JuniorDr Future medicine
The future of medicine Life as a doctor in 50 years time Virtual doctors Medical training in Second Life Mobile medicine Practicising with your PDA
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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
Dr Google will see you now
Triage
JuniorDr
ST2 Psychiatry
editor@juniordr.com
Editorial It was only a few years ago that patients sat in awe as their doctor formulated a diagnosis from a vague list of symptoms and a brief examination. No longer. Today patients can diagnose themselves on Google, buy the antibiotics on eBay and get back to work without coming into contact with the medical profession. Self-testing that would have been thought impossible a decade ago has crept into normality. From the comfort of your living room you can now test for HIV, coeliac disease and prostate cancer. Today you can simply prick your finger, pop the sample in the post and discover the likelihood of developing breast cancer, Alzheimers or liver failure. For doctors it seems like we are no longer needed for ‘simple’ conditions. We’ve become brokers and project managers arranging services our client is requesting in secondary care from their own research. Next year will be a milestone in the evolution of medicine and self treatment. Microsoft has launched a personal medical records service, Google is working on the world’s biggest medical
Editorial Team Kiran Shilliday Manchester
Michelle Connolly London
Hi Wu-Ling Nottingham
Muhunthan Thillai Chelmsford
Thanks to Andro Monzon, Gil Myers, Mun Hong Cheang, Rhona Atkin
Ashley McKimm Editor-in-Chief ST2 Psychiatry
Newsdesk news@juniordr.com Printing partners Witherbys, UK Advertising & Production Rob Peterson ads@juniordr.com
JuniorDr PO Box 36434 London EC1M 6WA Tel - 020 7684 2343 Fax - 087 0 130 6985 info@juniordr.com
Health warning JuniorDr is not a publication of the NHS, Tony Blair, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not necessarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual orientation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash. All rights reserved.
Get involved We’re always looking for keen junior doctors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out juniordr.com.
database project and new self test kits allowing people to diagnosis more complicated conditions will appear in pharmacies. In this issue we look at the future of medicine and how it will affect our practice - from nanorobots that can remove atheroschlerotic plaques, to the 3D virtual world of Second Life which is already showing signs of revolutionising medical training.
“Today patients can diagnose themselves on Google, buy the antibiotics on eBay and get back to work without coming into contact with the medical profession.” It’s both an exciting and uneasy future for both patients and doctors. Nobody knows where medicine will be in five years time - if you do a search on Google you will most likely find the prognosis.
> What’s on the inside The future of medicine A look at the NHS in fifty years time Page 10
Virtual doctors Medical training in Second Life Page 12
Latest News Page 4
PDAs How doctors are going mobile Page 14
The Secret Diary of a Cardiology SpR Page 19
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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
Working conditions
Job restrictions on overseas doctors ruled ‘unlawful’
Proposed new doctor regulations ‘not in best interest of patients’
LONDON Government restrictions on overseas doctors working on Highly Skilled Migrant Visas in the UK have been deemed unlawful by the High Court in a ruling this month. The appeal brought by BAPIO (British Association of Practitioners of Indian Origin) follows a temporary injunction which was granted in March. The appeal was deemed necessary after Department of Health guidelines to deaneries in February required them not to consider applications to MTAS for applicants whose visas were due for renewal before 1st August 2007. As a result doctors on a HSMV were considered for posts in the last MTAS round but future
LONDON Government plans to change the way doctors are regulated would not be in the best interests of patients, the BMA has stated in response to details outlined in the Queen’s Speech. The proposals under the new Health and Social Care Bill would abandon the current ‘beyond reasonable doubt’ in fitness to practice cases. Instead, doctors could be stuck off the medical register on the ‘balance of probabilities’. “If a doctor is at risk of losing their livelihood then surely nothing less than the current criminal standard of proof will do. The BMA will continue to lobby very hard to maintain this,” said Dr Hamish Meldrum, Chairman of the BMA. The proposals follow a statement in February from government in which they felt it was necessary to change the way doctors are regulated. The changes include having appointed, rather than elected, GMC Council members and changing the composition of the GMC Council to comprise 50 percent non-doctors. In addition, all practising doctors will relate formally to a ‘responsible officer’, most likely the employing trust’s medical director. The BMA has already stated that they have ‘serious anxieties’ about the nature of the role of the ‘responsible officer’ and are concerned that too much authority would be placed in the hands of single individuals.
> The British Association of Physicians of Indian Origin jobs had remained uncertain prior to this ruling. Dr Raman Lakshman, Vice Chair for Policy at BAPIO said they were “absolutely delighted” by the ruling: “Doctors on the HSMP came to the UK on the understanding they are required here and will be treated fairly. This judgment means that these International Medical Graduates can expect to be treated on merit for the 2008 recruitment process and onwards.” Improper assessment
“This judgment means that these International Medical Graduates can expect to be treated on merit for the 2008 recruitment process and onwards.” Dr Raman Lakshman Vice Chair for Policy BAPIO
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The high court concluded that the Home Office did not carry out a proper Race Impact Assessment and that the Department of Health gave incorrect guidance to NHS employers on the way doctors on Highly Skilled Migrant Visas were to be treated. Mr Ram Moorthy, chairman of the BMA’s Junior Doctors Committee, also supported the decision: “The BMA believes this is the right decision. Doctors on the Highly Skilled Migrant Programme came to the UK in the honest expectation of careers in the NHS. The BMA has never wavered from the view that they should be able to compete for
training posts alongside their UK colleagues.” Support from British doctors An earlier BMA survey questioned British doctors and medical students for their views on overseas trained doctors working in the UK. Two thirds (64 percent) agreed that overseas students who graduate from a UK medical school should not be prevented from competing for training jobs. Of the 737 surveyed just over half (57 percent) thought that doctors who qualified overseas should be entitled to compete with UK graduates for training posts, although most thought that this should apply only to those who were already working in the NHS. Commenting on the survey results Dr Terry John, chair of the BMA’s International Committee said: “The thousands of overseas junior doctors currently providing essential services in UK hospitals must not be scapegoated for the government’s poor workforce planning. They came to the UK in good faith, and the honest expectation of training opportunities in the NHS.” www.bapio.co.uk www.bma.org.uk
www.bma.org.uk
JuniorDr Ultimate fighting and boxing should be banned, says the BMA in a new report released this month. “As doctors we cannot stand by while violent fighting tournaments are allowed to take place,” said Dr Vivienne Nathanson, the BMA’s Head of Ethics and Science. The BMA has campaigned for a boxing ban since 1982 and wants Britain to follow Norway and Iceland where the sport is prohibited. www.bma.org.uk/ap.nsf/Content/boxing
Forgetful? Eat more fish A diet rich in fish, omega-3 oils, fruits and vegetables may lower your risk of dementia and Alzheimer’s disease, according to a study published in the journal Neurology. The study of 8,085 men and women over the age of 65 for four years found people who ate fish at least once a week had a 35 percent lower risk of Alzheimer’s disease and 40 percent lower risk of dementia but only if they did not carry the gene, ApoE4, which increases the risk of Alzheimers. www.neurology.org/cgi/content/abstract/69/20/1921
Run away from MIs Endorphins and other morphine-like substances released during exercise may protect against damage from an MI, according to University of Iowa researchers. They showed that blocking the receptors that bind morphine, endorphins and other opioids removes the cardiovascular benefits of exercise. They also demonstrated that exercise was associated with increased expression of several genes involved in opioid pathways that appear to be critical in protecting the heart. ajpheart.physiology.org
Asthmatics all choked up Young people with asthma are twice as likely to suffer from depressive and anxiety disorders, according to a study published in the Journal of Adolescent Health. The study of 1,300 young people aged 11 to 17 by the University of Washington School of Medicine found that those with asthma were 1.9 times as likely to have such depressive or anxiety disorders. About 16 percent of the young people with asthma were found to have depressive or anxiety disorders. www.jahonline.org
Training
Royal College of Surgeons opens new training centre LONDON A new £3m state-of-the-art surgical skills centre has opened at the Royal College of Surgeons as part of it’s Eagle Project - a scheme to provide the UK with a world-leading surgical training centre by 2010. The new Wolfson Surgical Skills Centre takes advantage of the Human Tissues Act 2004 which means, for the first time, surgeons can practice surgical techniques on donated human bodies before taking their skills into the hospital operating theatres. The RCS says this new development will allow trainee surgeons to practise putting in new hips and heart valves, developing manual dexterity at a very early stage in their training. “The new surgical skill workshop will enable the 12,000 surgeons who annually take RCS courses to access hands-on experience in new and existing surgical procedures under expert guidance,” said Dick Rainsbury,
