What do you think?

Most viewed discussions

The most viewed discussions on doc2doc this month

What should a fourth year Medical student learn from a four week attachment to UK General Practice?

Posted in General clinical at Tue, 22 Apr 2014 18:02:02


Posts: 4
Joined: 18 Apr 2014
We have a fourth year Medical student attached to our Practice for four weeks. I hope she will learn someting obout General Practice, learn some medicine and hopefully enjoy her time at this busy General practice. What things do you thing are the most important thing to learn from a General Practice?

Should Government Provide Treatment to Illegal Drug Users?

Posted in General clinical at Tue, 22 Apr 2014 03:26:52


Posts: 0
Joined: 23 Apr 2014

Consumption of illegal drugs is widespread through a global black market.  In December 2012, the U.S. state of Washington became the first state to officially legalize cannabis in a state law. In December 2013, Uruguay became the first country to legalize growing, sale and use of cannabis.-------not going in the pros and cons of legalization of illegal drugs------I want to know your personal views regarding the provision of treatment facilities by the states/governments elsewhere to those who use such drugs?


Which type of writing instrument do you prefer?

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


Posts: 336
Joined: 23 Aug 2013

I wonder which type of writing instruments do you prefer during your clinical work, whether taking notes, or writing officially and why (if possible). I am not aware whether there are preferences for doctors on using special type of writing instruments or not.

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

Posted in General clinical at Tue, 22 Apr 2014 18:57:35


Posts: 4
Joined: 18 Apr 2014

In a personal view in the BMJ (http://www.bmj.com/content/348/bmj.g2625) Saurabh Jha decries the medical practice of ruling things out, something he likens to hunting for zebras in Texas. 

He describes a case of a student tackled in a game of soccer. A computed tomogram showed he had flank ecchymosis, fractured ribs and blood in the adrenal gland. Jha asked for follow-up magnetic resonance imaging to exclude the possibility of an underlying adrenal mass.
The trauma surgeon retorted: "Is being kicked in the flank not enough to explain adrenal haemorrhage?"
Who pays for this treasure hunt, asks Jha, as patients are shuttled from bed to CT scan to bed?
"Conquering uncertainty is impossible. Rule-out begets more rule-outs, more tests and more uncertainty," he writes.
Are doctors over-relying on the practice of rule-out medicine? Is this defensive medicine at its worst or a sensible quest for the best diagnosis?


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

Posted in Respiratory medicine at Sun, 20 Apr 2014 02:14:47


Posts: 3815
Joined: 24 Feb 2009

This week's clinical question of the week comes from our respiratory disease champion, DundeeChest.

There are a lot of new inhalers coming out in the next few months, mainly for chronic obstructive pulmonary disease (COPD) indications.  

Dual bronchodilator treatment seems to be the flavour de jour - with the mounting evidence that inhaled steroids increase pneumonia risk, it seems sensible that we should try to avoid them.  But with the increasing range of essentially unproven therapies, studied but only to prove non-inferiority or equivalence, how are you going to change your practice?  Inhaler device seems an obvious decision maker - keep the drugs in the same device, or ideally combined in a single device to keep it simple for the patients.  But the best device doesn’t necessarily have the best drug within it.  What will be your first line drug therapy for COPD?

why thrombolytics are contraindicated in NSTEMI & Unstable Angina?

Posted in Cardiology at Mon, 21 Apr 2014 19:35:18


Posts: 1091
Joined: 17 Jun 2011
good evening /morning dear fellowsSmile
i have one confusing question for me & i really need to get a clear,  reasonable answer "explaination" for it >>>why thrombolytics are Contraindicated in ACS except in STEMI of course ?

thank you in advance ^_^

Can trainees be encouraged to take up unpopular specialties?

Posted in Careers at Sun, 20 Apr 2014 11:46:22


Posts: 45
Joined: 14 Dec 2010

We recently published a article in BMJ Careers about whether trainees could be encouraged to take up unpopular specialties such as psychiatry and emergency medicine.

