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Posted in doc2doc feedback at Mon, 05 Oct 2015 08:57:59


Posts: 1484
Joined: 07 Sep 2009

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?

Mysterious severe right upper quadrant abdominal pain........please help

Posted in General clinical at Fri, 02 Oct 2015 04:32:10

Christa Jocelyn

Posts: 1
Joined: 02 Oct 2015
I know of a 29 yo caucasian female of otherwise good health who developed acute,severe onset of right upper abdominal pain always localized to right under ribs as if gall bladder and occasional severe pain in back , most of the time nausea, vomiting occasionally.This individual has had this persistant pain for over two months now. Since her first visit to emergency dept. she has had an ultrasound,endoscopy, CAT scan, Hida Scan, MRI, blood work up with no indication that gallbladder,pancreas, stomach,intestine,kidney,liver is functioning abnormally. Finally a surgeon, is refering her to a gastro enterologist with much hesitation. He really was going to just abandon the whole problem and suggested to just manage the pain...that was his solution. To just have her continue on taking morphine....not even wanting to pursue the challenge of finding a solution.
She continues to suffer every minute of every day....
Does anyone out there know of a solution??
She desperately needs medical attention

Retirement/part time

Posted in General at Sun, 04 Oct 2015 11:06:28


Posts: 4638
Joined: 24 Feb 2009

I would like to hear from our retired Doctors here about the transition from full time practice to retirement. I am in a position of being able to end my current job and just do consultant work periodically. But, I love my work and everything that goes with it. Of course it has aspects that are frustrating but on the whole it is very satisfying.

What was it like to stop full time practice where you were in a responsible position?

Do you wish you had gone part time if it were possible?

Would you like to have kept on working?

What have you done in retirement?

Have you kept in touch with medicine?

(I would not strictly be retiring as too young but cutting down).


Advice for new medical students, incl. free Survive Med School ebook

Posted in Student BMJ at Sun, 04 Oct 2015 12:15:04


Posts: 4638
Joined: 24 Feb 2009

September/October is the time most univeristies in the UK welcome new students with freshers' celebrations.

There are lots of tips for new medical students flying around on social media. We'll try and bring as many together as possible, as well as tips from our own very knowledgeable community, on this thread.


BMJ itself has lots to offer medical students:

Survive Medical School ebook

BMJ Best Practice topics

BMJ Learning modules and Masterclasses

OnExamination exam help

Student BMJ

The BMJEducation topics, researchnews

Some of it's free for everyone, some of it's free for students, some of it's free for BMA members.

How Useful are Medical School Rankings?

Posted in Public health at Fri, 02 Oct 2015 10:34:42

John D

Posts: 3767
Joined: 01 Feb 2010

‘The Guardian’ has reported how changes in the way Universities are ranked now give more recognition to the arts and humanities; previously, scientific and biomedical research carried much more weight.  http://www.theguardian.com/education/2015/sep/15/british-universities-slip-downing-global-rankings

Not surprisingly, the change has caused controversy as some UK universities have lost ground in world rankings.  Some have questioned how much these rankings really matter except to the business success of Universities.

The controversy might prompt us to look at the way UK medical schools are ranked and in what ways the rankings might or might not have any use.  In a recent ‘Student BMJ’ article Richard Wakeford has taken a critical look at some of the problems of ranking medical schools and how different guides use different criteria and so give different rankings for the same schools.

 Student BMJ 2015;23:h1359

Wakeford suggests that prospective students choosing a school might do better to consult a new GMC database that ranks schools by markers of later career progress.  The comparison, for example using pass rates for all major postgraduate exams, gives rather different ranking to the conventional ones.

Prospective medical students choose a medical school for all sorts of reasons.  Social factors can be important for some.  Some prefer to study a more traditional curriculum, others might choose a problem-based or integrated course.  The measurable differences in outcome seem to be small but even with the GMC database we still don’t know how to assess and compare the quality of doctors produced.  Quality of teaching can be highly variable and difficult to gauge in advance; it is usually represented by student questionnaire result but we lack  good measures of face-to face teaching quality.

One factor not included in any rankings is the quality of experience gained in the clinical institutions linked to each medical school.  Recent events in Cambridge have highlighted the difficulties involved in making these judgements but, arguably, it is the clinical experience that might matter most in choosing where to study.

