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There’s a live questions and answers chat on routes into medical research from The Guardian’s careers section this Tuesday (24th August). The topic is on routes and career options for a career in medical research, and should be highly relevant to most medical students, so why not check it out and take part.
The Guardian is hosting a Q&A on routes into medical research this Tuesday.
From the Guardian site:
The achievements and breakthroughs of medical researchers are rarely out of the headlines…..So if you want to know more about gaining the necessary experience to land yourself a research role — or perhaps about the ways you can make yourself stand out to potential employers — put you question to our panel of medical research experts on 24 August.
You can fing the link to the careers community here. The chat goes live on Tuesday the 24th of August, at 1pm-4pm GMT, and you can post questions in advance to an expert panel as we speak!
We’re going to add some useful scores and calculators to the blog. This was following a request for more useful ‘real life’ practical scoring systems which are often not focussed on when teaching medical students. Lecturers often correctly focus on the important pathophysiology a problem or condition. We feel that the use of validated scores (like this one) add practical value to medical undergraduates.
Why not try out some of these scores in your own practice/ when on the wards/ in the GP surgery to try and help identify why that patient has been discharged, or
The San Francisco CHESS algorithm from the Annals of Internal Medicine, 2006, click to enlarge
what the reason was for that particular management plan.
Take Syncope: its a massive subject, but its important for the general physicians to the oncologist treating a patient in outpatients, to the surgeon with his post op patient who has just collapsed. For simplicity we’ll define syncope as a sudden and temoporary loss of conciousness (there are numerous definitions).
A review article in the NEJM defines it as the following
Syncope is a sudden and brief loss of consciousness associated with a loss of postural tone, from which recovery is spontaneous.
Syncope does NOT refer to dizziness/ or other symptoms such as vertigo (the illusion of movement). Its
a really difficult topic to cover the causes are numerous:
Neurally Mediated (25% of cases)
Vasovagal
Situational/ other causes
Dehydration/ orhtostatic (10%)
Cardiac (20%)
arrhythmia/ obstructive cardiac lesions etc
Psychiatric (probably about 1-2%)
Drugs (probably about 5%)
Unknown
This isn’t going to cover all of these things, but lets look to see if there is a score to help us with this. There is! the CHESS score, or San Francisco Syncope rule.
Does the patient have CHESS?
CCF or history of CCF Haematocrit <30% ECG abnormal (non sinus rhythm or new changes compared to old ECG) Shortness of breath Systolic BP of<90mmHg at triage
As a rule of thumb (you can read the paper) to avoid serious adverse events admit patients with syncope with ANY of the above features: MI, PE, stroke, serious arrhythmia. Click the picture to the right for a full screen shot of the algorithm.
This has a sensitivity of >95% and a specificity of around 60%.
Read more about the study in Annals of Emergency Medicine.
The clinical bottom line: guidelines change and evolve, and your hospital / primary care centre/ doctor may not follow these guidelines. The take home message is there are simple predictive factors that can be used as a rule of thumb that you can keep in the back of your mind when seeing patients with syncope, and these scoring tools are useful as an educational aid. Remember no scores are 100% accurate, and any algorithm like this will lead to the discharge of patients that will go on to have serious medical pathology. Its use is as a guide.
This is the first in a series of articles on simple scoring systems for application by medical students. Why not post comments on other scores you have found useful as a student, with a reference.
Student Surgery: You’re a medical student conducting a surgery list under supervision from your GP trainer. Your next patient is a retired GP who has been booked in by his wife for concerns about his memory.
A 74 year old retired GP, Dr Wallis comes to see you.His wife reports that his memory is not ‘as it was’ however the retired GP dismisses this as ‘nonsense’ and proceeds to tell you about his early research on the use of anti tuberculous medications. His wife is concerned that he may have a brain tumour. The concern about this is that she has read brain tumours can cause memory problems.
Dr Wallis is frustrated by his wife’s concerns about his memory and mentions she is always meddling in his affairs. In his history his wife tells you he has put on a stone in weight, and fractured an ankle when being run over by a car 12 months ago.