The Pulse
BMA vs Ultimate Fighter
> The new Wolfson Surgical Skills Centre Director of Education at the RCS. “The innovative use of a highresolution video wall will means trainees will no longer need to travel to access courses. We can now provide education remotely, with courses run from the College and delivered to trainees locally, nationally and internationally.” The surgical skills workshop will combine the latest simulator
training with hands on experience and all of the centre’s tables are interconnected by monitors so that up to 50 surgeons can learn collaboratively at once. www.rcseng.ac.uk/about/eagle-project-launch
Working Conditions
BMA calls for an above inflation pay rise in 2008 LONDON An annual pay rise in 2008 of between 3.6 and 4.3 percent has been called for by the BMA in its evidence to the UK’s Doctors and Dentists Review Body. “Last year, the pay award to doctors was below the prevailing rate of inflation and failed to recognise the enormous contribution that doctors had given to the NHS in delivering on lower waiting times and providing high quality care for patients,” said Dr Hamish Meldrum, Chairman of the BMA. In their report the BMA stated that the MMC/MTAS process had resulted in serious implications for
job security for junior doctors and high levels of stress for many. They also pointed out that the basic starting salary for a new junior doctor is now lower than the average for graduates on other courses. “The medical profession is being constantly undermined, fuelled by attacks from the Government, on their levels of pay,” said Meldrum. “The Government is losing the opportunity to reap the benefits of the new contracts. It would be completely unacceptable if, yet again, the annual pay review was used to claw money back from well-deserved new contracts.” www.bma.org.uk
“It would be completely unacceptable if, yet again, the annual pay review was used to claw money back from well-deserved new contracts.” Dr Hamish Meldrum BMA Chairman
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JuniorDr Working Conditions
Medical Students
The Pulse
One in six GPs considering career change LONDON One in six general practitioners is considering a career change and only half would recommend their career to undergraduates, according to a survey by the BMA. GPs say the low morale is due to fears of privatisation and policies that place more emphasis on quantity and cost of care than on quality. The survey of 11,000 GPs showed that over half (53.2 percent) said morale has worsened over the last five years. 63.1 percent said changes in the NHS over the past decade make it harder to practice good medicine. “We have serious concerns that the traditional core values of General Practice, in particular continuity of care, risk being lost as the government encourages increased private sector
involvement,” said Laurence Buckman, chairman of the BMA’s General Practitioners Committee. “Yet it’s that long-term relationship with a family doctor that patients say time and time again is what they value the most about UK general practice.” The survey also showed that while around half (53.3 percent) of GP partners would consider extending opening hours if the resources were available, roughly three quarters (72.5 percent) do not believe it is a good way to spend NHS resources. The results come following a government survey of patients which showed that 84 per cent of patients are happy with their GP practice’s current opening hours. Only four in 100 patients wanted practices to open in the evenings.
Medical student debt could soar LONDON First year medical students may owe nearly £8,000 more than current graduates on qualification, according to a survey by the BMA. The introduction this year of variable tuition fees allows the annual fees to be up to £3,000, compared to £1,175 under the previous flat rate system. The survey of 1,737 medical students found that first year students owe an average of £7,776, up 12 percent from 2006. The average tuition paid by first year students was £2,779. “These figures are shocking, but sadly not surprising,” says Ian Noble, chair of the BMA’s Medical Students Committee. “We have been warning for a long time that variable top-up fees will make student debt much worse.” www.bma.org.uk/ap.nsf/content/studentfinsurvey1 7?OpenDocument&Login
www.bma.org.uk/gp
Training
FY jobs shortfall warning LONDON The UK could face a shortage of places on the foundation year training programme leaving some doctors unemployed, the BMA has warned. They highlighted a statement from the UK Foundation Programme Office that administers applications announcing that future UK medical graduates may only be offered a post for the first foundation year and then would have to reapply competitively for the second. “Completing foundation year one is essential to gaining full registration with the General Medical Council, and achieving the competencies of foundation year two is a minimum requirement to be able to compete for further training grades,” Dr Hamish Meldrum, Chairman of
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the BMA said in a letter sent to Health Secretary, Alan Johnson. The BMA outlined that the number of training posts available for newly qualified doctors is calculated by taking the number of UK graduates and adding a ‘headroom’ of 12.5 percent to allow for a number of overseas graduates. This year the ‘headroom’ has been slashed to around 5 percent. Ian Noble, Chairman of the BMA’s Medical Students Committee called the proposals “totally unacceptable”: “On average, a graduating medical student is over £20,000 in debt, having dedicated five years of their life to train to be a doctor. If the government refuses to open up sufficient training places for these young doctors, this will leave them unemployed, hugely in debt and wondering what on earth to do next.”
Cortisol on your console A computer game has been developed that reduces the stress hormone cortisol by 17 percent. The social-intelligence game developed at McGill University aimed to train people to change their perception of social risks and boost self-confidence but found this additional affect. Saliva tests were taken daily from a cohort of call-centre staff who who used the game for a ‘daily workout’. www.mcgill.ca/newsroom/news/?ItemID=27675
Pre-term mortality Babies born just a few weeks premature are six times more likely to die during their first week than full-term babies, according to research published in the Journal of Pediatrics. Respiratory distress syndrome, feeding difficulties, temperature instability (hypothermia), jaundice and brain development are already known to be raised in late pre-term babies. www2.us.elsevierhealth.com/inst/serve?retrieve=pii/S002 347607004519&artType=full
Spinach saves lives A diet rich in leafy vegetables may minimise the tissue damage caused by heart attacks, according to a study published in Proceedings of the National Academy of Sciences. They found that administering nitrite to animals, either intravenously or orally, can greatly limit the damage caused by a heart attack and the stress to tissue that follows during reperfusion. The researchers suggest it could be the secret ingredient in the heart-healthy Mediterranean diet. Europeans consume 76 mg of nitrite and nitrate daily compared with a 0.77 mg American intake - nearly a 100fold difference. www.aecom.yu.edu/
Sun, sea and STDs
“It costs in the region of £250,000 to produce a newly qualified doctor in this country; it seems a terrible waste of taxpayers’ money if there are not enough jobs for these graduates in the two years after their qualification.” Dr Hamish Meldrum BMA Chairman
One in five young Britons has sex with someone new while abroad, according to the study of 1800 people published in the journal Sexually Transmitted Infections. One in four men (23 percent) and one in six women (17 percent) between the ages of 16 and 24 admitted to having sex with someone new while overseas. Men were significantly more likely to have sex with Asian and North American partners. One in 10 men and one in 12 women who said they had sex while overseas assessed their HIV risk as high or moderately high www.bmj.com/cgi/full/335/7615/312
RSMtrainees Prizes open to Trainees New programme of meetings for 2008 The Royal Society of Medicine’s academic programme for junior doctors promises to be even busier in 2008 than it was in 2007. With feedback from junior doctors attending this year’s meetings including “Excellent course, thank you for organising it 10 times better than any course I have been on”, “Very practical and to the point”, and “Absolutely brilliant. Highly recommended!” - 2008 is eagerly anticipated. In addition to training days, advice on getting your work published and specialty academic meetings, we also offer the opportunity to submit abstracts of your work for prizes and awards. Cash prizes are up to £1000 and there are multiple travelling fellowships available for travel abroad including the annual Ellison-Cliffe Travelling Fellowship with a prize value of £15,000. For a full list of meetings run at the Royal Society of Medicine for our 2007/08 Academic year visit our diary at www.rsm.ac.uk/diary
Laryngology & Rhinology Section Ian Mackay Essay Prize Submission Deadline: 25 January 2008 Prize: £1,000 Anaesthesia Section Overseas Bursary for trainees in Anaesthesia Submission Deadline: 1 February 2008 Prize: £750 Young Fellows The John Glyn Young Fellows' Prize Submission Deadline: 25 February 2008 Prize: £300 For full details, please visit www.rsm.ac.uk/awards
Meetings for Trainees 25 January
12 February
20 March
Paediatrics & Child Health Section Training and education in paediatrics (joint meeting with RCPCH)
Young Fellows Histopathology training day
Sexuality & Sexual Health Section Trainees prize meeting in sexual health, genito urinary medicine and HIV
14 February
30 January
Obstetrics & Gynaecology Section Herbert Reiss O&G Trainees Prize
Young Fellows Histopathology training day
RSM Young Fellows/Trainee Membership -
2 April Urology Section Clinicopathology meeting
Young Fellows Histopathology training day Cardiac pathology
18 April
14 March
25 April
Cardiology Section Acute coronary syndrome Urology Section Rare urological cancers
The RSM has a graduated membership for Young Fellows, depending on the date of your qualification, starting at just £65 pa.
