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Re: Do we need to end the culture of diagnostic rule-out?

Posted in General clinical at Sat, 19 Apr 2014 14:33:07


Posts: 1394
Joined: 08 Oct 2010

In Response to Re: Do we need to end the culture of diagnostic rule-out?:[QUOTE]

We are forced to 'over-exclude' if you want to survive the army of lawyers and angry patients waiting for you in case you missed something.

Common sense has completely gone overboard and a practitioner can only think: 'I better make that scan, because if later this year it shows that there was a tumour I am out of my job and my family out of the house'. So yes, we over exclude but it is society imposing this upon us.

If health authorities and the medico-legal system would be more acceptant of the fact that no 'over excluding' can sometimes lead to missing something, only then we can move away from defensive medicine.

Posted by jrosman[/QUOTE]

I know you will think me naive and idealistic but when talking specifically about Medicolegal claims (excluding Complaints), if you practice sound medicine you are unlikely to run into legal problems.  I know that we are bombarded with advertisements from legal firms enticing people to sue their Doctor and that it must feel like you are in the trenches practising medicine but consider these please (they are not for you to post answers to):

Have you personally been sued?

Has a partner in your practice or of very close acquaintance been successfully sued?

Do you know of any Doctor personally who has lost their house from being sued?

(in the above questions I refer to people you know for sure have been sued and not apocryphal stories that abound)

All the cases I deal with concern legal claims against Doctors - the great majority get nowhere near a court (easily greater than 90%). Undoubtedly the whole experience is stressful and protracted but you pay indemnity cover for a very good reason - to deal with such issues if and when they arise. Of the remaining cases most are resolved on the eve of court appearance. The number of successful claims (I.e. the Doctor loses) are around the 1- 2% mark. And, quite frankly in such cases the Doctor has been judged negligent. Remember also that the judgement of good or negligent care is made by the medical profession.

I do not for one moment make light of the enormous distress involved in legal cases for Doctors. I reiterate I am not including complaints in this post and recognise that they alone cause great worry and take up very large amounts of time that is already a scarce commodity.

Good medicine is good law even though it sounds trite. Exceptions abound of cases where 'perverse' judgements are almost mythical. From the Medicolegal 'trenches' I urge you to practise medicine without second guessing yourself. Can I guarantee you will not have problems? No, obviously not. But the great majority of Doctors never get sued successfully during their entire career, but some do and some are considered to have been negligent in act or ommission. A 'negligent Doctor' is not an evil Doctor nor does it mean he/she is without skill or judgement. Frankly considering all the risks involved in practising medicine it is amazing there are not many more legal problems.

I look forward to an avalanche of responses at my naïveté!



Re: Clinical question of the week: What will be your first-line drug therapy for chronic obstructive pulmonary disease?

Posted in Respiratory medicine at Sat, 19 Apr 2014 12:45:08


Posts: 489
Joined: 21 Feb 2012

In Response to Re: Clinical question of the week: What will be your first-line drug therapy for chronic obstructive pulmonary disease?:[QUOTE]

In Response to Re: Clinical question of the week: What will be your first-line drug therapy for chronic obstructive pulmonary disease?:[QUOTE]

In Response to Re: Clinical question of the week: What will be your first-line drug therapy for chronic obstructive pulmonary disease?:[QUOTE]

I continue on the same horse until the evidence is overwhelming that another horse is better.

We receive a publication called Radar which demystifies the smoke and mirrors, the Pharma hype with guest speakers and weekends in flash hotels in Sydney, pork barrelling and tugging fore locks, ego buffing and celebrities from Spain, Italy and Magna Britannica who look tired, well-worn Pharma hacks that you wouldn't buy a used car from. 

Yes, the truth is out that there are lots of non-inferior more expensive but none-superior potions out there to capture the lucre of the COPD gold vein while tobacco companies stoke the fires of profits to ensure that the gold vein will go for miles and for hundreds of years.

Hail to thee, Jacques Nicot.


Posted by Odysseus[/QUOTE]Dear sir,

In your own inimitable  style ,you have shown us the existing trend!

Thank you.