PMHx
Previous history of skin psoriasis, treated with topical preparations only.
Drug history
Vitamin D tablets ordered over the internet (patient unsure of strength, wife believes it to be 1000 international units a day)
Examination
You proceed to examine Dr Wallis to evaluate him for any neurological problems. The examination is as follows.
Observations normal. Normal Cardiovascular, Respiratory and Gastrointestinal Examination
Neurology:
Upper Limbs
Lower Limbs
Right
Left
Right
Left
Tone
N
N
N
N
Power
5/5
5/5
5/5
5/5
Coordination
N
N
N
N
Sensation
Fine touch
Proprioception
N
N
N
N
N
N
N
N
Reflexes
Biceps
triceps
supinator
+
+
-
+
+
+
Knee
Ankle
Plantar
+
-
?
+
+
?
Cranial Nerve Exam
Normal. Fundoscopy normal.
Mental Test Score:
Question
Mark (x/10)
Age
Correct
DOB
Correct
Time (nearest Hr)
Correct
Person
Correct
Place (house number/ name of hospital)
Incorrect
Recall Address
Correct
WWII
Incorrect
Year
Correct
Queen
Correct
20-1
Correct
Adapted from Hodkinson HM. “Evaluation of a mental test score for assessment of mental impairment in the elderly.” Age and Ageing 1972;1:233-8
Recent blood tests
Test
Result
Normal Range
Hb
12.9
(12-15g/dl)
WCC
5.4
(4-10 x109/l)
Plt
152
(150-300 x109/l)
MCV
88
(80-99 fL)
INR
0.9
(0.9-1.3)
Na
137
(135-145 mmol/l)
K
4.8
(3.5-5.1mmol/l)
U
4.1
(4-9mmol/l)
Creatinine
88
(60-100 micromols/l)
Albumin
39
(35-45g/l)
Alk Phos
53
(<110iu/l)
ALT
45
(<40 iu/l)
Bilirubin
19
(<20 micromols/l)
CRP
9
<5
TSH
5.6
(0.5-5)
Fasting Blood sugar
6.2
(<7mmol/l)
What is the most likely diagnosis is this just ‘old age’, and does the patient require any other investigations? You can pick a maximum of 5 answers.
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A free subscription is on offer for what we judge as the best ‘free text’ answer to this question!
Don’t panic! Read our top tips for F1s. Image credit: ~John~, flickr
Dr Laura Davison, a GP ST1 from Milton Keynes, looks back at her foundation years and shares her top tips for all new doctors.
Congratulations, you’ve passed your finals! You’re finally a real doctor, but that was the easy bit – now the real work begins.
Medical school is a necessary evil to obtain the prestigious title and status “Doctor”, but I will warn you everything you learnt in the safety of the lecture theatre will be forgotten as soon as you set foot on the ward. But, never fear, this is normal! All you need to know to be a good doctor you will learn working in hospital.
After three years’ clinical experience, I’ve realised that the key to all medicine is knowing what is normal. Your first few weeks will be terrifying and feel alien, but it is reassuring to think that this is normal.
Foundation year one, aka the dogsbody year, is definitely the deep end: you have to learn to swim fast. It sounds scary and it feels it. But it gets easier I promise!
You may cry during your first weeks as a new doctor, when your first patient dies, when your consultant throws a strop or when you’ve had a beastly on-call and you haven’t even had time to pee, but remember this mantra – “It gets better as I get better”. It does and you will.
Your first day
On your first day you are likely to have to ask how to spell paracetamol and then have to look up the dose too, in secret (well I did, and this is normal). The BNF is every doctors’ best friend, and will be for many years. Don’t be ashamed to use it for every drug you prescribe if need be. It’s the only way you learn practical pharmacology and be safe for your patients..
F1s are newbies, the babies, hence expect to be treated as such. However, you will mature quickly and this lowly status and work life will improve as the year goes on, as you earn trust and respect from the already hardened NHS workers.
