juniordr issue 25
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The magazine for junior doctors by junior doctorsTRANSCRIPT
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LATEST NEWS
LoNdoN 2012 HEALTH FACTS
LONDON’S LEgaciES LoSt?
THE mEdiciNE bEHIND THE MEDALS
PRACTICE IN SafE prEScribiNg
COURSES AND coNfErENcES
O n July 27 the world’s greatest sporting event comes to London. As 10,500 ath-letes from 204 nations compete, an estimat-
ed four billion of us will take to our sofas to watch the Games at home.
Everything about London 2012 is record breaking - from the world’s largest McDonald’s serving 1,500 at any one time to the 350 tons of vegetables which will be consumed. We’ve collated the most impressive health facts about the Olympics on page 8.
No other single sporting event will have such an impact on health. The ambitions for London 2012 from its inception were to provide a national sport participation and physical activity legacy - the first Games ever to have such ideals.
The Labour government at the time promised to get one million more adults participating in sport three times a week by 2013 - a tar-get which has been dropped since by the coalition.
But with less than two months to the start of the Games, London is heading towards a story of unfulfilled promises and of legacies lost says Professor Mike Weed in our feature ‘Is the health legacy of London 2012 lost?’.
Will London 2012 be the first Games to have tried and failed to deliver a national sport participation and physical activity legacy? Read Professor Weed’s view on page 9.
As well as the public health impact we bring you the story of the medics behind the medals. Hundreds of doctors are involved in the organisation of the Games and in maintaining peak performance of the athletes.
Dr Richard Budgett is Chief Medical Officer to London 2012. We caught up with him before his appointment to talk about sports and exercise medicine in the UK and his role in leading medical cover (page 12).
With the world’s greatest sporting event the Olympics also bring a major public health and sports medicine challenge. If you’re one of the hundreds of junior doctors who have volunteered to help provide medical cover for the Games we wish you a fantastic event.
Good luck London 2012!
thE mEdiciNE bEHIND THE MEDALS
NEWS PULSE4
tell us your news. Email [email protected] or call 020 7193 6750.
82% of junior doctors vot-ed for outright strike action in the recent
BMA ballot - a higher number that all other branches of practice - published results show.
Of 11,113 who replied to the bal-lot an even higher 92% said they would get involved in industrial action short of a strike. However, turnout among junior doctors was among the lowest of all profes-sional groups at just 39.5%.
Industrial action, short of a formal strike, will take place on Thursday 21 June and will involve doctors only provid-ing cover for non-urgent cases. The BMA argues that the latest pension changes will see doctors paying up to 14.5 per cent of their salaries in pension contributions - twice as much as some other public sector staff. They will also have to work up to the age of 68 in order to receive their pension.
“This is not a step that doctors take lightly – this is the first industrial action doctors have taken since 1975,” said Dr Hamish Meldrum, Chairman of Council.
“We have consistently argued that the Government should reconsider its posi-tion, and even at this stage we would much prefer to negotiate a fairer deal than to take action. We are not seeking preferen-tial treatment but fair treatment. The gov-ernment’s wholesale changes to an already reformed NHS pension scheme cannot be justified.”
The BMA has confirmed its intention for further action if necessary after June 21.
www.bma.org.uk
4 IN 5 JUNIOR DOCTORS vOTE FOR A StrikE oN JuNE 21
INDUSTRIAL ACTION
WORKING CONDITIONS
J unior doctor pressure group RemedyUK has closed citing unsustainable manage-ment and leadership as the reason.
RemedyUK was formed in 2007 fol-lowing the mismanagement of the Medical Training and Application Service (MTAS) and exposed unfairness in the matching process and lapses in data security.
As well as political lobbying and mount-ing a legal challenge against the government it succeeded in organising a protest march of 12,000 people to Westminster.
In a statement on the RemedyUK web-site they said:
“We are immensely proud of everything that our small committee and 12,000 sup-porters have managed to to achieve during this time. Remedy was about providing the legitimacy and security to passionate med-ics who wanted to challenge the views of the establishment.”
They expect £2,000 will be remaining from all assets which will be donated to the Medical Benevolence Fund. www.remedyuk.org
rEmEdyuk cLoSES AFTER FIvE yEARS
WHAT THE PAPERS ARE SAyING?
“Doctor, doctor: why is my GP going on strike? Because a £53,000-a-year pension deal isn’t enough...”MAY 31
“Thousands of doctors ‘will defy’ the order to strike as they are deeply op-posed to action”JUNE 1
“A doctors’ strike puts the ethos of the NHS at risk”JUNE 2
N HS hospitals in England are owed as much as £40m in outstanding fees for the treatment of foreign nation-
als, according to an investigation by GP magazine Pulse.
Currently, when foreign nationals are not eligible for NHS care they, their insur-ers or their country of origin is approached for payment.
Of the 35 acute trusts who replied to the investigation the average unpaid debt for the provision of care to foreign nationals was £230,000. Extrapolated across all 168 trusts in England it puts the total owed to the NHS by foreign nationals at £40m.
St George’s Healthcare Trust in London had the largest outstanding debts, totalling £2m from treatment of foreign nationals from April 2009. Barnet and Chase Farm Hospital was next with £488,000 outstanding.
“A high percentage of our patients require life-saving trauma, neuroscience, cardiovascular or paediatric care. We’re working hard to improve the way we record overseas patients and the debt recovery rate,” said a spokesperson for St George’s.
The most inefficient trust in collecting money was Royal Wolverhampton, which collected only 24% of the £419,000 owed, followed by Newcas-tle-upon-Tyne, which collected 36%.
Dr Richard Vautrey, deputy chair of the BMA’s GP committee, said:
“Hospital trusts must put in place arrange-ments that ensure people cannot exploit the sys-tem. However, we need to be careful that we are not putting barriers in place that prevent people from getting access to healthcare. It can be quite challenging. It is too simplistic to call it health tourism. The reality is a lot more complex.”
www.pulsetoday.co.uk
O ne in 20 prescriptions written by GPs con-tains an error, according to a major study of GP prescribing by the GMC.
The study of practices in England found that while most errors were classified as mild or mod-erate, around 1 in every 550 prescriptions contain A serious error which could have resulted in seri-ous harm.
The most common errors were missing infor-mation on dosage, prescribing an incorrect dosage,
and failing to ensure that patients received neces-sary monitoring through blood tests.
“We will be leading discussions with relevant organisations, including the RCGP and the CQC, and the Chief Pharmacist in the Department of Health, to ensure that our findings are translated into actions that help protect patients,” said Pro-fessor Sir Peter Rubin, Chair of the General Medi-cal Council.
A number of factors were found to be associat-ed with increased risk of prescribing or monitoring errors. They included the number of medicines a patient was taking - there was a 16% increased risk of error for each additional medicine.
Children and those aged 75 years and old-er were almost twice as likely to have an error as those aged 15-64 years.
The research recommends a greater role for pharmacists in supporting GPs, better use of com-puter systems and extra emphasis on prescribing in GP training.
www.gmc-uk.org
1 IN 20 gp prEScriptioNS HAS AN ERROR PATIENT SAFETY
‘NhS touriStS’ OWE £40M IN UNPAID FEES NHS
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“We will be leading discussions with relevant organisations, including the RCGP and the CQC, and the Chief Pharmacist in the Department of Health, to ensure that our findings are translat-ed into actions that help protect patients,”
NEWS PULSE6
P rivate providers of GP out-of-hours services are more expensive and rat-ed worse by patients than those deliv-
ered by not-for-profit and NHS alternatives, according to analysis by Pulse.
The study looked at five indicators across 81 out-of-hours services - 32 pro-vided by not-for-profit organisations, 27 in house by the NHS and 22 by private firms.
They found that whilst companies often matched the performance of not-for-prof-it and NHS providers on the National Qual-ity Requirements, under which contracts are monitored, they fell significantly behind on patient satisfaction scores.