What do doc2doc members think of medical school rankings?

  Are they genuinely useful in making informed choices about where to study or are they of more useful in attracting funding for schools?

 This topic doesn’t seem to lend itself easily to a traditional doc2doc poll.


Clinical question of the week: abnormal LFTs

Posted in General clinical at Mon, 05 Oct 2015 08:54:55


Posts: 6
Joined: 21 Sep 2015

A 40 year old woman comes to see you because she has itching of recent onset. She has a history of autoimmune thyroid disease. Liver serum biochemistry shows normal aminotransferases and abnormal ALP and GGT (both five times the upper reference value). Liver ultrasound examination is normal.

Short Medicolegal Case report

Posted in Medicolegal at Mon, 05 Oct 2015 00:57:42


Posts: 11
Joined: 20 May 2014
Miss Z, aged 52 was a part time GP. She consulted her own GP regarding hot facial flushes, night sweats. palpitations, irritability and mood swings. She suspected it was the Menopause and her GP agreed. The GP did not carry out any physical examination or check any vital parameters.  She was started on HRT and did not need to consult the GP again for about 8 months - she automatically requested refills of prescriptions as needed. When she did return to her GP she explained that the symptoms were better since being on HRT but not eradicated. She also stated that over the last few weeks she had periodical intense headaches and anxiety which seemed to coincide with the hot flushes.
The GP changed the medication regime slightly and advised her to return if symptoms did not settle and they might consider other options. A week after seeing her Miss Z was taken unwell whilst at work. She explained to the Paramedics what treatment she was on (HRT only) and that she had noted her BP was high on several occasions (using her own sphygmomanometer) when she was flushed. Her BP on assessment in A&E by an SpR noted a BP of 190/115 but other parameters were all normal.
Twenty four hours after admission to hospital her BP was fluctuating between 190/115 and 210/110 but all other Parameters were considered within normal ranges. On day 3 of admission she suffered a severe haemorrhagic stroke which required intensive nursing and physiotherapy to achieve even a minimal level of independence.
It subsequently transpired she had Phaeochromocytoma which would have explained several of her symptoms. Miss Z felt very let down by her GP and hospital Doctor whom she felt should have considered Phaeo  and might, therefore have prevented the stroke.
She sued her GP and the hospital.

Struck off for signing sick notes - too harsh?

Posted in News & media at Mon, 05 Oct 2015 06:45:12


Posts: 77
Joined: 11 Feb 2010
A GP at the end of her career with no previous history of appearing before the GMC gets struck off the register for "dishonestly" providing sick notes for two schoolchildren over a three year period. It's thought the end-of-term sick notes enabled the children to travel to Egypt before school formally broke up for the summer.
Was the Medical Practitioners Tribunal Service panel judgment overly punitive? Certainly some of us wondered this when the issue was discussed at a BMJ daily news meeting this week.
Admittedly Therese Shortfall had giving diagnoses that were not clinically indicated, without examining the children or recording the notes in their records. 
She tried to remove herself from the register, didn't attend the hearing, and the panel derived “no satisfaction from removing a doctor from the register at the end of her career," but because she didn't appear, its members found it hard to impose a more lenient sanction.
Should they have done?

Grey Case

Posted in General clinical at Sun, 04 Oct 2015 11:59:48

John D

Posts: 3767
Joined: 01 Feb 2010

23 year old woman presented with severe joints pain,  fatigue, insomnia, shortness of breathing and palpitations

On examinaation she had dry eyes, decreased visual acuity, papilledema, and tender red nodules on both shins

BP and CVS are normal, ECG showed RBBB. Blood test showed anemia and Lymphopenia

1/ What is the most likely diagnosis ?

2/ What other clinical features may be found ?

3/ What other tests important to confirm the diagnosis ?

MRCP Part 1 practice question from OnExamination: prominent pulmonary arteries on CXR

Posted in General clinical at Mon, 05 Oct 2015 12:22:04


Posts: 4638
Joined: 24 Feb 2009

A 42-year-old restaurateur who has been human immunodeficiency virus (HIV) positive for eight years presents with progressive shortness of breath on exercise.