Handling seniors
It is normal to get grilled by seniors – in every department, in every profession – and though you may feel tiny at the time, you will learn quickly how to survive future grillings.
Preparation is key. If you know you have to go and discuss a patient with another colleague (usually a radiologist to beg for a CT spot, or a referral to another team to beg they take a high maintenance patient), be prepared: know your patient’s details inside out. Bloods, images, home situation, which leg is weak, which arm hurts, how the problem started, what their favourite hobby is, are they big or small, are they claustrophobic etc….
The senior doesn’t need to know all this gumph 99% of the time, but they will ask for it just to make sure you don’t cut corners and are kept on your toes.. They know when you don’t know what you’re talking about, so make sure you can surprise them!
Performing dreaded tasks
The first time you’re asked to confirm a death is one of the things that any newbie dreads. The first time will freak you out, either because
a) you have watched too many horror movies and are expecting the dead to suddenly open their eyes, reach up and grab you
b) because you will swear that you can still hear the patient’s heart beating.
To be honest, you can tell someone is dead just by looking at them – a pale waxyness, the “O-sign” of the mouth, cloudy eyes – you know it when you see it, but you have to listen and feel for a heartbeat, check breathing and their pupils for completeness. I will warn you, dead bodies creak – and one heart thud in 30 seconds does not constitute a life-sustaining heartbeat.
Coping with the stresses
When you get home from work, you will want to vent about the strains and idiocies of your day – so give housemates, spouses, parents a warning now, that being a doctor will turn your home life into a rant-zone! There’s nothing worse than bottling up fear, frustrations, anxieties and stresses. You won’t last the year. Get it off your chest somehow. Taking it out on the nurses and patients the next day will only come back and bite you harder than you can imagine.
The friends you live with during your house officer year will be your new bosom buddies. From my experience, the best thing I ever did was live in the hospital accommodation. Noone will understand how rubbish your day was better than someone who has gone through it too. It’s soothing to be able to vent your frustrations about the day, the patients, the staff, the seniors, the system, the canteen food, to someone else who has also witnessed it. Bitching sessions postshift are enlightening too. Maybe you didn’t have the “worst day ever”.
Acclimatising to life outside hospital
At the end of a day you will be so tired you will be willing to watch anything on TV, including The One Show. You will not be able to get the hospital smell out of your clothes or hands until the weekend. You will bring up inappropriately graphic topics and stories at non-medical dinner tables and in the pub but never, ever breach confidentiality.
A few tips – lay-folk don’t appreciate you saying that Holby City is medical tosh, TCP is not an acceptable odour to wear in public and describing what colour vomit you got on your shoes today at the dinner table is not acceptable – unless you’re with other medics.
On the plus side, as a junior doctor you have few outside work commitments, so relish it! For the first time in five years you have no homework, no assignments due, no tutor chasing you, no exams looming. In the words of Ferris Bueller: “If you don’t stop and look around once in a while, you could miss something”. Embrace this freedom and enjoy it
The wider picture
Being a real-life doctor is not glamourous; it is hard work and can be an unforgiving and thankless task at times, but it also can be extremely rewarding if you go about it in the right way. Respect your colleagues, care for your patients treat others the way you would want to be treated and above all treat yourself to the canteen pudding at lunch and you’ll enjoy work much more, guaranteed. Good Luck, and remember, it gets better as you get better.
Here are my top tips all “Newbies”:
Nurses are your best friends – You are not above them and you never will be. Realise that now. Even when you get to consultant level, the nurses test (?)you. Keep them sweet, ask them for their opinion (even if you decide not to follow it) – they have been there a lot longer than you! . If you want people to help you, help them, so offer to help out,.– the sentiment will hold you in excellent stead. Buy them the occasional box of biscuits and ask about their weekend Treat a nurse like a slave and you will NEVER have a peaceful shift.
Locate the nearest BNF – and don’t be embarrassed to use it! The more you use it the more you remember – the easier it is to spot when a prescription is wrong.
