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Sun, sea and surgery The rising popularity of medical tourism Prescription to party A nightclub for the depressed Medical murderers The top five killer doctors

JuniorDr.com Free for Junior Doctors Issue 6

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

Is this the end of goodwill in the NHS?

Triage

JuniorDr

SHO Addiction Psychiatry

editor@juniordr.com

Editorial There’s no greater honour than being a doctor. You get to let into people’s lives, to help them and ultimately save them. It should be the most rewarding and most enviable of all professions.

Editorial Team Mareeni Raymond London

Michelle Connolly London

Hi Wu-Ling Nottingham

Muhunthan Thillai Chelmsford

Thanks to Andro Monzon, Gil Myers, Mun Hong Cheang

But it’s not.

Ashley McKimm Editor-in-Chief ST2 Psychiatry

Doctors entered the new National Health Service in 1948 full of goodwill. The profession was a calling and they believed in comprehensive health provision free for everyone. They worked hard and they earned respect. Politicians brought in managers, set targets and interfered with care. They pushed for more but gave less. Tolerant doctors, working intensely for their patients, let the problems pass. Each time their goodwill eroded a little more. This year the goodwill of doctors has ended. The latest round of MTAS has beaten us to the ground. Forced to sell houses, relocate families and face sudden unemployment it was the final insult. What other profession would tolerate this? No accountant, no tube driver, no postman. For us

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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.

there’s no alternative. We have no choice if we wish to continue practising medicine than to stick with the NHS. There’s no morale left. A private health service would most likely improve our lives, but not those of our patients. For doctors it is a compromise that is often difficult to stomach. The NHS is slowly dying and we need an independent NHS run by doctors and patients if there’s any hope of saving it.

“The NHS is slowly

dying and we need an independent NHS run by doctors and patients if there's any hope of saving it.” For now we’re paid by the government, we’re employed by the government but we work for our patients. Hopefully they have enough goodwill to tolerate us until someone has the courage to make some tough decisions.

> What’s on the inside Sun, sea and surgery Patients who take a holiday from the NHS Page 10

The Secret Diary of a Cardiology SpR Page 17

Latest News Page 4

Prescription for a party The nightclub for the depressed Page 13

The top five killer doctors Page 22

JuniorDr

The Pulse

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

Working conditions

MTAS chaos continues as 30,000 doctors start posts “We didn’t know how many doctors to expect” - London Trust Trainees find jobs don’t exist or are forced to move sites LONDON Cancelled theatre lists, disappearing training posts and confused personnel staff greeted 30,000 junior doctors on August 1st as the fallout from MTAS continues. Scenes of confusion were reported by many new trainees who had secured jobs through MTAS. Some found they had been allocated different posts than issued by the deanery and were forced to relocate. Two doctors from the London Deanery who contacted JuniorDr, including one who had travelled back from Australia, arrived to find their posts did not exist. Both were found alternative placements by the hospital trust within days. Locum cover Locum agencies were put on standby to cover any potential gaps in clinical care as many trusts were uncertain about enough doctors arriving to deliver a full clinical service.

“The whole recruitment process this year has been an unmitigated disaster. The medical profession is fighting to make sure it never happens again.” Dr Tom Dolphin Deputy Chairman BMA Junior Doctors Committee

“We’re pretty clued up on what’s happening and we still weren’t sure how many doctors we’d have on the first day,” the medical personnel department of one inner London trust said. “I dread to think of the shock and surprise in some other trusts when they realise who will or won’t be turning up.” Surgical cancellations National newspapers carried stories of cancelled theatre lists with consultants claiming they couldn’t guarantee staff. Hospitals contacted by JuniorDr denied any addtional disruption occured to elective lists. This included Barts and the London NHS Trust who was widely reported in the press to

have axed three whole days of elective theatre lists for some specialities but told us the cancellations were normal: “As with previous junior doctor induction periods, the Trust reduced the number of non-urgent operations and non-urgent outpatient appointments taking place to ensure the smooth induction and enable enough additional senior staff to be available to help prepare junior doctors for their new roles,” the trust stated. “This year the induction process lasted three days rather than one because of the number of new junior doctors (500) starting at the Trust’s hospitals - The Royal London, Barts and The London Chest,” said a spokesperson for the trust.”

Nonsensical The Department of Health reports 1,000 posts remained unfilled as of August 1st. Most will be during a second round of recruitment in October. “The situation is completely nonsensical,” said Dr Tom Dolphin, deputy chairman of the BMA Junior Doctors Committee. Doctors have been facing the real possibility of unemployment, but at the same time, trusts are cancelling operations. There has been appalling confusion in the NHS over the last few weeks. Noone knows what’s going on.” “The whole recruitment process this year has been an unmitigated disaster. The medical profession is fighting to make sure it never happens again,” he said.

> Profile - New Health Secretary

Alan Johnson new health secretary as Hewitt resigns Former postman and education secretary Alan Johnson became Health Secretary following the resignation of Patricia Hewitt on August 1. Hewitt, who stated she wished to give more time to her ‘constituency and family’, had been widely criticised by senior doctors for her handling of MTAS. The BMA welcomed the appointment of Johnson but questioned the absence of junior

doctors recruitment fiasco in his opening address. Other health unions have also reacted positively to his appointment stating his past support of teachers pay. Johnson became general secretary of the Communication Workers Union in 1987 before becoming MP for Labour seat of Hull West and Hessle in the 1997 election. He has voted in support of the introduction of foundation hospitals and student top-up fees.

“We have listened a bit too much to the BMA and not enough to unions like Unison.” Alan Johnson Health Secretary Speech at deputy leadership contest

JuniorDr Two-thirds of nursing students believe it’s wrong to lie to patients - twice as many as in 1983. The survey, carried out by the School of Nursing in Greater Manchester, found that 66 per cent felt it was unprofessional to lie to a patients compared with 33 percent of those questionned in 1983. It also found that those agreeing with the statement ‘a good nurse should be prepared to change shifts at short notice to help out’ had halved to 25 percent. www.blackwellpublishing.com/Nursing/news/news. asp?id=196

Sleep for success Students who pull ‘allnighters’ and get no sleep are more likely to have lower academic grades, according to research published by the Associated Professional Sleep Societies. “As sleep quality and quantity decrease, academic performance worsens,” said Pamela Thacher author of the study. “The data collected in this study indicates that the use of a single night of total sleep deprivation is not an effective practice for achieving academic goals.”

Training

Training reforms will lower standards, say docs LONDON Nine in ten doctors believe that training reforms in combination with working time reductions will result in lower standards, a BMA survey suggests. 89% of the 2,255 doctors questionned disagreed with the statement ‘doctors will be trained to the required standard for an NHS consultant despite the reduction in training hours under MMC’. Almost as many (81%) said it would be unacceptable if the reforms resulted in the creation of a ‘sub-consultant’ grade of doctor. “The message to the new Health Secretary is clear – he needs to listen to doctors before making any more changes that might have the potential to create further problems for their careers,” says BMA Chairman Dr

Hamish Meldrum. “We’re not against the principle of doctors qualifying as specialists more quickly as long as they’ve been able to develop the right skills. There is a potential problem now that training has to be squeezed into a shorter timescale. We must not allow this to result in any dumbing down of UK medical training.” Nine out of ten doctors (87%) also said that traditional CVs should be used when doctors apply for specialist training. Over half (63%) remain opposed to using a national online recruitment system again - even if the problems with the MTAS system are resolved. Seven in ten junior doctors said they had not received good careers advice and almost half (46%) said they had considered leaving the country.

