Photo by JixarThe symptoms of stress vary, from feelings of anxiousness to outbursts of temper, and during times of increasing pressure or when something is important to you – like passing your exams – you should follow some simple advice to help keep yourself grounded.

Dr Fiona Donnelly is chair of the Doctors’ Support Network (DSN), which is a confidential peer review support forum for doctors with mental health concerns. These concerns include stress, burnout, anxiety, depression, bipolar disorder, psychoses and eating disorders.¹

She says: “Unfortunately medical student exams are only the start of your exam career – once qualified there appears to be a never-ending stream of exams, and it is important to learn techniques to deal with the stress involved.”

Looking after yourself and maintaining a good ‘work/life balance’ is very important.

Below, Dr Donnelly has provided some useful advice on how to handle stress:

• Make sure that you eat properly and have a regular sleep pattern.
• Exercise can be a really good way of switching off from the pressures of revising, and if you don’t normally exercise simply going for a walk is enough.
• Timetabling social outings is also important, and although medical friends are good, they can be stressful as they always seem to know more than you. It may help to try and spend time with non-medical friends socially prior to exams.
• On the subject of socialising, while the odd alcoholic beverage may be relaxing, too much leads to a significant lack of revision the following day – so drink in moderation!
• Students prepare for exams in different ways. For those steady revisers make sure you take on board the above advice and timetable in breaks, food and exercise.

Last minute revisers

“In an ideal world we would all prepare well in advance; however, I have to confess that I am a bit lastminute.com,” says Dr Donnelly. “For those in a similar position, ensure that you have left enough time to prepare; the night before is generally too late.”

Dr Donnelly advises that although caffeine may seem like the answer to all your problems, taken in excess it tends to increase anxiety and reduce productivity, so drink in moderation.

Don’t be late

The day before your exam ensure you know where you are going, how you are going to get there, and when you need to leave the house. Being late is one of the most stressful experiences and is not conducive to a good performance on the day.

If you find that your stress levels are going beyond those of other students, you are using illegal substances or are drinking too much, then contact your local student support service or GP as soon as possible for support.

MPS offers a free confidential counselling service to all members who are suffering from the effects of an adverse outcome or a medicolegal issue, and are experiencing emotional or psychological difficulties as a result. More information can be found on this service here.

¹Visit www.dsn.org.uk for more information.

Frankly, it’s a bit like saying you can have the Guardian free after three weeks – the news section has little value at that stage. I would say that even six months is ultimately too long for research

One of our contributors gives their opinion as follows.

Journals burn in the academic spring

Being part of the  peer review process for an academic journal is a prestigious position. There is a big but. I, and other researchers do this job essentially ‘for free’. One of the points being made by the Wellcome Trust is that journals are essentially making money out of having what would otherwise be a very expensive process. I wonder if they are saying: why should we fund researchers to perform the peer review process for you to publish articles that students can’t see?”

Another contributor, who has graduated in the last five years has a different perspective.

So my own institutions access policy was great. The amount it cost the university is not publicly available right? SO if it is the £1 000 000 that is quoted, then that equates to the fee’s of over 100 students just for the subscription to the journals. The biggest problem is that now I’ve graduated, I can’t actually access any of the journals I looked at on-line, because my NHS Trust library doesn’t subscribe to them!

What do you think?

Photo by Cabinet Office

NHS trusts across England will now be footing the bill for a minimum of four days “shadowing” of their new posts, in a bid to smooth the transition from undergraduate to Foundation year doctor. Final year medical students have the Junior Doctors Committee at the BMA and the Department of health to thank for the new initiative, due to be in place from July 2012.

Professor Sir Bruce Keogh has written a letter to all final year medical students here.

In it he writes about shadowing:

“This will help you to become familiar with your new working environment and include a handover of your clinical responsibilities. Shadowing will equip you with the local knowledge and skills you need to provide safe, high quality patient care, from your first day as a F1 doctor.”

A Medical Educator Contributor writes:

“This is great news for F1 doctors who were previously undertaking shadowing on an unpaid basis, and the experience will be critical to a less stressful transition from student to doctor.”

The advice applies to England only, with different arrangements being made in Wales, Scotland, and Northern Ireland.

Photo by the Italian voice

Even though it is becoming increasingly out of fashion to request a CV from a doctor during recruitment, some trusts still use a curriculum vitae (CV) to shortlist candidates or at interview stage, and indeed, for many GP posts.

Matt Green from BPP University College School of Health says: “The person who is shortlisting candidates for interview will have on average only two minutes to review your CV in the first instance to determine whether your application should be considered further. Therefore, when preparing your CV you should strive to be relevant, clear and concise.”1

Matt’s three top tips for a medical CV are:

1. Split your CV into different section headings – by separating your experience and achievements into a logical order of headings, it makes the life of those cross referencing your information with the person specification, a great deal easier. Follow a layout of education and professional qualifications, clinical experience, non-clinical skills, extra-curricular and finally referees.
2. Avoid solid blocks of text – it is far better to present your information in a given section as bullet points rather than paragraph after paragraph of solid text as this can be very off putting and daunting to the reader. The aim of a good CV is to make your experience and achievements jump off the page.
3. Tailor your CV to the position – before submitting your CV, as part of a particular application or invitation to interview, cross reference your information with the person specification to ensure you cover any salient requirements – for example, if the job specification focuses on leadership and management experience, ensure this section appears towards the beginning of your CV.

