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

Posted in Careers at Tue, 29 Jul 2014 19:30:44


Posts: 3
Joined: 24 Jul 2014

I guess the best criteria for choosing your job life (except of course your calling and personal reasons) is just research on the salaries and the conditions of each of the job you consider. Such research can be made by surfing websites like medpharmjobs.pl, where you can check out who the market is looking for, who is paid best and things like that. And on websites like that you can alco already try to get into some hospitals for training - after taking such training you will definately know whether you want to go that path or not.


And sometimes unpopular doesn't only mean "cool"but also just you way of life!

Re: Should doctors become managers?

Posted in Careers at Tue, 29 Jul 2014 19:01:03


Posts: 3
Joined: 24 Jul 2014

I think that managers don't have to be doctors. Or I could risk saying, that most of the time it is better if they are not doctors. Doctors have (or at least should have) a calling for being doctors. Sometimes decisions to be made in a hospital are just to difficult to be made by doctors. And a hospital is just a diffrent type of corporation. And corporations sometimes live by their own rules. 

Though it is most appreciated that a manager in a hospital has a slight idea of what the medical business is about - not just be any manager but be THE hospital manager.

It's like leading a school or kindergarden - for raising kids you need teachers - for running a scholl / kindergarden you just a manager.

I even saw some interesting job offers relating to this topic (medpharmjobs.pl or similar), just check ot the requirements for jobs like that. 


Florida’s physician “gun gag” law upheld.

Posted in General clinical at Tue, 29 Jul 2014 16:37:47


Posts: 669
Joined: 15 Apr 2011

Just when you thought that the US’ obsession with guns had gone about as far as it could go by promoting “stand your ground” laws and preventing the CDC and other government agencies from doing research on gun violence, along comes a law that is an extreme example of the reductio ad absurdum mentality of the gun lobby.  Their logic is that if doctors know about guns in the home they might urge their patients to take actions that might reduce the availability of guns.  So Florida passed a “gun gag” law in 2011 prohibiting physicians from inquiring about guns in their patient’s homes.  The law was initially invalidated as being an unconstitutional limitation of physicians’ free speech, but yesterday an appeals court validated the law stating:

"The act simply codifies that good medical care does not require inquiry or record-keeping regarding firearms when unnecessary to a patient's care," the majority opinion stated. "Any burden the act places on physician speech is...entirely incidental."  So if you keep a loaded gun in your night stand easily available to your three-year-old, your Pediatrician has no business asking about this or advising you about gun safety. 


Are you Ageist? I am!

Posted in Psychiatry at Tue, 29 Jul 2014 14:15:28


Posts: 639
Joined: 13 Oct 2009

I have been reading a bit on the subject of late :

Do you speak a little more loudly/clearly to old people or try to hold conversations when the back ground noise is less?

Do you start by using simpler language when discussing “high-tech” ?

Do you use shorter sentences ?

Do you value the life of your child more than that of your grandmother ?

Do you feel older people are more likely to have impairment of organ function?

Does it cross your mind that an old person statistically may live a shorter time than a younger one?

Would you offer to help an old person cross the road or give up your seat on a train/bus?

Would you offer to do the shopping or visit an old person who lives alone?

Do you disagree that Society has to accept that the needs of the elderly are as important as those of newborn or disabled children? (Interesting that the author elsewhere objects to the term elderly then uses it).

Would you prefer your airline pilot to be under 75 ?

Then  you are being patronising and ageist as well. Perhaps we should have begin to fight back to restore common sense.

DOI  One of what  used to be called elderly

45 years presented with breathlessness

Posted in General clinical at Tue, 29 Jul 2014 10:59:19


Posts: 382
Joined: 29 Jul 2010

This is the ECG of 45 years old man presented with breathlessness and palpitation

what is the clinical diagnosis ?



Tips for new doctors?

Posted in General clinical at Tue, 29 Jul 2014 10:58:24

Abi R

Posts: 13
Joined: 18 Nov 2013

I've written a story about the tips for new doctors that people have been sharing on Twitter via #tipsfornewdocs. 

I was wondering what advice doc2doc members would give to a newly qualified doctor about to start their first shift in a hospital. 

I would also love to hear about your experiences - what went well, what went not so well, what would you never do again?