Private providers were paid an average of £8.11 per head compared with £7.39 for not-for-profit organisations and £9.10 for NHS providers. However, just 59.5% of private ser-vices were rated good or very good by patients, compared with 65% for not-for-profit services and 64.7% for the NHS.
Harmoni, the country’s largest out-of-hours provider, performed significantly below average not only on patient satisfaction but on key requirements to assess urgent cases within 20 minutes and see them face to face within two hours.
The Primary Care Foundation said there was too much focus on fulfilling National Quality Requirements, and urged commis-sioners to also consider patient satisfaction, audits of clinicians and integration of services.
Commenting on the results Richard Hoey, editor of Pulse, said: “Private out-of-hours companies have increasingly taken over from the old-style GP co-ops, and yet our analysis suggests the private sector is not only perform-ing worse, but is more expensive.”
www.pulsetoday.co.uk
M edical schools which use the UK Clin-ical Aptitude Test (UKCAT) as part of their admission process reduce the
disadvantage faced by those in lower socio-economic groups, according to a study pub-lished in the BMJ.
Researchers at Durham University looked at 8,459 applicants to 22 UK medical schools which used UKCAT as part of their admis-sions process.
They found that candidates from under-represented groups applying to medical schools which relied upon the UKCAT heav-ily in making their admissions decisions did not suffer significant disadvantage.
“Our findings suggest that placing an
increased weight on an applicant’s UKCAT performance significantly reduces the disad-vantage faced by most candidates from under-represented sociodemographic groups,” say the team led by Dr Paul Tiffin.
The UK Clinical Aptitude Test (UKCAT) was developed in 2006 and assesses skills such as verbal reasoning and decision analysis. It is designed to ensure that candidates have the most appropriate mental abilities for a career in medicine.
At present only around 5% of entrants to medical school have parents from non-profes-sional backgrounds.
www.bmj.com
aptitudE tESt IS FAIRER WAy TO SELECT FOR MEDICAL SCHOOL
MEDICAL STUDENTS
privatE out-of-hourS firmS RATED WORSE THAN NHS PROvIDERS
NHS Night shifts double cancer risk
Working night shifts more than
twice a week is associated with an in-
creased risk of breast cancer, accord-
ing to a long term study published
in Occupational and Environmental
Medicine. The study of 18,500 wom-
en found that night shift work was as-
sociated with a 40% increased risk of
breast cancer compared with no night
shifts. One in ten of the European
workforce currently work night shifts.
oem.bmj.com
Whistleblowing process not working
‘Fear of consequences’ is the most
common reason (49%) why doctors
believe the current ‘whistleblowing’
process is not effective. The survey
of 1500 members of the Medical Pro-
tection Society also found that where
doctors had raised concerns about
patient safety less than 40% felt their
concerns had been addressed.
www.mps.org.uk
Old people smell nicer
The smell of old people is less un-
pleasant and less intense than young
and middle-aged people, according
to a study at Monell Chemical Sens-
es Center in Philadelphia. The blind-
ed study looked at the odours gathered
from pads worn by volunteers for five
days. Contrary to popular opinion old-
er people were generally accepted to
have more neutral and pleasant smells
than their younger counterparts.
www.plosone.org
Measles deaths drop 74%
Deaths from measles have
dropped by 74% worldwide since
2000 according to a report by the
WHO published in The Lancet. To-
tal global deaths from the disease
dropped from 535,300 in 2000 to
139,300 in 2010 - but still below
the 90% reduction target. 40% of
all measles deaths in 2010 occurred
in India where vaccination rates are
among the lowest in the world.
www.who.org
NEWS PULSE 7
A third of in-hospital cardiac arrests and subsequent attempts to resus-citate could have been prevented,
according to the latest National Confiden-tial Enquiry into Patient Outcome and Death report.
Better assessment on hospital admission, and recognition and response when acutely ill patients deteriorate could have prevented cardiac arrest and the subsequent resuscita-tion attempts in a third of cases.
The report showed that patient assess-ment on admission was deficient in 47% of cases, and there were warning signs that the patient was deteriorating and might arrest in 75% of cases.
However, the warning signs were not recognised in 35% of those patients, not acted on in 56% and not communicated to senior doctors in 55% of cases. NCEPOD Advisors found a lack of input from senior
clinicians in the 48-hours prior to cardiac arrest.
“Senior doctors must be involved in the care planning process for acutely ill patients at an earlier stage, and support junior doc-tors to recognise the warning signs when a patient is deteriorating,” said report author and NCEPOD Lead Clinical Co-ordinator Dr George Findlay.
“The lack of senior input fails patients by both missing the opportunity to halt dete-rioration and also by failing to question if CPR will actually improve outcome.”
The report, Time to Intervene?, calls for improvements in recognition and response to patient deterioration. It also recommends advance decision-making around what care is likely to benefit acutely unwell patients, including do not attempt cardiopulmonary resuscitation (DNACPR) decisions.
www.ncepod.org.uk
JuNior doctorS uNSupportEd WHEN DEALING WITH DETERIORATING PATIENTS
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LoNdoN 2012 oLympicSH E A L T H F A C T S A N D F I G U R E S
68,000 PEOPLE ARE ExPECTED
TO bECOME SO INTOxICATED
THEy WILL NEED MEDICAL
INTERvENTION 6 CONDOMS PER ATHLETE WERE PROvIDED IN bEIJING
2008 – A DECREASE FROM 8 IN PREvIOUS GAMES
THE PURPOSE-bUILT POLyCLINIC HEALTH
CENTRE WILL LATER
bE CONvERTED
INTO A HEALTH EDUCATION CENTRE
FOUR bILLION PEOPLE – 2/3 OF THE WORLD’S
POPULATION – ARE
ExPECTED TO bECOME Tv COUCH
POTATOES DURING THE
TWO WEEk EvENT
THE ONSITE MCDONALDS - THE WORLD’S bIGGEST - WILL
SEAT 1,500 AT ANy ONE TIME
IN ANCIENT GREECE ATHLETES ATE MAINLy CHEESE bEFORE THE GAMES,
IN LONDON THEy’LL
EAT 350 TONS OF
vEGETAbLES AND
100 TONS OF MEAT
ONLy THREE COMPANIES WILL bE AbLE
TO ADvERTISE INSIDE THE vENUES
– MCDONALDS, COCA COLA AND CADbURy
ExTRA-LONG bEDS HAvE bEEN ORDERED FOR SOME TALLER ATHLETES
oLYMPIC MEdICINE 9
LoNdoN 2012
Professor Mike Weed
dIRECToR of ThE CENTRE foR SPoRT, PhYSICAL EdUCATIoN ANd ACTIvITY
RESEARCh (SPEAR) CANTERbURY ChRIST ChURCh UNIvERSITY
IS THE HEALTH LEGACy OF
ALREADy LOST?Will London 2012 be the first games to have tried and failed to deliver
a national sport participation and physical activity legacy? Professor Mike Weed, director of the Centre for Sport, Physical Education
and Activity Research (SPEAR) at Canterbury Christ Church University, believes it may be.
oLYMPIC MEdICINE10
F rom the ambitions of the final bid presentation that secured the 2012 Olympic and Paralympic Games for London, through the legacy promises made in the previous Labour government’s action
plan, the sporting, social, cultural and economic devel-opment legacies have been referenced many times in Olympic planning.
Labour’s legacy action plan and the coalition govern-ment’s more recent priorities each appear to give billing to legacies in different areas however, the sport participation legacy is undoubtedly ‘first among equals’ in the minds of the IOC, LOCOG and the UK media.
In Singapore in 2005 Lord Coe, Chair of the London Organising Committee for the Olympic and Paralympic Games (LOCOG), secured the 2012 Games for London with a final bid presentation that included a promise to inspire a new generation to choose sport.
