.”

But it has always been a historical record of exams and qualifications earned, not of competence or performance. As such, it offers a limited assurance about whether each of us is maintaining the high standards expected of us throughout our careers.”

The proposals have been developed by the GMC in close collaboration with the Academy of Medical Royal Colleges, the four health departments, the NHS and other healthcare employers, the medical profession, and input from patients and patient groups. www.gmc-uk.org

nhs

DETAILS OF NEW ‘SICK NOTE’ REVEALED

N

ew guidance has been released to GPs and hospital doctors about the first overhaul to the sick note in sixty years by the Department for Work and Pensions.

The ‘fit note’ or Form Med 3 replaces the traditional sick note on April 6th 2010 and was developed following consultation with the RCGP, the BMA, employers and trade unions. It follows increaing medical evidence that work is good for health and wellbeing and can aid recovery for many health conditions.

In a simplification of the current system, the new fit note will incorporate the Med 5’s functions. Other changes will mean that doctors have more flexibility on when they can issue statements, for example after a telephone consultation. To help manage workloads, doctors will also no longer be asked to issue statements to people who are fully fit to return to work.

“This is a significant step forward. GPs can give more helpful advice to patients and their employers to support an earlier return to work.

We know work has beneficial effects on recovery,” said Professor Steve Field, Chairman of Royal College of General Practitioners.

“The fit note is in keeping with our holistic approach to patient care. We valued the opportunity to help shape the new Medical Statement and supporting guidance. We believe it will have benefits for GPs as well as patients.” www.dwp.gov.uk/fitnote

6

NEWS PULSE

The GMC has launched a new podcast to help medical students develop high standards of professionalism this month. It describes how good clinical knowledge, patient confidentiality and smart dress are all attributes that help to demonstrate high standards of professionalism. The podcasts supplement the guidance ‘Tomorrow’s Doctors’ and are available via the GMC website. www.gmc-uk.org

UK cleans up on hand hygiene The UK has been ranked as one of the leading nations when it comes to hand hygiene, according to research

by Swedish firm Svenska Cellulosa Aktiebolgat. Out of nine countries surveyed the UK came second only to China. Since 2009 89% of the UK have started washing their hands more frequently though less than half (44.4%) were washing their hands during key ‘at-risk’ situations like after sneezing or blowing their noses. www.hygienematters.com

UKCAT beats A-Levels alone A new aptitude test, aimed at increasing diversity and fairness in selecting applicants to UK medical school, still has inherent gender and socioeconomic bias, although it is less subject to bias than A level results alone, according to a study published in the BMJ. The UKCAT was first used in 2006 as part of the admissions process by a consortium of 23 medical and dental schools.

It was introduced when discriminating between large numbers of highly able applicants on their A-levels alone was becoming increasingly difficult. www.ukcat.ac.uk

Child prescribing errors common One in eight prescriptions given to children in hospital may contain prescribing errors, according to research published in the Archives of Disease in Childhood. The study of almost 3000 prescriptions across five London hospitals found 391 errors with an incomplete prescription the most common mistake made (41%). One in four prescribing errors included the use of abbreviations. www.adc.bmj.com

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News analysis

MMR scandal – The Timeline When Dr Andrew Wakefield linked autism to the MMR vaccine the rate of vaccination fell. The scandal which is finally seeing some closure was ignited when Wakefield’s controversial paper was published in 1998. JuniorDr’s Yvette Martyn recorded the events that followed.

April 1993

Andrew Wakefield suggests that the measles vaccine causes Crohn’s disease in a paper in the Journal of Medical Virology.

February 1998

The Lancet publish Wakefield’s study of 12 children. The article includes claims from eight of the 12 children’s parents that the onset of the developmental disorder was associated with the vaccine.

A press conference and video news release backup the article which arouses interest from the British media.

The media escalate the claims.

The next day The Guardian headline read: “Alert over child jabs” and the Daily Mail said: “Ban three-in-one jab urge doctors.”

The Medical Research Council arranged a meeting to discuss the study. The council were worried about selection bias and so asked how the patients were selected. Wakefield stated that the patients came from normal referral pathways.

A few months later Wakefield published an article in the medical journal, Gut, the study included the 12 original children and a further 18. This time only three parents associated the developmental disorder to the vaccine, down from the previously reported eight.

1998- 2001

Several studies are published which find no connection between the MMR vaccine and autism.

December 2001

Wakefield resigns from his job at the Royal Free and University College Medical School. National tabloids jump to his defense, backing him with campaigns.

February 2004

The Sunday Times publish an investigation, they expose that

Wakefield received £55,000 Legal Aid, funded through solicitors seeking evidence to sue the MMR vaccine manufacturers.

The paper also found that at least four of the eight children whose parents had claimed the developmental disorder was associated with the vaccine were covered by the Legal Aid contract. And that some of the children in the study were connected to the solicitor and had not come from normal referral pathways as stated, this was not disclosed to The Lancet.

The editor of The Lancet, Richard Horton was presented with the newspapers findings, despite an agreement that he was shown them in confidence The Sunday Times stated that he was so startled that he immediately went public. Horton said that due to the papers revelations the study was “entirely flawed” and should never have been published.

March 2004

unethically, dishonestly and irresponsibly. The GMC found that he had: • Communicated with a solicitor representing those who had allegedly suffered from the MMR vaccine, Wakefield then had his research funded

by Legal Aid this solicitor applied for.

• Was involved with a patent for a safer vaccine which could have replaced the MMR vaccine.

• Failed to disclose the Legal Aid or the patent to the Lancet.

• Stated that the children in the study came from a normal referral pathway when Wakefield actively referred four and another four were specifically referred for investigation into the role of MMR in their autism development.

• Took blood from children at his son’s birthday party without ethical approval.

Ten of the authors of the Lancet paper issue a retraction. They said: “We wish to make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient.”

1 February 2010

June 2006

2 Febuary 2010

The GMC announce that Wakefield is under investigation for professional misconduct, along with two other authors of the paper.

The Lancet fully retracts the paper from the published record in its online edition. Along with the statement that, following the GMC hearing: “it has become clear that several elements of the 1998 paper by Wakefield et al are incorrect, contrary to the findings of an earlier investigation.”

November 2008

The Health Protection Agency warns of a measles epidemic after 1,049 cases were confirmed during the first 10 months of the year, the highest total since 1995.

28 January 2010

The GMC conclude a two and a half year hearing and Wakefield was found to have acted

A press release is sent to journalists stating that Professor Trisha Greenhalgh, from University College London is to argue in this week’s BMJ that the Lancet should formally retract their paper.