Re: 43 year old male with daily fevers for 5 weeks. Your thoughts?

Posted in General clinical at Tue, 29 Jul 2014 10:42:49


Posts: 148
Joined: 14 Dec 2010

'No medications...no pain...'  but  'taking lots of ibuprofen for last month.'  Was that for the fever?  NSAIDS can be a cause of raised ALT and AST.

I'm only asking in case any other aspects of the history need checking. 

Do you need to consider other causes of immunosuppression apart from transplantation?

Research, Presenting, Publications and CV building - Points = Prizes, What is the reality?

Posted in Careers at Tue, 29 Jul 2014 07:04:37


Posts: 1
Joined: 29 Jul 2014

Hi guys,

This is my first post, and I tried to pick the kind of title that would attract some attention.

Essentially I am an FY1 at Royal Preston Hospital in the UK and trying to find out about what counts and what does not.

I have spent years doing Audits and case reports and literature reviews for the sake of improving care and increasing my knowledge base. None of the stuff I did was geared towards presenting or publishing and so I have not been able to take it forward.

Now for the FY1 programme, presenting no longer gives any points, and although it made little difference it makes me wonder does it hold the same for CT and Reg jobs?

If presenting no longer counts then it would be a waste to spend lots of money and time, making posters and travelling to other countries etc.

From my understanding courses, awards and publications are how you rack up points and get jobs (besides impressing at interview). 

I have 3 main questions:

1) Case reports are looking difficult to publish, with many journals not accepting them. Should you just  submit them as letters to editors in big journals or be happy with an actual case report in low "impact factor" smaller journals?

2) What counts as a proper publication these days?

I have replied to articles on BMJ, but it seems unless your article is an original under e.g. "Clinical Review" or "Views and Opinions" and gets printed it does not count? Does a reply they accept count towards publication even if not printed inn BMJ? I ask because I do not understand how it would be referenced.

3) Could someone help to rank the order of publications in how they are viewed when it comes to specialty training?

I understand it to be something like

1) Publication in a journal

2) Clinical review/ systematic review in journal 

3) Letter to Editor/Opinion piece

4) Abstract in journal

5) Case report in journal

6) Oral Presentation at National/International Conference

7) Poster Presentation at National/International Conference

8) Presentations at Local/Regional meetings


Please advise regarding what ever you can :)

Re: Interesting ethical/legal case from Israel

Posted in Medicolegal at Tue, 29 Jul 2014 02:08:02

Dr Linda

Posts: 186
Joined: 20 May 2010

S A S,

That is an interesting comment.  What do you mean by that?  Much can be read into it, but that would be my own interpretation.

So, what did YOU mean?

Re: Diagnosing those who we dislike with 'personality disorder'

Posted in Psychiatry at Mon, 28 Jul 2014 20:36:08


Posts: 403
Joined: 23 Aug 2013

In Response to Re: Diagnosing those who we dislike with 'personality disorder':[QUOTE]

. . . the term can be used dismissively - not what you say but how you say it? 

Posted by sken[/QUOTE]

Thanks sken. I learned that the terms moron, idiot, imbecile, hysterical, mentally retarded, neurotic, were used to describe neutral terms. The way these terms where used at one time was quite neutral, then it became a value judgement and unacceptable no more in medical practice. The change of nomenclature, did not correlate with notable medical advances in the field.

I wonder whether the term personality disorder became a notorious term as well.

Re: A lower age limit in competitive sport?

Posted in Psychiatry at Mon, 28 Jul 2014 19:46:17


Posts: 639
Joined: 13 Oct 2009

Very helpful. I had the non-physical factors emphasised for me about 1-2 years ago when chatting on the beach - the girl concerned had been a very promising sailor in her early teens. There were  2 aspects which made her opt-out. The first was that poor performers might be humiliated to encourage better performance - obliged to wear nappies for a day - the other was that education was displaced to way down the list of what was seen as important. There is world of difference between trying to train professional gladiators and encouraging voluntary participation in competitive sport - preferably a range of competitive sports -and giving opportunity and encouragement commensurate with competence.