Yet, as the popular press is fond of reminding us, no pre-vious Games has succeeded in raising participation in sport and physical activity. Systematic review of previous multi-sport events in the BMJ in 2010 concluded that “the avail-able evidence is not sufficient to confirm or refute expec-tations about the health of socio-economic benefits for the host population of previous major multi-sport events” (McCartney, et al, 2010).
However, this is not the full picture. Whilst it is true that no previous Games has resulted in sustained increases in sport and physical activity participation in host popula-tions, no previous Games has attempted to raise population levels of sport and physical activity participation.
SPORT PARTICIPATION
Participation data has merely been examined afterwards to explore whether Olympic and Paralympic Games have passively affected participation levels. As such, and as noted by the authors in their conclusions, the 2010 BMJ review should be interpreted to mean that there is no evidence for an inherent sport and physical activity participation legacy effect, in which benefits occur automatically from hosting an Olympic and Paralympic Games.
So what does this mean for London 2012? Was it rea-sonable to suggest that a sport and physical activity par-ticipation legacy could be possible? In short, yes. The lack of evidence for sustained population level effects follow-ing previous Games which did not attempt to deliver sport and physical activity legacies is not an indication that such a legacy could not be leveraged from the Lon-don 2012 Games.
In fact, a worldwide systematic review of the research evidence, conducted by SPEAR for the Department of Health (Weed et al, 2009), shows that there is evidence that mechanisms associated with Olympic and Paralym-pic Games have had a positive effect on sport participation where specific initiatives have been put in place to leverage such participation.
Such initiatives have however not been on a large enough scale to effect population levels of sport and physical activity
participation, hence the lack of evidence for an inherent effect found in the BMJ review.
The DemonsTraTion effecT
SPEAR’s review for the Department of Health provides evidence for two mechanisms which could be scaled up to affect population levels of sport and physical activity par-ticipation. The first of these is the Demonstration Effect, whereby people are inspired by elite sport, sport events and sportspeople to participate themselves.
However, and most importantly, the Demonstration Effect only works with those who are already positively dis-posed towards sport. As such, it can encourage those who participate a little to participate a little more, or encourage those who have participated in the past to participate again.
What it does not do is get those who do not and never have participated in sport to start playing. The problem is that people can feel daunted, they see someone like Kelly Holmes winning double Olympic gold and think that is so far removed from what they feel they could do, that it’s not even worth trying. This is called a competence gap.
A FESTIvAL EFFECT
For those that are not sporty, a second effect can be har-nessed; a Festival Effect. A Festival Effect taps into an indi-vidual’s sense of community and desire to be part of some-thing bigger than and beyond the sporting competition, and can be leveraged by emphasising the cultural and cre-ative value of the Games, and not mentioning sport at all.
This has the potential to reach the less active or even the sedentary, but for it to work, initiatives must be rooted in local cultural and community activities and tap into pre-exisiting ‘value hooks’ such as family or eco values.
One example might be the use of the commitment some individuals’ have to green values, which can be matched with the sustainability agenda of the 2012 Games, to get people involved in initiatives that clear and enhance local parkland, thus getting such people active, almost without them realising it.
“PoPULATIoN LEvELS of SPoRT PARTICIPATIoN IN ENGLANd hAvE
INCREASEd bY AN AvERAGE of oNLY 38,000 A YEAR ovER ThE LAST ThREE YEARS.”
“No PREvIoUS GAMES hAS SUCCEEdEd IN RAISING PARTICIPATIoN IN SPoRT ANd
PhYSICAL ACTIvITY.”
oLYMPIC MEdICINE 11
IS THE HEALTH LEGACy OF LoNdoN 2012 ALREADy LOST?
GETTING THE MESSAGE RIGHT
The key, however, is to ease up on health and exercise messages, and in particular to tone down what might be called ‘finger wagging’, especially where it is directed at the less active and sedentary.
Among such people, messages that are overtly about the science of health and exhorting people to become healthier fall on deaf ears, as the less active and sedentary are wholly fed up with being told they are unfit and unhealthy, and so tend to disconnect from the content of such messages.
So, armed with this evidence, surely good progress must be being made towards delivering a sport and physi-cal activity legacy from the London 2012 Games? Well, unfortunately not. Evidence from the largest and most robust survey of sport participation habits ever conduct-ed, Sport England’s Active People Survey, suggests that population levels of sport participation in England have increased by an average of only 38,000 a year over the last three years.
The problem appears to have been that, although evi-dence suggests that London 2012 could have boosted the nation’s sport and physical activity participation given the right strategic approach and investment, there is little indi-cation that policy has been based on evidence.
Instead, legacy aspirations have been pinned on the hope that there will be an inherent inspiration effect from the Games. The government’s Mass Participation Lega-cy Plan, Places People Play, focuses almost solely on sup-ply: of facilities, of fields, of leaders, and of opportunities. However, this is not Field of Dreams - there is no evidence to suggest that if you build a sport supply infrastructure, people will come.
a lack of progress
In short, the lack of progress towards delivering a sport and physical activity participation legacy from the London 2012 Games is a policy failing, in which legacy strategy has not been informed by the available evidence.
Nevertheless, a policy failing is not one of the explana-tions that have been respectively offered by Lord Coe and Jeremy Hunt, the Culture Secretary. Lord Coe has recently suggested that the Active People Survey is not capturing the
sport participation legacy, and that it is not to be trusted because Sport England, who commission the survey, have “singularly failed”.
As alternative evidence, Lord Coe suggests that ‘if you speak to [the British Cycling performance director] Dave Brailsford he will tell you he’s got half a million more cyclists than pre-Beijing’.
However, the Active People survey provides official National Statistics, and since 2005 has been carried out on behalf of Sport England by two of the most respected market research companies in the UK, IpsosMORI and TNS-BMRB.
Each year it has a sample size exceeding 175,000, which provides accuracy to within 0.2%. The same cannot be said of the anecdotal view of a national performance director, however genuinely-held it may be.
A LEGACY LOST?
In contrast to Lord Coe, Jeremy Hunt has not sought to explain the lack of progress towards a sport and phys-ical activity legacy by suggesting that National Statistics are flawed. Rather he has suggested that the wrong legacy target was set by the previous Labour government, which promised to get one million more adults participating in sport three times a week between 2007/8 and 2012/13.
This target has now been dropped by the Coalition gov-ernment because Mr Hunt says that a ‘more meaningful national measure’ is required. However, with less than 50 days to go to the start of the Games, a ‘more meaningful national measure’ has yet to be announced. Consequently, and somewhat conveniently, there is currently no nationally endorsed success indicator against which government policy to deliver a sport and physical activity participation legacy can be judged.
With almost no time left to enhance the impact of the 2012 Games on sport participation, it seems that London is heading towards a story of unfulfilled promises and of lega-cies lost. In which case, London will have the somewhat ignominious honour of being the first Games to have tried and failed to deliver a national sport participation and phys-ical activity legacy.
FURTHER READING
McCartney et al (2010). The health and socioeconom-ic impacts of major multi-sport events: systematic review (1978-2008). BMJ 2010;340: c2369
Weed et al (2009). A Systematic Review of the Evidence Base for Delivering a Physical Activity and Health lega-cy from the London 2012 Olympic and Paralympic Games. Department of Health.
“ThE LACk of PRoGRESS ToWARdS dELIvERING A SPoRT ANd PhYSICAL
ACTIvITY PARTICIPATIoN LEGACY fRoM ThE LoNdoN 2012 GAMES IS A PoLICY fAILING.”
oLYMPIC MEdICINE12
H is personal achievements in sport include assisting Sir Steve Redgrave to the first of his five consecutive gold medals winning the Men’s Coxed Fours at the 1984 Los Angeles Olympic Games. He is currently Chairman of
British Association of Sports and Exercise Medicine (BASEM) and Lead Physician EIS South East.