The Pulse

Nurses less naughty

“There is a potential problem now that training has to be squeezed into a shorter timescale. We must not allow this to result in any dumbing down of UK medical training.” Dr Hamish Meldrum BMA Chairman

www.aasmnet.org

Calmer and cholesterol Older white men who are better able to cope with stress experience higher levels of socalled ‘good cholesterol’ than men who are more hostile or socially isolated, according to a study published at the Annual Convention of the American Psychological Association. The study of 716 men did however find that same coping ability had no effect on the subjects’ ‘bad cholesterol’ levels. www.apa.org/convention07/

Rotten tomatoes Despite widespread reports to the contrary the U.S. Food and Drug Administration has found only limited evidence for an association between eating tomatoes and a decreased risk of certain cancers. The review found no evidence that tomatoes reduced the risk of lung, colorectal, breast, cervical or endometrial cancer. They did however acknowledge very limited evidence for associations between tomato consumption and reduced risk of prostate, ovarian, gastric, and pancreatic cancers. jnci.oxfordjournals.org

NHS

6 out of 10 doctors aren't frustrated that patients can’t lower cholesterol BIRMINGHAM Doctors don’t always feel that they can achieve healthy cholesterol levels in their patients, even though they are aware of the dangers, according to a study published in the International Journal of Clinical Practice. The survey of 750 doctors from 10 countries, conducted by the University of Birmingham, found that despite only 47% of patients reaching their cholesterol targets, 61% of doctors felt this was an acceptable statistic. Doctors in South Korea (80%) were most likely to be happy with only 47% of patients reaching their cholesterol targets, while doctors in Finland were least happy (48%). “Although doctors appear to

appreciate the risks associated with cardiovascular disease – which they identified as a greater cause of death than cancer - the importance of lowering cholesterol does not appear to be widely endorsed,” says co-author Professor Richard Hobbs, University of Birmingham. “Our study also highlighted discrepancies between what family doctors do when a patient has high cholesterol and what they are advised to do by national guidelines.” Only a quarter of UK GPs used national guidelines to set cholesterol lowering goals. Doctors reported that patients feared cancer more than cardiovascular disease and that they were much more likely to see smoking and obesity as high risk factors for cardiovascular disease than high cholesterol.

> Key findings > The percentage of doctors using national or local guidelines to set cholesterol lowering goals averaged 81% and was highest in South Korea (100%) and Brazil (93%) and lowest in the UK (45%) and Singapore (52%). > Statins alone were most likely to be prescribed by doctors in Brazil (15%) and the UK, France and Mexico (all 11%) and least likely by doctors in South Korea (2.5 %) and Denmark (6%). > Lifestyle changes alone were most likely to be recommended by doctors in Finland (62%) and France and Denmark (both 50%), with doctors in South Korea (23%) and Portugal (29%) least likely to recommend these. International Journal of Clinical Practice

JuniorDr Working Conditions

Training

The Pulse

Female docs face career barriers

Overseas docs in Australia work harder

LONDON Female doctors are facing barriers to careers in education and research, according to a study published in this month’s BMJ. The year-long Women in Academic Medicine Project study surveyed 1,162 doctors working in the NHS and other UK institutions and found that women were ‘strikingly’ under-represented in the university sector, particularly at senior levels. “Six in ten doctors who graduated from medical school last year were female, but the same is emphatically not true of the professors who taught them,” said Dr Anita Holdcroft co-chair of the BMA Medical Academic Staff Committee. Recommendations of the study include promotion of female role models, active discouragement of the long hours culture and more flexible careers structures. It also called for appointments

SYDNEY Overseas trained GPs working in Australia were younger, worked longer hours and prescribed more medication than their home-trained colleagues, according to a study by the University of Sydney. The three-year study found that overseas trained doctors (OTDs) worked almost eight hours more per week and prescribed ten per cent more medication. They were also ten times more likely to work in rural areas. Medical workforce shortages in Australia have led to increasing reliance on overseas doctors particularly general practice in rural areas - around a quarter of practising doctors have trained outside Australia. The study also found that OTDs managed less general, urological, social, skin and pregnancy problems, and more cardiovascular problems, urinary tract infections, tonsillitis and conjunctivitis.

> Key findings > Only two out of all 33 heads of UK medical schools are women > Only one in ten (11%) of clinical professors are women > Men are much more likely than women to be editors of medical journals (14% compared to 6%) > Men are more likely than women to receive encouragement from senior colleagues to apply for promotion (43% to 38%) Women in Academic Medicine Study

committees to greater reflect the diversity of staff required. “Women contribute a huge amount to teaching and research in the NHS and medical schools, but career barriers are preventing them from reaching their full potential. There is far more that could be done to create a level playing field in education and research,” said Holdcroft.

NHS

GP patient consultation time increases to 11.7 mins LONDON The average GP consultation per patient now lasts 11.7 minutes compared to 8.4 minutes in 1992, according the BMA’s latest workload survey. More complex cases and treating patients previously cared for in hospitals has raised the intensity and quality of the workload to an “all-time high” says the BMA. The study also found that GP working hours remain virtually unchanged at 44.4 hours per week. “What has changed is the way we work,” says Dr Laurence Buckman, chairman of the BMA’s GPs committee. “Intensity has rocketed. Patient care that used to routinely take place in a hospital setting – such as diabetic care,

Anchovies & Alcohol Men who binge drink have an insufficient intake of n-3 fats, one of the two types of Essential Fatty Acids, according to a study of 4,168 adults published in Alcoholism: Clinical & Experimental Research. Previous studies have also shown that requirements for these nutrients actually increases with greater alcohol use. They have advised those drinking more than one drink per day to increase their intake of oily fish. www.niaaa.nih.gov

Hearing voices The ability to listen to a phone message in one ear while a friend is talking into your other ear - and comprehend what both are saying - is a skill dependent on your genes, say researchers at the National Institute on Deafness and Other Communication Disorders. The study of 194 same-sex twins found that as much as 73 percent of the variation in dichotic listening ability was due to genetic differences - comparable to wellknown inherited traits such as type 1 diabetes and height. www.nidcd.nih.gov

More migraine misery Women who have migraine headaches with visual symptoms (or aura) have a 1.5 times greater risk of ischemic stroke than women who do not have migraines, according to a report published in the Journal of the American Heart Association. The study of 386 women also showed the risk increases further when other factors are added, such as recent onset of these headaches, smoking and oral contraceptive use. www.heart.org

Baby don’t go ... yet

cardiac care and asthma care - is now routinely done in general practice. It used to be commonplace to be called to a child with uncontrolled asthma, or a patient with heart failure and send them to hospital. Now it’s a rare occurrence.” The survey also showed that on average GP practices have 24 members of staff.