The chest x ray shows normal lung fields with prominent pulmonary arteries. Pulse oximetry demonstrates that he desaturates on exercise.

NICE delays Asthma Guideline

Posted in Respiratory medicine at Sun, 04 Oct 2015 19:33:58

Mark Levy

Posts: 1
Joined: 26 Nov 2009

Are you waiting patiently for the new NICE asthma guideline?  You'll be waiting a bit longer, after NICE decided today to delay the release of the guideline while they assess the impact it will have on routine clinical practice.  

The draft guideline from January took the controversial direction of removing the trial of treatment option from previous BTS/SIGN versions of the guidelines, instead encouraging GPs to carry out tests of airway hyper-responsiveness, such as FeNO and Mannitol challenge, in primary care.

GP bodies have responded with their concerns over monetary and time costs, as well as the requirement for re-training in technical and interpretative skills required to carry out these tests in primary care.

We got rid of oral steroid trials many years ago (everyone feels better on 2 weeks of steroids), but the trial of inhaled therapy was often very helpful, I found.  Perhaps the reasoning was to minimise the number of patients who get left on ICS long term, without actually having asthma, but adherence rates being as they are, it seems unlikely to be a major issue in the real world.

We continue to wait for the guidelines.   But I'd rather see a new COPD guideline first.

Are modern students too politically correct?

Posted in Careers at Thu, 01 Oct 2015 22:52:06


Posts: 1622
Joined: 09 Dec 2011

I am a bit out of touch with student thought but 2 items in the news in the last few days worry me. The first was at a (I think ) gathering for new students at the Univ of East Anglia - a local Mexican diner wanted to give out sombreros . This was seen as offensive in that Mexicans might be offended by non-Mexicans wearing this headgear.

 I had thought this must be something of a hoax - but then Warwick has decided to block a speaker organised by the Humanist and secularist group.

 Universities have sometimes had speakers who are pretty militant in their views , but it seems that much of what this speaker has to say is in promoting discussion on points that really do need to be debated - how far is religion "a bad thing" and how far religions can evolve. Clearly this will be more relevant to Islam but not clearly anti--Islamic. Trying to understand some of these areas of thought is one of the major problems of our time - by understanding we have a better chance of appreciating the varied ponts of view.

DOI  Some nostalgia for those  discussions on religion , with few holds barred , from student days.

Telling the truth

Posted in Medicolegal at Sun, 04 Oct 2015 17:04:40


Posts: 1622
Joined: 09 Dec 2011
Following trials in several parts of the country (UK) Polygraphs (Lie Detectors) will now be used to monitor offenders who have abused children. The belief is that their use is beneficial in assessing whether the offender has re-offended or is likely to. Whilst I am all for proper monitoring of such individuals I am concerned because there is no solid scientific evidence that Polygraphs work at all.
Polygraphs measure arousal, which can be caused by anxiety, anxiety disorders such as PTSD, nervousness, fear, confusion, hypoglycaemia, psychosis, depression, substance induced (nicotine, stimulants), substance withdrawal state (alcohol withdrawal) or other emotions; polygraphs do not measure "lies." A polygraph cannot differentiate anxiety caused by dishonesty and anxiety caused by something else.
Because there is no pattern of arousal that is unique to deception, the decision to classify a set of responses as untruthful is inevitably a leap from the shaky ground of ambiguous data into the fog of inference. As a result, techniques to "beat" a polygraph are simple and effective. The simplest strategy seems to be to increase arousal during the control questions, rather than trying to reduce arousal during deception, to eliminate any difference.
Polygraphy is widely criticized. Despite claims of 90% validity by polygraph advocates, the National Research Council has found no evidence of effectiveness. The utility among sex offenders is also poor with insufficient evidence to support accuracy or improved outcomes in this population.
Even using the high estimates of the polygraph's accuracy, false positives occur, and these people suffer the consequences of "failing" the polygraph. In the 1998 Supreme Court case, United States v. Scheffer, the majority stated that "There is simply no consensus that polygraph evidence is reliable" and "Unlike other expert witnesses who testify about factual matters outside the jurors' knowledge, such as the analysis of fingerprints, ballistics, or DNA found at a crime scene, a polygraph expert can supply the jury only with another opinion...".
The accuracy of the polygraph has been contested almost since the introduction of the device. In 2003, the National Academy of Sciences (NAS) issued a report entitled "The Polygraph and Lie Detection". The NAS found that the majority of polygraph research was "unreliable, unscientific and biased", concluding that 57 of the approximately 80 research studies that the American Polygraph Association relies on to come to their conclusions were significantly flawed. These studies did show that specific-incident polygraph testing, in a person untrained in counter-measures, could discern the truth at "a level greater than chance, yet short of perfection". However, due to several flaws, the levels of accuracy shown in these studies "are almost certainly higher than actual polygraph accuracy of specific-incident testing in the field". 
Polygraphy Tests are very common in the US with police departments but are not admissible in court in many States (with some specific exceptions). 
I am interested in what medics here think about this. Do you think measuring fleeting changes in BP, Pulse, Respirations and sweating are reliable physiological proxies reflecting dishonesty?
If you were accused of a crime would you be willing to take a Polygraph test?
Ps. It is also interesting that many Soviet Spies have passed the polygraph repeatedly - Aldrich Ames comes to mind.
PPS. The Green River Killer, Gary Leon Ridgeway, pled guilty to murdering 48 women in the Seattle area over a twenty-year period. Ridgeway was given a polygraph following the murder of his fourth victim and passed the polygraph exam.  He was then dropped as a suspect and went on to kill another 44 women.  He is listed as the most prolific killer in U.S. history.  