Re: our mind inside the heart not the brain

Posted in Cardiology at Mon, 28 Jul 2014 17:45:41


Posts: 403
Joined: 23 Aug 2013

If you see a tiger approaching you, an image is drawn over the retina, transmitted to the brain, and then the adrenaline rush which causes tachycardia & palpitation. A similar process (on auditory level) would happen if someone hears a lion's roar without seeing it, or smell a choking fume.
heartbroken heartenlightened

Re: Ebola spreads: Doctor dying and ill with it

Posted in News & media at Mon, 28 Jul 2014 14:14:01


Posts: 1430
Joined: 09 Dec 2011



This is the Crux of my Work in CBRN,  Terror from Bio, Chem, and Nuclear /Toxic threats.   As a side note The United States CDC and USAMARIID are working on a vaccine, and treatments for Ebola, and other of the bad  Viruses.



Hopefully a treatment will be found.


Re: Success at Consultant Interview

Posted in Careers at Mon, 28 Jul 2014 10:28:16

John D

Posts: 3089
Joined: 01 Feb 2010

Success to all applicants, if that is possible!

Technique IS important.   A method used for our trainees can used anywhere.    Get a group of your consultants, one or two will do, to ineterview you with a video running.  Then review what you said, and even more important, did!    Do you project a confident assured air, or display displacement activity that shows excess anxiety?

We think that that  this gives valuable feedback and bolsters confidence.


Re: Eid Greetings

Posted in General at Mon, 28 Jul 2014 05:33:43


Posts: 403
Joined: 23 Aug 2013

Wish you a happy and joyful lesser Bairam (Eid El-Fitr).

Re: Yes, Cheetos, Funnel Cake, and Domino's Are Approved School Lunch Items

Posted in Diabetes at Mon, 28 Jul 2014 03:42:36


Posts: 3986
Joined: 24 Feb 2009

In Response to Re: Yes, Cheetos, Funnel Cake, and Domino's Are Approved School Lunch Items:[QUOTE]

In Response to Re: Yes, Cheetos, Funnel Cake, and Domino's Are Approved School Lunch Items:[QUOTE]

In supporting Odysseus' thesis about the lack of terroir, let me relate an anecdote that demonstrates how bad this has become in the US. A good friend of mine is a home economics teacher at a middle class high school trying desperately to teach kids about good nutrition.  It is an uphill battle.  These are children whose mothers and grandmothers have always eaten out of boxes, as have they.  They literally have never eaten a meal prepared from scratch.  One day the class got into a discussion about vegetables and specifically about carrots.  My friend, somewhat mischievously started a discussion among the students about where carrots come from.  After some discussion the class voted that they came from carrot trees!

Posted by diabetesMD[/QUOTE]

The further in the production chain the consumer is from the primary food, the more the profit. Five cents of wheat makes an $8 box of Weeties. 

I just bought (rare for me) a slice of banana cake ($4) with coffee ($3.50). The ingredients of a whole banana cake as made by me would be about $2.00. Thus a banana cake with ten slices brings in $40.00 which is not a bad profit for $2.00. 

A monkey could make a banana cake. Monkeys pay $4 for a slice. 

Banana cake carries well and is good for school lunches.


Poor nutritional choices to my way of thinking is due at least in part, to a breakdown in the vertical transmission of cultural culinary practices and food gathering, down the generational ladder. The more removed the person is from his/her cultural bedrock, the more likely food will become tertiary or quaternary in its manifestion. The more removed from the bedrock, the more the profit by the food purveyors.

Women traditionally have been the custodians of culinary arts but as society fragments and as the extended family becomes more nuclear and insular, these arts are lost.

Thus, what has been posted by my Learned Friend is symptomatic of a wider and more pervasive societal malaise. But I could be wrong.