“Intensity has rocketed. Patient care that used to routinely take place in a hospital is now routinely done in general practice.” Dr Laurence Buckman Chairman BMA GPs Committee

Clamping and cutting of the umbilical cord should be delayed for three minutes after birth, particularly for pre-term infants, according to a report published in the BMJ. Delayed clamping is consistently associated with reductions in anaemia, intraventricular haemorrhage and the need for transfusion according to the team. Rates of early cord clamping vary widely in Europe, from 17% of units in Denmark to 90% in France. www.bmj.com/cgi/full/335/7615/312

RSMtrainees RSM top tips for MTAS Survival The Debate Rages on On Saturday 7 July 2007 The Royal Society of Medicine, in conjunction with The Medical Women’s Federation, organised a meeting ‘Living with MTAS 2007’. The meeting was chaired by Baroness Ilora Finlay, President of the Royal Society of Medicine, and was attended by over 120 disgruntled junior doctors. The meeting provided the opportunity for junior doctors to express their views regarding the MTAS process to those that have an influence over the whole system and might be able to change things for in the future. Amongst those that participated were Professor Sir John Tooke, Chairman of the Independent Inquiry into Modernising Medical Careers, Professor Martin Marshall, Deputy Chief Medical Officer at the Department of Health and Dr Hamish Meldrum, the Chairman of the BMA.

• Check Deanery websites regularly for jobs. • In terms of application forms, think quality over quantity. • Prepare thoroughly for interviews. • Don’t be afraid to talk to someone if you have any concerns over a job.

Following the meeting the Royal Society of Medicine has produced some top tips for MTAS survival (see opposite). All RSM Members can view presentations from the meeting on our website

For more information on these top tips please visit www.rsm.ac.uk/yf/ meetingreport.php

Prizes RSM Academic and Research

Meetings for Trainees

RSM Young Fellows/Trainee Membership -

Surgery Section

28 September

Submission Deadline: 3 September 2007 Prize: £250

Coloproctology Section Submission Deadline: 1 October 2007 Prize: Travelling Fellowship to American Society of Coloproctology and Rectal Surgeons Annual meeting

Otology Section Training Scholarships Submission Deadline: 2 November 2007 Prize: Dependent on location and duration of centre visited

Urology Section Submission Deadline: 12 October 2007 Prize: RSM travelling fellowship to the RSM Urology Section spring overseas scientific meeting

Young Fellows Meeting Advanced communication skills for doctors AND Young Fellows Meeting Teaching communication skills

9 October Young Fellows Meeting Handheld computer and smartphone workshop

15 October Climate change and health series: Global warming - setting the scene

18 October Young Fellows Meeting Win the Publications Game Young Fellows Meeting Histopathology training day

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

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.

JuniorDr The Pulse

Journal Review Success of prostrate surgery dependent on surgeons experience OXFORD Success rates for prostrate cancer improve dramatically following a surgeons first 250 operations, according to the Journal of the National Cancer Institute. Patients treated by inexperienced surgeons (those with only 10 prior operations) were nearly 70% more likely to have evidence of recurrence of their prostate cancer within five years than those whose surgeons who had performed 250 operations. Increasing experience after 250 procedures had little further influence on cancer recurrence. The study analysed data from 72 surgeons and 7,765 patients along with the number of procedures each had performed before the operation. The idea that more experienced surgeons perform more successfully is widely held but little data had been previously shown to support this. “Although the successful practice of surgery necessarily presumes a lifetime of learning, the large number of cases required before the learning curve plateaus suggests the need to expand opportunities for training in surgical technique for surgeons in the early years of training,” say the authors. jnci.oxfordjournals.org/cgi/content/full/ djm060v1

Warfarin more effective than aspirin in stroke prevention in elderly BIRMINGHAM Warfarin is more effective than aspirin in prevention of stroke in those over 75 with atrial fibrillation, according to a study published in The Lancet. The Birmingham Atrial Fibrillation Treatment of the Aged study (BAFTA) aimed to determine how warfarin and aspirin affected stroke risk, and whether use of these drugs outweighed the increased risk of bleeding in elderly patients. They studied 973 patients aged 75 years or over (average 81 years), all of whom had atrial fibrillation. Of these patients, 488 were randomised to receive warfarin and 485 to receive aspirin, and were followed up for an average of 2.7 years. The incidence of fatal or disabling stroke (either ischaemic or haemorrhagic), intracranial haemorrhage and clinically

significant arterial embolism were studied in each group. The researchers found that in the warfarin group, 24 serious events occurred – 21 strokes, two intracranial haemorrhages, and one systemic embolus. In the aspirin group, there were 48

serious events – 44 strokes, one intracranial haemorrhage, and three systemic emboli. Thus patients taking warfarin were less than half as likely to suffer a serious event (52% lower risk) as those taking aspirin. “We showed that the frequency of stroke, arterial embolism, and intracranial haemorrhage was significantly lower in patients on warfarin than in those on aspirin,” said the researchers adding that their results show that warfarin could safely be used much more widely by older people,” said the researchers. “We recorded no evidence that anticoagulants [warfarin] were more hazardous than aspirin therapy in this age group, although the study had limited power to detect those differences.” www.thelancet.com/journals/lancet/arti cle/PIIS0140673607612331/

Diet high in meat, fat and refined grains linked to colon cancer recurrence NEW YORK Patients in remission from colon cancer who ate a diet high in meat, refined grains, fat and desserts had an increased risk of cancer recurrence and death compared with patients who had a diet high in fruits and vegetables, poultry and fish, according to a study published in the Journal of the American Medical Association. The study looked at the

influence of two distinct dietary patterns on cancer recurrence and survival in a group of 1,009 stage III colon cancer patients. The fifth of patients in the lowest Western dietary pattern experienced a 3.3 times lower risk for cancer recurrence or death than those in the top fifth. Previous research has indicated that diet and other lifestyle factors have a significant influence on the risk of developing

colon cancer however few studies have assessed the influence of diet on colon cancer recurrence and survival. “The data suggests that a diet characterised by higher intakes of red and processed meats, sweets and desserts, french fries, and refined grains increases the risk of cancer recurrence and decreases survival,” say the authors. j a m a . a m a - a s s n . o rg / c g i / c o n t e n t / short/298/7/754

JuniorDr

MRI detects pre-invasive breast cancer twice as often BERLIN MRI is substantially more accurate than mammography in diagnosing the very early stages of breast cancer, according to a study published in The Lancet. Researchers from the University of Bonn studied 7319 women examined with both mammography and MRI over five years. In a total of 167 women the doctors found early forms of breast cancer – 152 (92 %) of these were found using MRT, 93 (56%) with mammography. Mammography highlights small calcifications which form in the milk ducts during ductal carcinoma in situ (DCIS) calcifications that were previously believed to be invisible to MRT. This study found that by using mammography only 93 cases of DCIS could be seen, compared with 153 cases detected by MRT “Our study demolishes a whole series of textbook dogmas. As our results show, the opposite is true. MRT is far more sensitive than mammography,” says