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The future

Wakefield now faces the GMC from April who will decide if he showed serious professional misconduct and what sanctions should be imposed, which could include being struck off.

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The Big Health Secretary Debate With less than two months until the likely date for the general election we asked you to submit and vote for your questions to put to the current and shadow health secretaries in England.

You asked their future priorities for the NHS, if they felt junior doctor’s pay should be reviewed and whether they support a health service independent of politicians. Read their responses then join the discussion at JuniorDr.com, Facebook and Twitter.

Question: Do you feel the NHS will still be under direct control of politicians in 10 years time?

Andy Burnham. Yes - I do. A national service should always be accountable to

democratically elected politicians and parliament. It has served us well for 62 years and I see no reason why it should not continue.

However, going forward, I believe that the centre should set a smaller number of national priorities and allow more local decision making. In particular, I want to see the NHS deepen its partnership with local government.

Andrew Lansley. No. We want to take politicians out of the day-to-day control of the NHS, so they can no longer take short-term decisions that undermine the clinical judgements of health professionals.

We saw the damage that this can do when Peter Mandelson resigned as the MP for Hartlepool. Before he resigned, the Department of Health had wanted the local hospital to be stripped of maternity services. When he resigned and a by-election was called, the Department of Health reversed the decision – purely for political reasons. Then, after the election, they demanded that the hospital be stripped of its maternity services after all.

We are committed to setting up an NHS Board to set the NHS free from this type of meddling.

It will be responsible for commissioning for improved outcomes throughout the NHS. Norman Lamb. I think the NHS is in desperate need of more accountability. The NHS

spends £110 billion of our money every year. Local people deserve a say in how it is run and the right to hold those who make decisions to account. It is a crazy situation when the only person accountable for the NHS is the Health Secretary. We’ve looked at how things work in Scandinavia. I believe that the answer lies in bringing an end to the crazy micro-management of the NHS from Whitehall and instead making the commissioners of healthcare locally democratically accountable to the communities they serve. This is the change I would want to see achieved so that in ten years time you do not have politicians in Whitehall directing the NHS.

General election

9

The Big Health Secretary Debate Question: What do you see as the three key priorities for the NHS over the next five years?

Andrew Lansley. First, to put patients at the heart of the NHS by introducing a

new focus on results, measured in terms of patient outcomes and experience, rather than narrow distorting targets, and by fostering a culture of shared decision making between patients and health professionals.

Secondly, to deliver autonomy, accountability and incentives for performance in the NHS - reversing the decline in productivity by rooting out bureaucracy and incentivizing efficiency and innovation at every level in the NHS. Thirdly, to tackle the real drivers of demand on the NHS by making improving our public health a new national priority. We will deliver public health reform through separate funding, a stronger local infrastructure and a focus on national strategies to unleash individual, family and community responsibility.

Norman Lamb. In my mind the three key priorities all link in to the financial situation we find ourselves in. Firstly, we need to decide how we can make the NHS more efficient so the money goes further and we put patients first. Secondly we need to engage with staff to let them drive the improvements we know they want to implement, refocusing the NHS on providing more personalised care and dealing with health problems as early as possible. Finally, we need more investment in prevention but also greater integration between primary and secondary care and social services so that those with chronic conditions get more joined up care. All the evidence shows that this can improve care and reduce costs in the long term.

Andy Burnham. Making the NHS more preventative, more productive, and more people centred. That was the vision of a great NHS that we set out in our document NHS 2010-2015: from good to great last year and I believe it is achievable because of all the progress we’ve made in the last decade.

“We need to do less in hospitals and we need to reassure the public that change can mean both better and safer care.” _______________________________________ Andy Burham, Labour

Question: Some junior doctors have seen their salary fall by as much as 40% due to the introduction of the European Working Time Directive. The basic starting salary for a junior doctor after five years of university is currently £22,190.

Would you support an independent review of junior doctors salary?

10

Norman Lamb. Yes, I think that we do need to look at the impact of the EWTD across the NHS and the impact on pay is one of the areas that need looking into. My own view is that the way the Working Time Directive has been implemented has been very unhelpful and could be damaging to patient care. That being said, we need to recognise that there are limited funds available in the NHS – especially at a time when the public finances are utterly wrecked like they are now.

Andy Burnham. At £31,066, average first year earnings of junior doctors are competitive with other graduate salaries.

The Department of Health and other UK Health Departments are already looking at the continued appropriateness of the present pay arrangements for trainees, and do not believe that an independent review is necessary. The Doctors’ and Dentists’ Review Body – which has been making independent recommendations to government on doctors’ pay since the 1960s - has asked the Health Departments to look at the options for change. The Department of Health accepted this recommendation, and has commissioned NHS Employers to consider the fitness for purpose of the present arrangements, and to scope possible options within the limits of the present paybill. The results of that work will be available soon.

General election

Andrew Lansley. We have been clear that we will seek to renegotiate the working time directive to give junior doctors greater flexibility in training.

Pay is for advice from the Review Body and between hospitals and staff side.

We will help improve your working conditions and morale by getting rid of the central diktats and bureaucracy that undermine your professional autonomy and morale. But we will also have to ask for your help in tackling Labour’s Debt Crisis, by keeping the cost of public sector pay only as high as the country can responsibly afford.

“I think that we do need to look at the impact of the EWTD across the NHS and the impact on pay is one of the areas that need looking into.” _______________________________________ Norman Lamb, Liberal Democrats

Question:

Andy Burnham. It is never possible to guarantee every job, but we’ve expanded the

The NHS is likely to face many financial pressures over the next few years. Do you envisage that doctors will face job cuts and would you ensure that training is not reduced in the face of demands for greater productivity?

number of doctors and we don’t want to see any return to days of restricted capacity and long waits.

The Pre-Budget Report committed to protect NHS frontline funding (95% of total health funding) in real terms in 2011/12 and 2012/13. There will be financial challenges ahead but we are committed to continuing improvement in frontline services, with the focus firmly on improving quality of care for patients.

In terms of training, there will be no reduction to the levy, which centrally funds training and development (MPET) in 2010/11. Funding arrangements for 2011/12 have not been finalised.

However, we have signalled to SHAs that they need to plan in the context of Sir David Nicholson’s public statement about the future financial position.

Andrew Lansley. We’ve pledged to increase health spending every year in the next Parliament to help the NHS meet the big demographic challenges we face in the years ahead. We have also made clear that we will cut bureaucracy so that we can reinvest these savings into front-line care.

