Themes – Research Skills, Critical Analysis Medical Students

Thesis – Research and critical analysis are important skills as highlighted by Tomorrow’s Doctors

Allen, drawing on many years’ experience as a researcher and lecturer in the Institute of Education, at Cardiff University has bridged the gap in Research methodology literature targeted at medical students. Pushing away from comparative texts somewhat dry and unengaging tones, this book encourages student interaction, empowering the student from start to finish. Not so much a book as a helpful hand guiding the student through the pitfalls and benefits of research and critical analysis from start to finish.

Photo by bjornmeansbearPart of the Learning Matters Medical Education series, in which each book relates to an outcome of Tomorrow’s Doctors, this book is written from the a lecturers standpoint, guiding students through making sense of research, judging research quality, how to carry out research personally, writing research articles and how to get writings published. All of these are now imperative skills in what is a very competitive medical employment market.

This concise book, through its clarity, forcefulness, correct and direct use of potentially new words to the reader, Allen manages to fully develop the books objectives, using expert narrative skills.

With Allen’s interest in Global health, it is little wonder why this books exposition is clear and impartial, Allen consistently refers back to the Tomorrows doctors guidelines at the beginning of each chapter, enabling students to link the purpose of that chapter to the grander scheme. This enables Allen to argue the relevance of each chapter to the student before they have disregarded it. Openly declared as a book aimed at medical students (and Foundation trainees where appropriate) the authors style remains formal, but with parent like undertones. It is written to encapsulate and involve the student reader personally, with Allen frequently using ‘you’ as if directly speaking to the reader, and useful and appropriate activities that engage the reader in the research process, in an easy to use student friendly format.

This book is an excellent guide for all undergraduate health students, not limited to medical students, and I thank Ann K Allen for imparting her knowledge in such a useful and interactive way.

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Photo by Jonathan Ah KitIt is December and over the last year you have provided good care to your patients, so how nice of them to show their appreciation by giving you a present? Accepting presents, however, can create conflicts of interest and threaten probity.

Individual GP practices and most hospitals will have their own gratuities policies, but as a rule the GMC states in its ethical guidance on conflicts of interest, that GPs in particular “must not ask for or accept inducements, gifts or hospitality which may be seen to affect judgements, nor should these be offered to colleagues”.

The guidance also states that GPs “must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit them”.

Pallavi Bradshaw, MPS medicolegal adviser, says that all doctors need to be sensible and objective when accepting gifts from patients.

“GPs, in particular are more likely to be given presents as they have known their patients for longer. Care needs to be taken when deciding whether to accept or decline a gift as you don’t want to break the professional boundaries of the doctor-patient relationship.”

If you accept a gift from a patient you should say thank you and record it in your practice/hospital’s gift register. Keeping a record of all gifts offered or received and discussing the matter openly with colleagues promotes transparency. All GP practices should have a gift register and some individual trusts will have their own policies – so always check.

If you decline a gift be polite and explain the reason why you cannot accept it, and record in the gift register what you were offered.

Do not leave wine bottles in doctors’ rooms – this can look unprofessional and give the wrong message to patients.

In an article in the BMJ Dr Sean Spence wrote that the most appropriate advice is to take nothing for granted and reflect upon the gift and its timing. A polite refusal may be preceded by reference to the ethics of medical practice or could emphasise that declining a gift does not equate to rejecting the patient. He adds that whatever the outcome, a thank-you note is appropriate.

What if I am given an expensive gift?

Under the General Medical Services (GMS) contract GPs are obliged to declare any gift from a patient worth more than £100 to their local commissioning body. This rule also applies to gifts received by spouses of partners or staff. If you work in a hospital and a gift is of particular value, you should discuss this with your departmental manager.

“If you are given cash by a patient, I would be reluctant to accept it,” says Dr Bradshaw. “I would also encourage the sharing of gifts given to you with the rest of your practice, for example, a box of chocolates. There have been cases when patients have left large sums of money in their inheritance to their GP. I would advise you to be cautious about this, and if you do decide to keep it then maybe invest the money into the practice or give it to charity.”