Getting your medical CV right is really important – it is the one document where you can include detailed information about yourself and what you have to offer your prospective employer.

C2, part of The Careers Group, University of London, have also offered these top tips:

1. DO use clear headings and structure and arrange them in a way that makes it easy for the reader to find the evidence they are looking for (eg, audit, teaching, management, research).
2. DON’T just provide a list of jobs – convince the reader that you are safe and reliable, by providing details of what the role involves, your responsibilities, skills developed and the clinical experience that you gained.
3. DO include achievements, but give some consideration to what you want to include. What inferences do you or don’t you want the reader to make about you? What value does the information add to your CV?

If you are an MPS member, we offer all hospital doctors in training a free copy of the Definitive Guide to Specialty Training Application Forms and CVs by Medical Communication Skills Ltd.

Further information

See the following websites for more information:

www.c2careers.com

www.bpp.com

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1 Green M, Preparing the perfect medical CV, BMJ Careers, accessed 23 February 2012

Photo by jasleen_kaurManagement of hypertension is becoming increasingly complex.

Here our contributors summarise the complex use of BP to measure cardiovascular risk.

“Its always a case of measuring multiple things. We know we should be aggressively treating BP with patients with chronic renal disease and diabetes, but what about those without? Follow the NICE guidelines with our quick digest.”

We recommend management in accordance with the recently released NICE 2011 Hypertension guidelines.

Our step-by-step guide is below:

So the answer is?

In the case above, with a BP of 148/94,  we need to do two further blood pressure measurements in the clinic. If the lower of these is >140/90, then offer home ambulatory blood pressure measurement.

You can read a quick reference version of the 2011 NICE guidelines here.

Photo by Daquella maneraDoctors actually have a dual responsibility – to their patients and to society. The GMC states that disclosure without consent may be justifiable in exceptional circumstances where it is in the public interest to do so, where it is necessary to protect the patient or others from serious risk of death or serious harm. And, in certain circumstances, disclosure may be required by law.

But what constitutes a serious risk of death or harm? What about a patient who has been involved in public disorder? Should a doctor pass on this person’s information? Just how far should doctors make decisions about how serious a crime has to be before it is reported?

The GMC’s Supplementary Guidance Confidentiality: Reporting Gunshot and Knife Wounds, says:

“Such a situation might arise, for example, when a disclosure would be likely to assist in the prevention, detection or prosecution of serious crime, especially crimes against the person.”

Confidentiality may seem a very straightforward principle, but translating principle into practice can be problematic. There are all sorts of situations where it is difficult to know if patient information should be shared or not – with the police, for example, or Social Services.

MPS Senior Medicolegal Adviser Dr Su Jones says:

“Don’t get caught up in any public frenzy; have a measured, professional response in situations such as large-scale public disorder and rioting. Reflect on whether the disclosure is really in the public interest to avoid a knee-jerk reaction.”

It is important to bear in mind that it is not the medical profession’s responsibility to maintain law and order, as The Independent’s Health Editor Jeremy Laurance says:

“Its duty is to provide care to those who need it, non-judgmentally, without fear or favour.”

If you do decide to disclose a patient’s information, you should take care to document all decisions and discussions that have taken place.

Remember: You must weigh the harm that is likely to arise from non-disclosure of information against the possible harm both to the patient, to others and to the overall trust between doctors and patients, arising from the release of that information.

If you are unsure whether or not to share information, seek advice from an experienced colleague, or call MPS for advice.

This is a summary of an article that appeared in MPS Casebook. Read the full article here.

Also read Jeremy Laurance’s article, ‘Medical life: Patients’ trust must not be betrayed in the wake of the riots’ which appeared in The Independent here.

And after reading his case, the diagnosis is:

d. Ramsay Hunt Syndrome

Firstly this is a lower motor neuron (LMN) facial (CN VII) palsy: facial weakness of the whole of the face.*

Bell’s is a lower motor neurone lesion which is idiopathic in nature.

The aetiology is probably thought to be a herpes virus and there is some evidence to support the use of short course oral corticosteroids and aciclovir.

• about 50% of people will get better with no treatment
• steroids for approximately 1 week seem to help 50% of cases
• the benefit of aciclovir remains controversial

Read the Bandoleir review here

However: Ramsay Hunt is a facial nerve palsy caused by associated herpes zoster infection (as manifested in this case by the vesicles). When a patient presents with a CNVII weakness, this is one of the key reasons to perform otoscopy, as otherwise you may miss the vesicles.