12 June Ophthalmology Section Trainees' prize meeting
For a full list of meetings visit www.rsm.ac.uk/diary
We also offer a 50% discount on your subscription rate if you are temporarily out of work, enabling you to continue using the RSM training, networking and library to further your career at a lower rate. Visit www.rsmmembership.org for more information.
Visit www.rsm.ac.uk or call 020 7290 2991
JuniorDr The Pulse
Journal Review Feeling positive does not increase cancer survival PHILADELPHIA A patient’s emotional state has no effect on cancer survival or disease progression, according to a study published in the latest issue of CANCER. The study conducted by the University of Pennsylvania looked at 1,093 patients with head and neck cancers who completed quality-of-life surveys during their treatment. They found that a patient’s positive or negative emotional state was not associated with survival even after excluding confounders such as gender, tumour site or disease stage. “The hope that we can fight cancer by influencing emotional states appears to have been misplaced,” said Dr. James Coyne, lead researcher. “If cancer patients want psychotherapy or to be in a support group, they should be given the opportunity to do so. There can be lots of emotional and social benefits but they should not seek such experiences solely on the expectation that they are extending their lives.” Previous studies have suggested that a link exists between a positive emotional state and prolonged survival. The researchers believe their study’s large homogeneous population and high death rate would have allowed the detection of even small effects. www.cancer.org/docroot/MED/content/MED_2_1x _Cancer_Survival_is_Not_Influenced_by_a_Patien ts_Emotional_Status.asp
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Overweight and obese men twice as likely to die from prostate cancer BOSTON Overweight and obese men at the time of diagnosis are nearly twice as likely to die from locally advanced prostate cancer than patients who had a normal BMI, according to a new study published in CANCER, the journal of the American Cancer Society. The study by Massachusetts General Hospital followed 788 patients with locally advanced prostate cancer over eight years to examine any independent relationship between BMI and prostate cancer specific mortality. They found that being overweight or obese at the time of diagnosis was a unique, independent risk factor for death from prostate cancer. Compared to men with normal BMI (BMI<25),
men with a BMI between 25 and 30 were over 1.5 times more likely to die from their cancer. Similarly, men with BMI over 30 were 1.6 times more likely to die from their disease compared to men with normal range BMI. After five years, the prostate cancer mortality rate for men with a normal BMI was less than seven
percent compared to around 13 percent for men with a BMI over 25. The study was the first to use data from a large randomised prospective treatment study with long-term follow-up to investigate this relationship. “Further studies are warranted to evaluate the mechanisms for this increased cancer-specific mortality among overweight and obese men and to assess the impact of BMI on survival following other management strategies and in clinically localised disease,” said Dr. Jason Efstathiou, lead author. “Whether weight loss after prostate cancer diagnosis alters disease course remains to be determined.” http://www3.interscience.wiley.com/cgibin/abstract/114298617/ABSTRACT
More educated suffer a four per cent faster cognitive decline with dementia NEW YORK Dementia sufferers with more years of education lose their memory faster than those with less education, according to a study published in the journal Neurology. The study followed 488 participants for a period of six years using annual cognitive tests. They found that for each additional year of formal education the rapid accelerated memory decline associated with
oncoming dementia was delayed by approximately two and a half months. However, once this decline commenced those with more education saw a four percent faster decline for each additional year of education. “Our study showed that a person with 16 years of formal education would experience a rate of memory decline that is 50 percent faster than someone with just four years of education,” said Dr Hall, lead researcher.
“This rapid decline may be explained by how people with more education have a greater cognitive reserve, or the brains ability to maintain function in spite of damage.” The study corroborates previous research which indicates that people with more education had more rapid memory loss after diagnosis of dementia. www.neurology.org
JuniorDr
Doctors shut out pain to better treat patients CHICAGO Doctors learn to ‘shut off’ the part of their brain that helps them appreciate the pain their patients experience during treatment, according to researchers at the University of Chicago. The functional MRI study found that doctors instead activate a portion of the brain connected with controlling emotions. Previous research has shown that the neural circuit that registers pain is activated if a person sees another in pain. The response is automatic and is believed to reflect a panic response developed evolutionally as a means of avoiding danger. Because doctors sometimes have to inflict pain on their patients as part of the treatment they must develop the ability not to be distracted by the suffering said Jean Decety, Professor in Psychology and Psychiatry and co-author of the study. “[Doctors] have learned through their training and practice to keep a detached perspective,”
he says. “Without such a mechanism, performing their practice could be overwhelming or distressing, and as a consequence impair their ability to be of assistance for their patients” Brain responses were recorded as individuals from the two groups looked at short video-clips in which people were pricked with acupuncture needles in their mouth, hands, and feet. Unlike the control group doctors registered no increase in activity in the portion of the brain related to pain. However doctors, in contrast to the control group, did register an increase in activity in the frontal areas of the brain the medial and superior prefrontal cortices and the right temporoparietal junction. This region is related to emotion regulation and cognitive control. The research shows for the first time that people can learn to control that automatic response. www.thelancet.com/journals/lancet/article/P IIS014067360761232X/
Tamiflu survives sewage process STOCKHOLM Tamiflu, the antiviral drug used to treat and prevent the influenza virus is not degraded during normal sewage treatment, according to Swedish researchers. They fear that where Tamiflu is used at a high frequency, such as by Japan, that there is a risk influenza viruses in nature will develop a resistance to it. The study demonstrated that oseltamivir, the active component of Tamiflu, passes virtually unchanged through sewage treatment “The biggest threat is that resistance will become common among low pathogenic influenza
Roach and shine Cockroaches trained in the evening have high retention rates whereas those trained in the morning are incapable of forming new memory, according to scientists at Vanderbilt University. The finding that cockroach’s memory is so strongly modulated by its circadian clock may help understand the link between learning and biological clocks in humans, say the researchers. www.vanderbilt.edu/exploration/stories/cockroach. html
Hungry have risker sex African women who do not have enough food are more likely to sell themselves for sex, according to a study published in the PLoS Medicine. The study of 2000 woman in Botswana and Swaziland found that women in both countries who reported food insufficiency were nearly twice as likely to have used condoms inconsistently and to have sold sex as women who had sufficient food. medicine.plosjournals.org
Tired and emotional Being sleep deprived causes the brain to dramatically overreact to negative experiences, according to research published in Current Biology. Participants who were kept awake for 35 hours were over 60 percent more emotionally reactive. The researchers believe that without sleep the brain reverts back to a more primitive pattern of activity unable to put emotional experiences into context. www.current-biology.com
Did you hear something? Having a tendency to extract messages from meaningless noise could be an early sign of schizophrenia, according to a study at Yale University. Eighty percent of participants who ‘heard’ phrases of four or more words in length when listening to a virtually incomprehensible recording went on to develop schizophrenia. www.yale.edu
viruses carried by wild ducks,” says Bjorn Olsen, Professor of Infectious Diseases at Uppsala University. “These viruses could then recombinate with viruses that make humans sick to create new viruses that are resistant to the antiviral drugs currently available.” www.plosone.org/doi/pone.0000986
Don’t bother to stretch Stretching before or after exercise has little or no effect on muscle soreness, according to a team of researchers at the University of Sydney, Australia. The study looked at different amounts of stretching from 40 seconds to 10 minutes. www.medfac.usyd.edu.au
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JuniorDr Features