JuniorDr’s Ivor Vanhegan spoke to Richard Budgett about his career and the future of sports medicine in the UK.
What was your general medical training that lead to your career in Sports and Exercise Medicine?
After completing my medical degree at the Middlesex Hospital I quickly chose a training path in general practice with a view to going into some form of sports and exercise medicine (SEM). I was a keen rower and wanted to see how I could get involved in sports as a doctor. I completed a diploma in sports medicine which was being offered at that time by The Royal London Hospital. I had previously done some research at the newly opened British Olym-pic Medical Centre in Northwick Park Hospital during my first year of GP training which had concreted my interest in the field. That led to my continued research interest into fatigue and under-performing athletes which has now become known as ‘unexplained underperformance syndrome’.
Initially I split my time 50:50 between General Practice and Sports Medicine but in 2004 I went full time into SEM. I was the Director of Medical Services for the British Olympic Association from 1994-2007. I have also been the Chief Medical Officer with Team GB at the last six summer and winter Olympic Games in Atlanta, Nagano, Sydney, Salt Lake City, Athens and Turin.
What aspect of athlete treatment are you involved with: general physical wellbeing or only musculo-skeletal injury?
There is an increasing body of evidence to say that the two go hand in hand. Taking a common cold as an example: as well as ade-quate treatment of the symptoms one must consider isolation from other members of the squad, when and to what extent the indi-vidual can return to training and how to implement preventative measures for the future.
As a growing specialty we can only base our decisions on pre-sumed best practice and available evidence, however, taking this holistic approach does appear to be working. Certainly more rigor-ous research in the area is required and we rely on journals such as the British Journal of Sports Medicine to increase the evidence base.
What is the current situation of SEM Training in the Uk?Things have progressed enormously in the last few years since
SEM training officially started in London in February 2007. The training programme currently has 16 places with four ST3 vacancies annually; there are a further 16 ST posts nationwide.
The programme runs from ST3 to ST6 with applicants main-ly coming from Core Medical Training but also from General
Practice Training posts and ACCS trainees. Now that the special-ty is affiliated to two Royal Colleges, has formalised training and is increasing research, I feel the UK has become a leader in SEM and has overtaken the likes of Australia and The United States in this regard.
How can an interested trainee get involved in SEM?Before making the commitment to something like the diplo-
ma I would first suggest immersing yourself in the profession to see if it is right for you. Getting involved in sports medicine in any capacity is always a bonus and assisting as a paramedic doing crowd work is always a good place to start. From there I would highly recommend any of the introductory weekend courses run by BASEM to provide a good idea of what’s involved.
What is your role for London 2012?In February 2007 I was appointment Chief Med-
ical Officer for the 2012 games in London. Unusu-ally for me this meant I spent my entire time at the Beijing 2008 Olympic Games more as an observer than actually as a treating doctor.
My general remit is to ensure the safe medical care for the athletes themselves, their coaches and auxiliary staff, specta-tors, dignitaries and anyone else who is present at the Games. The num-bers run into the many thou-sands which presents a logistical challenge.
Furthermore, you have to consider that the Games will be spread over 36 sites: the main Olympic Park in Stratford, tennis in Wim-bledon, Triathlon in Hyde Park, Rowing in Dorney Lake Eton, sailing in Wey-mouth, and the football at multiple locations around England, Scotland and Wales with the final in Wembley.
In effect we will be setting up a polyclinic within the Olym-pic Village with MRI, CT, x-ray and diagnostic ultrasound facili-ties available. There will be some of the country’s top musculo-skeletal radiologists on hand as well as other appropriately trained senior doctors to provide immediate and expert advice.
The Homerton Hospital in East
THE mEdiciNE bEHIND THE MEDALSIn the field of sports medicine there is no greater ambassador than Dr Richard Budgett. He has been the Chief Medical Officer to Team GB for the past six consecutive Summer and Winter Olympic games and is the current CMO to the London Olympics in 2012.
oLYMPIC MEdICINE 13
London will be the main referral centre for athletes at Stratford, and University College London Hospital for those closer to cen-tral London.
We have ensured that they will have a fast, efficient and discrete service to fast-track them to the relevant services they require in each of these hospitals to ensure optimum care. The Royal London will be the port of call for major trauma.
you must have come across so many weird and wonderful things given the breadth of your work?
It’s the constant variation that makes this such a brilliant career to go into. One particular event I can recall was when I was at the Beijing Games. As I mentioned I was only meant to be there in an overseeing capacity and not as a treating doctor.
There was one occasion however, when I was out at the rowing venue which was near the Great Wall of China. The family of an athlete who had recently won a medal were caught in a freak thun-der storm and they all sought refuge in one of the towers.
Due to bad luck the tower was hit by lightening and everyone inside sustained a mild shock but about three people were affected more severely.
Unfortunately, one of those hit was the brother of this athlete who, for reasons better known to himself, had chosen not to wear any shoes. As you can imagine, the lightening was able to pass straight through him and knocked him out cold for well over a minute.
As the nearest British medic on hand I saw him 30minutes later and had to rack my brains as how to and manage victims of light-ening strikes. I must admit it had been some time since I’d even read up on what to do in such circumstances but am pleased to report that he made a full and uneventful recovery.
With special thanks to Lynn Morris, medical administrator at Bish-am Abbey.
THE mEdiciNE bEHIND THE MEDALSDr. Richard G. Budgett OBE
MA MbbS dIP SPoRTS MEd. ffSEM fISM
SuggEStEd rESourcES
London Deanery info for applicants to SEMwww.londondeanery.ac.uk/specialty-schools/
sport-and-exercise-medicine
British Association of Sports Exercise Medicine www.basem.co.uk
Faculty of Sport & Exercise Medicine (UK) – Specialty Training and Diploma information
www.fsem.co.uk
voluntering for London 2012www.london2012.com/get-involved/volunteering/the-
volunteer-programme.php
oLYMPIC MEdICINE14
I n the fight for an Olympic gold medal, worth just less than £150, billions are spent to shave milliseconds off competi-
tion times. From high-tech swimsuits which reduce water drag to high altitude training which avoids muscle fatigue, sports training has become big business.
The Olympics started as a demonstration of the won-der of the human body in the 6th century BC but it is now also a long-term investment business delivering high returns. British athletes winning gold in Lon-don 2012 are expect-ed to earn £2 million from subsequent spon-sorship deals and com-mercial partnerships.1
gENEticSDespite the
hundreds of hours athletes devote to the gym and track training it contributes
less than 40 percent of the maximum pow-er of our fast-twitch muscle fibres. More important for performance is the impact our genes have on the quantity and quality of these fibres.
The impact of genetics is most obvious in track athletes. Sprinters who trace their ancestry back to West Africa hold 95% of the best times in the 100 and 200 metres. Middle and long distances runners from Kenya and surrounding regions make up
50% of the best times.West Africa has a surprisingly high
dominance of the genes for fast-twitch muscle fibres - particularly the sub-type which is metabolical-ly most efficient. In contrast white athletes have a predominance of slow-twitch fibres more suited for other sporting events.
Kenya’s dominance of run-ning is astounding. Runners from Nandi, a small region of green rolling hills at the
edge of the Great Rift Val-ley, despite having a popu-lation of just 560,000, win an impressive one in five
world championship
long-distance events - way ahead of any oth-er country in the world.
tEchNoLogyHaving the ideal genome for an Olympic
athlete may provide a headstart to the podi-um but without the right technology you’ll still be chasing the pack.
At the 2008 Beijing Olympics 25 new swimming world records were set - more than any Olympics except 1976 when gog-gles were introduced for the first time. The reason? A new full-body swimsuit from Speedo which has since been branded ‘tech-nological doping’ and banned from many international competitions.