Wear comfortable shoes – You will walk miles every day. Girls, beware of heels, it is very embarrassing to walk down a quiet ward in clip-clop heels.
Smile – You get away with (almost) anything.
Communication is the magic word – To ensure what you want doing is done – communicate it! Write instructions down CLEARLY (there is no excuse for illegible handwriting. Hand it over, inform the nurse – every time.
Ask for help – You’re new. You are not expected to know everything (or even anything in your first few weeks). Use your team. Don’t worry about asking for help from the SHO, reg or even the boss. If you are struggling with the work load, tell someone. What’s harder, asking for help, or explaining to the boss why it all went tits up?
Don’t stay late – Well, don’t make a habit of it, no-one will thank you for it and you will hate it. Good handovers are essential. Don’t handover day-time dross though (like drug-charts and TTOs), it will come back to haunt you. “House Officer Hand Over Revenge” will be inevitable.
Lunch and pee-breaks come first – If you don’t eat you are no good to anybody. Even if you think you don’t have time for lunch, you DO!. LUNCH! The only reason to miss a lunch break is a crashing patient.
Get an Oxford Handbook – the Foundation Programme Guide is excellent. Have it nearby, particularly if you’re on-call. It’s a Godsend. I still use it now in ST1.
Be organised – To your team, you are the dogsbody, the “Gofer”, the team PA. You need to know who your patients are and where they are, so keep an up-to-date list every day. Have investigation results on all patients to hand, a spare pen, a stethoscope and a tournequet. Know where your SHO, registrar and consultant are to ask for advice and avoid when you’re on a break. Lots of house officers use folders or clipboards to store their information in, but there’s no hard and fast rule – use what works for you. Also you’ll see many, mainly female junior docs carrying around little shoulder bags brimming with stuff; I just recommend pockets and belt-loops. Bags get in the way when leaning over patients all day long.
Risk assessment needed prior to administering post exposure prophylaxis
Hep C 3%[1]
PCR testing for Hep C virus will give most accurate and reliable indication of transmission
Hep B 30%
Consider repeat Hep B booster/ IvIG (local policies)
The rule of 3’s
The risk is higher with hollow bore needles than with normal needles (e.g. suturing). This data varies widely across specialities. Individuals vaccinated against Hepatitis B have a lower risk of transmission following a needle stick.
The prevalence of needle stick injuries has been estimated to be as high as 33% in a 6 month period for healthcare workers.[2] A good review on needle stick injuries can be read from Bandolier here.
Hep B is the most transmissible of all 3 conditions. As a healthcare professional with a transmittable disease it may preclude you from working in certain specialities e.g. some surgical specialities.
Remember the prevalence of Hepatitis B, HIV and Hepatitis C in the UK is still low (<1% for each).
[1] The risk of Hep C transmission rate varies from 3-5%. If a person is exposed, the usual practice is to PCR the blood for the hepatits C virus . MS Sulkowski et al. Needlestick transmission of hepatitis C. JAMA 2002 287: 2406-2413.
[2] A study of 75 medical students and interns in New York
F Resnic, MA Noerdlinger. Occupational exposure among medical students and house staff at a New York City medical center. Archives of Internal Medicine 1995 155: 75-80.
In another seemingly obvious medical breakthrough, the EarlyBird Diabetes trust has found that its not how much exercise you do, but what you eat that makes you fat as a child. But how do you go about proving something like this?
Ground breaking genetic research suggests this young child has a desire to go into a career in the health sciences. Who gave him the scalpel?
It sounds obvious, but it puts advice into perspective that its lack of exercise that is the most important factor in childhood obesity. With the alarming rise in obesity in Western Europe and North America, and the failure of recent pharmacological therapy to provide an answer in adults (sibutramine whipped off the market by teh European medicines agency in the UK because of the cardiovascular risk profile: myocardial infarctions and stroke disease), the evidence now suggests we should be switching the three times a week exercise regimes for our children to three times as less packets of crisps in the lunch boxes.But where do these findings come from, can we trust them, and how do you go about finding out these things?