Treat those patients who give you gifts the same as any other patient, but a nice gesture would be to send thank you letters to patients who brought you presents during the festive period.

Section 23 of the Health and Social Care Act 2001 requires practitioners providing family health services (GPs) to declare financial interests and the acceptance of gifts and other benefits. It also states that doctors and other NHS employees in the hospital sector are required to refuse all gifts from patients except those which are of low intrinsic value, such as diaries or chocolates.

NHS employees should not accept “substantial” gifts from patients or others and monetary gifts are not allowed.

What is the intention of the patient?

It is advisable for a doctor to judge the intention of a patient before making deciding whether to accept it or not. Some patients may attempt to influence care or secure preferential treatment through the offering of gifts or cash. Acceptance of such gifts is likely to damage the integrity of the doctor-patient relationship. Doctors should make clear that gifts given to secure preferential treatment compromise their obligation to provide services in a fair manner.

The nature of the gift itself must also be considered. Accepting a gift, such as lingerie would be inappropriate, as would gifts of large sums of money. Giving either of these gifts may represent an attempt to equalise the power structure of the relationship, or may be a conscious or unconscious bribe. Giving a gift to influence an outcome is a bribe, and as such, it is unethical. In most organisations the demands of probity require that employees decline gifts that might be seen to influence their judgment.

If you are in doubt about whether to accept a gift, seek advice from MPS.

References:
Dr. Sean Spence (BMJ, December 24, 2005).

a. Coal Tar

This is the classic salmon pink rash of psoriasis. You can see the surface has a scaly appearance.

As the rash in psoriasis is palpable and spread over an area of >0.5cm it is called a plaque not a macule – (If it was an impalpable area of colour change it would be called a patch).

Skin psoriasis is treated by emmollients, vitamin D analogues, coal tars, dithranol, topical steroids and oral retinoids. Methotrexate and Anti TNF therapy in addition to other immune modulating therapies are used in severe cases. Remember the four main types:

1. plaque (seen here)
2. pustular (pustules often occuring on the hands and feet)
3. guttate ( teardrop lesions -sometimes occuring following a streptococcal infection)
4. erythrodermic (diffuse skin involvement – potentially lifethreatening)

Capsaicin is a Rubefacient: a topical skin irritant. Its use is based on the principle that irritation of the skin produces a “distracting” effect from the pain from OA/ neuropathy (e.g. post herpetic neuralgia).
It is used topically for osteoarthritis and neuropathic pain.

Capsaican is the “active” ingredient in chillies which gives them their heat. Its use over a rash like psoriasis would be liable to produce excruciating pain and significant inflammation.

Photo by clemsonunivlibraryIn December, the long nights and cold mornings make things tough for medical students on their way to clinical placements. Friday the 7th of December was no exception as the first round of the Situational Judgement Test (SJT) rolled out across the UK for medical students. The SJT is used to help to rank the job applications of thousands of medical students qualifying to be doctors in 2013.

So what was the verdict on the new assessment? Our own contact with students suggests two key themes: question difficulty and time pressure. This left many students struggling to cope with the time pressure, grasping for answers, and filling out the final questions without reading them in detail.

“It was horrible”

Recurring comments include long stems, long answers, and similar question responses making things difficult. As some students turned to the range of revision resources available, no single source seems to have provided all of the answers. A writer who has produced situational judgement tests for MedicalEducator gave her thoughts.

“It’s not surprising that the SJT proved a tough task for medical students. A new assessment, with one question every two minutes seems tight for what are detailed scenarios. For some students it will be relief that the SJT round is over, for the second half of UK medical students, at least they know what to expect- a difficult, time pressured assessment.”

The second round of SJTs will take place in January 2013. MedicalEducator has authored a range of situational judgement tests for the MPS, which are freely available to all members of the MPS. Just sat the SJT? Give us your verdict below!

Dr Hajra Siraj, an F2 doctor, says new doctors should use “every challenge faced as an opportunity to improve”.