This will mean that we can support frontline jobs. Too often, junior doctors have

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General election

11

The Big Health Secretary Debate been the victims of short-term workforce planning and the raiding of training budgets to deal with deficits arising in the acute sector.

A vital lesson of the MMC debacle was that doctors must own their own training. We backed Sir John Tooke’s report on medical education, and have argued consistently that doctors must be given greater autonomy in determining their education, training and career paths.

Norman Lamb. I think the only thing that we can say with any certainty about the public finances is that the threat to the NHS over the next few years is very disturbing.

We will continue to see rising costs because of an ageing population, new drugs coming on-stream and the impact of life-style conditions. At the same time, the era of continuous large real-terms increases in NHS finding are over for the time-being. We need to make sure that the NHS is as efficient as possible and one of the key ways to do this is to invest in training. We are likely to need more doctors and they must have access to worldclass training. We need to monitor the situation carefully to ensure that training doesn’t get cut.

“We want to take politicians out of the day-to-day control of the NHS, so they can no longer take short-term decisions that undermine the clinical judgements of health professionals.” _______________________________________ Andrew Lansley, Conservatives

Question: Do you feel the British public are correct in feeling that being in hospital is the safest place when ill?

Andrew Lansley. In most cases where secondary care is considered necessary by a

patient’s GP, the answer will be yes, and this is certainly our wish for every patient.

We know that in many of our hospitals across the country, our doctors and nurses are delivering care and treatments as good as anywhere in the world.

But sadly, there are a small minority of hospitals where tick-boxes and targets have been prioritised above patient safety. The recent report into Stafford Hospital demonstrated the tragic consequences of this sort of culture. We need to move to a new system where we focus relentlessly on patient safety, experience and outcomes.

Norman Lamb. In many circumstances this assumption is correct. However, it is also clear that, if the NHS is to be sustainable, we have to ensure that we improve care close to home. We have a lot to learn from organisations like Kaiser Permanente in California – a non profit making integrated health organisation.

Their emphasis is on maintaining the care of patients so as to avoid the need for costly and disruptive hospital admissions. Then hospitals can focus on the patients who really need to be there.

Andy Burnham. I think the political and clinical community need to work together to change public perceptions of healthcare. We need to do less in hospitals and we need to reassure the public that change can mean both better and safer care.

Follow our election coverage and join the debate at: www.juniordr.com

12

General election

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The Ha

One emergency to the next:

One month after the devastating earthquake that struck Haiti, the numbers are still difficult to digest: more than 200,000 deaths, 300,000 injured and hundreds of thousands made homeless.

From day one, doctors from Médecins Sans Frontières (MSF) have been providing life-saving surgery and care.

These needs are now evolving as delivering post-operative care and improving people’s living conditions emerge as the greatest priorities.

earthqu

one month

Paul McMaster, a surgical advisor for MSF who has been on the ground in Port-auPrince since the earthquake, tells of the initial horrors of street amputations and the new challenges faced by his team one month after the disaster.

W

hen we first arrived in Haiti we saw the acute phase of casualties being brought out from under the rubble. Many of those with severe head and chest injuries in the earthquake had already passed away so we were left trying to stabilise patients with serious limb injuries or shock and start their surgical treatment.

We weren’t able to work inside the hospitals because the buildings were unsafe so we were forced to operate outside on two makeshift operating tables in the courtyard. As the causalities poured in we just went from one table to the next providing the best care we could. We worked with only a few hours break during the night.

The team had rigged up a couple of lights into the tree overhead

14

Haiti Earthquake

which meant that we could continue to operate into the evening.

In those first few days we didn’t have water or food for the patients and no electricity.

The blocked off road outside became our recovery unit. Patients were carried outside after surgery and placed on mattresses where they were cared for by a family member if they had one. We didn’t have nursing staff to provide any post-operative care.

OVERWHELMED BY NUMBERS Things changed a lot in those first few weeks. Much of our equipment that hadn’t managed to reach us in the first four or five days began to arrive and things became relatively more stable.

aiti hquake

month on

Paul McMaster and the surgical team in Port-auPrince (Photo Julie Remy)

AMPUTATIONS We no longer saw as many critical cases and much of the work now turned to stabilising fractures and injuries we had previously treated. We moved from the road to an abandoned school just adjacent to us and for the first time operated inside in a clean classroom with patients being treated in tents outside.

The biggest medical challenge wasn’t the complexity of cases but the shear numbers of casualties that we faced. Every time there was a further aftershock hundreds of people flooded into the road area looking for some sort of safety. This was a massive earthquake in the middle of a city and we were surrounded by something approaching a million population.

The wounds we saw were often deeply infected by the third or fourth day when people were still being brought out from the rubble. The surgery needed was not very complex but involved removing dead and damaged tissue and amputating limbs. Having to amputate the limbs of children who have already been deeply traumatised is always hard to do.

We saw a lot of damaged limbs and had to decide whether you can preserve it or whether it’s too badly damaged and must be removed. It can be a very difficult decision but when a person has been crushed for days in a building the greater danger is overwhelming infection and septic shock setting in.

Haiti Earthquake

15

One emergency to the next:

The Haiti

earthquake We were constantly trying to judge whether to remove a small area that’s clearly severely damaged, and protect the rest, or whether that damage is too severe. It’s a very difficult judgement to make but generally the younger the person is the greater the potential for the tissues to heal - sometimes you have little alternative but to remove the limb because of the extent of the damage.

one month on A hospitalised child is stabilised in a relatively quiet corner, away from the crowd, outside of Carrefour hospital, Port-au-Prince.

(Photo - Julie Remy)

“We weren’t able to work inside the hospitals because the buildings were unsafe so we were forced to operate outside on two makeshift operating tables in the courtyard.”

MSF has wide experience in conflict and other earthquake disasters and we’ve sadly learnt that it is necessary early on to take that critical decision and undertake amputation. Surgeons without that experience are often shocked by the extent of injuries and some recoil from the idea of doing an amputation on an otherwise fit person.

We have clear guidelines on the management of severe wounds.

On presentation we remove all dead tissue leaving the wound completely open and do no suturing at that stage. Five days later, the whole limb and wound is re-examined and a final decision taken.

If healing is beginning, then the wound itself can be closed. If not, then further action will be needed. We do a lot of teaching with our surgeons coming in to make sure they understand that the normal surgery we undertake in civilian practice really doesn’t prepare you for the shock of these types of injuries.

HELPLESSNESS Performing trauma related surgery somewhere like Haiti presents immense challenges that we wouldn’t face in any other major western city. Most of the staff in the hospitals in Haiti, with their homes demolished and having lost family members, understandably left the region. Those that remained were often still deep in shock.