Bigorexia: a disorder or societal anger

Posted in Psychiatry at Sun, 04 Oct 2015 15:30:11


Posts: 1121
Joined: 13 Oct 2009

Medical literature started using the term bigorexia to explain men who are doing excessive exercise and body building. It falls under the subtypes of dysmorphobia. Basically, it's about men going to the gym. I wonder about the validity and reliability of such diagnosis. Would like to learn your opinion about this new born, gym related disorder.

Short summary of empa-reg outcome

Posted in Diabetes at Fri, 02 Oct 2015 01:11:45


Posts: 7
Joined: 16 Jun 2013


Today’s Medical Science is challenged by the bitter sweet-epidemic, the diabetes which affects 382 million people, globally. (1) Type 2 diabetes is a major risk factor for cardiovascular diseases , which, in turn cause, 70% of deaths in these diabetics.(2)

It is crucial to establish the safety benefits of glucose lowering drugs in cardiovascular patients, because, not only they lack the evidence to reduce the rates of cardiovascular events and deaths, some of them lead to adverse cardiac outcomes.(3,4)

Zinman. et.al.(5) conducted a long-term major trial on how empagliflozin, a glucose lowering drug ,improves the mortality (length of life) and morbidity (quality of life) in   Type 2 Diabetics with high risk of cardiovascular events, as an added drug to the standard care. It supports the long-term use of empagliflozin and evidences a reduction in cardiovascular risk.


The investigators selected 7020 patients who were on standard therapy for cardiovascular disease and diabetes. On the basis of the added drug, they divided them into three groups giving: one third 10 mg of empagliflozin; the other third, 20 mg; and the rest, a placebo (drug with no effect). They observed the pooled empagliflozin groups vs the placebo group for about 3 years, for either one of the following three primary outcomes: death from cardiovascular causes; nonfatal myocardial infarction (heart attack); and nonfatal stroke; And for hospitalization due to heart failure.


A significant reduction in the cardiovascular death drove the overall result in the study. They observed benefits of empagliflozin vs the placebo from as early as 6 months. Empagliflozin reduced overall risk for the 3 primary-outcomes by 14%, cardiovascular death by 38% (which earned the paper a round of applause at the EASD conference on 17th September, 2015), and improved survival by reducing all-cause mortality by 32%. It also reduced hospitalization due to heart-failure by 35%.They found no significant between-group differences in the myocardial infarction and stroke rates.


A trial with such encouraging results, is a new hope in medical sciences. Yet, the exact mechanism for reduction in all-cause mortality, effects of the drug in a different patient population and the long-term renal safety outcome, are few questions, the researchers need to find an answer for.