Women see men with masculine faces - features such as a square jaw, larger nose and smaller eyes - as significantly more dominant, less faithful, worse parents and less warm, compared to their ‘feminine’ counterparts - with finer facial features with fuller lips, wide eyes and thinner, more curved eyebrows, according to a study published in Personality and Individual Differences. www.srcd.org

Pain in the mouth

radiologist Professor Christiane Kuhl, one of the researchers. “The second prejudice is that MRT often leads to a ‘false positive’. Among our patients that was even less the case with MRI than with mammography.” Despite the findings further training and experience is needed before MRT would be suitable as a mass screening tool says Kuhl: “Too little use is made of the method in the field of breast imaging, so correspondingly there are too few radiologists who have been able to gain sufficient experience with this specific application,” she says. www.thelancet.com/journals/lancet/arti cle/PIIS014067360761232X/

Abstinence only fails to cut HIV OXFORD Sex education programmes that exclusively encourage abstinence from sex do not appear to affect the risk of HIV infection in high income countries, according to a study published in the BMJ. Compared with various controls, no programme had a beneficial effect on incidence of unprotected vaginal sex, number of partners, condom use, sexual initiation, incidence of pregnancy, or incidence of sexually transmitted infection. The researchers at the University of Oxford reviewed 13 trials involving over 15,000 US

Macho men

young adults to assess the effects of abstinence only programmes in high income countries. They note that currently a third of US HIV prevention funds from the President’s Emergency Plan for AIDS Relief (PEPFAR) is used for abstinence only programmes. In contrast programmes that promote the use of condoms greatly reduce the risk of acquiring HIV, especially when such programmes are culturally tailored behavioural interventions targeting people at highest risk of HIV infection, say researchers in an accompanying editorial. www.bmj.com/cgi/content/full/335/76 13/248

Stress, anxiety and depression are associated with periodontal disease, according to a study published in the Journal of Periodontology. Researchers found that 57 per cent of the studies in the review showed a positive relationship with poor oral health. They speculate that the hormone cortisol may play a role. www.joponline.org

Milking those muscles Drinking milk after heavy weightlifting can help exercisers burn more fat, according to research published in the American Journal of Clinical Nutrition. The milk drinking group had lost nearly twice as much fat two pounds - while the carbohydrate beverage group lost one pound of fat. www.ajcn.org

Tired of being tired Animals who are chronically partially sleep deprived over consecutive days no longer attempt to catch up on their sleep deficit, according to researchers at Northwestern University. Chronic loss of even two to three hours per night was found to have detrimental effects on the body, leading to impairments in cognitive performance, as well as cardiovascular, immune and endocrine functions. www.northwestern.edu

Cuppa memory Caffeine may help older women protect their thinking skills, according to the journal Neurology. The study found that women age 65 and older who drank more than three cups of coffee per day had less decline over time on tests of memory than women who drank one cup or less of coffee or tea per day. www.aan.com

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JuniorDr Features

Sun, sea and

- the advent of medical tou Not long ago the term ‘medical tourist’ was used to describe unscrupulous patients entering the UK to obtain free treatment on the NHS. Today, in contrast, it is used to describe the thousands of British citizens who flee the long waiting lists to seek private healthcare abroad. JuniorDr's Michelle Connolly looks at the surge of medical tourists travelling abroad for sun, sea and surgery.

Whether it’s for a hip replacement, valve surgery or a simple rhinoplasty medical tourism is booming. Last year alone some £130m was spent on medical tourism procedures outside the UK. However, Britons are still in the Ryanair league compared to countries like the United States where 150,000 Americans jet off each year for long-haul procedures in countries as far away as India, Thailand, Argentina and Malaysia.

But the UK is catching up, according to research by analyst Mintel. Their survey suggests that 12 per cent of Britons would consider surgery abroad because of the substantial savings - costing up to eighty per cent less in some cases - compared to private treatment in the UK. Dental surgery is the most common overseas procedure with around 20,000 Brits travelling to favourites such as Hungary and Poland for a better smile at around £2,500 a time. Cosmetic surgery comes a close second with 14,500 of us shelling out for facelifts, breast augmentation and liposuction at a cost of £50 million each year. Those wishing to skip NHS waiting lists for elective surgery, the most frequent of which are joint replacements and cataract surgery, make up a further 10,000 patients spending £36 million. Word-of-mouth is one of the main drivers for overseas treatment. International medical facilities are promoting good

service and reward schemes to encourage ex-patients to recommend to friends. Jacqueline Wilson, a 48 year old Herefordshire housewife travelled to Gdansk in Poland for tooth veneers after first getting quotes from British dental surgeons. “Poland was nearly three thousand pounds less than the price I was quoted in Harley Street and I combined it with four-day spa holiday too,” she said. “The hospitals were clean, the operation fast and the staff were very pleasant and spoke English. I’d recommend the experience without question.” Selling surgery Foreign governments and private firms have begun to realise the potential of medical tourism. Brits are being wooed abroad by development agencies such as the Singaporean government’s Singapore Medicine, which describes the UK’s ageing

population as “a great potential to be tapped into”. Intermediary brokers are one of the big drivers for overseas treatment in what is a difficult process for potential patients to negotiate themselves. Dipa Jethwa, from the London-based Taj Medical Group, explained how they try to simplify medical treatment abroad for clients: “We liaise with the patient’s NHS consultant to obtain their clinical records. We then arrange flights, visas and their admission to hospital.”

Thailand’s Bumrungrad hospital is the number one international hospital in the world treating some 450,000 medical tourists annually.

Features

JuniorDr

surgery

urism

While the mainstay of treatment is joint replacement operations, Taj Medical is also benefiting from the obesity epidemic. “We are seeing an increase in the number of patients, particularly from the US and Canada requiring gastric banding surgery.” And it’s not just small brokers that are benefiting from the public’s new acceptance of private treatment overseas. High street tour operators such as Thomas Cook have realising the potential and have established partnerships with agencies like Taj Medical. Because of these new medical expectations centres in countries targeting medical tourists are no longer typical hospitals - they are ‘resort hospitals’ with enticing names such as Kuala Lumpur’s ‘Palace of the Golden Horses’. Thailand’s Bumrungrad hospital is the number one international hospital in the world treating some 450,000 medical tourists annually. To accommodate Westerners it has a specially built

Starbucks in the reception and a pizzeria upstairs. Americans driving the market Americans lead the way in medical tourism partly because of the baby boomer generation and also because of sporadic healthcare cover. With 45 million Americans uninsured overseas treatment is the only way to avoid huge medical debts. Last year, the average healthcare expenditure for a family of four exceeded the total annual earnings of a minimum wage worker for the first time. Howard Staab, a 56 year-old carpenter from North Carolina has become the industry’s poster boy. His local hospital demanded a $50,000 deposit from him for a mitral valve replacement before warning him that the cost of treatment could rocket to $200,000. He got change from $10,000 for a pig valve in New Delhi - and also a trip to the Taj Mahal.