Sterilisation systems had broken down and post-operative care was often minimal so the surgery we could perform had to take account of that. Putting it simply, we couldn’t do complex six-hour surgery expecting intensive care support - it simply wasn’t available.

“We did difficult and upsetting amputations under local anaesthetics because we’d run out of anaesthetic agents.

Makeshift operating tables in Carrefour Hospital, Port-auPrince (Photo – Julie Remy)

16

Haiti Earthquake

If there was a major disaster in western capitals people would be arriving in the hospitals within hours. In Haiti, most of the injured we saw had been wounded two or three days earlier and infection had already set in. It was a very different context of surgical management which had to take account of the risk of infection and the context of the staffing support available.

Dealing with the emergency

O

n 12th January 2010, the existing MSF health structures in Port-au-Prince did not escape the wrath of the massive earthquake that hit Haiti. For several days afterward many MSF staff members remained unaccounted for. We later learned that seven had died.

Within minutes of the catastrophe, however, people with severe injuries started arriving at the sites of MSF’s existing hospitals in Cité Soleil, Martissant, Trinité and Carrefour.

Emergency first aid was provided all evening and throughout the night, the medical teams illuminating their work with flashlights and the headlights of cars.

Only when the sun rose on the following morning was the scale of the disaster revealed. It quickly became clear that the volume of injured people would overwhelm what was left of the medical facilities and the resources the medical teams had on hand. The need for emergency care and surgery was immense. MSF teams treated as many people as they could— performing operations in makeshift facilities in the street, under plastic sheeting, and in converted shipping containers—while also seeking out new places in which they could set up operating theatres. Many of our Haitian staff worked through this very difficult period despite the fact that their homes and lives had been so damaged.

At present MSF is working in more than 20 locations in and around Port-au-Prince and the nearby towns of Leogane and Jacmel, including running 10 operating theatres for major surgery and five for minor. In the past month, MSF teams treated more than 18,000 patients and performed more than 2,000 surgical procedures.

You can read about the latest work of MSF in Haiti at

www.msf.org.uk

TOP: Makeshift camp in Jacmel (Photo – Julie Remy) Middle: Carrefour after the quake (Photo - MSF) Bottom: Haiti in ruins (Photo - Julie Remy)

For the medical staff there is often a feeling of helplessness or wanting to do more. Sometimes it’s the frustration that equipment hadn’t managed to reach us. At others it’s the difficult and upsetting procedures of amputations needed under local anaesthetics because we’d run out of anaesthetic agents. The emotions and the feelings are very strong.

We wondered whether the anger and frustration in the local population would boil over with the shortages of water and sanitation and food, but we saw very little evidence of that. There was very little evidence of violence or looting and we were able to move quite freely.

The overwhelming feeling we got from people in Haiti was one of just desperate need for support, help and understanding.

Paul McMasters is 66 years old and currently working as surgical advisor for MSF in Amsterdam. He travels to MSF project locations as a surgical advisor and also to do hands on surgery when needed.

Paul was born in Liverpool and lives in Drotwich, Worcestershire.

He has two children. Prior to working for MSF he worked in the Department of Surgery, University of Birmingham.

Follow Paul McMaster and MSF in Haiti online at: www.juniordr.com/haiti

Haiti Earthquake

17

The medicine behind

Dr Richard Budgett OBE –

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 18

SPORTS MEDICINE

Atlanta, Nagano, Sydney, Salt Lake City, Athens and Turin.

What are your current work commitments?

My main role is at the English Institute of Sport at Bisham Abbey where I look after rowers, hockey players, canoeists, synchronised swimmers and tennis players among others.

I work two and half days a week as part of a multidisciplinary team which consists of four doctors, eight physiotherapists, two dieticians, a sports psychologist, strength and conditioning coaches and many physiologists.

I also have a half day clinic for the British Olympic Association at the University College London Hospital where I look after high performance athletes from varying Olympic sports. In addition to that I work one day a week in my role as CMO for London 2012 as well as in two separate sport clinics.

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

the medals

Dr. Richard G. Budgett OBE, MA MBBS MRCGP Dip Sports Med. FFSEM FISM

– Chief Medical Officer to London 2012 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 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

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The medicine behind the medals 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 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.

What can we as junior doctors do to help out at London 2012?

The Games is on a simply vast scale necessitating some 70,000 total volunteers and in the region of 3000 medical volunteers. You can register an interest in volunteering now on the official web-site (http:// www.london2012.com/get-involved/volunteering) and vacancies will be advertised in July of this year with interviews being held in early 2011.

By June 2011 most of the medical posts will be filled in time for the test events – these are large scale ‘dry-run’ events to be held in each of the venues. 600 doctors will be needed who will hopefully be consultants or GPs. They will volunteer their time and expertise in the form of specific SEM doctors, multiple trauma specialists with resuscitation/air ambulance skills, and also GPs. They will work on a completely voluntary basis giving up a minimum of 10 days working (two weeks annual leave) and will work in 8hr shifts.

Roles appropriate for junior doctors include the 100 or so blood collection

officers. I am taking a firm stance on antidoping and as part of that effort we will have an expert team organising urine collection. We will need doctors or phlebotomists for the blood taking aspect.

In addition there will be hundreds of vacancies as ‘first aiders’ which keen and suitably trained and interested junior doctors would be ideally suited for. They would provide simple first aid and crowd safety.

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.

Dr. Richard G. Budgett OBE MA MBBS Dip Sports Med. FFSEM FISM

London Deanery info for applicants to

Faculty of Sport & Exercise Medicine

SEM

(UK) – Specialty Training and Diploma

www.londondeanery.ac.uk/specialty-schools/ sport-and-exercise-medicine

information

British Association of Sports Exercise

Volunteering for London 2012

Medicine

www.london2012.com/get-involved/ volunteering/the-volunteer-programme.php

20

SPORTS MEDICINE

Mahmood F Bhutta, Research Fellow, Nuffield Department of Surgery (University of Oxford)

Introduction Umbilical lint is colloquially known as “belly button fluff” (Am: navel lint). It describes the collection of a soft mass in the umbilicus, formed of textile fibres intermingled with exfoliated skin cells and occasionally the hair of the sufferer. Experience suggests that the disorder is common, but probably under-reported as many of those affected may find the disorder emotionally difficult to discuss1. The medical literature on this disorder is surprisingly sparse, and there are few high-quality studies in this field. Nevertheless, some significant advances in aetiology and treatment have been made in recent years.