The answer is in a cohort study. A cohort study is a study where you follow up a group of people who may not have a disease (in this case obesity, but it could be anything, multiple sclerosis, rheumatoid arthritis, motor neuron disease) over time (longitudinal) and see what happens to them. This way you can look at all sorts of factors, and see how they appear to influence other outcomes (obesity , depression, getting a job).
Lets take a look at some of the key findings of this cohort study:
Children’s activity not determined by environmental opportunity- Green spaces and sports centres do not influence the physical activity of children
Like most things biological, a child’s activity level seems to be ‘set’
by the brain, and therefore strongly defended against change
These things may seem common sense, but someone needs to go out and prove it.
Healthy weight for life? Start at birth. Most excess weight (90% in girls) is gained before the child ever starts school
That’s more like it. Its because this is a well designed cohort study that this question can be answered. They didn’t go back and look at the records of obese children and compare them to children of normal weight (a case control study), and there are obvious advantages in the (often expensive) cohort design.
So where do we go from here with genetics, and our long term health? Well good medical research is all about how you go about answering these difficult questions that life poses.
Only a few days ago in the news more evidence (from the journal Neurology) from a cohort study of patients with depression suggests the following. Again this is more cohort study data. More info here.
Depression is associated with an increased riskof dementia and AD in older men and women over 17 years of follow-up.
The largest longitudinal genetics study of its kind has just finished recruiting in the UK. Visit their homepage.
What this is showing is the potential power of a well designed cohort study: groups of children followed up over time with data collected on their health, allowing comparisons between the children in the cohort, or other patients. Its more cohort studies like these that will hopefully provide the answer to a number of the outstanding genetics questions that are being posed at present. The UK Biobank study is the largest of its kind in the UK has just finished recruiting. Find out a little more from this excellent BBC coverage of the project in the video below.
Finally lets have some views from the students. Suppose we need to know more about a what causes a rare form of myositis (e.g. 1 in 1 000,000)/ or haematological cancer? What’s the best approach to designing a study to look into this. Would a cohort study like these do the job?And what about the consent for the Biobank project. Can people ever really know what they are letting themselves in for? More questions, we’ll have to wait for the answers. Comments please…
• Children’s activity not determined by environmental opportunityGreen spaces and sports centres do not influence the physical activity of children Like most things biological, a child’s activity level seems to be ‘set’
by the brain, and therefore strongly defended against change
Thought APACHE II was the latest and greatest game for the Xbox? Not in our book it isn’t. Check out some of our useful free resources that we know and love and think you will find helpful. And best of all, they are all free – not a penny to take out of your loan/grant!
The MPS has a range of online resources and clinical information to help guide medical students and healthcare professionals through their medical training. One thing we like is their magazine for newly qualified junior doctors which are handy for a quick read through relevant junior doctor experiences of life at work. New Doctor magazine can be found here, and Medical Student pages (UK) here.
We like this sitter from IMAIOS, who provide detailed pictures like the one you can see here of the famous Scottie dog. We thought it looked like a lumbar spine. How wrong we were.
By the way, you won’t see many more lumbar spine radiographs because your local radiologist will probably have a heart attack if you try to request one! This is because they are notoriously useless at picking anything important up, other than fractures.
The BMJ weigh in with a great free resource which requires no subscription. The BMJ really are helping doctors make better decisions (we’re aiming to help you as a medical student make the best decision).
We love this app from the developers at Imobilemedic.com. You might get a few funny looks from doctors over45 at the next cardiac arrest if you whip this out, and remember not to spill your coffee on your iPhone.
Thought the Anion Gap was a tourist attraction north of Watford? We’ve got new for you….
If you need to work out a BMI, GCS or Disease Activity score quick? Check out Med Calc… It works on most smart phones. As one contributor said: “I use this most days at work”*
We are fairly certain this is just to show off, but we love this app.
