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Poll archive

Posted in doc2doc feedback at Wed, 19 Nov 2014 12:09:24


Posts: 600
Joined: 18 Mar 2014

I love the new poll feature, its a great way to see what everyone thinks on some of these issues. What do people think of creating a page with all the previous poll results on?

Should patients have the right to record consultations?

Posted in News & media at Sun, 23 Nov 2014 19:48:23


Posts: 10
Joined: 31 Mar 2014

Hello everyone 

I'm replacing Matthew Billingsley as moderator (I've introduced myself in the new members' bit of doc2doc). So, here's my first discussion thread...!

An observation in the BMJ focuses on a discussion thread on a consumer forum about a patient whose doctor would not allow her to record her consultation. http://www.bmj.com/content/348/bmj.g2078

Patients were supportive of the patient's point of view, saying it was a form of note taking and she did not need to ask her doctor's consent. Doctors were, unsurprisingly, more cautious, saying that it could lead to defensive medicine. 

What do you think? Is recording a consultation a right? Or does it harm the doctor-patient relationship?

Identify the lesion on the nose

Posted in General clinical at Mon, 24 Nov 2014 16:06:09


Posts: 1
Joined: 24 Nov 2014
Identify the lesion on the nose ---

Winter`s Blues

Posted in General at Mon, 24 Nov 2014 11:49:23


Posts: 600
Joined: 18 Mar 2014

Winter is around the corner---------with possible winter blues for some people, a medical condition called Seasonal Affective Disorder (SAD) it is believed that affected people react adversely to the decreasing amount of sunlight.

Do you know anyone with this medical condition?

Here is a beautiful quote from Albert Canus, the noble laureate

‘’ in the depth of winter, I finally learned that within me there lay an invincible summer’’  

Thank you for input

Are overweight doctors a poor example to patients?

Posted in News & media at Fri, 21 Nov 2014 10:35:59


Posts: 810
Joined: 13 Oct 2009

Many newspapers have seized on the size of the new Belgian health minister, GP Maggie de Block. Dr de Block is, to put it bluntly, large, reportedly weighing around 20 stone. 

The Times reports concerns of commentators who question her ability tospread public health messages. Tom Van De Weghe, a reporter for Belgian VRT television, wrote. "Belgium has been given a health minister who is obese. Criticism is rejected as nonsense but what about her credibility?"

In May, the chief medical officer for England, Dame Sally Davies, in her habitually trenchant style told GP magazine how she was "perpetually surprised" at how many NHS workers were overweight. She said that patients might not take advice to lose weight seriously if they felt doctors were not following it themselves.

"How are they going to have the impact on patients if they are not taking note and thinking about it for themselves?" she said. 

What do you think? Should overweight health staff be urged to lose weight? Or are doctors who struggle with their size in a better position to empathise with patients? 

Should drinking during pregnancy be criminalised?

Posted in Medical ethics at Mon, 24 Nov 2014 10:58:22

Andrew Morrice

Posts: 22
Joined: 29 Jan 2009

The Court of Appeal is currently hearing a case brought on behalf of a seven-year-old girl who is claiming for payments from the Criminal Injuries Compensation Authority for the severe damage inflicted on her by her pregnant mother's heavy drinking.

The mother's high level of alcohol consumption was equivalent to attempted manslaughter, lawyers are arguing. 

The test case raises questions about whether the mother’s drinking constitutes a criminal act and whether the child was legally an individual the time she suffered injury. And, according to the Guardian, around 80 other claims on behalf of children suffering from foetal alcohol spectrum disorder are awaiting the outcome.

According to lawyers for the local authority, under whose care the girl now is, the mother drank up to half a bottle of vodka and eight cans of strong lager a day while pregnant, despite attempts by social workers and health care professional to get her to stop. The girl now has developmental problems. 

The case raises all sorts of questions: is a foetus a legal entity? What powers should professionals have over pregnant women whose behaviour causes potential harm to their unborn children?


How to refer to female genitalia...?

Posted in General clinical at Fri, 21 Nov 2014 21:46:42


Posts: 4442
Joined: 24 Feb 2009

There's an interesting little piece in the BMJ this week about doctors' squeamishness when referring to the vagina and vulva.

Michael Berry, an anaesthetist, has observed that doctors collude with female patients' awkwardness . He writes:

"Conception­—that is, sex—and stages of cervical dilatation are all freely and proudly discussed. However, the regular vaginal examinations are secretively disguised as an internal examination or shortened to an acronym such as VE. The comedy or tragedy depending on how you view it does not end there. Delivery by forceps entails half a dozen healthcare professionals peering intently at a women’s vulva and repeated examinations down below are loudly announced by obstetricians of varying seniority. On more than one occasion has the rightly concerned birthing partner turned to me and whispered: “Where are they going to examine?”