Posted by Dr.Chid[/QUOTE]

Thank you, Dr Chid. Some think I speak in riddles but my tongue is nothing compared to the divine utterance of ambiguity spoken by pharmaceutical oracles with indeclinable p values, improbable odds ratios swooned to the smoke of laurel leaves. 



Posted by Odysseus[/QUOTE]

Yes,but.no answer to your repartee!




Re: Lancaster bans e-cig sales in local market!

Posted in Respiratory medicine at Sat, 19 Apr 2014 10:19:00


Posts: 334
Joined: 23 Aug 2013

I understand a similar policy has been adopted in the Royal Free Hospital, NHS, UK,  & Ireland. Other journalist reports about philadephia & NYC. The Harvard Health blog  had concerns about its safety. The WHO had concerns regarding its safety.

In my hsopital, it is currently recognised as a form of smoking & is banned on grounds of health concerns & aesthetic (smoking behaviour like) concerns.

Happy Easter To All

Posted in General at Sat, 19 Apr 2014 09:46:06

Mukhtar Ali

Posts: 773
Joined: 14 Nov 2010

Wishing you all a very   Happy----Glad----Grand-----Great ---- Easter

Re: M*A*S*H and Time

Posted in General at Sat, 19 Apr 2014 00:06:58


Posts: 3808
Joined: 24 Feb 2009

In Response to Re: M*A*S*H and Time:[QUOTE]

Eh? Cannot find any reference to Johnson saying that, or anything similar, about priests or sex, but much on marriage, especially a second marriage, which is, "The triumph of hope over experience, Sir!"

I wouldn't know about Homer; it was Socrates whose original career was as a soldier, serving in the Peleponnesian war.  "All wars are undertaken for the acquisition of wealth."


Posted by John D[/QUOTE]

You are misreading me. I was talking about Dr Johnson and your comments about war and that he had not gone to war.

Oats are in his lexicon and the description is inimical to the Scots.

I take exception to the quote by Socrates.  I think some are but not all. Some are out of ideals, the fight against tyranny or a desire for freedom.  The fact that we are able to write this is a testimony to this notion.

Today we are free to celebrate Easter which was about a struggle of ideas. The ideas won.

Later this week we celebrate ANZAC Day (25 April) which is a solemn day of remembrance and thanksgiving for those who perished in battle and who left a legacy to a freedom-loving people.

"Evil flourishes when good men do nothing".



Re: Can trainees be encouraged to take up unpopular specialties?

Posted in Careers at Fri, 18 Apr 2014 20:43:53


Posts: 3808
Joined: 24 Feb 2009

Water finds its own level if let run freely.


Re: Are telephone consultations the way forward?

Posted in General clinical at Fri, 18 Apr 2014 11:49:59

Ms. Sarah

Posts: 4
Joined: 01 Jun 2013
The medical practise is all about the patient and this goes beyond the patient's story. How the patient tells the story, mannerisms, appearance and the likes must come to play. Examining the patient is also a part of it. Telephone conversations or skyping can't achieve all these. Plus they make the patient-doctor relationship less personal. Except telephone consultations are for fixing appointments, they will only end up creating the impression that more patients are reached at shorter time, whereas the quality of patient care may actually be compromised.

Re: Do You Live in Couch Potato Culture?

Posted in General at Fri, 18 Apr 2014 11:43:58


Posts: 3808
Joined: 24 Feb 2009

Nothing is new under the sun. The Romans ate while reclining on couches and had floor mosaics depicting the cast offs of the meal; fish heads, chicken drumsticks and fruit and other rubbish. 

Perhaps this is all déjà vu. 


Re: Which type of writing instrument do you prefer?

Posted in General at Fri, 18 Apr 2014 10:09:37


Posts: 334
Joined: 23 Aug 2013

In Response to Re: Which type of writing instrument do you prefer?:[QUOTE]

 I find that when I use pen in any creative writing there is a different process taking place than with type. But that may just be me. The joys of a Moleskin with a fine pen. 


Posted by Odysseus[/QUOTE]

Typing is an impersonal process. It does not matter whether you have an expensive or a cheap keyboard, what OS do you prefer, the options are relatively stable bold, italic, underline, font shape, colour and size (which are all preset).