Differences in doctor’s salary partly explain why such considerable savings can be made. The average salary of a US family doctor is $161,000, compared to just $35,000 in India. India With four doctors for every 10,000 people, compared with 27 in the US, India is hardly a healthcare model to be copied. Yet India is now seen to be leading the world as a medical tourism destination - with the finance minister calling for the country to become a ‘global healthcare destination’. Efforts have been made to improve infrastructure to help smooth the arrival and departure of medical tourists. Import duty on medical equipment has been slashed and the government has introduced a special medical visa which permits tourists to stay in the country twice as long as before. As a result India’s medical

> Medical tourism negatives > Little or no aftercare on your return > Often questionable quality of blood transfusions > Weak malpractice laws meaning redress is difficult and malpractice awards abroad are capped at a much smaller amount > Draining away of medical services from local population in order to serve the tourists > The British Transplantation Society has warned medical tourists considering China that they might be receiving the organs of executed prisoners

JuniorDr Features

The medical tourism industry is worth $100bn growing at 15 – 20 per cent per year Source: Ernst and Young

tourism industry is set to balloon to $2 billion by 2012, according to a joint report by the consultancy McKinsey and the Confederation of Indian Industry. Effect on the NHS Many expected the boom in medical tourism to lead to a reduction in UK private healthcare prices - instead the effect has been largely an efflux of

“Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less than they earned in the West.” Anil Maini Director of Corporate Development Apollo Hospitals Group, India

medical tourists. Fiona Harris, head of personal markets at BUPA, the UK’s largest private healthcare provider, denies that their business is threatened by the boom in medical tourism: “Sometimes BUPA customers will seek treatment abroad where it is not available in the UK; in these cases we meet the equivalent UK costs of the treatment.” Social costs Often the last thing a patient planning an operation overseas considers is the affect on the local community but it’s one of the key concerns that objectors raise. Many fear an internal brain drain whereby doctors leave small rural practices to work in better equipped urban centres that cater for medical tourists. Anil Maini, director of corporate development at the Apollo Hospitals group - India’s largest medical tourism organisation - doesn’t deny this is

the case: “There is an internal brain drain but there are enough doctors available to serve both rural and urban populations,” he says. “Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less, than they earned in the West.” There are many who believe medical tourism hails the beginning of a much broader overhaul in the world’s healthcare systems - the advent of medical outsourcing. Outsourcing means that it won’t be the patient who decides to travel for treatment, it will be your insurer or government who sends you abroad to save money. Just as manufacturing and call centre operations were relocated to countries such as India healthcare is likely to follow. References Burkett L (2007). Medical tourism. Concerns, benefits, and the American legal perspective. J. Leg. Med. 28: 223-45.

> Cost comparisons > The average procedure in India is one-tenth of the cost in the US. > Singapore is a more expensive destination but the savings are still large - a liver transplant would cost $300,000 in the US and just $150,000 in Singapore. > Partial hip replacement India $4,500 US $18,000 > Full hip replacement India $3000 US $39,000 > Orthopaedic surgery India $4500 US $18,000 > Knee surgery India £8000 UK (Private) £20,000 > Gall bladder surgery India $7500 US $60,000 Figures are epproximate. They do not include travel and accommodation costs.

Features

JuniorDr

Depressed? Then the last thing you’d probably consider on a Saturday night is dancing to some tearful tunes. Well think again, Feeling Gloomy is a London-based club aimed specifically for those feeling low and helping to support the charity Depression Alliance. Michelle Connolly found out more from the founder Carl Hill. Carl says he’s never suffered explicitly from depression. “I have dark teatimes of the soul like anyone,” he laughs. “I’ve never been clinically diagnosed but then I’d never seen a doctor about it.” The direct inspiration for the club came, quite aptly, through his stereo. After his sacking from running the popular School Disco he was without a job, had no girlfriend and was approaching thirty. Life didn’t look too rosey. “I was lying on my bed feeling the most down I’ve ever been and The Smiths’ classic ‘There Is A Light That Never Goes Out’ came on and it actually made me smile,” he recalls. “The Smiths are typecast as a depressing band and it made me think that some of the sadder songs can actually bring you up.” A great deal of hard work later, and despite it being on paper, as Carl admits ‘commercial suicide’, Feeling Gloomy began its highly successful run at Bar Academy, Islington. The evening is hosted by Carl’s alter-ego, Cliff, and takes an irreverent ‘working-class gallows humour’ poke at miserabilism. Depression Alliance Carl quickly established ties with The Depression Alliance, the UK’s leading charity for people with depression. It’s unusual for a club to become involved

Carl Hill Founder, Feeling Gloomy

with a charity but then it’s unusual for a club to become involved with a miserable music only policy. “We approached The Depression Alliance because we wanted to be more than a club night, we wanted to raise money for a cause that affects a quarter of the population at any time in their life,” says Carl. “It’s all too easy not to be socially responsible: people are inherently lazy, but this time I was determined I would act.” "The leaflets are not a joke!" People who are clinically depressed come regularly to the club and pick up the literature from charities that’s lying on the tables. “Some clubbers thought the leaflets were a joke!” recalls Carl. “Many people tell me they suffer from depression and they agree we’re doing a good thing,” he says. In a BBC poll for 6 Music, another Smiths’ number ‘I Know It’s Over’ was the tune people most often turned to when feeling down. REM's ‘Everybody Hurts’ also featured in the top ten. It seems

counterintuitive to suppose miserable songs help people who are clinically depressed but Carl says this isn’t entirely so:

“Some Germans

one evening told me it’s very British: it’s that British sense of humour of laughing in the face of adversity.” “If you listen to downbeat music incessantly, then that probably will have an effect on your mind,” he says. “But the positive effect is that the listener feels an empathy with the singer, as if there’s someone who understands their situation.” The study of the link between music and mental health is at a nascent stage but experts have shown that endorphins, endocannabinoids, dopamine and nitric oxide may play a role in the musical experience and that music

therapy may have a role in the clinical management of psychiatric disorders. “I think Feeling Gloomy is therapeutic. It is about the narrow line that divides happiness and sadness: melancholia. Some Germans one evening told me it’s very British: it’s that British sense of humour of laughing in the face of adversity.” Indie Air Guitar Feeling Gloomy is also supporting the Samaritans with ‘The Indie Air Guitar Showcase’. “Feeling Gloomy hosts the world’s only indie air guitar band, The Miserabilists, and so we felt people would prefer to try their hand at indie air guitar, as opposed to rock air guitar, which seems to be the preeminent form of the artistry,” grins Carl. You can find out more about Feeling Gloomy at www.feelinggloomy.com.