The words you dread hearing moments into your first ever job, “Phew, don’t worry, the doctor-in-charge is here now…”

It was one year ago when I qualified, and was finally let loose on the wards. Despite my initial burst of enthusiasm and excitement, I couldn’t ignore the intense apprehension pulsating through my nerves.

Whilst having studied medicine for a whopping six years, I don’t think I could have ever really been prepared for what lay ahead of me as a year one junior doctor.

In the harsh and rapidly changing hospital environment, it is not a Swiss army knife or a military compass you need to protect and guide you; it’s a stethoscope, a strong dose of caffeine, and the BNF that you need to survive.

The first few weeks were a complete hurricane of information; new patients, new systems, new names and new anxieties to deal with.

My tips for staying afloat in this initial stage would include being organised, documenting accurately and concisely on ward rounds, and maintaining a positive attitude – a smile can get you very far.

One of my bleakest memories is of the third Friday into my medical career. A series of ill-fated misfortunes, including my consultant being on holiday and my registrar being off sick, resulted in my worst nightmare coming true; I was left to do the surgical ward round all by myself.

After suffering a well-concealed mini heart attack in the doctor’s office, I soon realised that I had better start getting on with things, as it was already 7.55am. My scrupulous calculations led me to believe, if I spent five minutes with each of my 27 patients, I should be done and dusted by 10.15am. Oh, how misguided I was…

My bleep bellowed mid-way through reviewing the first patient; I was called away urgently to see a post-op gentleman, Mr F, who was vomiting up blood. I took a brief history, and proceeded to assess him using the failsafe ABCDE method.

I quickly gauged that his blood pressure was plummeting, and his heart rate was even faster than mine; Mr F was clearly very unwell. After three frantic attempts I managed to insert a cannula into his wrist and draw urgent bloods, including a group and save. Whilst he was being resuscitated with fluids, I called for help.

I stayed with Mr F until the on-call surgical registrar finally arrived. I prescribed the three units of blood, and arranged an urgent endoscopy. By the time I felt I could leave him and start seeing my other patients, it was already 3.30pm.

New doctors will undoubtedly come across many challenging clinical situations early on, and indeed these may prove to be the most fruitful of learning opportunities; however, it’s important to remember that help and advice, if required, should only be a bleep away.

What struck me the most about being a new doctor was how much I had to deal with things I really wasn’t expecting. If only there was a module at medical school entitled ‘how to dampen fiery family disputes’ or ‘how to stop the despondent drunk self-discharging’ to help us along our careers. Very often, the patient will see us as their closest ally. It is therefore, unfortunately, most likely to be us they turn to for help and advice if things go sour in their personal lives. On occasion you may stand witness to a ward disintegrating into a roaring episode of ‘The Jeremy Kyle Show’.

I found it vital to make friends with my colleagues in this work setting. Not only did their experience in other specialty areas aid me in caring for my patients holistically, but I also realised having a giggle in the backroom with a hot chocolate and a biscuit lifted my spirits, even on the worst of days.

About four or five months into the foundation year, there is a period of calm. By this point, my awareness and judgement of clinical situations had really improved and my anxiety levels had started to plateau. I felt I could prioritise tasks more effectively, and at last start to enjoy managing complicated and quirky clinical cases.

One case that has engraved itself into my memory is that of Mrs S, a 79-year-old lady who sustained a neck of femur fracture following a fall. Post-operatively she baffled us with persistent complaints of visual hallucinations; she saw ‘little people’ running around her bed.

Numerous investigations were performed – infection screens, CT/MRI heads, even toxicology testing – all negative. There were no signs of alcoholism from her blood tests, and no family to take a collateral history from.

Finally, after many weeks of deliberation and further investigation, it transpired Mrs S was suffering from Charles Bonnet Syndrome. This is a well-recognised phenomenon affecting people with visual impairment, resulting from over-excitability of cells in the visual cortex. With reassurance that these symptoms didn’t signify any underlying psychiatric or degenerative disease, Mrs S at last felt she could start living her life again.