The of
in thirty years time the three leading causes of illness are predicted to be HIV AIDS depression and ischaemic heart disease Source WHO
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JuniorDr Features
future Medicine The first 50 years of the NHS saw enormous advances in the technology of healthcare. The physician's medicine cabinet in 1950 was virtually bare and the only imaging available was a primitive X-ray. Today’s practice of medicine is incomparable and the speed of change isn’t likely to slow down says Steve Ginn as he looks at some of the key predictions for the future. Genetics and pharmaceuticals When Dr Francis Collins of the Human Genome Research Institute said that the Human Genome Project provided a tool to ‘uncover the hereditary factors to virtually every disease’ it was hard not to be impressed. We are rapidly realising that advanced genetic testing can pinpoint the cause of a disease so exactly that any condition will be considered an individual event and will have an individually tailored treatment. Being able to obtain a unique DNA signature for each patient will enable identification of disease susceptibility and optimal drug, vaccine or gene therapy treatment. Because of the enormous genetic variability between individuals, this leads to a corresponding variability in responses of patients to modern medical treatments. In the future, instead of wasting time on trialand-error treatment, physicians will be able to use a genetic test to identify patients with the most potential to respond to a drug. It may also be possible to combine genetic treatments with other technologies. Professor Sikora, a leading cancer researcher in Hammersmith Hospital, suggests that susceptible people may be able to be implanted with a ‘gene chip’ which would detect the earliest signs of genetic mutations that produce cancer. A patient could then check themselves with a home computer which could then contact the GP by email to arrange
an appointment for review. Nanorobots Nanotechnology, the control of matter on an atomic and molecular scale, is another big hope. The name comes from the microscopic scale at which this work is measured - by the nanometer. The field has its own journal ‘Nanomedicine’ and the latest issue discusses futuristic topics such as the advances in using nanotubes to fight bacteria and nanoparticles for cancer diagnosis and therapeutics. Expectations for a subspeciality of ‘Nanorobotics’ the technology of creating machines or robots on a nanometer scale - are even higher. Robert Freitas, senior research fellow at the Institute for Molecular Manufacturing in California, describes its development as one of humanities ‘greatest and most noble enterprises’. Once introduced to the body
“In the future, instead of wasting time on trial-anderror treatment, physicians will be able to use a genetic test to identify patients with the potential to respond to a drug.”
these ‘nanomachines’ will be able to repair cellular structures, isolate cancer cells on an individual basis and deliver drugs directly to specific receptors. Nanotechnology may even make indefinite lifespans for humans possible if it’s potential is fully realised. Sensors We’re used to sensors being all around us in our homes, cars, security systems and household appliances. In the future, sensors will be embedded in the walls and ceilings of our homes or even woven into clothing to monitor our health. Remote transmission of pulse rate and blood pressure from the homes of patients with chronic illness is already possible. New devices that can sense hypoglycaemia in diabetic patients and can differentiate between the odours produced by ear, nose and throat infections are nearly complete. This last technology has further applications in hospital infection control when combined with air monitors to detect and report any visitor who might transmit airborne infection. Bionics From the Cybermen in Doctor Who to the Borg in Star Trek, lovers of science fiction will already be well acquainted with alien races who are part machine. This technology is now being developed and has already found
some impressive applications. The most widely reported example is Mr Nagle, a man from Massachusetts, who was left paraplegic following a knife attack. He was fitted with a 4mm-square chip or ‘Braingate’ that reads signals from the primary motor cortex of his brain allowing him to open emails, play computer games and operate a prosthetic limb. The possibilities of ‘cyborg technologies’ appear almost limitless. As well as providing prosthetic limbs or restoring sight we could be seeing applications with the intent of enhancing the human body beyond its natural capabilities. Imagine for instance putting on a prosthetic suit and running from London to Manchester; or implants that could allow you see clearly at night. The Challenges of Technology Over the coming decades it is a certainty that technology will play an increasing role in the provision of healthcare. It is possible that with advances the doctor’s role will become obsolete - or perhaps we will find that our patients need our help more than ever to provide a friendly human face and a guide to the technologies on offer. More concerning is that given the budget difficulties of the NHS it may be just the rich who will benefit from the advances. It could leave a technologically poorer group in society who can’t afford the new healthcare and with a dramatically lower life expectancy and higher morbidity.
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JuniorDr Features
virtual doctors Medical training
in Secon
Forget those late nights on the wards grappling with real patients to perfect taking a history for the MRCP medical training is going virtual. Second Life, the online 3D world, is set to become the world’s largest medical training institution and, as Bertalan Meskó reports, it could change the way we view education entirely. Second Life is an online virtual world, a bit like a computer game where you play the lead character. Since it was opened to the public in 2003 it has grown explosively to more than 10 million ‘residents’. The main benefit of Second Life is that it makes it easier to communicate with people from around the world and to use videos, images, texts and web links at the same time. Until recently it was ruled by entertainment and casinos but now that gambling is forbidden Second Life has entered the golden age of education. The number of medical projects is growing rapidly benefiting from the ability to collaborate with people of the same field or interest from around the world. Second Life makes working together on projects easy as you can create links between in-world activity and real-world information resources. If you’re a patient, you can find people
> Ann Myers Medical School
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coping with the same problems as you, meet them virtually, discuss your problems and listen to doctors attending Second Life’s world. For doctors and medical students it makes it easier to educate with online presentations, tutorials and e-learning tools. You can do PubMed searches or browse among the many books of the virtual libraries. Virtual Medical School One of the earliest projects is the Ann Myers Medical Center - a virtual medical school - where medical education gets a unique opportunity to find new ways of training medical students. It was created to test the possibilities of virtual training for real world medical and nursing students. There are dozens of physicians, medical students and animators
behind this unique project who pledge their sparetime and money to this idea. AMMC currently has a voluntary staff consisting of consultant specialists, medical students and several nurses. The founder, Doctor Ann Buchanan (Second Life name), a US physician, envisions a hospital where medical students and nurses could be trained. Currently participants focus on patient history, physical examination and telemetry. A virtual mentor gives the students a disease process with which to familiarise themselves and they have to present it to the physician. Teaching is a passion, DoctorAnn told JuniorDr as she discussed the project in Second Life. “I went into medicine because I love to heal. The way medicine is, currently, physicians do not heal. I went into teaching because
> Heart Murmur Sim I love to open minds, but there again, my hands are somewhat tied - this allows me the avenue to both things I love and do them well,” she said. Named after her mother, Ann Myers who has a brain tumour the main goals of AMMC include
JuniorDr
nd Life
Sounds pretty complicated, what’s it all about? Second Life is a virtual world that allows ‘residents’ to interact with each other via avatars. Avatars are 3-dimensional characters that you can personalise to look like yourself - or someone completely different if you wish. At present there are just under 10 million residents in Second Life - about the same as the population of Sweden. So how do you win? Although many people compare Second Life to a computer game there are no points to win and no ‘baddies’ to kill. The main point of Second Life is to explore, play and socialise. One of the developers aims was to allow users the freedom to innovate and develop new uses for the virtual world. Casinos, shops and virtual medical schools have been developed since.