On typing I prefer the very basic editors (no autocorrect, no formatting, no nothing), so as not to get distracted by the array of options & medically illlterate word processors, which tend to autocorrect medical jargon. I'd go for text-based editors e.g. Emacs (GNU/Linux & Mac) & then send text files to the secretary to enjoy the richness of word processors. I only type to save the secretary's time of re-typing if I wrote in pen; plus the paper will be ditched as soon as the content gets evacuated/transformed.

I do appreciate that many people find it a hassle to type, in a way it is disconnected from orthography. The most simple letter e.g. I or the most elaborate W, M, B, take the same action & same time 'press' a key.

I am not annoyed by typing, but writing with fountain pen is a personal joyous & aesthetic process (I know it is an oxymoron to type this though!). i found that the sales of fountain pen have been rising recently. Novelist Isamilov wrote an interesting blogpost at the BBC website expressing his passion about the fountain pen.


Re: Could new consumer technologies make remote consultations useful?

Posted in General at Fri, 18 Apr 2014 08:23:58

John D

Posts: 2860
Joined: 01 Feb 2010

Welcome to Doc2Doc, gstidolph!

D2D welcomes interested people from non-medical fields, who have a contribution to make to our debates.   Please introduce yourself in this thread, so that we know who you are,  if you are a doctor involved in this subject, or are you trying to get us involved.   That would be fine, but please note - we don't tolerate advertising!

You introduce an interesting subject, that is an extension of an existing thread here on telephone consultation.  Do doubt you can tell us more about that, too.  See: http://doc2doc.bmj.com/forums/open-clinical_general-clinical_telephone-consultations-way-forward

John (as Moderator)

Re: Are lay media misrepresenting brain scan research?

Posted in Stroke at Thu, 17 Apr 2014 20:56:46


Posts: 517
Joined: 13 Oct 2009

If a patient is diagnosed as PVS but subsequently found to have MCS (or even locked in syndrome as I think was found for one patient here) then there has perhaps been some misdiagnosis. As new tests and techniques emerge there is bound to be some reclassification and this seems to be what journalists are trying to highlight. This is similar to the work from Cambridge and must be pretty horrific for many of the public . It raises many ethical issues about pain (or potential pain management) , feeding etc...  For many people this is close to the ultimate awfulness of modern medicine - I remember a meeting a few years ago when only a handful of people in a large audience would have wanted to continue in this twilight state , but it will be difficult for doctors not to continue "care". There is also the problem of consciousness on these tests - how far does it correlate with significant awareness - certainly from what I have read earlier it does not seem to be enough for patient involvement about decisions for ongoing care. 

Re: Heart and Lung Transplant

Posted in Medicolegal at Thu, 17 Apr 2014 20:49:43


Posts: 3808
Joined: 24 Feb 2009

We may overlook the pernicious effect of then court process on lay people. It is a psychological ordeal which can drag on interminably and many a defendant doctor for example has suffered irreparable mental injury. It is running the gauntlet and death by a thousand cuts. The innocent may emerge from this ordeal traumatised as the lawyers emerge with much lucre and a smile.

Thus, an out of court decent and honorable settlement is the preferred option in this case unless you are unworthy to be an agent of Justitia as we are wrangling over a preventable death not a dented car or a dented ego.

Money can do nothing other than bring a sense of revenge/ justice and helps lower the heat  of the matter. It is a psychological transaction which really takes place, and a new energy state of relative calm/ peace.


Re: Should Government Provide Treatment to Illegal Drug Users?

Posted in General clinical at Thu, 17 Apr 2014 20:33:13


Posts: 517
Joined: 13 Oct 2009

An add-on is the use of sofosbuvir at about £35,000= a course for the treatment of hep C.. Should those continuing to use IV drugs have repeated courses to cut down on the hep C pool , bearing in mind that this is one of the main aims ?  I find it interesting that in the UK a bottomless pit of gold is assumed to underpin the NHS - at least for high profile groups. I think of late there are an increasing number of people who resent the fact that - on an estimate - nearly 40 % of the money goes on treating diseases where there is a major lifestyle component , particularly if the patient is unwilling to to try to alter these. At a time when the other 60% may be pushed into second place , let alone other demands on the public purse such as education and social care , perhaps we will need to have a re-think about how resources are allocated? Curretly it all seems reminiscent of Anglo-Saxon England and buying off the Danes with danegeld without trying to solve the underlying problems.  