Posted by Odysseus[/QUOTE]


Re: sulphonylureas and cardiovascular risk

Posted in Diabetes at Sun, 27 Jul 2014 18:02:33


Posts: 669
Joined: 15 Apr 2011

Ever since the UGDP there has been controversy about the relative benefits and possible harm of the sulfonylureas in lowering glucose.  In my ADA 2014 meeting blogs I summarized the current state of the controversy regarding the benefits of lowering A1C in reducing future cardiovascular events http://doc2doc.bmj.com/blogs/diabetes/#plckblogpage=BlogPost&plckpostid=Blog%3A6d73ea55-a255-4c4a-94ad-949eed7986b9Post%3A83b4f38e-29fb-472e-bf95-88462d0ac29e In summary, while lowering A1C likely has beneficial effects, they are small as compared to the benefit of lowering abnormal lipids and blood pressure.  The question naturally arises as you stated, why use them at all?  The answer is mostly based to their relative low cost and decade's long history of safety.  If the newer agents that are not associated with hypoglycemia were of equal cost to the sulfonylureas, then one could make the argument that the sulfonylureas should be retired and these newer agents should be added when metformin is no longer adequately effective.  However, the newer agents not just a bit more expensive, they are orders of magnitude more expensive.  So for now the sulfonylureas will continue to have a place in our treatment protocols for type 2 diabetes.


Re: How do you find medical blogging?

Posted in News & media at Sun, 27 Jul 2014 17:50:33


Posts: 403
Joined: 23 Aug 2013

In Response to Re: How do you find medical blogging?:[QUOTE]

I don't follow medical blogs and gave up posting such on this site as I ascertained they were a used car lot for ideas. People passed them by but few made any enquiries and narry a car was bought. 


Posted by Odysseus[/QUOTE]

Odysseus, thanks for your reply. In the light of what you said. One wonders whether blogging and medicine formed an infertile hybrid of medical blogging; where the need for serious medical writing for which medical opinion is made can never be met by the uncensored (non-peer reviewed) nature of the democratic nature of medblogging. On the other hand, physicians may not get interested in 'medically coloured' entertainment.

Re: How can medical students best use their summer holidays?

Posted in Student BMJ at Sun, 27 Jul 2014 08:05:45


Posts: 3
Joined: 24 Jul 2014

Just try to relax for a while at least. but doing something med related will be also good. 

Had the same problem last year, I  ran through some job pages and tried to look for stuff for students. The result - vacation and job during holidays. Was great.

Try pages like medpharmjobs.pl or similar

good luck!!!

Re: Should trainee doctors be allowed to opt out of the European working time directive?

Posted in General clinical at Sun, 27 Jul 2014 06:22:22


Posts: 1
Joined: 07 Aug 2009

In Response to Should trainee doctors be allowed to opt out of the European working time directive?:[QUOTE]

I believe the EWTD is very important. The focus of trainee doctors should be on training, not on routine staffing.

trainee doctors will be the workforce of tomorrow. We should foster and protect them, especially with patient safety on our minds. In addition, it is no longer unusual nowadays for doctors to have a social life. That part is very important to keep us healthy.


Re: Can India build 5.2m toilets by the end of August?

Posted in BMJ India at Sat, 26 Jul 2014 23:06:00

John D

Posts: 3089
Joined: 01 Feb 2010

Cattle excrement is sometimes considered not a waste but a raw material, that may be composted, generate methane as a fuel and provide valuable fertiliser from the end product (as it were).  One is in progress in that archetypal radio series "The Archers"! 

   Human effluent (to use it's polite name) is often, even in western societies, treated in a similar way.    Rather than merely providing for the polite and hygeienic disposal of human waste by public toilets , should not India seek to make small digester projects possible at  a local level, providing possibilities for small entrepreneuers to enter the energy and fertiliser markets.

The 'night soil' men redux!


Re: final nice guidance on statins released

Posted in Cardiology at Sat, 26 Jul 2014 19:52:20

tjaard hoogenraad

Posts: 37
Joined: 05 Feb 2009



Dear Professor Chalmers,

You wrote in your BMJ rapid-response dated 18-6-2014 about your complaints on muscle pain in your right upper arm and that you asked yourself: could these pains be caused by an adverse reaction on statin treatment? Should statin treatment be stopped? You would welcome information on possible unwanted effects of statin medication and proposed a randomized, placebo controlled withdrawal/discontinuation trial as the best available scientific efficient research strategy to obtain such information.

Of course, I fully agree with you: the strategy you propose would provide scientific evidence that could help you and other doctors to make better clinical decisions. However, a drawback is that it would not contribute much to a solution for the problems you have at this moment: should I stop taking statins or not?