Features
REAL WORLD guide to Second Life
I’ve heard it’s made some people very rich? Just like the real world, Second Life has it’s own currency - the Linden Dollar. It also has a real world exchange rate so you can turn your Linden lolly into pocketable cash and vice versa. A few people have made substantial amounts of money from Second Life - last year saw the first person become a real-life millionaire from their ‘Second Life’. Land speculation and selling virtual goods have been a big earner, as have casinos - though gambling has since been banned in Second Life.
assisting trainee doctors to become more proficient in initial exam, history and examinations and in the analysis of MRIs, CTs and X-rays. For example, a student can right click on an ECG machine and be taken to a page where they will have to accurately diagnose the medical complication. AMMC also run training sessions for students and doctors. Recently on the 9th of August 2007 medical students from schools in the USA, Canada, Brazil, Germany and Hungary participated in a virtual event
where they had to analyse a patient history, microscopic blood film and lab results in order to find out the proper diagnosis. After formulating a differential diagnosis the trainee doctors met in a discussion group where a mentor asked questions about the medical condition and reasons for the differential. Training Opportunities Among the other educational opportunities in Second Life there’s the ‘Heart Murmur Sim’ where you can listen to cardiac murmurs, or the Virtual Neurological Education Centre which offers an online virtual environment for training and
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JuniorDr Features
Michelle Connolly takes a look at some of the latest gadgets (and a robot) that tech heads reckon we won't be able to practise without in the future.
Robodoc ward round Already used in many hospitals across the US, the RP (Remote Presence)-7 robotic system may look like an industrial-sized upright vacuum cleaner but it’s not - it’s a robotic doctor. The flatscreen monitor allows doctors to project their face and control robo-doc’s movement to the patient’s bedside from a workstation. It means consultants can make more than one ward round per day whilst not actually being on site. Evidence-based medicine has shown that 24-7 intensivist coverage in ICUs lowers mortality rates. Robo-doc has been used in hospitals to allow consultant doctors increased presence from home and to consult with patients and their team in the ICU. “Patients love it. I was very surprised how much they enjoy interacting with the robot,” Louis Kavoussi, vice chairman of urology at John Hopkins Hospital told JuniorDr.
> Genetics Island
Genetics Island One of the biggest projects in Second Life is a whole island dedicated to the education of genetics. On the several floors of the main building, you can watch 3D tutorials or simple videos of common genetic experiments. There’s genetics quizzes, virtual experiments, videos and plenty of links to genetic resources. If you get tired of the dozens of educational opportunities you can make test crosses with flowers
“In Second Life you have an immersive environment in which students can actually “do” experiments that produce analysable data.” Dr. Mary Anne Clark Creator Genetics Island
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outside in the garden. Dr. Mary Anne Clark from Texas Wesleyan University, the creator of the island, explained how she came up with the idea: “Well, first, I teach genetics in real life. Second, because so much of genetics is quantitative, it’s easy to simulate genetics experiments in Second Life. Third, one of the problems with teaching online courses is creating meaningful laboratories. In Second Life you have an immersive environment in which students can actually do experiments that produce analysable data,” she said. “I’d like Genome Island to serve as a place where students and other people can meet and talk with professional geneticists.” The future for the future Second Life provides virtually limitless educational opportunities for doctors and medical students. Although it should never be seen as a substitute to ‘real world’ medical education in certain circumstances it should serve as an additional e-learning tool. The problem of credibility is still there at present and that’s why it’s crucial for Second Life educators to validate themselves by showing their credentials and real life identity. These projects have made the first steps into developing medical education in the virtual world their hope is that Second Life will become a second place for doctors and medical students to develop their knowledge. Bertalan is a student at the University of Debrecen and author of www.scienceroll.com.
www.intouch-health.com/products-RP7.html#core
medical inventions
demonstrating neurological disorders. One of the most comprehensive medical sites in Second Life is the Medical Library at Health Info Island which provides support, health information and a growing virtual community. Play2Train is an area designed for training through interactive role playing with simulated cases like mass casualty accidents. Both the Red Cross and the Center for Disease Control and Prevention both maintain a Second Life site. NHS London too, has it’s own hospital in Second Life.
veinviewer Trouble finding a vein and too vain to ask for help? Then try VeinViewer. VeinViewer is an aide for IV insertion and routine venepuncture - especially in paediatrics where small veins can make the process more difficult. Infra-red light from the veinviewer detects haemoglobin and the computer projects a real-time image of the underlying veins directly onto your patient’s skin, so you can locate the vein to within 0.06mm. It is also useful in locating spider and varicose veins and visualising the progress of sclerosant through vessels during treatment of telangiectasias. http://www.luminetx.com/Healthcare/VeinViewer/tabid/60/Default.aspx
Mobile clinical assistant The Motion C5 is a ‘mobile clinical assistant’ (MCA), which lets you access patient records at the bedside and order tests in real-time. The digital camera takes photos of wounds and it is hoped that the built-in barcode reader will cut drug prescription errors by up to 70 percent. Current inaccuracies in prescribing are estimated to cost up to 40,000 lives a year in the NHS. Indeed, a senior doctor has described the C5 as one of the “most exciting developments in my 25 years in medicine”. www.intouch-health.com/products-RP7.html#core
ultrasound steth The background-noiseindependent quality of the ultrasound stethoscope is particularly useful in locations such as at a RTA where background noise can reach 80 dB. In fact you could even use it at the front row of a rock concert, which reaches an earcrushing 120dB. This futuristic steth sends a beam of ultrasound into the body and when it bounces off the heart or an artery, the resultant Doppler effect is converted into sound. www.usaarl.army.mil/
16 and individuals of Jewish descent. Extraintestinal manifestations at diagnosis may include smalljoint polyarthritis 'seronegative arthritis', erythema nodosum, clubbing and sacroiliitis. Endoscopic features of Crohn's disease include asymmetric disease, deep longitudinal fissuring, a cobblestone appearance and the presence of strictures. Crypt distortion, inflammation and granulomas may also be present. Acute therapy revolves around the use of corticosteroids, with the addition of 5aminosalycilic acid compounds with or without azathioprine as a steroid-sparing agent. Injectable antitumour necrosis factor (anti-TNF) compounds are also now finding an important role in the treatment of Crohn's disease. Surgical intervention should be avoided if at all possible.
1. C - Paroxysmal atrial fibrillation This man has paroxysmal atrial fibrillation as evidenced by his irregular fast tachycardia. Episodes of tachycardia in this condition may occasionally be precipitated by an excess intake of alcohol or caffeine. Other causes may be acute myocardial infarction, atrial septal defect, or preexcitation syndromes such as Wolff-ParkinsonWhite. Atrial flutter is associated with an absolutely regular rhythm of 150-220 bpm. Standard therapy for atrial fibrillation of recent onset is electrical cardioversion, providing there are no contraindications. Intravenous flecainide may be considered for chemical cardioversion in the absence of a history of ischaemic heart disease; amiodarone is an acceptable alternative. Long-term prophylaxis with agents such as 3. D - New vessels on the disc sotalol may be required. Background diabetic retinopathy consists of dot and blot haemorrhages and hard exudates. 2. E - Crohn's disease Patients do not need to be referred to the Crohn's disease has a prevalence of around 1 in ophthalmologist unless these are within 1 disc 1000, and is most commonly seen in Caucasians diameter of the fovea. This can be monitored
annually at the routine clinic. Cataracts appear about 10 years earlier in type-2 diabetes than in non-diabetic patients. If the vision is significantly affected the patients warrant routine and not urgent referral to the ophthalmologist. Soft exudates suggest retinal ischaemia, which would require routine referral to the ophthalmologist. New vessels anywhere in the fundus are a feature of proliferative retinopathy and, as new vessels have a risk of haemorrhage and can threaten sight, they should be referred urgently to the ophthalmologist. 4. C - Amiodarone The features are suggestive of an adverse reaction to amiodarone. The drug accumulates in many tissues, but dose-related pulmonary toxicity is the most important adverse effect. Skin deposits result in photodermatitis and a greyish-blue discoloration on sun-exposed areas. Amiodarone blocks the peripheral conversion of thyroxine (T4) to triiodothyronine (T3). It is also a potential source of large amounts of inorganic iodine. Treatment with amiodarone may
therefore result in hypo- or hyperthyroidism. Lithium blocks the endocytosis of monoiodotyrosine (MIT) and diiodotyrosine (DIT) by the follicular cells of the thyroid and so T3 and T4 are not formed and released into the circulation. Even at therapeutic doses of lithium, this may result in hypothyroidism. Chronic lead poisoning may occur due to exposure to leaded petrol. Lead poisoning does not cause skin discoloration but may give rise to blue lead lines in the gingival margins. Mercury poisoning is extremely rare nowadays. Key industrial applications of mercury are found in the manufacture of chlorine, electrical equipment and thermometers. Chronic poisoning from the inhalation of mercury vapour results in a classic triad of tremor, neuropsychiatric disturbance and gingivostomatitis. Methylmercury intoxication mainly affects the central nervous system and results in paraesthesias, ataxia, deafness, dysarthria and progressive constriction of visual fields.