Most of the doctors I spoke to were against financial incentives as a way of increasing trainees numbers, and instead talked about ensuring a good work/life balance.

What do you think?


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

Mark Porter, the Times' newspaper's doctor, welcomes the UK government's announcement that 1000 GP surgeries are going to share £50m to fund ways to make them more accessible (the article is behind a paywall). However, Porter questions the value of longer opening hours and consultations via Skype, as suggested by David Cameron. 

Porter suggests that telephone consultations at mutually agreed times could be the way forward - rather than the current haphazard approach where patients wait for the doctor to call them when they have finished their surgery. 

He cites the example of a surgery in Leicester which has reduced the waiting time for an appointment to see a GP from just under a week to the same day after introducing telephone consultations. Porter does not include references but it looks like the health centre mentioned in this Health Service Journal article (written by the chief exec of the firm that introduced the telephone system so caveat emptor....!)

It's unclear in either the Times or HSJ article how the Leicester practice telephone system works but one model operates like this: the patient phones the practice and asks for an appointment; the GP then rings the patient back and there are three options: the patient is given advice; the patient is given an appointment with the nurse or nurse practitioner; the patient is given an appointment with the GP. 

What do you think? Are telephone consultations a good way to increase access to doctors? Or is face-to-face best?



The state of medical education in India

Posted in BMJ India at Tue, 22 Apr 2014 09:31:53


Posts: 3815
Joined: 24 Feb 2009

The old ones of doc2doc may have noticed that for the last 1 year I have been mostly absent from here and posted only sporadically. Now I can say that hopefully the exile is over. What was the reason of the exile you ask? Well I was participating in the great Indian carnival of postgraduate medical entrance exams to secure a specialty seat. It’s over for me and I have opted for general surgery at an institute of my choice.


Some background – about 40,000 MBBS graduates pass out each year all over India and the total annual postgraduate intake capacity is roughly around 15,000. There are two main ways of securing a postgraduate specialty – a centralized test called AIPG which has roughly 6000 seats distributed in colleges across India and rest are through entrance tests conducted by the individual states for which generally we eligible for one state only. The coveted clinical specialties are only around 8000. Apart from these, there are a handful of autonomous institutes but those are insignificant in the scheme of things.


This year more than 72,000 of us competed for those 6000 seats. In other words, the exam was so designed that 66,000 of us would be unsuccessful no matter how much knowledgeable we are. Most of us take a year break to study while negotiating with different hospitals for lenient workhours so that we get paid to meet our ends. The anesthesiologists were kind enough to grant me a 30 hours/week work. Many of us don’t get any specialty after 1 year of study. Then our whole life is put on hold, for a second year or for a third year or till the time we get a seat. One can find hostels full of doctors, all of different ages, all trying to secure a specialty.


And every year the cycle starts again.

Could new consumer technologies make remote consultations useful?

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

John D

Posts: 2862
Joined: 01 Feb 2010

I searched through the forums for previous posts about telemedicine and found the interactions were mostly from many years ago.

Now that technologies have moved on and patients can have good quality face-to-face conversations with doctors, could remote consultations become genuinely useful? I'm not suggesting all interactions should be virtual but that those with easily diagnosable and treatable ailments could be cared for in such a way that means doctors are more readily available for those who really need physical care.

What are you attitudes towards remote consultations? Would you be comfortable diagnosing this way? Is this the future primary care?

All and any opinions welcome.

Share your memories of "black Wednesday"

Posted in General clinical at Mon, 21 Apr 2014 03:45:33


Posts: 3815
Joined: 24 Feb 2009

The Academy of Medical Royal Colleges is proposing that the start days of training posts should be staggered, to end the "black Wednesday" phenomenon - the first Wednesday in August when all medical trainees in the UK move to a new post in hospital.

The academy is proposing that all foundation year one posts should begin on the first Wednesday in Agusut, but other training posts should begin in September.