Most of the GPs that we deal with from medical educator would be doing well to be dealing with most of the complex stuff listed on here. Need to know the classification system for bone tumours? Look no further.
Wikipedia is still top of our list for those obscure things you need to know about. As students you always need to be sure to check your sources, however there comes a time when you need fast reliable information, or when you need to read round a topic. The Journal Nature found that Wikipedia was as good as the Encyclopaedia Britannica across a range of scientific areas. That’s good enough for us, this represents web2.0 in action!
You didnt think we would leave ourselves out did you? If you don’t know already, signing up is completely free and gives you access to loads of our sample multi-questions, videos and podcasts.
Got any other top free resources that you know, use and love? Leave a comment and share the joy!
This blog requires a mention and was brought to our attention by a Cambridge undergrad currently wrestling with his research project.* The reason for the mention is the blog’s tag line which made the whole of our ward team chuckle:
“Scalpel or Sword? Because sometimes you need a sword”.
That wins our vote for best medical blog tag line, beating “unprotected text” to a close second. We would always however use a scalpel.**
*Recently defunct research project
**none of us can work out what we’re supposed to do with those mini scalpel blades that come in our suture and dressing packs which don’t have a scalpel handle. If anyone knows the answer to this please tell us. If you make the packs, pleas put a handle on the end of our scalpels, it makes us look more professional.
So you have finished uni, you’re fully qualified as a Junior Doctor and you’ve managed to land a job after an intensive application process. What next? Do you sit back on your laurels and enjoy that salary? Or do you take the plunge and jump onto the first rung of the property ladder?
Life is hard for a first-time buyer, now more than ever. There are fewer high loan-to-value mortgages than back in the glory days pre-2007 and after prompting from the Financial Services Agency, banks are reeling in on interest-only mortgages, which were a lifeline to first-time buyers.
It is going to be a while before you save for a deposit, what with paying back your student loan and saying goodbye to student discounts and benefits. However, once you have a few thousand in the bank you then need to find a mortgage you can actually afford.
Many potential borrowers get excited when they calculate how much they could actually borrow. The rate is usually four times your salary, so with an average doctor’s starting salary being around £33,000 or so, you could borrow £132,000. But, and there are some buts, what you can actually afford to pay back and what you can borrow quite often differ.
Say you want to borrow £120,000, if you can muster up a 10% deposit and opt for a three-year fixed rate deal over a 25-year term, you are looking at paying back £772.43 per month. And, seeing as the average UK house price is £205,598, this £120,000 figure is miles below this price.
Getting an affordable mortgage is therefore rather tricky. So what do you do? Well the best advice is to save as big a deposit as possible. Bigger deposits mean less risk for the bank and this results in a better rate for you, and opens you up to better mortgage deals.
You can also look at paying over a longer term as this will work to reduce your rate. But some banks are rather restrictive over this, so you need to fully investigate what each mortgage offers and thoroughly read the small print.
Before going to your bank, make use of online calculators such as the mortgage calculator from Santander. There are also repayments calculators so you can see how much you can borrow and how much you will have to pay back each month. Once you have found the right balance, only then can you approach your bank.
And if you do decide to get a mortgage, right now could be time to lock in a fixed-rate deal. OK – so for the past few months and for probably the next couple of months a tracker mortgage will come out as more cost effective, but the interest rate isn’t likely to get any lower, and with fixed-rate deals at their lowest levels right now, it makes sense to secure these rates for the next two to five years.
A medical student sustains a needlestick injury from an intravenous drug user. Unfortunately this user is Hepatitis C positive.
Regarding Hepatitis C which of the following statements is true?
a. Vaccination to hepatitis C is routinely available to healthcare professionals and confers some protection
b. The chance of transmission of hepatitis C is around 3%
c. The chance of transmission is around 0.3%
d. Hepatitis C if transmitted will lead to liver failure in that individual
e. The chance of transmission is around 30%
The Medical Protection Society is the leading provider of comprehensive professional indemnity and expert advice to doctors, dentists and health professionals around the world.
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