Of all the records set in Beijing all but one swimmer wore Speedo’s LZR Racer suit. Seemless and water-repellent it reduces drag by nearly 40% compared to a regular suit result-ing in a 3% increase in speed - enough to make the difference between last and first place.2
However, at a cost of £500 for the suit, which lasts just 10 races, it’s an expense that leaves many poorer nations at a huge disadvantage.
And it’s not just able-bodied athletes who are using technology to their advan-tage. South African paralympian Oscar Pis-torius fought a court battle in 2008 for the right to run against able-bodied athletes.
He was banned not because he would be at a disadvantage but because it was feared that his prosthetic legs would actually put able-bodied runners at a disadvantage. It was claimed that he used 25% less energy than other athletes.3
hard WorkThe good news is that genetics and tech-
nology alone do not guarantee a place on the podium. Recent science has confirmed the dual importance of nature and nurture in sporting success. Sport remains a skill requiring intense training and practice - no matter whether you have the genes or tech-nology which might suggest otherwise.
WHAT MAkES THE uLtimatE athLEtE?As 10,000 athletes arrive in London to compete in 300 different Olympic events what really makes a gold medal winner? Unshakable stamina, round-the-clock training and a life’s dedication to your chosen sport? Or is the likelihood of clinching gold or being left on the starting line already determined by the time we’re born?
REfERENCES
1. how much is a british gold medal worth? £2m http://www.independent.co.uk/sport/olympics/ how-much-is-a-british-gold-medal-worth-2m-6283727.html
2. fina extends swimsuit regulations http://news.bbc.co.uk/sport1/hi/ olympic_games/7944084.stm
3. Prosthetics don’t give sprinters an unfair advantage, research suggests http://www.guardian.co.uk/science/2009/nov/04/ prosthetics-athletes-oscar-pistorius
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fINANCE16
T he last 12 months have seen a num-ber of proposed changes to the NHS Pension Scheme, as well as reduc-
tions in the amount individuals can save into a pension tax efficiently. Ian Morgan, National Sales Manager at Wesleyan Medi-cal Sickness, looks at the proposed changes to the NHS Pension Scheme and how they may impact junior doctors.
WHAT IS HAPPENING TO THE NHS PENSION SCHEME?In March, the government published
its final proposals for the new design of the public sector pension schemes in England and Wales, including the NHS Pension Scheme (NHSPS). A bill will be introduced in the next Parliament, with the aim of implementing it in 2015. The main changes to the scheme will be:
• It becomes a career average scheme for all members. Hospital doctors’ pensions are currently based on their final salary while GPs already have a career average scheme. This type of scheme means you build up a ‘slice’ of pension each year of your ser-vice, based on your salary in that year. That slice – and future slices – will be re-valued each year in line with the increase in the Consumer Price Index (CPI) rate of inflation, +1.5%. On retirement, the total accumulated ‘slices’ make up your pension pot.
•There will be an accrual rate – the amount of pension you build up each year – of 1/54th (1.85%) of pensionable earnings. This is very similar to the 2008 Scheme (1/60th or 1.67%).
•The normal retirement age will fall in the line with the State Pension Age – current-ly between 65 and 68. However, mem-bers will retain the option to retire after
55, although early retirement is likely to result in a reduced pension. You can take your NHS pension before your State Pension Age.
•Employee scheme contribution rates will increase by an average of 3.2%. These increases are be-ing introduced over three years from April 2012. Higher earn-ers will see a 2.4% increase in contributions.
DO THESE CHANGES AFFECT PENSION RIGHTS ALREADy EARNED?
No. All pension rights earned in the NHSPS up to April 2015 will be unaffected and you can access it in full at your current normal pension age.
WHAT OTHER CHANGES SHOULD yOU bE AWARE OF?From April 2012, the Lifetime Allow-
ance, the total amount of benefits that can be drawn from pensions without tax pen-alties being applied, reduced from £1.8 million to £1.5 million. At this stage in your career this sounds like a lot of mon-ey, but over a 40 year career which is like-ly to include promotions, you may find yourself impacted by changes in the Life-time Allowance, especially if you also save into a personal pension. This could influ-ence how you build your pension and you might need to consider other savings prod-ucts such as ISAs to run alongside your pen-sion for retirement planning.
In April 2011 the Annual Allowance, that is the total amount you can save into your pension each year with tax relief, fell from £255,000 to £50,000. The likeli-hood of exceeding the Annual Allowance will be determined primarily by the yearly increase in your NHS pension and also if
you contribute to a private pension plan or pay additional voluntary contributions.
WHAT WILL HAPPEN IF DOCTORS bUILD UP MORE IN THEIR PENSIONS THAN THE LIMITS ALLOW?
Exceeding your pension allowances can be very costly – if your pension accrual over the year is more than the Annual Allowance of £50,000 and you do not have any unused Annual Allowance to carry forward from the previous three tax years, you’ll be taxed on the additional amount at your marginal rate, which will likely be either 20% or 40%.
THESE CHANGES SOUND COMPLICATED, HOW CAN DOCTORS bE SURE OF THEIR PARTICULAR SITUATION?
Wesleyan’s Financial Consultants are regularly briefed by our technical experts about all the changes affecting the NHS pension scheme and retirement savings. Combined with their in-depth understand-ing of the medical profession, they will be able to help you understand your individual circumstances.
Specialist financial services for doctors
0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk
• Savings and Investments
• Retirement Planning
• Life and Income Protection
• Mortgages
• Motor, home and travel insurance
Wesleyan Medical Sickness and Wesleyan for Professionals are trading names of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Limited is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham B4 6AR. Telephone calls may be recorded for monitoring and training purposes.
Motor, home and travel insurance is arranged by Wesleyan for Professionals.
focus on finance - in association with Wesleyan Medical Sickness
WHAT’S HAPPENING WITH yOUR pENSioN?
The above information does not constitute financial advice. If you would like more information or need specialist financial advice, call Wesleyan Medical Sickness on 0800 358 6060 or visit the website at www.wesleyan.co.uk/doctors.
Wesleyan Medical Sickness is a trading name of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Ltd is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham, B4 6AR. Telephone calls may be recorded for monitoring and training purposes.
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rEady, SEt, go! HOW JUNIOR DOCTORSCAN coNtributE to thE oLympicS
1818
T he Olympic Games is just around the corner and more than 5,000 doctors have already offered their services as medical volunteers to work at the event, to attend to the millions
of spectators, press and associated workers who will be present.Foundation doctors who were hoping to volunteer as so-called
Games Makers have been turned away, however, as they are not eligible to volunteer in a medical capacity.
Dr Iain Barclay, Head of Medical Risk and Underwriting at MPS, said that MPS has been approached by a number of foun-dation doctors who were hoping to volunteer, but unfortunately, owing to statutory restrictions, F1 and F2 grade doctors are unable to work at the Olympics as it is not an approved practice setting.
However, this does not mean that should a medical emergency arise that foundation doctors should not provide assistance by way of a good Samaritan act.
WHAT IS A GOOD SAMARITAN ACT?
A good Samaritan act is one where a doctor provides medical assis-tance, free of charge, in a bona fide medical emergency where they are not on duty. Foundation doctors may attend the Games as spectators, and assisting a fellow spectator would be an example of such an act.
WHAT SHOULD yOU DO?
When called into action whilst off duty, you must remember to:
• Only intervene if the situation is an emergency
Medicolegal Advice - in association with the Medical Protection Society
AT ThE 2008 bEIjING oLYMPIC GAMES ThERE WERE A ToTAL of 22,137 MEdICAL ENCoUNTERS WITh STAff, joURNALISTS,
vISIToRS ANd AThLETES.
The term good Samaritan stems from the bible – a person who gratuitously gives help to those in distress. During
the Olympics, foundation doctors cannot apply to be medical volunteers; but you can provide assistance by way of a good Samaritan act.