According to a UK study this day has traditionally seen a 6% spike in mortality rates (Jen, M.H. et al. (2009) Early in-hospital mortality following trainee doctors' first day at work. PLoS One, 4(9), p. e7103 ) An international study showed  increased patient  mortality of between 4.3-12.0% and increased length of patient hospital stay of between 0.3-7.2% around trainee doctors’ changeover dates. (Young, J.Q. et al. (2011) 'July Effect': Impact of the Academic Year-End Changeover on Patient Outcomes. A Systematic Review. Annals of Internal Medicine Volume 155, pp. 309-315.)

Have you seen evidence that "black Wednesday" is mroe dangerous than other days of the year? What do you think of this proposal? 



Lancaster bans e-cig sales in local market!

Posted in Respiratory medicine at Mon, 21 Apr 2014 20:32:42


Posts: 336
Joined: 23 Aug 2013

The City of Lancaster has banned the sale of e-cigarettes in the street markets that it holds in the town.     Councillor John Barry, responsible for markets, told the Council that e-cigs would not be regulated and licenced by the UK Govenrment until 2016 at the earliest, and that until then it would be unwise to allow their sale by market traders.   The council agreed unanimously to enforce the ban.

Lancaster already has three shops selling e-cigs, and the ban would not affect them.  The Council also decided to make no distinction between real tobacco and e-cigs in its standing 'smoke free policy' in all council buildings.   No other town in the North of England has banned e-cig sales in street markets.

Hooray for Local Councils! Today in Lancaster - Tomorrow in the World!

I can find no similar report on the whole 'Net of action like this by a local government body.

The demand that all and sundry, stalls selling items totally unrelated to smoking, be allowed to sell e-cigs demonstrates further the awful truth, that they are potentially as addictive as tobacco and certainly that they are a dreadful fashion item.

Can anyone else report on local e-cig bans?    What is your hospital doing about them?



M*A*S*H and Time

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


Posts: 3815
Joined: 24 Feb 2009

I've enthused here before about one of my favourite TV programmes, M*A*S*H, the series about an American "Mobile Army Surgical Hospital" in the Korean War, that was made during the Viet Nam War.   It's being shown two episodes at a time, every night on Channel 61, and I've enjoyed the Time Machine trips this revival has given me.  But tonight it showed how old it, and I have grown.

MASH usually, as most soaps do, deals with relationships, with the added frisson of the characters being doctors and nurses.  We -  well, I - would like to be the witty, self-examining (and everyone else examining) Hawkeye, or the homebody BJ, almost always secure and grounded in his love for his family back home.   And  Colonel Potter is their father figure, while the dear Chief Nurse Houlighan is given a sexist raw deal.   It's a family affair. I love it!

But tonight, the story was of a patient,  who our surgical heroes have torn back from the arms of death from wounds, who then volunteers to give blood for his buddy.    Yes, it does get a bit sugary at times, but then they check his blood for typing.  And discover atypical leucocytes.  Our heroes are surgeons but even they can recognise leukaemia.   Which is incurable, isn't it.   They have saved him and condemned him at the same time.

And of course that isn't true any more. The whole schtick of the story just wouldn't work today.    We recognise many forms of leukaemia that may vary the survival, but over 40% live more than five years and over 30% more than  ten.   In children, survival is twice as good, so the outlook continues to improve.    You just couldn't write that story today, it's one that has been overtaken and sent to the history books by medical progress.    The same might be said of a military  hospital in WW1, before antibiotics, the subject of a new series on TV, or the emergence of any treatment at all for spinal injuries as a recent play about Ludwig Guttmann and the Stoke Mandeville Games showed.

But those were avowedly historical.  MASH was about a war twenty years before its time, and I'm watching it again thirty years later.   Nostalgia, but also pride - we have come a long way.


Are lay media misrepresenting brain scan research?