"Finally, after a delivery by caesarean section, the last steps of the procedure always involve “cleaning you down there”—that shameful abyss, which like Lord Voldemort in the Harry Potter series is not allowed to be named. What a paradoxical situation then, where looking at, examining, suturing, and cleaning are all done on full display but the use of the word vagina or vulva almost never occurs."

It's an amusing piece and too true but I think it's something we grow up - how many parents would actually use the correct terms with their children. I know that I have tip-toed around this with my own children - talking down belows, front bottoms etc. Maybe I should bite the bullet.


Should the performance data of individual doctors be published?

Posted in News & media at Mon, 24 Nov 2014 11:55:29


Posts: 600
Joined: 18 Mar 2014

From today the NHS website  has started to publish the performance data of individual surgeons in 11 specialties. Two more specialties - neurosurgery and urogynaecology - will come online soon.

The data has been provided by surgeons' own specialty associations and patients can search for individual surgeons by name. I've had a cursory glance at the data and, as a patient, I would find it incredibly difficult to understand and work out whether the surgeon booked to do my operation had a higher risk or not. 

Critics of the plan have pointed out that the data does not show whether the procedures performed by individual surgeons are high-risk or not. 

John MacFie, president of the Federation of Surgical Specialty Associations, said the data published was crude and misleading.

"In reality ver few deaths can be attributed to surgical error alone and this data only attracts attentio away from institutional failings," he said. He told Radio 4's Today programme that there was anecdotal evidence that publishing this data has encouraged risk-averse behaviour among surgeons. 

But Bruce Keogh, himself a heart surgeon and medical director of the NHS, told the programme that publication of the data means that surgeons and patients now share the risk of the operation.

He said: "That really focuses the mind about the appropriateness of surgery for that particular individual and well functioning surgery groups will share between them that risk and ensure that the most appropriate surgeon does the operation." 


Do you have to like your patients?

Posted in General clinical at Mon, 24 Nov 2014 20:26:23


Posts: 4442
Joined: 24 Feb 2009

To have a good doctor-patient relationship do you have to like your patients? Do you ever give better/preferential treatment to patients you like better than others? Even if you do it unwittingly do some patients get more of your time and are you more willing to go that extra mile for patients whom you like better than others?

And do you ever suspect that your patients don't like you? Does it matter? 

I don't particularly like my GP but I think she's a good clinician so I'll carry on seeing her. But I don't think I would ever want her to give me bad news as her bedside manner is appalling.  

A tragic case, compounded by legal insensitivity.

Posted in News & media at Mon, 24 Nov 2014 11:02:39


Posts: 4442
Joined: 24 Feb 2009

You will have read of the poor mother of four children, three of whom had an incurable neurological condition, that would handicap their childhood and deny them adulthood.  She smothered them, while thier father and eldest daughter were away, and tried to kill herself.

I don't want to discuss the family and their tragic situation, but to ask if anyone else was as shocked as I was by part of  the prosecution counsel's case against her for manslaughter.     Ms Zoe Johnson QC argued that because she did not seek help for her depression,  she was culpable for the deaths of her children, even though the Crown Prosecution Service (who Ms Johnson represented) has previously accepted that she was mentally ill, and could not be charged with murder, but "only" manslaughter.

What breathtaking ignorance from an allegedly educated lawyer!    Surely the essence of depression is the loss of selfworth, the feeling that nothing can be done and that the sufferer isn't fit to live let alone be treated?   To say such a thing as a passing, unconsidered remark is at best insensitive, but to have that argument as part of the prosecution case is disturbing, as revealing ignorance in the UK's national legal system about the commonest mental illness of all .


POISE-2Trial and Pre operative care guidelines

Posted in Cardiology at Fri, 21 Nov 2014 18:31:02


Posts: 8
Joined: 02 Sep 2011

What should be the pre operative prescription, if any, to reduce CV events close to surgery in high risk patients?

Recent recommendations say:

Continue beta-blockers, ASA and statins if in use. Do not start if not in use.

In short, mostly keep doing your regular stuff, nothing else for most cases. Then, what should be the role of a GP, internist or cardiologist in the routine pre-op care?

What's your diagnosis? A returning traveller with fever, facial swelling and skin lesions

Posted in General clinical at Fri, 21 Nov 2014 14:36:33


Posts: 1
Joined: 18 Apr 2013

The case below was printed in the BMJ a few years ago. What are the possible differential diagnoses? I'll publish the answer in a few days. 

A 58-year-old man presented to the emergency department with fevers and lethargy. He had recently been in Zambia for 15 days, where he had spent time in Lusaka and at a game reserve. Three days earlier, while still in Lusaka, he had noted painful swellings on his right leg and fever, and although a malaria test was negative the fevers continued, so he returned home to Germany early.