When I look back upon my year as a whole I can see how much I have learnt, not only about my patients and their illnesses, but also about myself as a professional and a person.

My advice to new doctors would include using every challenge faced as an opportunity to improve. Although the new responsibilities and pressures may seem daunting at first, with a hard-working and positive attitude you will undoubtedly lay down a solid and unshakeable foundation to build your future career upon.

Read the MPS publication, New Doctor, for all the latest news affecting junior doctors: http://www.medicalprotection.org/uk/advice-and-publications/new-doctor.

It will apply to fully registered foundation year 2 doctors, and all speciality trainees. The trainees will officially have to report to different representatives of the General Medical Council (GMC) depending on where they live. For example in England, this will be the postgraduate dean.

This process may be confusing already confused junior doctors! This from an ST doctor from the West Midlands:

“We are already operating in a highly structured system of mandatory training, appraisal and work place based assessments. I’m not really sure how this revalidation applies to us, it seems to be an assessment of what we are doing already.”

Early indications from the GMC suggests that this opinion may largely reflect the truth for doctors in training. It seems the responsible officers will review evidence already collated at the annual review most doctors have (ARCP or RITA), but can also take into account other information ‘from employers’. As an ARCP or RITA can already do this, we don’t anticipate the system will produce dramatic changes for trainees.

So, the process of certifying doctors are at an appropriate standard continues. We feel this area may be particularly important for undergraduates being called to any interview process in the coming months, due to it being a topical issue. Further information can be found from the GMC here.

Photo by the russians are hereBefore practising in a new country it is important to protect yourself: new countries may bring new risks. Having indemnity and access to 24-hour medicolegal advice is vital, and this is where MPS can help.

MPS can protect you whether you are relocating permanently, for just a year, or working on an expedition or voluntary project. The NHS indemnity scheme, which is limited to clinical negligence claims arising from NHS hospital care and claims made against the trust, does not extend to doctors working abroad.

In an article in New Doctor, the risks are discussed in more detail.

Dr Pallavi Bradshaw, MPS Medicolegal Adviser, says: “Junior doctors must be alive to the ever-increasing risks of clinical practice. Doctors travelling abroad should be alert to the current legal and ethical climate within a particular country. Being aware and managing these risks will safeguard you for the future.”

MPS protects the interests of members when concerns are raised about their practice, in any form – claim, complaint, medical council investigation. With members practising in more than 40 countries, if you are planning to work overseas MPS membership can often be arranged.

Talk to a membership adviser before travelling if you are planning to work overseas. Use the helpline number 0845 718 7187, or email international@mps.org.uk. You should provide details of your scope of practice and where you intend to work, so we can confirm the correct subscription rate for your work.

Read more about the service here, and read the New Doctor article in full here.

We asked you about this 27 year old female who presented with a 3-day headache. After looking at her lumbar puncture results, the diagnosis is….

a. Benign Intracranial Hypertension

The pressure is very high! The CT was normal essentially excluding raised intracranial pressure secondary to an obstructive hydrocephalus (e.g. meningioma obstructing the 4^th ventricle draining CSF). The red cells are high in the first sample of CSF but as further CSF is tapped off, this clears. This supports a slightly “traumatic” tap. Xanthochromia testing in the sample is negative, providing no evidence of a prior bleed into the CSF which has then been broken down into xanthochromia.

To diagnose a S.A.H. you have to have either blood or altered blood in the CSF. As a rule of thumb you should have “no” red cells in the CSF if its not a traumatic tap and there is no other pathological processes.

The diagnosis is BIH. This is reasonably common in young people and is not benign: untreated it can threaten sight. Treatment is via means to reduce CSF pressure e.g. repeated lumbar punctures.

Get more free questions >>

Her lumbar puncture shows the following.

What is the most likely diagnosis?

a. Benign Intracranial Hypertension
b. Tension headache with traumatic Lumbar Puncture
c. Sub arachnoid haemarrage missed on CT
d. Stroke
e. Sub Arachnoid Haemorrage
f. TB Meningitis