Prescription for a party - a nightclub for the depressed 13

Features

JuniorDr.com NHS net made easy - the impact on your clinical care of the £12.4bn NHS network upgrade So what’s it all about? It sounds pretty confusing. It is. There are two main parts to the current NHS network upgrade - the first is connecting all the hospitals, GP practices and NHS facilities across the UK. You can think of it like building a mini walled-off version of the internet. Big firms like BT and computer giant Fujitsu won contracts to build it. There will also be a VOIP service which means phone calls can be made over the NHS network just like Skype - saving the NHS money. The second part of the project is to collect patient records in one place so no matter where doctors are they can easily access all the details, previous investigations and summaries. In many cases you be also able to view past X-rays and videos of investigations such as endoscopies. Sounds impressive but isn’t it going to be very expensive? The budget is £12.4bn over ten years. This sounds huge but it represents just over 1% of the NHS budget for each of those years. Based on potential decreases in missed appointments, administrative staff reductions, transport and current communication costs government statisticians have decided that it’s cost-effective. Can patients get access to their electronic details? Yes, and much more besides. From home patients are able login to an account where they can view a restricted version of their medical history. There’s also the ‘Choose and

B o o k ’ s e r v i c e w h e r e patients can view available appointments with their GP, or in some cases hospital procedures, and book via the internet or TV. Over 3 million bookings have been made already and, although not properly audited, initial reports show it decreases non-attendance at appointments. Doncaster & Bassetlaw Hospitals NHS Foundation Trust’s DNA average before Choose and Book was around 11%. For electronic bookings, it dropped to 2%. Shouldn’t we be worried about patient confidentiality? We are. According to a study by research firm Medix more than half of all doctors believe it will reduce confidentiality but 70 per cent feel it will enable them to make better clinical decisions. Experts point out that most prescribing mistakes are made from lack of information. Patients will have the option to opt out of electronic records if they wish and doctors will be granted different access levels which means it’s unlikely you’ll be able to view patients that are not on your clinic or inpatient list. So do we have to wait decades while like other NHS upgrades? Nope. In fact much of the project is ahead of schedule and already operating in some areas. GP’s across England are currently using ‘Choose and Book’ to make 16,000 bookings each day. You can find out more and when new services are coming to you at: www.networks.nhs.uk

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cardiology websites

European Society of Cardiology www.escardio.org/knowledge/guidelines

Surgery (without the scrubs)

Comprehensive guidelines on pathogenesis and how to treat wide variety of cardiology conditions. Access is free after registration and there’s also the option to download a PDA version to carry with you.

Review Trauma Center- Second Opinion Nintendo Wii RRP £39.99

eMedicine www.emedicine.com/med/cardiology.htm Probably the best source of medical information on the internet eMedicine is always informative, easy to use and evidence quoted. Although categories are logical you might find the information is presented in difficult to digest chunks. Despite this it’s a high quality resource that’s also free. Cardiology Site www.cardiologysite.com Professional site which claims to offer ‘classroom lectures and demonstrations with the use of the latest web-based technology’ - and it does a pretty good job too. Lots of 3D animations, videos and sample questions. Heart Sounds Tutorial www.blaufuss.org Packed with great graphics and interactive functions it’s a simple way to understand the often bizarre sounds that emanate from a patients chest - and the pathologies behind them. ECG Encyclopedia sprojects.mmi.mcgill.ca/heart/egcyhome.html 33 ECG case studies that allow you to guess at the abnormality, fail miserably and then look up the comprehensive answers. It’s a useful way to practice ECG reading and learn the associated pathologies thanks to the easy to understand interpretations.

Features

JuniorDr

Only a few years ago the closest wannabe surgeons got to practising their scalpel skills outside of theatre was the boardgame Operation. That was before the Nintendo Wii. Now five year olds can perfect their sutures, diathermy leaking aneurysms and get stroppy with the theatre nurses for handing them the wrong retractor. Although bearing minimal resemblance to any real procedures Trauma Center Second Opinion is fun enough to distract doctors in the mess from actual patients. Holding the controller like a pencil you can cut, suture and diathermy to save your virtual patient from a whole host of futuristic infections and injuries. And just like real hospital life patients die and experienced surgeons > Screen shots are forced to make a humiliating exit after making a cut in the wrong place. Fortunately the programmers omitted the GMC so you’re free to start a new game and massacre another patient’s abdomen without the fear of a coroners inquiry. Overall, fun but anatomically frustrating and sadly not challenging for those who’ve played trauma surgeon in real life - though it’s just about addictive enough to keep you up all night just like in the real world. Overall -

4/5

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Education

Is it

Ethical? This question is asked numerous times a year in surgeries, wards, research laboratories, health planning departments, government committees and in the media. Of course it cannot be answered without knowing the exact details of the particular situation and thinking clearly through all the issues.

Making Sense of Medical Ethics A hands-on guide Alan G. Johnson Paul R.V. Johnson November 2006 RRP £17.99 978 0 340 92559 1

With so many conflicting signals in modern medical ethics, Making Sense of Medical Ethics offers a no-nonsense introduction to the principles of medical ethics, as applied to the everyday care of patients, the development of novel therapies and the undertaking of pioneering basic medical research; helping you cut through the noise to give you a pragmatic guide to modern medical ethics. Why not test and apply your ethical principles on the scenarios below …

Scenario 1 A Muslim woman came to a clinic complaining of a breast lump and was seen by a male surgeon who asked if he could examine her breast, but she refused. There was no female consultant in the hospital, so the surgeon asked a female junior doctor to examine and report her findings. He decided to operate on the basis of these, but in the theatre found that the lump was different and larger than he expected and needed a larger operation. What should he have done before and during the operation? Scenario 2 A 55-year-old woman has come into hospital for investigations for anaemia and shortness of breath. She says she will kill herself if she is found to have cancer. The results confirm a malignant tumour. Do you risk her life by telling her she has cancer? Scenario 3 A white male kidney donor leaves his kidney for transplantation after his death on condition it is only given to a white recipient. If you were the transplant surgeon, would you accept it? Scenario 4 A man needs a coronary artery bypass surgery for severe angina but he is 75 and has diabetes. Can you ensure that the treatment will benefit him without doing harm?

Making Sense of Medical Ethics answers these questions and many more ... Order your copy today and SAVE 30%, details below -

Special 30% discount offer JuniorDr Readers SAVE 30% on the featured titles from Hodder Education. Place your order online today at www.hoddereducation.co.uk/healthsciences Remember to quote promotional code W0000334 at the checkout when prompted, to secure your discount. * Special offer is valid until 31 October 2007 on the featured titles only. This offer is only available in the UK/EU.