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


Posts: 517
Joined: 13 Oct 2009

I was interested by an article in the Guardian on the 16th April 2014, "Scans find conciousness in brain-injured patients": http://www.theguardian.com/world/2014/apr/16/pet-scans-predict-brain-injury-recovery-trials    The online article included a link to the Lancet paper it was based on, and I fear that the tone of the Gaurdian's article was at odds with the paper.    You can decide for yourselves, if you read the abstract at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60042-8/abstract

The article said that the paper raised "ethical questions about the best treatment for those in an unresponsive state." and quoted one of the  authors, Prof. Steven Laureys of the University of Liege, as saying that, "a third of the patients referred to them by doctors elsewhere had been misdiagnosed."    I fear that this is a personal opinion of the Prof's, as the abstract contains no evidence to that effect.

The study involved 41 patients referred to the hospital over five years.   The investigators used clinical tests as the 'gold standard' and compared those with Positron Emission Tomography (PET) using a glucose analogue to highlight metabolic activity, and Functional Magnetic Resonace Imaging (fMRI).   They also assessed outcome after a year.

  They found that, "PET had high sensitivity for identification of patients in a minimally conscious state and high congruence with behavioural CRS—R scores."    fMRI was less sensitive.  They also found that, " 13 of 42 (32%) of the behaviourally unresponsive patients (ie, diagnosed as unresponsive with CRS—R) showed brain activity compatible with (minimal) consciousness (ie, activity associated with consciousness, but diminished compared with fully conscious individuals) on at least one neuroimaging test; 69% of these (9 of 13) patients subsequently recovered consciousness" but offered no comparision with clinical testing.   Moreover, the conclusion found that, " Cerebral 18F-FDG PET could be used to complement bedside examinations and predict long-term recovery of patients with unresponsive wakefulness syndrome." (My underline)   That is very different from misdiagnosis or an ethical diliemma.


Do You Live in Couch Potato Culture?

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


Posts: 3815
Joined: 24 Feb 2009

The list of medical conditions which in fact is preventable, is alarming both for underdeveloped and developed countries due to sedentary lifestyle adopted by the people due to one or other reason. Do you think that the society you live in is or becoming a couch potato culture in future.

Happy Easter To All

Posted in General at Mon, 21 Apr 2014 06:49:10


Posts: 960
Joined: 16 Aug 2012

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

Diagnosing an MI afterwards

Posted in Cardiology at Sat, 19 Apr 2014 17:49:25

safia dirie

Posts: 37
Joined: 30 Oct 2013


I haven't posted in a while so I thought I'd throw a quick question out there that I was asked by a patient while out volunteering with the ambulance service. The patient asked me how MIs can be diagnosed later in the day after the attack itself has passed. I explained to him about how the ECG would show ischemic changes and then about how blood tests can detect cardiac markers. Firstly, what actually are these cardiac markers, and secondly, how long will they remain in the blood? How long after an MI can one be diagnosed as having happened?



Any single parent doctors out there?

Posted in Careers at Mon, 21 Apr 2014 16:51:29


Posts: 1
Joined: 21 Apr 2014



I am planning to adopt as a single parent and work as a consultant paediatrician. I wondered if anyone has any top tips for childcare for overnight on calls. The adoption agencies want some concrete plans in place.



Fetal growth app for iPhone/iPad

Posted in General clinical at Tue, 22 Apr 2014 18:41:03


Posts: 4
Joined: 18 Apr 2014

Recently, we released an app that runs on iPhone/iPad called FetalGrowth (available from iTunes) which performs fetal weight calculations and plots customized growth charts for both singleton and twins pregnancies. Some unique features, include:
-  twins specific customized growth models.
-  the ability to save the patient's details in order to track the progress of the fetal weight percentiles during pregnancy.

The app was developed by OBGYN professional.

 We would appreciate some feedback from obgyn professionals who would be interested to use this app.



Any single parent doctors out there?