What chemical is most probably responsible for his condition? A) Lead B) Mercury C) Amiodarone D) Lithium E) Prednisolone
Given this clinical picture, which is the most likely diagnosis? A) Ulcerative colitis B) Small bowel lymphoma C) Coeliac disease D) Tropical sprue E) Crohn's disease
Pharmacology A 45-year-old, petrol-station attendant complains of tingling and numbness in his hands and feet, breathlessness, lethargy, weight gain and fatigue. He is on treatment for an irregular heartbeat and for a bipolar disorder. On examination, a greyish-blue discoloration is noted on his face with slowing of peripheral reflexes.
Gastroenterology A 27-year-old woman attends for review. She has a past history of perianal abscess but nothing else of note. During the past few months she has twice presented to A&E complaining of grumbling abdominal pain. In addition, she has suffered intermittent episodes of bloody diarrhoea. Microcytic anaemia is found on blood testing and she has mild hypokalaemia. Albumin is reduced but other liver function tests are unremarkable. Barium imaging reveals a small bowel stricture with evidence of mucosal ulceration extending into the colon, interspersed with normal looking mucosa 'skipping'.
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What is the most likely diagnosis? A) Ventricular tachycardia B) Sick-sinus syndrome C) Paroxysmal atrial fibrillation D) Atrial flutter E) Sinus tachycardia Cardiology A 54-year-old man presents with an irregular tachycardia of around 130 bpm. He played in a cricket match the previous day and consumed 28 units of alcohol on the evening of the match. On examination his blood pressure is 95/50 mmHg.
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Which of the following is most likely to need immediate referral to the ophthalmologist? A) A few dot and blot haemorrhages B) Some hard exudates > 1 disc diameter from the fovea C) Cataract D) New vessels on the disc E) Two soft exudates in the temporal field Endocrinology A 54-year-old man, newly diagnosed with type-2 diabetes mellitus, presents to the clinic for his first assessment. He is found to have changes in his eyes on fundoscopy.
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Doctors across the country are abandoning their notepads, diaries and textbooks by instead putting some processing power in their pockets. Mohammed Al-Ubaydli offers some advice on choosing a handheld computer and the benefits it can offer. A handheld computer is a computer small enough to hold in your hand or fit in your pocket. For clinicians, it is arguably the bestdesigned computing device - particularly with newer models, known as smartphones, because they also work as mobile phones. There are many things you can do with a handheld computer. For example, the free software from Epocrates (www.epocrates.com) includes a formulary that is updated daily with dosages, indications and side-effects. The software also allows you to check for interactions between medications that your patient is prescribed whilst with that patient and their drug chart at the bedside. Use in hospitals Increasingly in the UK hospitals are investing in these devices to help clinical workflow. For example, MercuryMD’s software (www.micromedex.com) allows doctors to access patients’ full medical records during ward rounds and initiate investigations. MedHand (www.medhand.com) is selling textbooks including the BNF and the Oxford Handbook of Clinical Medicine. Connectivity to the Internet is great for continuing medical education allowing you to access evidence-based medicine resources like UpToDate (www.uptodate.com) and search P u b M e d (www.nlm.nih.gov/mobile) during ward rounds. What to buy? So what should you buy? The decision is whether to get a dedicated handheld computer, or a more advanced smartphone. Although the former is cheaper, the convenience of the latter means you should make the investment, especially as you’ll need a mobile phone anyway. Pick a smartphone with a keyboard - one that is built-in
rather than attached or unfolding. Also, make sure the keyboard has a key for all the alphabet rather than just the number pad with letters superimposed. This is important because you want to be able to type a lot - lecture notes, patient history, and jobs lists all benefit from easy typing. The trick to typing is to hold the smartphone with both hands and use your thumbs to do press the keys. Which operating system? Next decision to make is the operating system for your smartphone. This is the software on which other programmes can run. Microsoft Windows is the operating system of most PCs and has by far the most medical software available to run on it. The market is not so skewed for smartphones but the principle is the same and the Microsoft Windows Mobile and Palm Operating System have the most clinical software available. More recently, clinical software has become available for Blackberry devices, which are the gold standard for e-mail whilst on the move. Get organised Do not underestimate the power of the organiser software that is included. The address book allows you to track all the phone numbers for different wards and GP offices; the task
“During my house jobs we regularly beamed the hospital phone directory to new doctors; jobs lists during the handover to those starting their shift; lecture schedules as we learnt of new teaching sessions; and lecture notes to colleagues who were not able to attend.” list allows tracking of the jobs you have to do for patients every day along with their priority and time of completion; the diary stores teaching session timetables, including alarms before a session starts and easy setup of repeating sessions; finally, you can also store notes from each of these sessions.
my house jobs we regularly beamed the hospital phone directory to new doctors; jobs lists during the handover to those starting their shift; lecture schedules as we learnt of new teaching sessions; and lecture notes to colleagues who were not able to attend.
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Software You should budget around 100 pounds for extra software on top of what you spend on the device itself. Websites like Handango (www.handango.com) list software in categories including a medical one, and helpfully arrange downloads by popularity. But no matter how good the software seems to be you should not buy it immediately. Instead, use the trial version and test it out during your daily work to see whether it saves you time and is worth the money.
Beam to colleagues Many smartphones also allow you to share the information you enter with your team by ‘beaming’. To do this you simply line-up two handheld computers and select ‘beam’ from the menu. Information will be copied from your device to your colleagues. During
Whichever device and software you choose you will find, like many doctors already have, that having a smartphone is convenient for you and improves the care you deliver to your patients - that’s more than a simple phone can do! Mohammed Al-Ubaydli is author of ‘The Doctor’s PDA and Smartphone Handbook: A guide to handheld healthcare’ published by RSM Press. You can find out more at www.handheldsfordoctors.com.
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If you’ve been following this column then you’ll know my time in research is coming to an end. I’ve been here for nearly eighteen months and the MD was only supposed to last two years. I’ve finished many of my experiments with cardiac myocytes. Aside from them making a couple of new cytokines when stimulated with other cytokines, I haven’t found much. No new treatments. No life changing ways of treating patients with myocardial infarcts. The worst thing is that my research seems to have led to a dead end and if nobody follows it up then it will have been a waste of two years of my life. But at least I didn’t have to do any on-calls. I spend the afternoon writing up some more of my results. I’ve been trying to get to grips with the statistics software but have failed miserably for the past few months. I can barely work out standard deviations let alone do the complicated stuff. I leave early and head off home to put my feet up and watch a little television. There’s a documentary about the melting ice in the Antarctic and I fall asleep looking at penguins mating. Tuesday Back in the lab today to do one of my last experiments. My phone goes off and I answer it. I get a couple of dirty looks from my colleagues but ignore them. The board by the lab door has a list of ten rules of things not to do including eating, drinking, breathing and using your mobile whilst conducting experiments. I’ve managed to ignore at least six of them. The call is from James. He wants to know if I’m free for dinner and I say yes. He was supposed to be on call but has swapped out as a favour for someone else. The afternoon is spent writing up my results from the day. I leave by five and go straight home to wash the formalin smell out of my hair. I change into a little blue dress that he hasn’t seen yet and get to the restaurant on time. James is a cardiothoracic SPR whom I’ve been seeing for nearly four months - a long term relationship by my standards and things are moving very fast. The strange thing is that I’m not in the least bit scared. With his wind swept blond hair and rugged looks
he reminds me of an old 50’s movie star and for a heart surgeon he isn’t too nasty. Most of them make us cardiologists look like Bambi. We end up going to his place for dessert.