Method A literature search was undertaken of the Pubmed database using the search terms “umbilicus lint” and “navel lint”. Two relevant articles were found. An internet search was also undertaken using the Google search engine and the same terms. Over 50,000 hits returned, and the first 100 were analysed for relevance.

History The early history of umbilical lint is uncertain, because the disease does not leave any trace in the fossil record. It is likely that the disorder was first encountered when Neolithic man began using woven fibres for clothing 10,000 years ago. The oldest preserved example of umbilical lint was discovered earlier this year in a sealed 17th Century bottle found in London2, mixed with urine, and designed to prevent a witch’s curse. It is not known whether this was effective, but nitrogenous human waste has not been demonstrated to possess occult powers in other contexts.

Epidemiology and Aetiology

Suggested Resources:

www.basem.co.uk

Clinical Review:

www.fsem.co.uk

Most of what is known of the epidemiology and aetiology of umbilical lint is due to the pioneering invitational survey in 2001 of Kruszelnicki3. Although this included nearly 5000 participants, the sample is likely to be subject to response bias, and the study has not been subject to peer-review. The survey suggested the disorder affects 66%

Umbilical lint (“belly button fluff”) The hertitability of disease has not been determined, but genetic determinants of hair morphology and structure are likely to play a significant role. Known molecular mediators of hair follicle growth include FGF, TGF-β pathways, Sonic hedgehog signaling, IGF, EGF, HGF, and PDGF as well as components of the cytokine and hormone signaling pathways8. These represent excellent candidate association genes for future research.

Pathology and Microbiology FIG 1 - UMBILICAL LINT

of people, with a 3:1 male to female ratio, but no racial predilection3. The single biggest risk factor for disease is the presence of body hair, and this may explain the gender difference in prevalence. Additional possible risk factors for the disease are listed in table 1, although these are largely anecdotal.

Albert4 and Biesecker5 hypothesized that the origin of umbilical lint is from hair that traps clothing fibres and then directs these fibres towards the umbilicus (80% of those affected describe the presence of a trail of hair from the pubic area to the umbilicus3).

However, this theory remains unproven, and importantly, extra-umbilical early-stage disease has not been documented. A disorder similar to umbilical lint can occur in the natal cleft and is known colloquially as “bum fluff”: this disorder likely has a common aetiopathology and affects a similar population.

Umbilical lint is a chronic disorder, and may recur daily. In a longitudinal study6, Steinhauser found the most common mass of umbilical lint to be in the range 1.21.29g. However there is a skewed normal distribution, with values recorded as high as 9.17g. One individual has collected pathological specimens every day for 20 years7.

It is not known whether this individual has co-existent psychiatric disease.

Table 1: Risk factors for development of umbilical lint

MAJOR

MINOR

Body hair

Inverted umbilicus

Age

Washing clothing in a top-loader machine rather than a front-loader

Male sex*

New clothing

* may not be an independent risk factor cf. body hair

Electron microscopy has confirmed that umbilical lint is composed largely of textile fibres3. Lint may come in a variety of colours, but is frequently reported as of a dull blue/grey hue, no matter what the colour of clothing (figure 1). The reason for this is unknown.

Culture of umbilical lint9 has shown the frequent presence of skin commensals, in particular coagulase negative staphylococci (75%of cases) and corynebacterium (75% of cases). Pseudomonas, acinetobacter, klebsiella and enterococcus species may also be found.

Treatment Self-treatment is frequently employed in the management of umbilical lint and the disorder rarely comes to medical attention.

Digital evacuation of disease is the most common treatment regime, but the diameter of the fingertip10 can exceed the narrowest diameter of the umbilicus in some individuals, leading to incomplete treatment and residual disease. Consequently a variety of purpose made mechanical aids have been devised. This includes simple evacuation devices11, adhesive strips3, and a device utilizing the solidification of wax in the umbilicus to assist in cleansing12. Unfortunately these have not been subjected to randomized controlled trials, and their clinical effectiveness is anecdotal.

Preventative strategies have also been employed. There are reports that umbilical piercing or shaving of peri-umbilical body hair can prevent disease3. However, piercing carries attendant risks of soft-tissue infection13 and shaving must be repeated for sustained prevention of disease6.

Complications Umbilical lint can be an embarrassing and socially stigmatizing condition. There have been no studies on the psychological

effects of the disease, nor have there been quality of life assessments in the afflicted population.

Future Research Although umbilical lint is clearly a prevalent disease, it has been the subject of very little research in the medical literature. The reasons for this are unclear, but the probable inefficacy of pharmaceutical treatments may be responsible for a lack of large-scale commercial investment. The onus is clearly on non-commercial researchers and funding bodies to further investigate this common but neglected disorder.

Competing Interests: The author occasionally suffers from umbilical lint, but has no commercial interests in its diagnosis or management.

References 1. Anon. personal communication, 2009; 2. de Bruxelles S. Witch bottle is uncorked to discover spellbinding content. The Times June 4, 2009; 3. Kruszelnicki K. Q and A with Dr K. Sydney: Harper Collins, 2001; 4. Albert T. BMA News Review. London: British Medical Association, August 1984; 5. Biesecker M. Technician. North Carolina: North Carolina State University, April 1995; 6. Steinhauser G. The nature of navel fluff. Med Hypotheses 2009;72(6):623-5; 7. www.feargod.net/fluff.html; 8. Stenn KS, Paus R. Controls of hair follicle cycling.

Physiol Rev 2001;81(1):449-94; 9. Kikuchi M, Yano K. Lint in the belly button. J Plast Reconstr Aesthet Surg 2009;62(2):282-3; 10. Murai M, Lau HK, Pereira BP, Pho RW. A cadaver study on volume and surface area of the fingertip. J Hand Surg Am 1997;22(5):935-41; 11. http://trailerparkbarbie.wordpress.com/2007/12/11/ homemade-gifts-for-your-tasteless-girlfriends; 12. Okajima T, Fujinami, S. Body recessed portion cleaning agent (US patent #2007/0041923). 2007; 13. Khanna R, Kumar SS, Raju BS, Kumar AV. Body piercing in the accident and emergency department. J Accid Emerg Med 1999;16(6):418-21.

Summary Umbilical lint is a very common but under-reported disorder The aetiology is thought to involve trapping of textile fibres by hair below the umbilicus Untreated disease can reach a mass exceeding nine grams A variety of treatments are available, but these have not been subjected to randomised controlled trials

CLINICAL REVIEW

21

Medico-Legal Advice - in association with Medical Protection Society

Writing reports J

unior doctors can be asked to write reports on many different things, but it need not be a daunting experience, says Sara Williams from MPS. You witness an adverse incident while working in A&E. There are a number of ways in which this incident could be investigated – as a complaint, a criminal case, a clinical negligence claim, a disciplinary matter, a coroner’s inquest, or a GMC referral.