Re: Would you be offended if a patient asked if you had washed your hands?

Posted in General clinical at Thu, 17 Apr 2014 20:23:58

John D

Posts: 2860
Joined: 01 Feb 2010

Of course not.  We should be able to say with certainty that we do so everytime we leave a patient and go to another.

But this is not a new idea.  My own father, a surgeon, told me this more than forty years ago, so why is it a question now?   It's pressure of work.  There is good evidence on workload and cross infection, from ICUs to out patient clinics.  As the number of patients who pass through the area rises, cross infection is held until a critical level at which it rises abruptly.    And clinic throughputs, and bed occupancies are higher than ever before.  Long ago, the King's Fund found that bed occupancy should not be higher than 80%, else this and other factors suffered, but financial and managerial pressure has kept it far, far higher.  At times, my own ICU has had a bed occupancy of more than 100%.

It can't continue.   The pips are squeaking, or rather the bacteria are laughing.  Unlike the jolly monsters in those TV commercials for lavatory cleaner, they escape being washed away in a flood of disinfecting water and soap, as nurses and doctors fight to keep their units afloat, and just have no time to wash as they juggle the clinical balls and keep them aloft.


Re: Docotrs and lawsuits

Posted in General at Thu, 17 Apr 2014 18:31:57


Posts: 1394
Joined: 08 Oct 2010

Mr Johnson, as John has made clear your advertisement is not appropriate for doc2doc. If however you have some Medicolegal insights to share and debate that would be great. I and other doc2docers would be very happy to be informed about interesting issues facing Doctors in the States. Internet defamation is not a matter of concern to UK Doctors and long may it stay that way.


Re: Multi-speciality Logbook app for iPhone

Posted in Medical education at Thu, 17 Apr 2014 17:29:41


Posts: 3
Joined: 18 Feb 2014

Yes. Ultimately it's a matter of recording the data in any way that you find most comfortable. A lot of trainees still use paper.  The beauty of using your phone to log is that it's always with you. 

Devices can go wrong but cloud storage means that you can drop your phone in the sea and your data remains intact. 

 The trick with electronic recording is to backup regularly. 

Another major advantage of the Universal Logbook is the ability to quick summarise (tables and bar charts) your data for appraisals.

but as I say. Each to their own as long as you're accurate and consistent. 

Re: Share your memories of "black Wednesday"

Posted in General clinical at Thu, 17 Apr 2014 17:10:56


Posts: 1439
Joined: 25 Jan 2009

I heard one suggestion that they should be available to support the transition of the incoming FY1 replacing them in their post, basically that the shaddowing period should be moved from summer time to that first cross over month


Re: The state of medical education in India

Posted in BMJ India at Thu, 17 Apr 2014 09:13:20


Posts: 61
Joined: 18 Mar 2014

Congratulations to Dr Deb_D - I hope we see more of your contributions over the coming weeks/ 

Re: Is medical education in India up to the mark?

Posted in BMJ India at Thu, 17 Apr 2014 03:53:38


Posts: 3808
Joined: 24 Feb 2009

Depends on where the mark is and who put it there.

Mediocrity has a low bar but if everyone is a midget, the bar is high. 

It is only when a hyena meets a lion that a lion looks so grand.


PS On entering the Barnes Hospital foyer in St Louis, Missouri I noticed the framed photopgraphs all aound me. They were Nobel Laureates from that institution. At CalTech they have a special car parking area for Nobel Laureates. 

Re: dementia

Posted in Neurology at Thu, 17 Apr 2014 03:50:05


Posts: 568
Joined: 23 May 2012

What do you think aboth  fisetin in dementia. Is it actually slows dementia.fisetin is a flavonol that are found in fruit and vegetables. Pl discuss.

Re: Aesthetics in an anaesthetic profession. What does it do to you?

Posted in General at Wed, 16 Apr 2014 21:35:48


Posts: 3808
Joined: 24 Feb 2009

We are too busy to think. Too busy to appreciate, to breathe, as medicine  is the jockey, and we the horse and the scenery on the way is but a blur.

Before I did medicine I enjoyed aesthetic appreciation of many things but during the medical course and later ordeal, I could feel it being squeezed out of me as if I was an olive in a press. 