Wednesday I’m in early today as I’ve got a quick meeting about lab maintenance before my angio list in the morning. We talk about cleaning up the work surfaces and not spilling our coffee in the corridor. I try not to look bored. I leave and go straight into hospital where I spend the next three hours carrying out a variety of different procedures including two stents which are placed perfectly. After lunch I perform a few echoes and then help one of the medics put a temporary pacing wire in. I head back to the lab after work and spend a couple of hours a l o n e finishing off an experiment that is nearly completed. I leave around seven and write on the rules list before I turn off the lights. I get home, shower and have bowel of soup and a glass of Merlot before climbing into bed around ten. My parents call a little later and I let my voicemail get it.
Thursday I get into work a little late as I have no further experiments to do for the time being. Someone complains about a new eleventh rule on the board telling ‘scientists to stop complaining.’ I don’t protest my innocence. I try my hand at statistics all morning and make a small amount of headway. After lunch we have a couple of meetings regarding funding. The hard thing about science, aside from the small salary, is the fact that you keep having to put grants in to get funding for your work. We listen to a management consultant tell us that our main problem is that when we write grants we write them as if we’re handing in a scientific paper. Dry, boring and hard to read - a bit like most of my colleagues. The Professor comes in towards the end. He’s been away in Canada all week presenting a conference. He’s off to a few meetings but asks to meet him
tomorrow afternoon to discuss my thesis. Later, my phone rings and it’s James. We’re meeting for a drink and he’ll be a little late. I leave around six and go straight to the bar. He looks nervous all evening but I don’t push it. We go back to my place and after a couple more glasses of wine he asks me if I want to move in with him. I’m completely floored but badly want to say yes. Sometimes you just know. I tell him to let me think about it until tomorrow.
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The Secret Diary of a Cardiology SpR Names have been changed to try to keep our cardiology SpR in a job - though she’s doing a pretty good job of trying to lose it without our help!
Monday
Friday I get to work late and very happy. I can’t stop thinking about last night and know
already what my answer will be. I spend the rest of the morning teaching some medical students how to use a T-cell assay. Something I had never even heard of when I was their age. After lunch I carry on writing up my thesis. The Professor wants to meet me late, around four. I spend some time tidying up my work as no doubt he’ll want to see my latest draft. I pop into his office when he’s free. The place, as usual, is a complete mess. Papers everywhere and mugs of coffee on top of books on the floor. Messy office, clean mind is what I’ve often thought. He tells me about his time in Canada and that he’s been speaking to a friend about my work. He talks about what I’ve achieved so far and how I could potentially do so much more. I don’t see where he’s going with this until it’s too late. His friend, an Immunologist at the University of Montreal, has offered to pay for me spend an extra year with him. Complete my work and change the MD into a PhD. I tell him I need to think about it for a while and leave his office with my head spinning. A year in Canada would be a huge leap but also an amazing opportunity. One that is perhaps too good to turn down. My phone rings and I look at the caller ID. It’s James.
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Interview skills An overview of the selection process for entry into GP training
Courses
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Selection for GP training has become increasingly competitive over the years and the selection process has become more rigorous. The selection process consists of three core stages, which will take place between 5 January and 20 March 2008. Stage 1 - The application form The form merely requests information to determine whether you satisfy the basic eligibility criteria and will be made available through the national GP recruitment website at www.gprecruitment.org.uk from 5 January. Submission date: 20 January 2008. Stage 2 - The written exam Two 90-minute papers. The exam will take place on 9 February in various centres around the UK. Paper 1 - Clinical Problem Solving paper: 100 scenario-based questions in the MCQ and EMQ formats. The level of difficulty is set at junior doctor level. Paper 2 - Professional Dilemmas paper: 50 questions designed to test your behaviour when facing difficult situations. You are given a number of scenarios with a list of possible actions, which you must rank in order of suitability. Stage 3 - The selection centre A one-day selection centre consisting of three stations. This will take place between 3 and 20
March 2008. Station 1: Role play: a 20-minute consultation with a professional actor playing the role of the patient. This could deal with topics such as breaking bad news, explaining the management of a chronic condition, dealing with a difficult patient, etc. This station is testing your communication skills, ability to cope with pressure and lateral thinking abilities. Station 2: Group discussion: a 20-minute discussion with three other candidates, on a topic given before the session. This station is testing your communication skills and team playing abilities. Topics could include NHS issues, allocating budgets between different priorities, dealing with a complex patient scenario, dealing with difficult colleagues, etc. Station 3: Prioritisation exercise: 5 or 6 tasks to prioritise in writing. The tasks could include emergency situations, patient-related nonacute situations or even personal problems. You will be required to explain how you identified your priorities in an essay-type answer.
Prepare early for your GPST assessment with our full revision package. Five comprehensive books covering all aspects of the GPST recruitment (MCQs, EMQs, SJTs, role play, group discussions & prioritisation). Regular courses for Stage 2 & Stage 3 preparation. Small groups of 12 participants only, ensuring maximum participation. Book early. Courses fill quickly.
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Meetings for Trainees 15 January Cardiology Section Pulmonary hypertension 4 March Pathology Section President's prize 24 April Young Fellows Histopathology training day 6 May Orthopaedics Section President's prize papers
9 May Urology Section Geoffrey Chisholm communication prize
16 June Cardiology Section Heart muscle disease
21 May Comparative Medicine Section Section Young Fellows’ award meeting
26 June Young Fellows North & South Thames Histopathology training day: Marrow pathology and molecular diagnostics in haematopathology
5 June Young Fellows Histopathology training day - First years only 13 June Anaesthesia Section Prize presentations
11 July Cardiology Section Pre-op assessment and prize evening 17 September Cardiology Section Echocardiography 2
For further information please contact Marie Blythe on (+44) 020 7290 3846 or young.fellows@rsm.ac.uk
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JuniorDr Employment
Enrich your career. Enhance your quality of life. Practice medicine in rural British Columbia, Canada. Variety and challenge, the chance to make a difference in peopleâ&#x20AC;&#x2122;s lives, a lifestyle most people only dream about â&#x20AC;&#x201C; just a few of the advantages enjoyed by BCâ&#x20AC;&#x2122;s rural physicians. With its natural beauty, recreational opportunities, clean air and affordable housing, British Columbia offers a quality of life that is envied around the world. Create your future in rural British Columbia. Competitive compensation and benefit packages include signing bonuses, relocation travel, fee premiums, retention bonuses and continuing medical education assistance. For more information and to register, visit our website. Our experienced recruitment consultants can help you match your skills and lifestyle interests to the many exciting opportunities available.
Register today: www.healthmatchbc.org Please note: Specialists with postgraduate training from the UK or Ireland must hold the CCT/CCST or equivalent from the UK Higher Specialist Training Authority (Medicine or Surgery). Family Physicians/ General Practitioners must have a minimum of 2 years of approved and accredited post-graduate training.
Health Match BC is a province-wide physician, registered nurse and pharmacist recruitment service funded by the Government of British Columbia, Canada.
Locums
AUSTRALIA AND NEW ZEALAND Our client hospitals have vacancies for 2008 â&#x20AC;&#x201C; variable start dates available, some as soon as January. Australia and NZ offers a unique and fantastic environment to work as a doctor. Good orientation programmes are on offer and junior doctors are highly valued and appreciated. Talk to us about finding the best job in the right location for you, and the right support and expertise to move internationally. Register today www.genevadoctors.com - freephone UK to NZ 0800 051 6743, medical@genevahealth.com
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Finance
Financial Management Est. 1982 Accountancy
Mortgages
A member of The Capitax Group
Financial Planning
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.
Capitax Financial Management is an appointed representative of Personal Touch Financial Services Limited which is authorised and regulated by the Financial Services Authority. There will be a fee for mortgage advice. The precise amount will depend upon your circumstances but we estimate it to be ÂŁ195.00 *Higher lending charges may apply. Tax Planning is not regulated and **Buy to Let mortgages may not be regulated by the FSA.
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
Reach the UKâ&#x20AC;&#x2122;s junior doctors. Advertise here. Speak to Rob at JuniorDr on 020 7684 2343.