At presentation, he was drowsy and his speech was slurred, so the history was obtained from his sister. He had not taken antimalarials during his trip, but he had been vaccinated against tetanus, diphtheria, and rabies before travel.

On examination his temperature was 39.4°C, respiration 18 breaths/min, pulse 96 beats/min, and blood pressure 95/80 mm Hg. His Glasgow coma score was 12/15, and facial swelling was noted around his eyes and cheeks. Apart from moderate hepatosplenomegaly and a systolic mitral valve click owing to a St Jude prosthesis implanted five years earlier, his physical examination was normal. There was no focal neurological abnormality or evidence of meningism. A generalised macular exanthema was noted on his trunk, along with two indurated skin lesions about 6 cm in diameter on his right leg (see below).

Blood tests showed haemoglobin 126 g/L (normal range 140-180), leucocytes 5.6×109 cells/L (4-11; lymphocytes 0.02 (0.25-0.4.), neutrophils 0.84 (0.50-0.75)), platelets 40×109 cells/L (150-400), C reactive protein 1807 μmol/L (8-31), creatine kinase 364 U/L (<171), total bilirubin 51.85 μmol/L (<17.0), aspartate aminotransferase 163 U/L (<35), alanine aminotransferase 205 U/L (<45), γ-glutamyltransferase 274 (<55) U/L, serum creatinine 477.36 μmol/L (<97). Serum electrolytes were within the normal range. Urine dipstick was positive for protein, erythrocytes, and leucocytes as well as some hyaline casts. Blood films were negative for malaria but showed unusual extracellular structures.

Should 'bed-blockers' face legal action?

Posted in News & media at Mon, 24 Nov 2014 17:33:57


Posts: 810
Joined: 13 Oct 2009

There's an interesting story on the BBC today about a hospital in Bournemouth which is threatening to sue patients who refuse to leave hospital when they are fit to go.

About 70 patients are on wards in Bournemouth Hospital and are medically fit to leave, with around half that number having a home or care home to go to. The discharge manager at the hospital says families are giving spurious reasons as to why they won't take a family member and view NHS care as free board and lodging.

One family asked the hospital to keep hold of an elderly relative so they could have a two-week holiday in Turkey. 

Katie Whiteside, clinical manager for discharge services, told the BBC: '[Relatives] are deconrating the house or having a granny annexe built and they know that while the patients are here they are being fed, watered and looked after." 

The hospital is planning to give patients a week's notice to leave. 

I have some sympathy with the hospital which says that this is having a knock-on effect elsewhere in the hospital and the NHS is not a care home but what about the 35 patients who don't have a place to go to? 


Thoughts on IE prophylaxis?

Posted in Cardiology at Sat, 22 Nov 2014 13:47:45


Posts: 7
Joined: 04 Sep 2014

Although limited,  recent evidence suggests the new NICE guidelines might have been a step back, not forward, on IE prophylaxis. Should the guideline be updated backwards based on new evidence?


Will the new duty of candour make patients safer?

Posted in General at Fri, 21 Nov 2014 13:10:30


Posts: 600
Joined: 18 Mar 2014

Later this month the new duty of candour will be introduced. The duty requires organisations to tell patients/carer when treatment or care has caused serious injury or death. And doctors and other organisations will also be required to inform employers if treatment or care causes serious injury or death. Doctors will also be required to apologise and put matters right where possible.

Doctors already have a duty to be honest and open under their professional registration so are legal sanctions necessary?

Writing in the Guardian in April Michael Devlin of the Medical Defence Union thinks not: "The proposed statutory duty, with possible criminal sanctions, is likely to do very little to contribute to the open culture of learning from mistakes that we need to build the safest platform on which to deliver care to patients. It could instead lead to delay and defensiveness that are inconsistent with the delivery of safe care."

What do you think? Will the new duty have any impact? 



Cardiovascular risk, will ezetimibe IMPROVE-IT?

Posted in Cardiology at Fri, 21 Nov 2014 01:45:36


Posts: 7
Joined: 04 Sep 2014

After quite a long time on the market, the first evidence supporting the use of ezetimibe to reduce CV events became available. The IMPROVE-IT study followed a very large cohort of very high-risk individuals for a very long time to demonstrate a small, yet significant, reduction and a composite CV outcome.

I am not particularly impressed, and would probably only use it for a restricted number of patients, but I am rather curious on how others see the data.




Posted in Respiratory medicine at Sun, 23 Nov 2014 15:30:31


Posts: 657
Joined: 21 Feb 2012


           this is a patient 35 y immnuocomptent male living from south india

                             history of fever/chills-5 days

                             dry cough - 3 days

                             no SOB/ no hemoptysis/no wheeze

                    no past h/o TB

          CECT CHEST: bilateral basal segments consolidation with air bronchograms.