You need to find room in your life to keep the flickering candle burning so when you are old, the flame can light other candles and you will not just be a discarded olive pip and a boring one at that.


Re: MRCGP exams in the news

Posted in News & media at Wed, 16 Apr 2014 17:28:32


Posts: 12
Joined: 29 Jul 2009

It is quite clear that there is a huge disparity in the performance between white candidates and ethnic minority candidates but instead of sitting around and speculating why this disparity might be, would it be too much to make video monitoring available in these exams? in that way there would be a more objective explanation to the difference and the examination would be fairer to all involved. Many of the royal college examiners are also of ethnic minority origin so, racism is not the most convincing explanation here

Re: Can we warn patients against quackery?

Posted in General at Wed, 16 Apr 2014 15:49:17


Posts: 542
Joined: 04 Jul 2010

Mail 3 - My rebuttal

Dear Mr. X,

Thank you for your reply. I will address your responses point by point. Firstly let us look at “world famous cardiologist” Dr. Al Sears.

You resort to appeal to authority regarding Dr. Al Sears, it is not a valid debating tactic. Regardless let us examine the credibility of Dr. Al Sears. In his website, Dr. Al Sears advocates the use of magnesium supplements and vitamin pills to control blood pressure instead of beta blockers. This leaves him with no credibility. But perhaps the Florida Department of health and licensing board of physicians will convince you – “AUTHORITY VOID - the licensing board or department voided practitioner's license. Practitioner can not practice in the state of Florida and is not obligated to update his/her profile data." (Reference – hereand here).

So the world famous cardiologist quoted by you isn’t even licensed to practice medicine.

Also Dr. Sears claims that he is board certified by American Academy of Anti-Ageing Medicine. Sounds well and good, yeah? Except that it is not recognized by either the American Medical Association or the American Board of Medical Specialties (the actual organization that issues certificates of specialization) (Reference – here). You do realize what touting an unrecognized certificate means, don’t you?  

Now let me resort to some appeal to authority. Quoting from the Updated Recommendation for Adults from the American College of Sports Medicine and the American Heart Association – “Primary Recommendation: To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week.” Notice how much they stress on aerobic exercise? Surely American Heart Association trumps the personal opinion of someone who is not licensed to practice medicine, does it not?

"The longer we indulge in aerobic activities, such as typically described earlier, the more we secrete a nasty little group of hormones called glucocorticoids, with the stress hormone cortisol, chief amongst them. One of the lesser known qualities of cortisol is that it is catabolic in nature, meaning that it breaks down muscle tissue along with fat in order to metabolise this stored energy for immediate fuel. Why is this bad?  IT IS MUSCLE THAT GIVES US SHAPE AND DEFINITION AND MORE IMPORTANTLY FROM A FUNCTIONAL POINT OF VIEW GIVES US BALANCE.If we lose muscle faster than we lose fat,then we are proportionately fatter even if the scales tell us that we are several kgs lighter. In a society that  places a higher priority on what we weigh, and the medical community is no saint in this regard,this is a difficult concept to grasp but nevertheless true."

I don’t think you are qualified in any way to discuss glucocorticoids, as is evident from your profoundly ignorant comment about glucocorticoids and adrenal gland from your article. You wrote – “Cortisol leads to adrenal fatigue, yo-yo-like fluctuations in blood sugar and completely throws your digestive system off gear.”  For your information, there is no such thing called adrenal fatigue. The Hormone Foundation of the Endocrine Society has clearly stated so. “Adrenal fatigue is not a real medical condition.There are no scientific facts to support the theory that long-term mental, emotional, or physical stress drains the adrenal glands and causes many common symptoms.” This has been endorsed by 14000 endocrinologists. So when your basic understanding of endocrinology is such shockingly flawed that you can promote a false disease on a newspaper, forgive me if I don’t buy into your arguments on glucocorticoids. For what it’s worth, glucocorticoids are absolutely lifesaving in several conditions.

 "This brings us back to the " chunky aerobics instructor"  with her 22-24% body fat. From a clinical point of view,admittedly, 22-25% fat is not alarming as your quoted report suggests. We are merely saying that for a conditioned athlete or trainer these are not acceptable figures. We are also quoting these figures  when comparing them with sprinters who definitely clock less training time yet have much less body fat."