On 9-6-2014 I posted on BMJ-online doc2doc a rapid response (see below) in which I warned for possible adverse effects of statins and for the idea that statins have reliably been tested on their value for prevention of heart disease. I wrote: “ Statins are said to inhibit HMG-CoA-reduction and to inhibit sterol biosynthesis. Statins lower cholesterol and are widely prescribed and prevent heart disease. However, up to now there are no reliable scientific clinical trials that tested the hypothesis and reported that statins can safely and effectively be used for prevention of heart disease. As long as that is the case statins treatment can best be regarded as unscientific unproven alternative medicines for prevention of heart disease”.                                                                                       Now, 7-7-2014, my ideas about how to present my warning rapid response has changed and I entitle it:


       But first I have to explain why I think that statins can best be classified as chelating agents. Chelating agents are chemical compounds that trap, bind or remove heavy metals from enzymes. My idea is that statins inhibit HMG-CoA-reduction by chelation of metals from the enzyme. I warn that chelating agents are known for their adverse reactions and that myopathy and muscle pains are known harms of statin treatment. My hypothesis is that muscle pains in persons like you who are treated with simvastatin are caused by an adverse effect of the chelating agent simvastatin.



        I am afraid that secrecy on the chelating effect of statins and other enzyme-inhibitors is damaging rational critical thinking in evidence-based medicine. I feel a commitment to transparency and open data and I warn for secrecy. Conflicts of interest may lead to keeping certain data secret. I think that knowledge that statins are chelating agents has been kept secret. This secret role of chelation is not specific for statins. On the contrary, metformin (drug for Diabetes type 2) and tamiflu (antiviral drug) are comparable enzyme inhibitors and up to now the secret that these drugs can for be classified as alternative chelation therapeutics has not yet been discovered completely.




    Underreporting is a major problem in medicine. “Underreporting research is scientific misconduct” were your words Prof. Chalmers in an article in the JAMA 20 years ago.          

     Underreporting on adverse effects of statins may have led to harm to patients with heart disease: estimates of benefits and safety of treatment may have been exaggerated and this may have inhibited efforts to discover more effective and safe treatments.

     Underreporting on adverse effects of chelating agents has led to harm to patients with various diseases.

     -   Underreporting EDTA-chelation for cardio-vascular diseases. The quality of reporting was poor; several fatalities were reported; non-fatal adverse effects were numerous.

     -  Underreporting adverse effects of penicillamine chelation therapy. Since its introduction in 1956 this unscientific, not-very effective and very unsafe therapy became worldwide known as treatment of choice for treatment of patients with Wilson’s copper disease. Estimates of benefits and safety had been exaggerated extremely and were not at all evidence based. This tragic underreporting of adverse effects of penicillamine inhibited the development of effective and safe oral zinc therapy that the Dutch neurologist Schouwink had developed and defended for his thesis in Amsterdam in 1961.

       -  Underreporting of the effectiveness of zinc therapy for Wilson’s disease. Schouwink had performed a comparative clinical trial comparing effectiveness of penicillamine versus oral zinc therapy. It is interesting to report here that Schouwink performed his study as a sort of ‘ N-of-1 clinical trial ‘ in 2 single patients. His attempts to publish his discovery in a worldwide international journal were unsuccessful. The manuscript did not pass the peer-review and was rejected for publishing. This underreporting of zinc therapy is shameful severe scientific misconduct and has led to many unneeded harms, unneeded dismay, unneeded deaths and unneeded liver transplantation.


N-of-1 RCT (Randomized Clinical Trial)


Dear Professor Chalmers, at first sight I fully agreed with you that your proposal to set up a placebo controlled withdrawal/discontinuation trial for identifying side effects attributable to statins would be the best available scientific research strategy.

However, at second sight and on some more reflection I think that your strategy could win by being transformed in a placebo controlled withdrawal/discontinuation clinical trial in a single patient (N-of-1 RCT). It should not be difficult to change the protocol from RCT to N-of-1 RTC and neither difficult to find patients to participate in such a clinical trial. In my opinion you would develop in this way the best available scientific strategy to stop taking statins and to help doctors to make better clinical decisions.

I look forward hearing your response to this suggestion,





Tjaard Hoogenraad



Re: what do you think of dabigatran?