Posted in Medical mums at Sun, 20 Apr 2014 17:54:27


Posts: 2
Joined: 20 Apr 2014

I am planning on adopting as a single Mum and am a consultant paediatrician. Does anyone have any tips on childcare for nights on call? The adoption services want some concrete plans in place.


Why not we screen pilots and young athletes for cardiac abnomalities?

Posted in General clinical at Tue, 22 Apr 2014 17:08:22

yoram chaiter

Posts: 2020
Joined: 03 Mar 2009


ECG pattern in Brugada syndrome. According to a recent consensus document, type 1 ST segment elevation either spontaneously present or induced with Ajmaline/Flecainide test is considered diagnostic. Type 1 and 2 may lead to suspicion but drug challenge is required for diagnosis. The ECGs in the right and left panels are from the same patient before (right panel, type 1) and after (left panel, type 1) endovenous administration of 1 mg/kg of Ajmaline during 10 minutes



In many occasions we have seen famous football players, and other athletes collapsing in playgrounds, and many of them have lost their lives,  in addition to that, many planes have crashed, or lost their destination without a reasonable explanation, the best example is the last accident of the Malaysia Airlines last month

Many well known cardiac abnormalities may be the cause of such tragic events. For example Brugada syndrome, which can cause sudden death may be one of the causes.

I think we can screen pilots and young athletes for many cardiac diseaes, inherited, cogenital or aquired disorders. In Brugada syndrome , for instance, the injection of  class 1A ( Ajmaline) , or 1C ( Flecainide), causes specific ECG changes, the most important is ST segment elevation by 2 mm (0.2 mV). Family history, Genetic analysis and Echocardiography are all available and cheap methods to diagnose such important  condition, and we can be able to protect against many unexplainable accidents and deathes



3D Printing in Medical Industry: Questionnaire for Doctors

Posted in General at Mon, 21 Apr 2014 10:07:37


Posts: 1
Joined: 21 Apr 2014

Hey All,

I am doing this research on market potential of 3D Printing/Additive Manufacturing in Medical Industry as to how it can revolutionize the healthcare industry.

I would need your response regarding the same through a small questionnaire:


Requesting you to please fill and also circulate the questionnaire with your doctor friends to fill this survey.




authenticity in medicine

Posted in General clinical at Tue, 22 Apr 2014 21:39:20


Posts: 3815
Joined: 24 Feb 2009

I've just been reading this editorial in this weeks print BMJ


authenticity is defined as

' entails discovering, understanding, and being faithful to your core values and purpose. Instead of emulating the characteristics, traits, or practices of others, authentic individuals interrogate their life experiences to discover their values and purpose through a process of continuous self reflection.'

Personally it strikes a chord - I often think that medical education is much more target focussed in the UK than previously (maybe this is the NHS in general? ). Does this apply in other medical education systems?


Civil Ceremony and Children

Posted in General at Tue, 22 Apr 2014 18:40:01


Posts: 4
Joined: 18 Apr 2014

I went to a civil ceremony this weekend for a couple of gay friends of mine. My 6 year old niece was hovering around me and shouted out in a kind of impatient stage whisper 'Uncle, but where is the bride?'. People naturally chuckled but it got me thinking about whether her parents should have spoken to her about the event before hand,  or, if they had drawn attention to the fact prior to arrival it would have opened a difficult conversation for them.  I say 'difficult for them' because they are quite religious and do not really approve of homosexuality - for myself I have no concerns whatever about two people who love each other saying publicly that they want to commit themselves to each other for the rest of their lives.

I would be interested in others views. How would you have managed the situation as a parent? (I recognise this is not a medical issue).


Hello,Spring! You are welcome

Posted in General at Wed, 23 Apr 2014 05:45:30

Mukhtar Ali

Posts: 774
Joined: 14 Nov 2010

Behold, my friends, the spring is come; the earth has gladly received the embraces of the sun, and we shall soon see the results of their love!

Sitting Bull