Charlotte Hudson explains
19
• Assess your own competence in handling the situation – eg, you may be under the influence of alcohol – and proceed accordingly
• Make a full clinical record after treatment, and give your con-tact details to the appropriate official.
If you encounter a situation that would normally be beyond your competence, you may still be able to help. There will be millions of people at the Games and any situation that is beyond your com-petence may still benefit from your input, to a degree. For example, you can use your clinical skills to:
• Take a history
• Make an examination to reach a prelimi-nary assessment
• Give an indication of the likely differen-tial diagnosis and suggest options for the management of the situation pending ar-rival of support.
In the unlikely event that legal proceedings follow a good Samaritan act, MPS members are tentitled to apply for assistance, no matter which country the legal proceedings are com-menced in; this is important as many specta-tors will be drawn from around the world.
Medicolegal Advice - in association with the Medical Protection Society
MPS is the leading provider of comprehensive professionalindemnity and expert advice to doctors, dentists and healthprofessionals around the world.
We actively protect and promote the interests of members and believe that education is an integral part of every healthprofessional’s development. As well as providing legal adviceand representation for members, we also offer workshops,conferences and a range of publications designed to aid goodpractice.
MPS is not an insurance company. All the benefits ofmembership of MPS are discretionary as set out in theMemorandum and Articles of Association.
About MPS
MPS Members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.
www.mps.org.uk
The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.
About MPS info for articles.qxd:MPS Checkup 12/2/10 10:05 Page 1
Whilst London 2012 is a once in a lifetime experience, the medicolegal risks remain the same as any other clinical encoun-ter. By following the above advice, you will not only safeguard yourself against the risks, but you will contribute to making the 2012 Olympics a safe and enjoyable event.
Read Olympic Dilemmas in the latest issue of MPS Casebook – http://www.medicalprotection.org/uk/casebook-may-2012/olympic-dilemmas.
SAfE PRESCRIbING20
T he British Pharmacological Society has taken steps to try and remedy this with a dedicated prescribing exam, which at the moment is optional. Medical schools examine prescrib-
ing in the final clinical years and some NHS Trusts now formally test junior doctors’ prescribing skills6.
The teaching of safe prescribing varies across the UK but pro-grammes of didactic lectures in clinical pharmacology, pharmaco-kinetics and pharmacodynamics seem to have been abandoned by most UK medical schools in favour of problem or case-based teach-ing comprising vertical themes throughout the medical degree; where, although the teaching and learning approaches are effec-tive, teaching hours may be too few and poorly structured to be truly effective7. The result is that it is becoming increasingly rare to encounter a junior doctor who really knows how drugs are metabo-lised and how they work.
Exactly how harmful interactions arise, therefore, remains a mystery until more detailed study at membership level. Hard-ing8 devised assessments on clinical phar-macology topics essential to a junior doc-tor’s working knowledge comprising extended matching questions and unobserved structured clinical examinations to simulate real clinical scenarios where failures in appropriate prescribing might result in real harm to patients.
These scenarios included prescribing anti-coagulant drugs with antibiotics, post-operative analgesia, insulin, treating diverticulitis and an exacerbation of COPD. Only 20% of doctors consistently prescribed safely, 50% of doctors had variable, middling scores and 30% consistently prescribed poorly with lethal errors in some cases.
LEarNiNg aNd aSSESSmENtAs we try to simulate the clinical environment in undergraduate
teaching, we have shifted emphasis away from the study of individual drugs or families of drugs and moved towards scenarios that demand a working knowledge of how to assess a patient’s need for pharmaco-therapy depending on their medical history and clinical state.
We ask medical students to consider whether a patient needs fluid resuscitation or electrolyte correction while prescribing intravenous fluids? How much fluid should be prescribed before the patient is reassessed and the blood results reviewed? What analgesia should be prescribed for a patient with acute large bowel obstruction? What should be done about the patient’s regular medical and INR of 5.6?
Prescribing without really assessing the clinical situation is, and should be, impossible. To this end, problem and case-based learning is invaluable, but the volume of cases needs to be significant and if this cannot be achieved in teaching sessions in the clinical classroom or in practice on the wards then medical students need resources to practise and learn from. Exactly how all aspects of prescribing are examined in the final years at medical school remains the subject
of debate but it is likely that a combination of written and OSCE assessment will be used widely until the national prescribing exami-nation is universally implemented.
The implications for student learning and assessment before the Foundation years and beyond are significant. As safe prescrib-ing stresses patient assessment and review alongside a firm grasp of the pharmacology and interactions of common medications, it is implicit that junior doctors completing drug charts on the wards know their patients and update themselves of their patients’ prog-ress day by day or, in some instances, hour by hour, depending on the clinical problem.
From a practical perspective, keeping up with a patient’s prog-ress is yet another challenge in a modern healthcare system where one junior doctor may not be the main prescriber for a patient as
patient care is shared amongst specialists, e.g. the pain or palliative care teams. Doc-tors now work in shifts and the daily ward round where the drug chart is reviewed may be supervised by doctors also rotating through shifts.
The Medical Schools Council work-ing group on safe prescribing has put together eight competencies expected of foundation year doctors9:
1. The ability to establish a drug history2. The ability to plan therapy for common indications3. The ability to write a safe and legal prescription4. The ability to appraise critically the prescribing of others5. The ability to calculate appropriate doses6. The ability to provide patients with appropriate
information about their medicines7. The ability to access reliable information about medicines8. The ability to detect and report adverse drug reactions
Below you will find examples of questions used to prepare stu-dents for final exams and, more importantly, the Foundation years. We aim to provide some basic science amidst clinical priority but would argue that what we really need to equip our students and junior doctors is effective training on the ward, in the classroom, online and ready access to formularies and a familiarity with clin-ical guidelines10-13. If students can get used to these before they qualify their practice as doctors may be considerably easier.
tESt your kNoWLEdgEYou admit a 75 year old gentleman with abdominal pain dur-
ing your surgical on-call. The patient has a metallic heart valve in situ and is, therefore, on lifelong warfarin therapy. On examination the patient’s abdomen is soft with left iliac fossa tenderness and no overt signs of peritonism. A diagnosis of acute diverticulitis is made. On checking his blood tests you note he has an INR of 6.5.
PRACTICE IN SafE prEScribiNgJunior doctors are more likely to make prescribing errors than their more senior colleagues and a major reason for this may be that junior doctors seem to know less clinical pharmacology than they used to1, 2. Whether this may put patients at risk is the subject of numerous studies in the NHS and overseas3-5.
oNLy 20% of doctorS coNSiStENtLy prEScribEd
SafELy
SAfE PRESCRIbING 21
Question 1:
What should be the target range for his INR?
A. 2.0 – 3.0B. 2.5 – 3.5C. 3.0 – 4.0D. 3.5 – 4.5E. 4.0 – 5.0
The answer is C.
A is the target range for long term ther-apy for atrial fibrillation and mitral steno-sis with embolism. C would be the tar-get range for recurrent DVTs and metallic heart valves. Patients who have biopros-thetic heart valves without atrial fibrilla-tion do not require anticoagulation. If they have atrial fibrillation, a history of systemic embolism or those with intra-cardiac throm-bus, a target INR of 2.5 should be achieved.
Reference:
1. keeling et al. british Committee for Standards in haematology Guidelines on oral anticoagulation with warfarin – 4th edition. br j haem 154 (3): 311-324. http://www.bcshguidelines.com/documents/warfarin_4th_ed.pdf Page 1
2. 2.8.2. oral anticoagulants: british National formulary http://www.bnf.org/bnf/go?bnf/current/2791.htm
Question 2: From the options below what is the single most appropriate
management of his INR?