21-24% body fat is at fitness level, not just acceptable. They are way better than acceptable. What will a normal person gain by being compared to sprinters when their body fat composition is absolutely fine? The sprinters form an outlier group that’s why we don’t compare normal persons with sprinters.

"Core fact in conditioning- More is definitely not best when it comes to time spent under physical stress. The key word is intensity!"

Evidence please, I can just as well say more is definitely best. It’s meaningless unless you provide evidence (a scholarly article, not anecdotes as that’s what evidence means).

"A little more science: To understand one more reason why aerobics is not my favourite fat burn method , we need to consider a substance called myoglobin. Myoglobin is a large protein that binds to oxygen inside your muscle cells. It is repeatedly used and reloaded during the work and recovery phases of interval type anaerobic type training. However, as the duration of the work periods increase ( as in the case of long,slow aerobic conditioning),myoglobin stores are reduced. Myoglobin holds enough oxygen to last for 5 to 15 seconds. Intervals which last beyond this point at which myoglobin loses its supply of oxygen rely more on carbohydrate as a source of energy. this explain why short, hard intervals promote greater rise in fat burning.While you rest after achieving momentary failure, the myoglobin gets a chance to 're-load' again."

Again, evidence please, not just assertions.

The evidence at hand suggests that aerobic exercise is better than anaerobic exercise. Let me state the conclusions from a study comparing aerobic and anaerobic exercise – “We conclude that training above the anaerobic threshold has no or even negative effects on blood lipoprotein profiles. Therefore, beneficial adaptations in lipoprotein profile must be achieved with moderate training intensities below the anaerobic threshold.” (Effects of aerobic and anaerobic training on plasma lipoproteins. International Journal of Sports Medicine [1993, 14(7):396-400])

Compare that to the beneficial effect of aerobic exercise. “Regular aerobic exercise modestly increases HDL-C level. There appears to exist a minimum exercise volume for a significant increase in HDL-C level. Exercise duration per session was the most important element of an exercise prescription. Exercise was more effective in subjects with initially high total cholesterol levels or low body mass index.” (Effect of Aerobic Exercise Training on Serum Levels of High-Density Lipoprotein Cholesterol: A Meta-analysis. Arch Intern Med. 2007;167(10):999-1008.)

Lipoproteins are markers of cardiovascular risk. Negative effects on lipoprotein profile means it increases the risk of a cardiovascular event like heart attack, stroke, sudden cardiac death etc. HDL-C is good cholesterol, that is, increase in HDL-C reduces the risks of cardiovascular outcomes. Hence anaerobic exercise increases the risk of cardiovascular events instead of decreasing it.

The evidence suggests quite the opposite of what you are saying.

Mr. X, you have demonstrated profound ignorance by touting “Adrenal Fatigue” – a condition that is considered to be nonsense by the medical community all over the world. Furthermore, in your rebuttal you quote someone as world famous cardiologist who is not even licensed to practice medicine. I think this amply demonstrates the depth of your knowledge and leaves you with zero credibility. I suggest that before publishing any thing related to health or disease you get it verified by a qualified medical practitioner. Though we all like to hate doctors, you have to concede that they are far more knowledgeable about health and disease. 


Thanking you,


Re: what is the diagnosis?

Posted in General clinical at Wed, 16 Apr 2014 14:34:02


Posts: 35
Joined: 10 Sep 2009

That was a good one... Expecting more!smiley

Re: intercalated bsc/msc or not??

Posted in Student BMJ at Wed, 16 Apr 2014 10:49:44


Posts: 3
Joined: 28 Jun 2013
In Response to Re: intercalated bsc/msc or not??:[QUOTE]

You could always try to see if there are any scholarship for masters for international students. I know there are some which UCL offers. You still have some time to decide whether you want to take the bsc or not. However I would recommend to go for a master instead.

Do you have to do the masters at kings or can you try other universities?

Posted by m.a.ns[/QUOTE] No I could a masters anywhere as long as I get permission from Kings. Thanks for the UCL info. I will try to find out. I was looking through funding options and it just seems to difficult to obtain funding from anywhere unless I am doing a specific project within the bsc with a particular named supervisor!