*Remember in UMN lesions the upper half of the face (highlighted here in yellow) is spared as there is bilateral UMN innervation. You would not expect this in Ramsay hunt as its a LMN lesion. The image below shows a LMN CNVII weakness.

Remember, we have a completely free question bank in our login area – register now for more free questions!

The saying goes “what happens on tour stays on tour”, but when posting online bear in mind that what happens on Twitter stays on Google forever. Doctors should exercise caution when making entries on social networking sites – the internet is not a private space and nothing is truly anonymous.

Photo by Florian SEROUSSIMPS is aware of cases where junior doctors have discussed patients on social networking sites, assuming that they would not be identified – but they were exposed and those involved were disciplined.

The Journal of the American Medical Association uncovered many online breaches of patient confidentiality on social networking sites. The study found explicit postings from trainee doctors that revealed private patient information. Most were in blogs, including one on Facebook, containing enough clinical information that a patient could be identified.

Social networking sites blur the boundary between an individual’s public and professional life. Be wary of posting inappropriate material on social media sites, such as photos that may bring your professionalism or that of colleagues into question, even if they are taken in your free time.

However, tight privacy settings can create a false sense of security. Comments about your day-to-day work and the patients you have seen, even if anonymous, still pose a risk, as the information may be identifiable and so may breach confidentiality.

Protect yourself

Follow these tips from Sophos to protect yourself when using social media:

• log out when you move from one terminal to another
• check what levels of privacy you have set up
• enable secure browsing using https. This can be found under the account settings tabs of most social networking sites.
• choose a password with a mixture of upper and lower case letters and other characters, and change it as regularly as is practical.

Things to remember:

• Your ethical and legal duty to protect confidentiality applies equally on the internet.
• Do not accept current or former patients as friends/followers.
• It is inappropriate to post informal, personal or derogatory comments about patients or colleagues on public internet forums.
• Defamation law can apply to any comments posted on the web made in either a personal or professional capacity.
• Ensure that you do not inadvertently breach your contract of employment, by being aware of your local commissioning body or health board’s policy on blogging, etc.
• Be conscious of your online image when posting images on the web and consider how it may impact on your professional standing.
• Doctors and medical students who post online have an ethical obligation to declare any conflicts of interest.

The appetite for social networking can only get bigger, so doctors should take advantage of its many benefits, as long as they are balanced against the risks.

This is a summary, read the full article here. The BMA has also produced useful guidance here.

Top time for Hot Water in 2012?

“Personal profiles on Facebook and other social-networking sites are a trove of inappropriate and embarrassing photographs and discomfiting breaches of confidentiality. You might expect that from your friends and even some colleagues — but what about your doctor?” Time Magazine

This is current news in 2012, but if you look at the date of publication of this time article, it’s September 2009. Although this was published over two years ago, we think medical students are going to be coming under increasing scrutiny as the year unfolds.

It’s happened before, in the UK…

Remember people playing the lying down game? Roll back to Swindon, UK. A number of junior doctors were suspended for what many medical students and doctors considered hijinks: posing for photographs whilst lying down in unusual places. See our example of the latest MRI-PET scanner here:

It’s happening now…

A research paper from 2010 looked at a small group of medical students in Liverpool, UK. Over half had witnessed unprofessional behaviour by their colleagues on social media.

Dr Amy Cunningham, a lecturer from Cardiff University recently highlighted on Twitter and her blog about doctors using slang on social media, e.g. referring to ‘mad-wives’ instead of midwives. For her efforts, both she and the doctors in question were both applauded and criticised by healthcare professionals and different elements of the national press.

Help is at hand…

If things seem a bit blurry and you dont know who to turn to for advice, fear not – as we have compiled a handy list of references:

• From Your Institution – Check if you have guidelines at your University, and follow them!
• From Professional organisations
• From the MPS: The pitfalls of social networking
• From the BMA: Using social media: practical and ethical guidance for doctors and medical students
• From the AMA: Social Media and the Medical Profession: A guide to online professionalism for medical practitioners and medical students.
• Help From Within – We think ‘use your moral compass’ is a great adage. See the moral compass example of one experienced GP below.

Advice from an experienced user of social media

One of our medical professionals says this:

“I use this principle. If I wouldn’t be happy with any of: my mother, friends, work colleagues, peers, nurses, receptionists, patients, friends of patients, children of patients, professional licencing bodies, line manager seeing it, don’t post it. Do not post anything relating to your workplace, patients, or patient care online. If you have a grievance, use formal channels.”

What about anonymity online, protected tweets, protected postings?

“Just be careful. Is it worth risking your professional status over such minutia? The security of these areas is becoming increasing difficult to police. Don’t go there.”

Happy – and safe – tweeting in 2012!

The most likely diagnosis is:

a. Steven Johnson Syndrome
b. HIV
c. Stroke
d. Ramsay Hunt Syndrome
e. Bells Palsy

Leave your answer as a comment below – answer in a few days!