A. Continue warfarin and give 1mg vitamin K intravenously B. Continue warfarin therapy as he is not actively bleedingC. Give fresh frozen plasma
D. Stop warfarin therapy E. Stop warfarin and administer 1mg vitamin K intravenously
The answer is E.
Warfarin should be stopped until his INR is therapeutic. Giving a low dose of vitamin K allows for his INR to be lowered, without totally reversing the effects of warfarin so that he can remain anti-coagulated on warfarin. If he had a diverticular bleed, reversing the INR would have to be weighed up against preventing life-threaten-
ing haemorrhage. Fresh frozen plasma (containing clot-
ting factors) may be used to correct INR in cases of haemorrhage or when INR must be rapidly corrected.
Vitamin K is a cofactor required for the synthesis of prothrombin (factor II) and
factors VII, IX, and X within the coagulation cascade. Vitamin K converts the glutamate in vitamin K dependent proteins to gamma carboxyglutamate. A series of oxidation and reduction reactions then occur which finally convert the chemical back to vitamin K, which is known as the vitamin K cycle. Humans are rarely deficient in vitamin K as it is continuously recycled in cells.
Synthetic vitamin K is phytonadione. After oral administra-tion of vitamin K blood coagulation factors increase in 6-12 hours; within 2 hours after parenteral administration. Full effect may take up to 24 hours.
Question 3: The next day the patient develops brisk rectal bleeding. He
becomes tachycardic and hypotensive and his haemoglobin falls from 14 g/dl on admission to 9 g/dl.
In terms of correcting his INR which ONE of the following is most appropriate action to take?
PRACTICE IN SafE prEScribiNg
30% coNSiStENtLy prEScribEd poorLy With
LEthaL ErrorS iN SomE caSES
fIG. 1-3
SAfE PRESCRIbING22
A. Continue warfarin as the risks of stopping warfarin are too great
B. Stop warfarin immediatelyC. Stop warfarin and administer platelets D. Stop warfarin immediately, give 1mg vitamin K
intravenouslyE. Stop warfarin immediately, give 10mg vitamin K
intravenously F. Stop warfarin, give fresh frozen plasma and ProthrombinexG. Stop warfarin, give fresh frozen plasma, Prothrombinex and
1mg vitamin K intravenouslyThe answer is G.
As vitamin K will take 24 hours to take full effect, fresh frozen plasma should be given as it corrects coagulopathy rapidly. Infu-sions of large volumes may be problematic, however, in terms of how fast they can be given and ready availability. In this situation, as surgical resuscitation and intervention proceeds haematological advice should be sought and Prothrombinex administered (25–50 IU/kg) as it is effective (depending on dose) within 15 minutes. Prothrombinex is a freeze dried preparation of all vitamin K depen-dent clotting factors (factors II, VII, IX and X).
The plasma half-life of individual clotting factors is:
• Factor II 40-60 hours• Factor VII 3-6 hours• Factor IX 16 – 30 hours• Factor X 30 – 60 hours
Reference:
keeling et al. british Committee for Standards in haematology Guidelines on oral anticoagulation with warfarin – 4th edition. br j haem 154 (3): 311-324 http://www.bcshguidelines.com/documents/warfarin_4th_ed.pdf Page 6
Question 4Complete the drug chart for this gentleman at admission. His
previous medical history includes hypertension for which he takes 2.5mg enalapril twice daily and furosemide 40mg once a day. See
drug charts Fig 1-6.
Comments:1. The patient details include a unique
identifier such as hospital number or date of birth.
2. Allergies need to be documented correctly. Rash or anaphylaxis are allergic reactions, nausea is not; withholding effective medication from patients who have not had an allergic reaction or adverse event related to the drug should be avoided.
3. Date and sign all entries, keeping your name and contact number legible.
4. Prescribe all regular medication in addition to new medication you start on admission. Any medication you choose to discontinue that the patient usually takes at home, document on the drug chart, explain your changes to the patient, and inform the GP on discharging the patient.
5. You are allowed to consult the British National Formulary (BNF) at all times. Get used to using this on the wards and online.
6. The duration of a course of antibiotics should always be specified. You may decide to change your mind and curtail or prolong the course. In that case you can make changes to the chart again but don’t let this stop you from writing the initial limits of the course. Changes should be clearly labelled. Do not write over an original prescription.
7. There is a 10% approximate cross-reactivity between cephalosporins and penicillins in penicillin allergic patients but as this is based on structural similarities of the molecules, the cross-reactivity is greatest in first generation cephalosporins. Cephalexin is a first generation cephalosporin14.
8. A patient with bowel obstruction and heart disease will not necessarily have normal saline infused at a rate of 125ml/hr. The key is to check how much the patient needs and adjust the rate of fluid with regular review rather than prescribing
PRACTICE IN SafE prEScribiNg
fIG. 4-6
multiple bags of fluid from the outset. Conversely, not prescribing enough fluid and leaving this for a doctor unfamiliar with the patient is always a pitfall. Try to make sure that fluid prescription follows clinical assessment of volume status (clinical signs of dehydration or overload, chest Xray findings, central venous pressure or non-invasive and invasive measures of cardiac output) and renal function and electrolyte results.
9. Try to write up fluids at rates of ml/hr rather than 6 hourly or 8 hourly.
References:
1. doman T, Ashcroft d, heathfield h, Lewis P, Miles j, Taylor d, Tully M, Wass v. An indepth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. final Report EQUIPstudy. GMC Uk 2010
2. Ross S, Loke Y. do educational interventions improve prescribing by medical students and junior doctors? A systematic review. br j Clin Pharmacol 2009; 67(6): 662–670
3. Tobaiqy M, McLay j, Ross S. foundation year 1 doctors and clinical pharmacology and therapeutics teaching. A retrospective view in light of experience. br j Clin Pharmacol 2007; 64 (3): 363-372
4. Aaronson jk. A prescription for better prescribing. br j Clin Pharmacol 2006; 61(5): 487-491
5. dean b, Schachter M, vincent C, barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002; 359 (9315): 1373 – 1378
6. kidd L, Shand E, beavis R, Taylor Z, dunstan f, Tuthill d. Prescribing competence of junior doctors: does it add up? Archives of disease in Childhood 2010; 95(3)219 - 221
7. o’Shaughnessy L, haq I, Maxwell S, Llewelyn M. Teaching of clinical pharmacology and therapeutics in Uk medical schools: current status in 2009. br j Clin Pharmacol 2010; 70(1): 143-148
8. harding S, britten N, bristow d. The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardized clinical cases. br j Clin Phamacol 2010; 69 (6): 598 – 606
9. outcomes of the Medical Schools Council Safe Prescribing Working Group, November 2007
10. E-Learning for healthcare – Safe Prescribing http://www.e-lfh.org.uk/projects/safe_prescribing/index.html
11. Prescribing practice at onExamination from bMj Learning http://www.onexamination.com/self-assessment/prescribing-for-students
12. bNf prescribing resource at onExamination from bMj Learning http://www.bnf.org/bnf/go?bnf/current/204259.htm
13. keeling et al. british Committee for Standards in haematology Guidelines on oral anticoagulation with warfarin – 4th edition. br j haem 154 (3): 311-324
14. Campagna et al. The use of cephalosporins in penicillin-allergic patients. A literature review. j Emerg Med 2012; 42 (5): 612-20
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AUTHORS
Nadia Bukhari BPharm MRPharmS PG Dip FHEA
Clinical Lecturer, MPharm Student Support Manager & Pre Registration
Co-ordinator, UCL School of Pharmacy
Ali Sameer Mallick MBBS BSc MRCS (DOHNS)
Academic Clinical Fellow ENT Surgery, Nottingham University
Seema Biswas MSc FRCS
General Surgeon, Health Delegate, British Red Cross
Night sweats?It’s four a.m.
You’ve been bleeped.
You know what to do.
But it would be good to get a second opinion – just for peace of mind.