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JuniorDr The Mess
Dr Fairytale (B.H.S, M.&.S, R.S.V.P.) General Practitioner to the Stars
Ethical advisor Katie's hysterectomy - an ethical analysis
Medical Report - HAL 900 Background History HAL is an artificial intelligence, on-board computer of the spaceship Discovery featured in the film 2001: A Space Odyssey. HAL is usually represented only as his television camera ‘eyes’ that can be seen throughout the spaceship. Dementia Over the course of the journey to Jupiter HAL’s consciousness degrades. As is often seen in dementia recent memory goes first, leaving longer-term memory intact. HAL can be seen to regurgitate material that was programmed into him early in his memory, including announcing the date he became operational, or his birthday, losing all sense of the current date. Eventually HAL’s logic is completely gone, he begins singing “Daisy, Daisy, Give me your answer do ...” something clearly learnt in early infancy and not at all relevant to the Activities of Daily Living for a spaceship computer. As such, this is clearly a progressive decline in cognitive function due to damage to his ‘brain’ beyond what might be expected from normal aging. NICE guidelines would not favour using any anti-dementia drugs as his MMSE score is <12 and he doesn’t have any cholinesterase to inhibit. Cluster B Personality Disorder Bringing together dissocial PD (known to the Americans as antisocial personality disorder) narcissistic PD and emotionally unstable PD this is a collection of psychiatric conditions characterised by a common disregard for social rules and cultural norms. An individual will display impulsive behaviour and indifference to the rights and feelings of others. At the same time they will also continue to hold a belief that they have a special purpose and the right to judge others. As documented in the Space Logs while some of his passengers were outside HAL was seen to kill three hibernating scientists by deactivating their lifesupport systems. When asked why, HAL was heard to assert that the mission is ‘too important’ to allow anyone to jeopardise it. There is no cure for personality disorder but it would be prudent to suggest that HAL is no longer left to monitor the life-support
Assessed by Dr Gil Myers
systems on the ship.
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Red Eye A minor problem given that HAL is, clinically speaking, demented and dissocial. However, ‘red eye’ or ‘hyperaemia of the superficial blood vessels of the conjunctiva or sclera, caused by diseases or disorders of these structures or adjacent structures that may affect them directly or indirectly’ is not something to be ignored. As a spaceship computer, HAL would need full visual acuity and no photosensitivity. Normally a simple topical antibiotic would clear this up. It should be noted that cannabis is known to cause conjunctival reddening as well as psychosis and mood alteration. Before anything else it would be worth asking HAL for a sample for a urine drug screen. Or at least some oil.
Recently, the mother of Katie - a 15-year-old girl suffering from a severe form of cerebral palsy - asked doctors to remove the girl's uterus to prevent her from menstruating. Is this ethical? The ancient Greeks believed the uterus could roam around a young woman’s body, sometimes all the way up to the throat (think globus hystericus), causing hysteria and other unpleasant conditions. Over two thousand years later, the uterus is once again in the spotlight. A key question is whether the distress will be sufficiently profound to warrant a hysterectomy, with its associated risks and side-effects. That this question cannot be answered with any degree of confidence introduces a high level of uncertainty in the decision to operate. We simply do not know whether or not surgery will be in her best interests. My immediate response, when first reading the case, was to advocate a ‘watch and wait’ approach to see how Katie copes with this additional challenge. Perhaps, with time, she will not be as distressed as anticipated. Perhaps less invasive alternatives will work. Alternatively, menstruation could prove unbearable and a hysterectomy may be the best option. One source of controversy is that the surgery is not medically indicated. The short-term injury of a hysterectomy will be incurred without clinical benefits. This should rightly raise a red flag. “If it ain’t broke, don’t fix it” is generally wise advice. But what is the ‘it’ in Katie’s case? The uterus ain’t broke, but her mother would argue that it is her overall well being that is threatened. Clinical benefit is but one element of overall benefit. As psychological and emotional factors play key roles in our happiness, we should not reduce well being to the mere functioning of bodily organs. If we believe that one of medicine's aims is to reduce human suffering, then removing Katie’s uterus may be medically indicated. Others will
disagree with this interpretation of medicine, perhaps calling the hysterectomy, unhelpfully in my view, a form of mutilation. It is notoriously difficult to imagine what others are feeling. Studies show that chronically ill and disabled persons tend to rate their quality of life higher than healthy persons asked to imagine themselves in their situation. Our imaginations are prone to overestimate the dreadfulness of future or hypothetical states. Are we falling foul of this tendency when anticipating that menstruation will be awful for Katie, and will continue to be so no matter how accustomed she becomes to it? In such thorny cases, decisionmakers should make sure that all the relevant moral factors and plausible alternatives have been considered and that, whatever the decision, they can defend it with strong justifications. When this is done, it is often more helpful to support, rather than criticise, the decision-makers, for their own welfare is not infrequently bound with the decision and its outcome, and Katie’s happiness too cannot be entirely separated from the happiness of her mother. This article originally appeared, in a longer version, on the BBC News website.
Dr Daniel Sokol is a Lecturer in Medical Ethics at St George's, University of London, and Director of the Applied Clinical Ethics (ACE) course at Imperial College, London. There are four MPS bursaries for junior doctors to attend ACE 2008, starting in March. E-mail daniel.sokol@talk21.com for details.
Medical Ethics and Law - Surviving on the Wards and Passing Exams Sokol and Bergson £14.95 ISBN 0954765710
JuniorDr
TV dramas
The Mess
5 medical Top
Hospital 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 -
Ribena 288ml carton Childrens Ward (1989 - 2000) Granada Television (UK) Children’s Ward told the fictional life of patients and staff on a children’s ward filmed at the Royal Bolton Hospital. Aimed at children coming home from school it introduced many a wannabe doctor to a career in paediatrics over their afternoon milk and cookies. Despite winning a BAFTA in 1996 and being retitled ‘The Ward’ it ended in 2000.
Written by junior doctor Jed Mercurio, Cardiac Arrest was the UK’s gritty alternative to Casualty. Part comedy, part political and part thriller it portrayed life as a doctor in it’s raw uncaring state controversially showing unstable relationships, suicide and racist staff all at once.
55p
They think you’re doughnuts at St Thomas' Hospital London
WOW!
55p
Tell Homer Simpson about Newham General Hospital Newham
40p
Pocket-sized packet of Kleenex Just hope you don’t catch a cold Royal Berkshire Hospital Reading
WOW!
45p
Prices not to be sneezed at Royal London Hospital London
35p
LOW!
Next issue we’re checking a small hot chocolate (takeaway), toasted cheese sandwich and a banana. Email prices to team@juniordr.com.
Which mess is the best?
Cardiac Arrest (1994 – 1996) BBC (UK)
Enjoy a nice cold drink at Royal Free Hospital London
LOW!
Casualty (1986 - present) BBC (UK)
This multiple Emmy winning slapstick medical comedy sees life in Sacred Heart, a teaching hospital, through the eyes (and dreams) of John Dorian played by Zach Braff. It was advertised in the US as ‘half as long as ER and twice as funny’.
79p
A plain doughnut
ER is America’s longest running primetime medical drama set in the fictional Cook County General Hospital. Written by Michael Crichton, part filmed by Steven Spielberg and starring George Clooney - emergency medicine has never been so sexy. The series is reportedly due to end next season.
Scrubs (2001 - 2007) NBC (USA)
WOW! LOW!
ER (1994 – present) NBC (USA)
It may be more sedate that it’s American rival but who wants heartburn whilst eating their takeaway on a Saturday evening? Casualty is the world’s longest running medical drama with an impressive 602 episodes and shows no sign of ending just yet.
Enough to turn you purple at Queen Elizabeth II Welwyn Garden City
> Trafford General Hospital, Manchester
What it’s got “The Mess has a newly decorated lounge, which includes a television and snooker table. Adjacent to the mess, a quiet area for study is available with PC, printer and Medline Search facility and CD-ROM texts (a lap top and CD-ROM can also be borrowed). The Doctors also have their own dining area where Barbara the waitress serves breakfast and lunch. Outside these times, ‘Trafford Fayre’, the main hospital dining room is open between 8.00am and 7.00pm. In the restaurant foyer vending machines sell snacks, drinks and chilled foods. The latter may be reheated in the adjacent microwave ovens.” JuniorDr Score - 2/5
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