  1. https://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf
  2. www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
  3. Bennett WL, Maruthur NM, Singh S, Segal JB, Wilson LM, Chatterjee R, Marinopoulos SS, Puhan MA, Ranasingher P, Block L, Nicholson WK, Hutfless S, Bass EB, Bolen S: Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med 2011, 154:602-613. OpenURL
  4. Rosenstock J, Marx N, Kahn SE, Zinman B, Kastelein JJ, Lachin JM, Bluhmki E, Patel S, Johansen OE, Woerle HJ: Cardiovascular outcome trials in type 2 diabetes and the sulphonylurea ontroversy: rationale for the active-comparator CAROLINA trial.Diab Vasc Dis Res 2013, 10:289-
  5. EMPAGLIFLOZIN, CARDIOVASCULAR OUTCOME, AND MORTALITY IN TYPE 2 DIABETES.Bernard Zinman, M.D., Christoph Wanner, M.D., John M. Lachin, Sc.D., David Fitchett, M.D., Erich Bluhmki, Ph.D., Stefan Hantel, Ph.D., Michaela Mattheus, Dipl. Biomath., Theresa Devins, Dr.P.H., Odd Erik Johansen for the EMPA-REG OUTCOME Investigators September 17, 2015DOI: 10.1056/NEJMoa1504720





Anticoags - NOACS or not?

Posted in BMJ at Fri, 02 Oct 2015 15:35:36


Posts: 1121
Joined: 13 Oct 2009

The indications for anticoagulation seem ever increasing and there are numbers of cost effective comparisons , safety profiles etc... .  often with somewhat seem to  a bit borderline.

So how to choose ? Went I had a THR recently I said to the surgeon beforehand I would prefer LMWH to a NOAC and he more or less I think felt that was not now a surgical decision and would leave it to me or the hospital protocol. The hospital then said that it had changed back to LMWH in view of side effects with NOAC , so no problem there. I was then asked about a district nurse giving the injection which seemed a pretty ridiculous idea. Surely the NHS should not be funding that sort of activity unless there really is a special need ? Talk about "nanny state" - if an able person declines to do something as simple as that , then offer aspirin or warfarin as an alternative .... A similar problem arises with diabetics who refuse to inject themselves when otherwise quite capable.

Of course the real problem is the numbers on long-term antioagulation. My wife was skiing down the slopes last winter when her sister mentioned in passing that she was on a NOAC. I worry a bit that there are so many folk out there now on these that potential hazards are being belittled - particularly with a drug that is not readily reversible. Just think of event docs such as John D when faced with an accident hear "Oh yes , I am on one of those funny new drugs.." Just hope none of the World Cup Rugby players are on them  , particularly when playing against Fiji. Their match against Wales was one of the best I have seen for a long while.

BMJ Open journal club: what do GPs think of managing dental problems in general practice?

Posted in General clinical at Mon, 05 Oct 2015 14:44:45

Emma Gray

Posts: 7
Joined: 25 Aug 2015

In this research paper, Cope et al sought to produce an account of general practitioners' (GPs) views on the management of dental conditions in general practice, and explore how GPs prescribe antibiotics in the treatment of dental problems.

For many GPs, dental problems make up a regular part of the workload - despite many feeling that they haven't received the correct training to deal with such problems. Clinical guidelines recommend that a dental practitioner should be the first port of call for acute dental problems, for surgical intervention.

The prescription of antibiotics for dental problems by GPs remains common - although attitudes differ widely between GPs on whether to prescribe them or not. Some GPs are more likely to provide messages about the use of the service and alternative places to seek care, as prescription of antibiotics by GPs may contribute to patient morbidity and antimicrobial resistance.

The paper concludes by saying that interventions are needed to support patients in accessing the appropriate care for dental conditions. What are your thoughts on the management of dental problems by GPs? What form could these interventions take?


More information about this article:


Objectives This study aimed to produce an account of the attitudes of general practitioners (GPs) towards the management of dental conditions in general practice, and sought to explore how GPs use antibiotics in the treatment of dental problems.

Design Qualitative study employing semistructured telephone interviews and thematic analysis.

Participants 17 purposively sampled GPs working in Wales, of which 9 were male. The median number of years since graduation was 21. Maximum variation sampling techniques were used to ensure participants represented different Rural–Urban localities, worked in communities with varying levels of deprivation, and had differing lengths of practising career.