That’s exactly what Best Practice provides. A trusted second opinion on the assessment, treatment and management of patients.
On call. All day. All night.
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DIAGNOSE • TREAT • MANAGE • LEARN
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hoSPITAL MESS24
SiErra LEoNE
T oday looks to be a fairly quiet day by our standards, there are only about 50 patients in the waiting area. Things soon turn hectic, though. Within minutes of me sitting down to check e-mails and
sort out a few other things after the triage, a baby is rushed into my room, carried in by one of the nurses.
“Dr Mikey, look dis pickin not blowing fine!” she says, with panic written across her face. The baby is definitely breathless, the telltale signs of the stomach being drawn in under the ribs giving an obvious clue to the pneumonia underlying the baby’s breathlessness.
I manage to get the baby on our only working oxygen machine and we give a stat dose of ceftriaxone, thankfully on oxygen the baby’s satu-rations creep back up to a reassuring 97%.
I try to get a bit of peace from the tornado of chaos swirling around as the patients are triaged to explain to the mother that the baby is going to need to be admitted overnight so we can keep an eye on her. As soon as I say the word “admit”, she starts crying inconsolably, chunky tears streaming down her face and land-ing in a sad little puddle on the dusty floor.
I’m a bit taken aback, I know my Krio is far from perfect but I was sure she had understood what I was saying about how the child will most likely get better in a cou-ple of days. The situation really is not that bad at the moment and the baby seems to be getting better.
One of the nurses eventually manages to get through to her on a deeper level, doing a far better job of using the standard “Ideas, Con-cerns, Expectations” model that we are all taught in medical school than my limited Krio will allow.
It turns out that she took the child to a government hospital a few days ago and wasn’t allowed in without a bribe, which she couldn’t afford. She explains that she spent her last 1000 leones (15 pence) on transport money to get here and has nothing to left to give.
I feel a certain amount of pride in the nurses working here as Jestina explains that we don’t take bribes and reassures her she has done the right thing in bringing the child here. Once she understands that we really are a free hospital, she relaxes hugely, the way a boiler decompresses after turning the safety valve on. Soon the baby is on oxygen and has a bed, and mum looks much happier.
The whole experience sets me thinking that evening about the ideal of free health care and how for so many that is still just an ideal. In a coun-try where nurse’s salary is less than £100 each month, some desperation and need for money is understandable, but ultimately the children here so often pay the price.
Read Mikey’s blog online at www.juniordr.com
MAkING THE bEST OF IT IN
1 Political party; sequence of actions by which the baby and afterbirth are expelled from the uterus at childbirth (6) 2 In research, the tendency of a rater to overestimate a subject’s
response based on prior assumptions; a popular video game series featuring cybernetically enhanced super-soldiers (4) 4 Furuncle (4) 5 Fever of low intensity or short duration (9) 6 Many or multiple; the one who puts the kettle on (4) 8 The acute form of this condition often present with erythema nodosum and polyarthralgia (11) 10 His incision is made in the right side of the abdomen, paralleling the thoracic cage, for cholecystectomy (6) 14 bandage wound spirally around an injured limb (5) 16 Single photon emission computed tomography (5)
1 Of Nirvana’s Nevermind album; mood stabiliser (6)
3 1990s alternative rock band featuring brian Molko; sham medical intervention (7) 5 Inherited defect in G6PD causing red blood cells to become sensitive to broad beans (6) 7 Type of wine
specifically linked to Marchiafava-bignami syndrome (3) 9 Gout of the foot, especially the big toe (7) 11 Summer fruit; aneurysm at junction of posterior carotid with internal carotid, or of anterior communicating with anterior cerebral or bifurcation of middle cerebral artery (5) 12 Lowermost element of the backbone (6) 13 kanner’s syndrome (6) 15 billroth operation (11) 17 Anaesthetic agent used as party drug; NMDA antagonist (8) 18 Either corner of the eye (7)
You can find the crossword solution by searching for ‘crossword answers’ at www.juniordr.com
Compiled by Farhana Mann
ACRO
SSDO
WN
“She took the child to a government hospital a few days ago and wasn’t allowed in without a bribe”
FY2 Dr Mikey Bryant is in Sierra Leone with health-care charity Mercy Ships. He has been volunteering in a children’s clinic for a year in a country where one in five children don’t live to see their 5th birthday. In this regular
column he gives us an update on his experience.
hoSPITAL MESS 25
Good for your health but not your pocket at,
69p Royal Cornwall Hospital, Truro
Munch-tastic at,
45p Hinchingbrooke Hospital, Cambridgeshire
Playing chicken with your cash,
£4.85 Royal Free Hospital, London
Finger-lickin good at,
£2.48 basildon Hospital, Essex
Tell your dentist about,
£2.49 Manchester Royal Infirmary, Manchester
Keep on brushing at,
£1.65 Ninewells Hospital, Dundee
Next issue we’re checking the cost of an apple, chicken and chips and a tube of toothpaste. Email prices to [email protected]
W hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular
column of the best and worse hospital essentials you’ve reported:
42” TV with Sky Digital, 10 PCs with Internet Access, a plasma information screen, a modern kitchen, two snooker tables and a Fussball table.
Complimentary tea, coffee, toast, newspapers and maga-zines are provided daily and there’s a lunchtime snack bar selling sandwiches, soup, jacket potatoes and snacks, solely for the use of doctors.
JuniorDr Score: ★★★★✩
Apple
Toothpaste
‘Writing in the notes’ is our regular letters section. Email us at [email protected].
Writing in the Notes
Extending retirement age will put
patients at risk
Dear Editor,As Mr Lansley continues his demands to
reduce our pension, increase contributions and
delay the age of retirement perhaps he should
take note of your news article ‘Surgeons aged
between 35 and 50 provide safer care’ (Iss 24;
p5). Numerous studies have now shown how
medical skill declines rapidly after the age of
60, particularly the manual dexterity required
in surgery. Perhaps Mr Lansley should worry
less about trying to extract more contributions
from our profession and focus more on provid-
ing the safest care for patients.NAME WIThhELd
ST6 oRThoPAEdICS, LoNdoN
Leaving the fy shadow behindDear Editor,
Finally, a shadowing scheme has been put in place for new trainees ‘Four days shad-owing for FY docs’ (Iss 24; p6). I remember when I started my PRHO jobs and we were literally thrown on the ward without knowing any practical skills or even where to find ven-flons. It was spectacularly unsafe and terrify-ing for both new house officers and patients. Glad to see things have finally changed.CARoLINE MCdoUGLAS GP TRAINEE, oxfoRdShIRE
QUEEN’S MEDICAL CENTRE, NottiNgham
more than gmc rules needed to stop
gagging
Although GMC guidance that doctors
must be allowed to speak out when they
believe patient safety or dignity is being
compromised is a good start there is a long
way to go ‘Guidance preventing doctors
being gagged comes into effect’ (Iss 24; p4).
Sadly these rules will do little in a culture
where doctors fear for their jobs and loyalty
to senior colleagues seems to trump all oth-
er issues. Changing this perception is likely
to have a larger impact than any statutory
guidance.NAME WIThhELd
ST4 CARdIoLoGY, LoNdoN
Chicken and chips
EvENTSdR.CoM26
THE MEDICAL COURSE AND CONFERENCE DIRECTORY
A s doctors we hate scouring the web to find where and when we can attend the next exam revision course, training event or conference.
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You wouldn't go into an exam without revising to be as well prepared as possible. The same applies to an interview! But an interview is not an exam - there is no pass mark. It's a competition, and you need to beat the competition by being properly prepared - on the Hammersmith Interview Course.Your career depends on itMore information & booking on websitewww.medicalcommunicationskills.com
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MRCPCH PART 1
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MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE
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MPS_JrDr_Advert_SPRING_P4.indd 1 29/03/2012 10:39