You may be required to write a report, either as a lay witness or a professional witness. If you are writing as a lay witness, this means you are writing as a member of the public. If you are the doctor involved in some aspect of the patient’s care, you will be asked to provide a report as a professional witness.

There are various situations in which you may be required to write a report: • for your employer • for the coroner • for a solicitor • for the police • for a patient’s employer or insurance company

How to write your report

• Your own recollection • The medical records.

Facts or opinions?

The majority of reports that you are asked to provide will be statements of fact – giving an account of what took place.

You should only report the facts as you know them. If you are asked to give an opinion, you must only comment within your expertise.

What should your report include?

• Personal details – your qualifications, the number of years you’ve worked, any relevant clinical experience • Relevant local factors – for example, if your hospital is on two sites and this affects the time taken to get to an incident • Details of other healthcare professionals involved • Patient details • Presentation and history – you should include dates and, where possible, times • Findings on examination • Diagnosis and whether a differential diagnosis was considered • Investigations and subsequent management, including dates • Follow-up arrangements and information given to the patient or relatives • It should be clearly signed and dated.

An important starting point is your written report on the circumstances of the incident. Your report should be: • Objective – state the facts. Do not use the report to criticise others.

• Detailed – providing too much information is better than too little.

About MPS info for articles.qxd:MPS Checkup Disclosure 12/2/10 of 10:05 1 patientPage information • Clear – avoid ambiguity and be clear about who did what and when.

A report will, more often than not, involve the disclosure of confidential inforYour report should be based on: mation about a patient. You need to make • Your usual practice sure you have the authority to disclose

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.

this information, by getting your patient’s consent and checking they are clear about the information you will be providing, to whom, and why it is necessary and how it will be used.

Do not...

• Stray beyond your level of competence or expertise • Deliberately conceal anything – this will cast doubts on your integrity and will make subsequent comments less credible • Comment on behalf of others – you can say “Dr X said…”

Do… • Write your report honestly; don’t be influenced by others • Write it as soon as possible after the event, while the incident is still fresh in your mind • Make sure that you have seen the complaint or Letter of Claim, or details of any court proceedings, before writing • Include details of only the events that you were personally involved in • Include relevant facts; your opinion is only necessary if specifically asked for • Ensure that you review your original report, the medical records and any new documentation, if you are asked to write a supplementary report.

Report writing tips

• Write in the first person singular – “I did this…”

• Address the report to an intelligent lay person; avoid jargon and abbreviations • Bear in mind that the patient or their relatives are likely to see the report; avoid

Improve your presentation skills 10 tips for good PowerPoint presentations in association with ISC Medical

P

resentations appear everywhere in the medical world and there is an art to creating good PowerPoint slides which can keep your audience riveted. Here are 10 top presentation tips from ISC Medical:

any pejorative, humorous or unnecessary subjective remarks • Organise the report chronologically – give actual dates, and use either a 24hour clock to give times, or state whether you are referring to am or pm • Give each incident or event a separate paragraph or section • Check spelling, punctuation and grammar before submitting • Your report should be typed, signed and dated • Keep a copy of the report in your notes and a note of how, when and to whom you submitted it • If you are asked to change the report, you should think very carefully about the event before doing this, and only make changes if a factual mistake needs to be rectified.

Asking for help

If you have any questions or concerns about what you have been asked to produce and what you are allowed to disclose, you should contact MPS for further advice.

1. PowerPoint won’t rescue a poor presentation Slides are meant to complement your presentation. Make sure you clearly define the messages you are trying to convey to your audience before you even consider writing any slides.

2. Keep it simple Avoid having too many messages on one slide. Avoid complex graphs, fancy graphics and animations. If you use bullet points, use no more than 5 with 5 words in each.

3. Keep the number of slides low Too much information in one and your audience will lose concentration.

Use simple graphs instead of a series of numbers and pictures to emphasise a point.

4. Don’t read your slides Yours slides are not your notes. If you read from them, then you may as well give your audience printed copies and not turn up. Remember: they have come to listen to you, not to look at the back of your head.

5. Time the distribution of your handouts Some members of the audience may want the handouts early so that they

can keep notes, but on balance, your presentation may be better understood if people concentrate on what you say rather than take notes.

6. Produce readable slides Dark text on a light background looks best, though avoid white as it can show too much contrast. Use simple fonts like Arial, with a minimum size of 24pt, preferably 30pt.

7. Keywords only Whole sentences take time to read and will interfere with your own verbal sentences. Only write keywords on your slides.

8. Use charts appropriately Pie charts are good to highlight percentages. Vertical bar charts are good to demonstrate changes in quantity over time. Horizontal bar charts are good to compare quantities. Line charts are good to demonstrate trends.

9. Spend time in the slide sorter Test the flow of your presentation by rehearsing it without using the slides.

If you get stuck, the order may not be right. Get your story straight and the slides will follow.

10. Deliver to your audience Remember you are talking to people and not just to the walls. Maintain good eye contact, use your hands and remember it’s okay to move around the room/stage.

Further information

• GMC, Good Medical Practice (2006): www.gmc-uk.org • GMC, Confidentiality (2009): www.gmc-uk.org • MPS, Confidentiality factsheets series: www.mps.org.uk/factsheets • DH, Confidentiality and Access to Health Records: www.dh.gov.uk/en/index If there are any medicolegal topics you would like to see covered, please contact sara.williams@mps.org.uk

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Secret Diary of a Cardiology SpR Monday If you’ve been following this column you’ll realise that after accepting a consultant post in my London teaching hospital I decided to take up a Fellowship position in California. It was supposed to be six months surfing in Melbourne but I decided that the ocean would look better with a cheeseburger in my hand so I chose the USA. However, the 6am rounds and health conscious freaks that I work with turned that quarter pounder into a skinny blueberry muffin which I was forced to eat on the ward round every day.

I had been due to go home but I applied for an extra six months with the excuse that interventional stenting of the left main was better here (which it was) and that the benefit would be felt by my cardiac challenged patients in the NHS for decades to come. My funding body bought it and said that it would be fine as long as I published the short case series that I was due to be writing up.

That’s why I find myself back in my apartment overlooking the Pacific with a glass of Californian red in one hand and a sheaf of angio notes in the other. I stay up reading and typing on my MacBook Air and trying not to spill red wine into the keyboard. At least once I get the iPad (not the sanitary version) I’ll be able to wipe the alcohol straight off the screen.