Also from the ‘Making Sense’ Series Making Sense of the Chest X-ray A hands-on guide Paul F. Jenkins 2005 · RRP £17.99 978 0 340 88542 0

Making Sense of Your Medical Career Your strategic guide to success Riaz Agha 2005 · RRP £17.99 978 0 340 88737 0

Making Sense of Clinical Examination of the Adult Patient A hands-on guide Douglas Model 2006 · RRP £17.99 978 0 340 92824 0

JuniorDr

Isle of Man

Features

Weekend ward escape to the

The Canary Islands have the sun, the island of Ibiza has the clubs and Malta has the history so why would you choose the Isle of Man? Well, if tail-less cats, horse-drawn trams and a big water wheel sound like a welcome change from sunburn, sore ears and showy sights it might just be the island getaway for you. Getting there It may be close but being stuck in the middle of the Irish Sea makes getting there a little tricky. Flights from carriers such as BA and Flybe leave from most UK airports including London, Edinburgh, Manchester and Newcastle. If you’re worried about your carbon footprint you can take ferries from Liverpool, Belfast or Heysham - prices are from £39. Journey times can be a long 3 hours but it does leave you within walking distance of Douglas, the island’s capital. Where to stay? Douglas is probably the best base for a weekend trip especially if you decide against hiring a car. Trams and buses connect from here to all the main towns and tourist destinations. For a cheap but comfortable stay try the Arrandale which offers rooms from £60 per night. Apartments are also available if you prefer more independence (www.arrandale.com). Alternatively, you could try the Regency Hotel in the centre of Douglas, which although mainly catering for business customers offers good weekend rates (www.regency.im). Eating Manx kippers are probably the island’s best know delicacy. Kippers - herrings that have been filleted and cured by smoking used to form one of the islands biggest industries until fish stocks dwindled and now supplies are brought in from the North Sea. Try them for breakfast with bread and butter or take a tour of Moores factory (www.manxkippers.com)

which has been ‘kippering’ since 1882. For dinner try Ciapellis - rated as one of the UK’s top restaurants - serving great Italian and seafood (Noble’s Park, Douglas). Alternatively try fish and chips at the Harbour Lights restaurant in Peel at the other end of the island (www.HarbourLightsIoM.co.uk). Key attractions Laxey Wheel – For such a small island it can be quite a surprise to find the world’s largest waterwheel with a diameter of 72ft. It was built in 1854 to drain water from the surrounding mining industry. TT races – This, the island’s biggest tourist draw, brings over 60,000 visitors for probably the world’s most famous road motorcycle road race. It’s one of the most exciting spectator events which also makes finding accommodation from the end of May into early June tricky Snaefell – An electric tram takes you 2,000ft to the top of the island’s largest mountain. On a clear day you get a magnificent view of the entire island and can look out over England, Scotland, Wales and Ireland. House of Mannanan - Located in the fishing town of Peel on the islands west coast is an interactive heritage centre which shows how the Manx Celts and Viking settlers shaped the island’s history. Perfect for when it rains. Find the full Isle of Man guide at JuniorDr.com.

Key facts

The pics Clockwise from top left Map of Isle of Man; Flag; TT races; Laxey wheel; Horse Tram; Manx Kippers

> Population - 75,000 > Language - English > Currency - 1£ = 1£

JuniorDr Features

Dr Fairytale (B.H.S, M.&.S, R.S.V.P.)

Courses

RSMmeetings

General Practitioner to the Stars

Meetings for Trainees Medical Report - Mr Homer Simpson Clearly Mr Simpson exhibits a number of poor lifestyle choices that are having a detrimental effect on his health. His excessive eating, drinking and lack of exercise have resulted in obesity. Mr Simpson also continues to put himself in situations which result in sustained traumatic head injuries. Without further brain imaging it would be difficult to estimate the extent of this damage. However, it would be remiss not to look beyond the (large) surface and think about some of the other possible conditions that Mr Simpson could be suffering from. Radiation Poisoning Mr Simpson's hair loss, pronounced skin darkening (around the face and neck) and fatigue could be the effect of chronic exposure to dangerously high levels of radiation. This may be in part due to his own carelessness or because of poor safety control at Mr Burn’s nuclear power plant. Excessive exposure to ionising radiation can cause damage to organ tissue which the body cannot repair. Most symptoms appear after around 15 years - Mr Simpson started work in late 1980s. Kleine-Levin Syndrome A rare disorder which is characterised by hypersomnia excessive amounts of sleep, sometimes over 20 hours/day - and compulsive hyperphagia - which can be indiscriminate in its nature and takes in all food sorts. Patients may also show an abnormally uninhibited sexual drive resulting in attempts to perform acts without due care and attention to discovery - for example on a public crazy golf course. Although, adolescent males are the predominant victims of the disorder, it can appear at any age as a result of autoimmune disease. There is only symptomatic treatment.

Assessed by Dr Gil Myers

Congenital hepatic fibrosis Mr Simpson is yellow. His father is yellow. His wife is also yellow as are his children. This is suggestive of a genetic condition that is inherited in an autosomal recessive pattern. CHF is such a disease. Medically speaking it is a ‘fibrocystic liver disease associated with proliferation of interlobular bile ducts within the portal areas and fibrosis that do not alter hepatic lobular architecture’. The end result is that jaundice is widespread in the Simpson family and Bart, Lisa and Maggie should consider having their future partners genetically screened to avoid passing this on to further generations - or at least attempting to date someone who isn’t yellow.

Intermittent explosive disorder IED is a behavioural disorder characterised by extreme expressions of anger, often to the point of uncontrollable rage that are disproportionate to the situation at hand. On several occasions Mr Simpson has been reported to have been attempting to ‘throttle Bart’ with only the flimsiest of reasons. He was also smiling. Research suggests that subjects often reported a feeling of relief or even pleasure while committing the acts. While I am in no doubt that this is learned behaviour there does appear to be an inability to resist resorting to these actions - sometimes more than once in a 30 minute period.

20 October Young Fellows Meeting Interview Skills Training Day Trainees

17 November Society Conference Making sense of medical careers 22 November Young Fellows Histopathology training day

29 October Climate change and health series: Global warming and infectious disease: human and animal hazards

26 November Climate change and health series: Action for the health consequences of climate change

12 November Climate change and health series: Global warming and food production: will we starve?

27 November Occupational Medicine Section The road to practicing OH in the 21st century – the future of OH training

28 November Geriatrics & Gerontology Section Trainees’ prize evening 14 December Young Fellows Meeting Teaching skills Young Fellows Meeting Histopathology training day Obstetrics & Gynaecology Section Training in our speciality – a time of despair or promise?

To view the full list of RSM meetings please visit www.rsm.ac.uk or call 020 7290 2900

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JuniorDr Employment

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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. Family/ 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.

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Financial Management Est. 1982 Accountancy

Mortgages

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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.