Posted in Cardiology at Sat, 26 Jul 2014 16:10:36


Posts: 1430
Joined: 09 Dec 2011

The most commonly reported side effect of dabigatran is GI upset. When compared to people anticoagulated with warfarin, patients taking dabigatran had fewer life-threatening bleeds, fewer minor and major bleeds, including intracranial bleeds, but the rate of GI bleeding was slightly higher. Dabigatran capsules contain tartaric acid, which lowers the gastric pH and is required for adequate absorption. The lower pH has previously been associated with dyspepsia; some hypothesize that this plays a role in the increased risk of gastrointestinal bleeding.   Lowering the gastric PH also tends to destabilize other components of the GIS syatem, IE-Beneficial Flora, and absorbtion of nutrients, and other medicines.  There are better drugs out there, yet Pradaxa - USA Name - Remains on the most issued list in some locales...


Re: Fears of the Spread of a new Respiratory Virus

Posted in General at Sat, 26 Jul 2014 15:13:53

Mukhtar Ali

Posts: 811
Joined: 14 Nov 2010

Nigeria 'on red alert' over Ebola death in Lagos


A woman's life in Gaza - can anyone help?

Posted in News & media at Sat, 26 Jul 2014 09:07:35


Posts: 72
Joined: 29 Jan 2009

We are all watching the terrible events in Gaza unfold. Such a tragic loss of life, such inhumanity. Of course Israel should show more restraint, we think, the killing of so many children and families can never be justified.

Thinking on from this, what of the future? What if Israel could somehow be neutralized, and prevented from retaliating in this way? What if the blockade is lifted? Would things be better?

Gaza is one of the most densely populated in the world.  In 1950 it had a population of 245,375, nearly all refugees from Palestinian territories seized by Israel. Now it has 1,816379. This is not from immigration – everyone else has now left and the population is now 98.2% Sunni Muslim.  This is entirely produced by a fertility rate of 4.9 children per woman (in 2010), one of the highest in the world.  51% of the population is younger than 18, a very high dependency ratio. The age group 15 to 29 constitutes 59% of the population. We see these vast numbers of young people every day on our televisions. What hope have they got of ever getting jobs and having a decent life?

It goes without saying that development in Gaza since independence in 1995 has been crippled by sanctions, intifadas and wars. But it was heavily urbanized before that and now has no resources to support this huge population, even if at peace.  The whole population exists on aid, mostly from the USA and Europe; the water supply (aquifers) are contaminated by salt, and electricity is in short supply. So their main crops – fruit and vegetables – are failing, and there is malnourishment  and food poverty.  Sanitation is very poor. Eighty per cent of households receive some form of assistance and 39% of people live below the poverty line. This is much less to do with war and more to do with the huge unsustainable rise in population. For instance, even before the latest war the country needed to provide 240 schools urgently for the increasing number of children.

What can the life of a woman be like in Gaza? They are educated – there is 98% literacy in Gaza. But women do not work outside the home – that is not the culture. The work they do to support their families is unpaid work in the fields. They may be widows, their husband having gone to fight and often maimed or killed. 80% of them are anaemic (as are their children) from frequent child bearing.  Surely they must know that having more children in this scenario is madness? We know that their religion prizes having many children and polygamy is common. But would they be able to use contraception?  Are we doing all we can to ensure that it is even available for them?

There must be some hope.  The fertility rate is falling, and estimated to go down to 2.9 by 2020. So perhaps some are using contraception of some sort, though it seems no contraceptive pill is registered in Gaza. But against that, the young people already born will produce a huge population rise even if they only have 2 children each.  Paradoxically war and destruction increases the birth rate - a year after the Haiti tragedy the fertility rate had increased substantially, as contraception is not the first thing on women’s minds when they are struggling to exist from day to day.

Emigration is never an option. This is an intensely radicalized society, even the neighboring Arab states, Egypt, Turkey, Qatar, won’t take Gazans; indeed blockade from the Arab states has produced just as much destruction to the economy as has that from Israel. Europe isn’t taking many Syrians, and is hardly likely to take people from Gaza. 

Politically there seems no solution.  At least can we try to lighten the load of these women by seeing if there is not a way in which we can provide some sort of contraception? Can we at least try to discuss population as the root cause of much of this misery, and not treat it as somehow taboo?  Is anybody out there that thinks like I do?