Results Most GPs reported regularly managing dental problems, with more socioeconomically deprived patients being particularly prone to consult. Participants recognised that dental problems are not optimally managed in general practice, but had sympathy with patients experiencing dental pain who reported difficulty obtaining an emergency dental consultation. Many GPs considered antibiotics an acceptable first-line treatment for acute dental problems and reported that patients often attended expecting to receive antibiotics. GPs who reported that their usual practice was to prescribe antibiotics were more likely to prioritise patients’ immediate needs, whereas clinicians who reported rarely prescribing often did so to encourage patients to consult a dental professional.

Conclusions The presentation of patients with dental problems presents challenges to GPs who report concerns about their ability to manage such conditions. Despite this, many reported frequently prescribing antibiotics for patients with dental conditions. This may contribute to both patient morbidity and the emergence of antimicrobial resistance. This research has identified the need for quantitative data on general practice consultations for dental problems and qualitative research exploring patient perspectives on reasons for consulting. The findings of these studies will inform the design of an intervention to support patients in accessing appropriate care when experiencing dental problems.

Link to the full text version of the paper: http://bmjopen.bmj.com/content/5/10/e008551.full

Fed up with training- quit and locum full time (ST6 Orthopaedics)

Posted in News & media at Sun, 04 Oct 2015 19:42:14


Posts: 1
Joined: 04 Oct 2015

Hi all

As with many of us, I'm getting fed up of Hospital life and the contract changes that Jeremy Hunt is proposing. I have been extremely dedicated to Orthopaedics and have my number and am currently an ST6 in London and it seems to constantly be undervalued and underrewarded. I always thought that that we would endure our junior doctor years and hopefully have a civilised life as a consultant. However my consultant is telling me that they are being forced to go onto a rolling rota, work weekends with a view to doing elective work on weekends, and there have also been discussions to stop them doing private work as the NHS trained them....

My mates recently quit and signed up to a website (Everylocum.com) and they just do full time locums. They said that because they can work for many different agencies from this one website, they have too much work and are earning a good wage already with minimal stress. They work when the want and basically have no more hospital stress.

I loved orthopaedics, have spend over 15k on doing it but am getting fedup with it all and everylocum seems to offer me an easy way out.

Clinical question of the week: An uncommon case of sternoclavicular septic arthritis

Posted in General clinical at Mon, 05 Oct 2015 20:11:20

John D

Posts: 3767
Joined: 01 Feb 2010

An 85 year old woman taking immunosuppressants for an exacerbation of Crohn’s disease described increasing left shoulder pain. Shoulder and chest radiographs were normal. She subsequently developed a tender erythematous swelling in her left neck. Computed tomography identified left sternoclavicular joint (SCJ) septic arthritis, secondary left sternocleidomastoid abscess (A), and pathological fracture of the clavicle (B)



What are the complications of SCJ septic arthritis?

Why do doctors insist on being ridiculous?

Posted in doc2doc feedback at Mon, 05 Oct 2015 10:59:43


Posts: 1121
Joined: 13 Oct 2009

2 contrasting comments in the past few days. Firstly , Maureen Baker of the RCGP “It is deeply insulting and demeaning –as well as being highly unethical – to suggest that offering GPs money will change the way in which we care for our patients”. Money has featured greatly , and often for the good,  in the way  GPs care for their patients. Contracts have been negotiated on that basis. The precipitant – possible payments for not referring to hospital – is not something for such a self righteous response but for information and audit on the inappropriateness of referrals. If this is happening - then why : poor guidelines , more training needed , complaining patients always seen as in the right etc...


The second full feature article by a GP in the Guardian / Observer was against the evils of private practice. Totally different from GPs : hospital doctors do things because of the money. The evils listed will be well known to many of us and it is time we tackled them more forcefully –but not on a doctrinal basis. No mention of the frustration of some doctors when they are discouraged from seeing patients on the NHS even by running unpaid extra clinics. No mention of using private sessions to raise money to improve services for all patients etc…  And the usual issue about whether a UK taxpayer should lose rights to NHS services if seen privately. It has never been so crucial to try to establish an ethical way in which the MHS and private sectors can compliment each other – my impression is that it happens already more often than we realise.