Tuesday Angio list this morning. As usual, there is much supervision. I used to think this was because they were scared of me coming from the developing world (all countries outside the US are thought of in this way) but actually the attendings are just scared of litigation.

The notes are all electronic and as I write down everything after each patient I see that my boss is watching on a separate screen. Every now and again she makes a note as an insert where she wants to add something or slightly change what I say.

For example, where I have written that there was ‘minor bleeding at the site of catheter entry’ she immediately circled it and added in an annotation which read ‘minor bleeding at site of catheter entry which is to be expected with this procedure and is not out of the ordinary in this case’. As I said, it was all about litigation. In London someone would have just ignored it. Or perhaps drawn a doodle of a cat sitting on a wall. I finish the day early and spend some time at the gym in my building before heading up for a long bath and an early night.

Wednesday Today is my teaching day. After early rounds which begin just after 6am I take a group of students to see some interesting cases. We tick off cardiomyopathy, atrial flutter and pacemaker insertion in less than an hour and I reward them (and myself) for this speediness with a round of coffees in the hospital’s cafeteria - which, like everything else around here, is actually a Starbucks.

In between lattes and decafs we talk more about cardiac pathology and, as they take notes, I realise that four out of the six are typing into electronic devices. It’s hard to tell whether they are taking notes about my cases or simply instant messengering each other about how dull this is. Either way it’s starting to put me off and the endless taps and beeps are giving me a headache.

The other two students are writing onto pads of paper which on reflection seems even more pointless. Surely they’ll only have go to home and then type it all up again - who uses hand written notes 24

SECRET DIARY

* 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!

these days? As I watch them tap away I think about how their training is so different to how mine was. I wonder who had the better deal? I go home late after catching up with some paperwork and stay up even later trying to sign off the case series so I can send it back to my sponsor.

Thursday A whole morning of rounds. First for our team has the charismatic James Kawani in attendance. We went out for a while but realised that neither of us had the heart for it (I came up with that one myself) and now we just spend the odd night together which suits us both very well. After seeing a number of standard cardiac patients I lead rounds of patients from other teams. The objective here is to finish a series of consults before their problems get worse and they get turfed over to our care. In that respect things are the same in all parts of the world.

We find a lady in her sixties who has been left in reasonably frank pulmonary oedema overnight and whilst James finds doctors from the team to shout at I take her to the cath lab where we do a quick stent and are done by lunchtime. James watches over me while I type the notes making sure that we take the credit for sorting her out whilst not actually placing any blame on the admitting doctors who could no doubt be sued by her family. I do some echos during the afternoon and go out for a few drinks with the rest of the team. I go home early for once. I must be getting old.

Friday Wave rounds today which means surfing at dawn for the whole team. I’m now as good as, if not better than, most of the attendings including James. We break early for breakfast as we have a lot of patients to talk about at our usual table in the corner of the café which overlooks the beach. One of the juniors produces a laptop and we can look at all the results as well as update patient notes over a secure link that goes back to the hospital.

As we discuss a patient, someone makes notes into the laptop and the information is seamlessly updated back on the ward. We can’t prescribe drugs in this way (yet) but can do pretty much everything else from ordering tests to reviewing ECGs whilst wearing sandals with our feet covered in sand. When it works, technology is pretty impressive.

But there are times when it goes wrong. I think of the lady who nearly expired because of the lack of communication between two teams on a night shift. It doesn’t take a tablet computer and a wireless connection to tell you that if someone is in refractory pulmonary oedema they may have an acute heart problem and it might be worth calling a cardiologist.

No amount of 3G data makes up for the real data you were supposed to learn in medical school.

Focus on Finance - in association with Wesleyan Medical Sickness

M

Dealing with Debt

edical students graduate from university with an average debt that is 25% higher than that of non-medical students. This probably won’t surprise you. After all, you had to study for two to three years longer than your non-medical peers, incur more additional expenses for books and equipment and you had fewer opportunities to work part-time to finance your studies.

You have however embarked on a career that will ultimately give you good financial rewards. Even so, you can’t afford to be complacent about money. As a junior doctor, you’ll have seen at first-hand what happens when people neglect their physical health. Neglecting your financial health might not kill you but it can have dire consequences.

Most of us have to go to work to earn a living and to have a standard of life that we’re happy with. We all have to keep our spending and our borrowing in check in order to ensure our financial security, regardless of what we may earn now or in the future.

Adopting this attitude early on will put you in good stead for the rest of your life. Don’t be tempted to think you can leave all of this boring stuff about money until you’re older – financial planning should start now, especially if you’re living on borrowed money.

The first step in building a financially secure future is to manage your debts. Don’t be tempted to put your head in the sand and hope they will disappear because they won’t and ignoring them will only make matters worse.

Almost everybody has some form of debt – the most common being a mortgage. So you’re unlikely to become completely debt

free for some years. The important thing is to stay in control of your debts and pay them off regularly.

If you have debts, a good way of dealing with them is to make a list of everything you owe including unpaid bills, loans from family and friends and money you owe on credit cards.

Then sort your debts according to priority; it’s not the size of the debt that makes it a priority but what creditors can do to get their money back. So priority debts include mortgage or rent arrears. If you’re struggling to pay back these priority debts talk to an agency who can offer free impartial debt advice such as the Citizens’ Advice Bureau.

Once you know exactly what you owe, draw up a realistic budget for yourself. Work out how much money you’ve got coming in and how much you need to keep aside for bills, rent, food and other key expenses such as travel. Then you’ll have a clearer idea of how much money you’ve got left over at the end of each month once all of your main expenses have been met. You can use this to start reducing your debt.

If you’re not yet in a position to reduce

your debt and in fact need to borrow more then remember these key points: • Don’t run up an overdraft without first talking to your bank as you may be charged for an unauthorised overdraft.

• If you use credit cards check the interest rates and the small print on any offers – some cards that offer 0% balance transfers charge a transfer fee.

• Try and pay off the whole balance of your credit card in full each month or at least clear the interest.

• Never buy goods on hire purchase unless you can afford the monthly repayments.

• If you buy goods on interest free credit make sure you pay off the balance before interest starts to kick in because it’s likely to be at a much higher rate.

• Be very careful about taking out loans especially if you still have your student loan to re-pay.

• Make sure you understand the terminology around loans, particularly the difference between secured and unsecured lending. If you take out a secured loan, you are using your house as surety and you may lose it if you cannot make the loan repayments.

Having debt is inevitable for most of us these days. It’s not the debt that’s necessarily the problem but how you manage it and your ability to repay it. Get into the practice of planning your finances sensibly today and it will be a skill that holds you in good stead for years to come.