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Journalism The Medical Journalistsâ&#x20AC;&#x2122; 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

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Ethical advisor

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How to analyse an ethically difficult case (part 2) In the second of two columns Daniel Sokol looks at how to resolve an ethical problem you may encounter in your clinical practice. So there you are, on the ward, faced with a thorny ethical problem. You ask your colleague for advice, but you’re not convinced by his dismissive, unsupported response. “Right”, you say to yourself, “let’s think about this methodically” (if you really can't picture yourself saying this, just imagine a more sensitive or nerdy soul instead). In the last issue, I presented the famous ‘Four Principles’ approach to case analysis: respect for autonomy (allow competent people to make their own choices about their lives), beneficence (do good), non-maleficence (avoid causing harm) and justice (be fair and respect rights). You consider each of these principles, ask yourself which is morally weightier if they clash with each other, and then act accordingly. This column introduces you to a lesser known but nonetheless useful method, called the ‘Four Quadrants’ (or ‘Four Topics’) approach. The four topics are: > Medical indications > Patient preferences > Quality of life > Contextual features The first step in your analysis is to be clear about the medical situation. What’s the patient’s medical history? What’s the diagnosis and prognosis? Then ask yourself what the goals of treatment are. What are we trying to achieve with this treatment, and how likely is it to work? These questions may sound obvious, but at times no one seems to know why a patient, perhaps in the final stages of a disease, is on a certain treatment. The second step requires you to consider the patient’s own preferences about treatment. Since our conception of what’s desirable and undesirable (in medicine and

other realms of life) is largely subjective, it makes good sense to involve the person affected. Is he competent to express preferences? If not, has he expressed them in the past, either in the form of an advanced directive or through talking to relatives? If not, then involve the relatives in making a ‘best interests’ decision. Remember also to familiarise yourself with the forthcoming Mental Capacity Act 2005. Third, consider quality of life issues, notably in end-of-life cases. What are the prospects of returning to a normal life, with and without treatment? What kind of physical, mental and social deficits might the patient experience? Are these so bad that reasonable people might say “don’t bother”? The final quadrant is a hotchpotch of different issues not captured directly by the other quadrants, ranging from potential prejudices in your analysis, to issues of confidentiality, religion, culture, law, resource allocation and other financial factors. Note that, like the principles approach, it doesn’t automatically give you an answer. It merely serves to highlight key issues through a series of probing questions. In many medical ethics cases, asking the right question is the key to a good analysis. Some people might not even see the case as having an ethical dimension (moral blindness). Others might, but will fail to identify the pertinent issues. A few will both perceive and reason through the problem wisely. Then may come the tricky business of implementing the decision, especially if a senior colleague is of a different opinion (moral courage). But that is another subject altogether …

Daniel K. Sokol is lecturer in Medical Ethics and Law, SGHMS

medical murderers

Harold Shipman (1946 – 2004) Killed - Approx 250 GP Shipman was convicted in 2000 and initially sentenced to 15 consecutive life sentences. However, he only served four years, and was found hanged in his cell on the 13th January, 2004. An official inquiry after his death concluded that he had probably killed around 250 people, with 218 of those ‘positively identified’. John Bodkin Adams (1899 – 1983) Killed - Approx 163 Adams was a much loved GP in Southend but concern arose after being mentioned in the wills of over 100 of his patients. The Home Office pathologist deemed 163 death certificates to be suspicious. Many were given bizarre injections of substances which Adams kept secret from the nurses. He was arrested in 1956, by which time, he had become the richest doctor in England. Robert George Clements (1897-1947) Killed - 4 wives Dr Robert George Clements was a physician and a fellow of the Royal College of Surgeons in Belfast. He is thought to have murdered four of his wives. Police finally came to arrest him following the suspected murder of his fourth wife, a wealthy industrialist, in order to inherit her money but they found Clements had already committed suicide. Hawley Harvey Crippen (1862 – 1910) Killed - Wife Dr Crippen was hanged in 1910 following conviction for the murder of his wife. After killing her he disposed of the body by removing and then burning her bones in the kitchen stove. Her organs were dissolved in acid and her head was placed in a handbag and thrown overboard during a day trip to France. George Chapman (Jack the Ripper) (1865 - 1903) Killed - 5 Many believe Seweryn Antonowicz Kosowski, to be the infamous Jack the Ripper. Failing to qualify as an assistant surgeon in Poland he moved to England where he renamed himself George Chapman. He was convicted of murdering a number of prostitutes in the East End and hung in 1903.

JuniorDr

Walking the corridors

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 -

Magnum Classic Ice-cream

While we doctors are puzzling over squiggles on ECG traces, prescribing IV nystatin and ordering MR scans for patients with metal implants there are a bunch of people in the background quietly observing what’s going on. Porters, students, secretaries and canteen staff see the other side of hospital medicine. We’ve asked them to tell all. Consultants can be equally demanding. I once had to spend an hour explaining to one cardiologist that he couldn’t just stick everyone with an infection on Tazocin and Vancomycin. He couldn’t grasp the concept of tailoring your antibiotics to the type of infection. Once, we had a patient with suspected CJD. The blood had contaminated three of our machines after one of my technicians accidently spilt it. As we couldn’t wait for the postmortem diagnosis we had to change the machines at a cost of nearly eight thousand pounds. Needless to say she didn’t last long in the job. We work demanding hours but I suspect that’s the same of everyone in the NHS. Except GPs of course, who seem to have longer and longer lunch breaks these days. We’re on call from home and have to come in when asked to by the microbiologist on call. One at our site relishes in waking us up at 4am to run urgent samples. That’s the worst time of day because by the time you get home you can’t really sleep and then it’s time to go to work again. If I could go back to the beginning then I would still choose the same career. I love what I do and the fact that it helps people means everything. Even if we never get to meet those we ‘treat’. My only complaint is that my lunch hours are getting shorter these days - then perhaps I should have become a GP.

Sends a shiver down your spine Whipps Cross Hospital London

WOW!

£1.49

Lick-tastic prices at Edgware Community Hospital Edgware

£1.10

LOW!

Dairy Milk (49g) They’re milking their customers at Addenbrookes Hospital Cambridge

WOW!

49p

Remember chocolate is good for you Belfast City Hospital Belfast

40p

LOW!

Jacket Potato with cheese Emm, maybe just have butter instead Chase Farm Hospital London

WOW!

£2.10

Say cheese -

LOW!

QE2 Hospital Welwyn Garden City

£1.50

Next issue we’re checking a Ribena 288ml carton, a plain doughnut and a pocket-sized packet of Kleenex. Email prices to team@juniordr.com.

Which mess is the best?

DAVID MICROBIOLOGY LAB TECHNICIAN I have been a microbiology lab technician for over thirty years. I started in a small DGH and have worked my way up to the head of a department in a large teaching hospital in the North of England. Is my job as dull as it sounds? Usually. But there are exceptions. I used to be at the forefront of hospital based testing. I’d come in at weekends to run CSF samples from patients with suspected meningitis from A and E. Nowadays I spend most of my time in meetings. The hospital (like most trusts around the country) is trying to save as much money as possible and as department head it’s my job to steer them away from us and towards the biochemists. I also do a bit of teaching for the junior doctors. It’s amazing how many of them don’t understand aseptic techniques. I took a grotty tie from a particularly arrogant medical registrar last year and brought back an armful of petri dishes a week later showing how many bugs I had grown off it. Another thing that really annoys me is when doctors don’t bother labelling the tubes properly - or when all they write on blood culture forms is ‘fever’. We need the information to help us come to a conclusion. It’s like a patient with chest pain telling you that it hurts but not offering any more details. But it’s not just the juniors.

The Mess

Hospital

> Royal Free Hospital, London

What it’s got Our own staffed lunchtime kitchen serving hot food. A bar (yes, an alcohol serving bar!). A balcony to enjoy the summer sunshine. Newspapers. A stocked machine dispensing Marks and Spencer sandwiches and ready meals. Tea/coffee. Reasonably comfortable sofas for on-calls. £10/month. JuniorDr Score - 5/5