                                      centrilobular nodules seen..consider BOOP!!!

                        help me  frnds with what would cause a bilateral lower lobe consolidation in an immunocomptent adult...i would rather consider BOOP(cop)as my last DD??

The Economic Burden of Obesity

Posted in News & media at Thu, 20 Nov 2014 11:33:20

Mukhtar Ali

Posts: 871
Joined: 14 Nov 2010

The worldwide cost of obesity is about the same as smoking or armed conflict and greater than both alcoholism and climate change, research has suggested.


Interest in Organic Psychiatry

Posted in Psychiatry at Fri, 21 Nov 2014 17:34:12


Posts: 472
Joined: 23 Aug 2013

A blog post by Dr Roxanne Keynejad discusses her interest in organic psychiatry. The blog is quite interesting because, I noticed many young doctors attempting to join psychiatry in search for the psychodynamic approach in psychiatry. I am impressed to find someone who is impressed by the organic aetiology of mental illness.

Are charity singles like Band Aid 30 patronising?

Posted in News & media at Fri, 21 Nov 2014 13:34:31


Posts: 600
Joined: 18 Mar 2014

The Band Aid 30 single (that makes me sound old!) has been released and it's aiming to raise money to treat the Ebola outbreak in West Africa.

The song has already attracted quite a lot of criticism for a) being patronising about Africa and its people  b) for rich people singing while it's us plebs who will have to fork out and buy the record and c) because money raised in previous Band Aid attempts has not always ended up going to the people who need it most. 

The clunkier lyrics of the previous Band Aid songs have been changed: eg "do they know it's Christmas time at all..."; "where no rain nor rivers flow....."; "tonight thank God it's them instead of you." (None of which lyrics I can write without hearing the warbling of Bono/George Michael/Banarama et al)

Is the song patronising or is anything okay if it's in the name of charity? 

Tribute to Robin Williams

Posted in Psychiatry at Sat, 22 Nov 2014 11:31:41


Posts: 472
Joined: 23 Aug 2013

The loss of Robin Williams was quite a sad one on the human aspect. The media coverage has been criticized for the way it dealt with it. I just came across this blog post from Greg Smith MD blog which discusses the issue from an interesting empathic psychiatric perspective.

I would be grateful to learn your thoughts about it.

An internship

Posted in Student BMJ at Sat, 22 Nov 2014 09:18:18


Posts: 1
Joined: 22 Nov 2014


Hope this post finds you well

I'd like to ask anyone with a previous internship experience , how can i get such an opportunity

actually i was looking forward to an internship in turkey but i can't get one

can you help me please  

rTMS for Tourette Syndrome

Posted in Psychiatry at Sat, 22 Nov 2014 11:21:53


Posts: 472
Joined: 23 Aug 2013

Just viewed a paper on The World Journal of Biological Psychiatry which is the official journal of The World Federation of Societies of Biological Psychiatry, discussing the possibility of treating cases of treatment resistant Tourette Syndrome with deep repetitive transcranial magnetic stimulation. I wonder whether you encounter such cases in your practice and whether you think that it this would be a promising treatment or not.

Ebola - a new facet

Posted in Psychiatry at Sun, 23 Nov 2014 15:06:19


Posts: 262
Joined: 14 Dec 2010

I gather some likely Ebola infected material has been stolen. Provided those involved know about transport media etc... this has interesting implications. It seems quite likely that the transport need not even be successful to build on the general level of background concern to produce some degree of panic? 

Why don't we expect more from patients?

Posted in Respiratory medicine at Mon, 24 Nov 2014 21:00:37


Posts: 810
Joined: 13 Oct 2009

In this day and age the vast majority of people (excluding me) seem adept in handling all sorts of smart phones , iphones etc... as well as being computer literate. Yet we insist on insulting them whenever anything medical is being considered. The range of useful gadgetry that is available from those for measuring glucose and blood pressure to those for recording cardiac rhythm are simple to use and interpret - nothing in comparison to an iphone. Where relevant results can be sent through to the GP without need for an appointment. The own patient results can also be a better base for planning care. Yet as a profession we seem loathe to part with any of our mystique and pressures of work. Are we responsible for the dependency syndrome or is it something on which Joe Public insists?

Similarly we spend hours anguishing over how to present options to patients in advising over tests when the vast majority perhaps have a better understanding of what this information means to them - as opposed to studies on what happens on average to several thousand in some trial - and have access to the same studies anyway.

Of course there will always be those who can't participate in this but I strongly suspect that the main fault is that we try to protect our "status". But just think if we all had more time for those folk or discussions where gadgetry is no substitute.

I wonder what AnneG thinks as a non-medic.?