You should consider taking regular advice from a financial services specialist who can guide you through the process of managing your money both now and in future.

The above information does not constitute financial advice. If you would like more information or need general financial advice, you can call Wesleyan Medical Sickness on 0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk

Specialist financial services for doctors • Savings and Investments

• Mortgages

• Retirement Planning

• Motor, home and travel insurance

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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.

FINANCE

25

Assessed

by Gil Myers

Compiled by Farhana Mann

Medical Report

ALICE IN WONDERLAND Multiple drug use Despite her protestations it is clear that Alice has a drug problem. Given any opportunity she ingests potions, wafers and mushrooms without concern for her personal safety. She reports bizarre variation in her height, changes in her perspective, loses track of time and space - even her own identity. She also refers on a number of occasions to a hookah-smoking caterpillar which suggests that her social network is that of drug users.

More worryingly, Alice displays a total lack of insight into her problem and has created a fantasy to justify her drug-induced hallucinations.

EBV Infectious Mononucleosis

Across:

1 Of Nirvana’s Nevermind album; mood stabiliser (7) 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.

26

HOSPITAL MESS

Infectious Mononucleosis is a diffuse disorder which, especially in adolescents and young adults, is characterised by fever, sore throat and fatigue. It can cause encephalopathies, which may include visual imbalance symptoms. Alice reports all sorts of odd things: talking white rabbits, morbidly obese twins and a mad hatter obsessed by teaparties. It would seem more likely that Alice’s symptoms are the result of this infectious symptomatology rather than simply ‘magical’. We know that IM is also known as the ‘kissing disease’ suggesting that Alice has probably not been as innocent as she claims.

Migraine with benign paroxysmal vertigo of childhood Alice may well be suffering from severe recurring vascular headaches.

A migraine is a neurological syndrome characterised by altered bodily perceptions, severe headaches, and nausea. These could explain how a young girl would start to talk about falling down a rabbit hole into a weird world full of odd things making her ill. In addition, several studies have found some migraines are triggered by changes in weather. The worst conditions for this being a high temperature mixed with humidity and we know that Alice was worst effected during a mid-summer picnic.

Alice in Wonderland Syndrome I should probably mention Alice in Wonderland Syndrome (AIWS) - a neurological condition. The symptoms are the result of cells in the brain firing inappropriately, giving rise to unusual perceptions and experiences. Patients report visual distortions where things seem to be closer or further away, disturbances of time and delusions of their own bodies for example, their head growing larger. In fact, AIWS or Todd’s Syndrome to give its dull name, is clearly a medicalisation of Alice’s attention-seeking behaviour. By claiming to have experienced such changes Alice is making sure she is the focus of interest to everyone around her. I would strongly recommend avoiding giving her reported symptomatology any credence by allowing this term to be used.

Writing in the Notes view?

Time for a pay re

of redundancy Dear Editors, e spared the fear er w e w s or ct ion. Now that As do during the recess d ce fa rs he ot y a formal review? that man that our pay had e r tim t no it is us have seen ou it’s over nt that some of ea m fs su ha e ’v D T ey The EW r FY1s th to 40 percent. Fo spay slashed by up ng their free ho vi ha mmy of ha w le om ub fr n do io e at fered th consider ation cut with no not pital accommod iew Body. I’m ev R tist’s Pay en D d line an in r to n io oc duct the D deserve a pay re ’t dn in di e rt w pa g g bi tin a sugges r banding played ou t bu st s ju ur at ho r ry la with ou basic sa laries. An FY1 sa in sic er ba ag g an in m at calcul a trainee w the same as ties over £20K is no the responsibili fle ldn’t pay re ct ou Sh . ds al on McD Anonymous of the job?

2 Surgery CT

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:

Toothbrush

£1.19 Cup of tea

nt resident on-c

alls?

Dear Editors, In your article (One in four pa tients suffer from delay in consul tant review Iss 15 p4) it sugges consultant advi ts that ce should be sought ‘accordin the patient’s clin g to ical condition no t the time of da Wouldn’t it be m y’. ore sensible for a pro-active appr by consultants oach – perhaps review ing new admiss with the junior ions doctors every fo ur hours by ph More sensibly, if on e. consultant opin ion is now the ex tation for all patie pecnts at the time of admission is it be ter that consulta tnts move to a re sident on-call sy stem?

Sophia

Akram ST2 Respirat ory Medicine , Birmingham

£2.49

St. Thomas’s Hospital, London

Teeth-tastic at:

(small)

Time for consulta

A trip to the dentist would be cheaper at:

Royal Free Hospital, London

Bring your own teabags at:

£1.90

Royal Free Hospital, London

Dose up on those antioxidants at:

60p Magnum classic ice-cream

St Bartholomew’s Hospital, London

Sends a shiver down your spine:

£1.49

Leicester Royal Infirmary , Leicester

Lick-tastic prices:

£1.25

Ulster Hospital, Dundonald

Next issue we’re checking the cost of a chocolate muffin, a bottle of Coca Cola (500ml) and a banana. Email prices to hospitalconfidential@juniordr.com

Patient-book k Dear Editors, le (De-Facedboo terest your artic in al ic ith ed w m t ad ns re I tion agai t disciplinary ac sts.

Iss 14 p16) abou al networking po ci so rofessional’ np nts ‘u tie r pa fo n ts he en stud happens w t ha w t ou ab popuI have concerns out doctors. By ab ks ar m re te ria p and make inapprop a Facebook grou s ha w no d ar w in. As a paediatlar demand our encouraged to jo en be durve ha aff st the using Facebook the patients are of y may s an nt m d tie ar pa w rics what I’m interested in d eat an t gr en be tm ld ea ou tr ing ations. It w ic pl im l ia nt te volved in post and the po ho have been in w s or ct do r he to hear from ot well e.

Kirsten Po a similar schem s, Luton ST3 Paediatric

‘Writing in the notes’ is our regular letters section. Email us at letters@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.

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HOSPITAL MESS

27

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MPS professional support and expert advice The Medical Protection Society is the leading provider of comprehensive professional indemnity and expert advice to doctors. MPS offers support to members with legal and ethical problems that arise from their professional practice and actively protects and promotes the interests of members and the wider profession.

There are many benefits to membership: � 24 hour medicolegal emergency advice line � Medicolegal publications – Casebook and New Doctor � Risk management materials including medicolegal booklets � Online resources including factsheets and case scenarios � Educational support through discounts with leading publishers

For more information call 0845 718 7187 Or visit 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.

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.