Both systems have evils which we need to tackle (it is not a problem of recognition) – but doctors are not influenced by money ……

Is it time to ban anonymous comments on HSJ?

Posted in News & media at Mon, 05 Oct 2015 20:03:14

John D

Posts: 3767
Joined: 01 Feb 2010

Alistair McLellan, editor of NHS management title Health Service Journal, has asked readers if anonymous comments to articles should be banned. A very small number of anonymous users, he argues, hide behind their anonymity to post comments that are "childish or puerile and, at worst, offensive."

The views of doc2doc members might be useful to Alistair. Are psuedonyms the answer? Should anonymity be banned?

The BMJ doesn't allow anonymous users - its pre-moderated responses ask for name, job title, affiliation etc.

One HSJ reader has weighed into the debate by arguing that anonymity should always be available as an option as it can generate valuable insider knowledge, which is worth 10 gratuitous remarks. Is anonymity the equivalent of "un-named sources?" Does it provide a safety net for whistleblowers?



Should QOF be removed from all GP contracts in the UK?

Posted in Careers at Mon, 05 Oct 2015 12:02:20


Posts: 1484
Joined: 07 Sep 2009

BMJ Careers reports that  the Scottish Government has committed to completely removing the quality and outcomes framework (QOF) from the GP contract in Scotland by 2017:

“QOF has delivered many innovations, but its time is past. Scotland’s GPs need a new and different future, starting in 2016. I want to move towards a system of values driven governance that reflects and is sensitive to the different needs of the different communities that you serve, allowing the best use of expertise to be shared across clusters of practices.”

A man of principle

Posted in News & media at Mon, 05 Oct 2015 07:10:25

John D

Posts: 3767
Joined: 01 Feb 2010

Dan Poulter is a doctor and a lawyer, being doubly qualified, and became MP for Central Suffolk in the 2010 election.    Until May this year, he was the Parliamentary Undersecretary of State for Health Services, a deputy minister in the present Government, who was in charge of the negotiations with the BMA on the new contract.    We don't know how he lost that post, but in the Guardian today he explains why - the Government and Minister Hunt renaged on all the previous work done, that had formed recognition by the Dept. of Health that better pay and conditions were required, and and the agreement in principle with the BMA.


So in our anguish on what that betrayal means for the NHS, we should praise Dr.Poulter for his honesty, and his bravery, in telling us and the British public of how they were traduced.   He is now training part-time in psychiatry.  I wish him well in his return to medicine, because he hasn't a hope now in politics.


Is 77 too old to drive a bus - or be a commercial airline pilot?

Posted in General clinical at Tue, 06 Oct 2015 00:26:36


Posts: 4638
Joined: 24 Feb 2009

In recent years in the UK there has been a lot of tortuous thinking in trying not to be ageist. A few years back I was hearing the argument that there should be no age restriction on commercial airline pilots if the pilots in question passed the usual tests. To think otherwise would be clearly ageist. And yet - we screen older patients because of a statistical chance of finding covert disease. Are "mandatory " tests for those driving public service vehicles enough - an eyesight test and ecg clearly would not be. Tests of physical strength become more  relevant too as well as those around reaction times , but whatever test there is always the thought that statistically there is a greater risk of something untoward. I am not favour in keeping drivers off the road on the grounds of age , but wonder whether there is an age at which vehicles or planes used by the public should be driven by someone more youthful. Is it really ageist to suggest some additional tests for the older drivers or pilots?

Of course , the same issue arises in medical decisions - in helping a patient decide on the statistical chances of benefitting form a surgical intervention perhaps we should take the likelihood of demise in the next 3-4 years into account before submitting someone to a procedure with a 6-12 month recovery time. I find the argument that if someone wants an operation and only has a very short time to live , then that person should have it for ethical reasons as their window of opportunity is smaller than the person with greater life expectancy , a touch bizarre. Most decisions in medicine require a degree of common sense but we seem to be losing it. For myself , before agreeing to a treatment I do a SWOT analysis and wonder whether we should introduce patients to this concept?

MRCPsych Paper B practice question from OnExamination: buprenorphine in opioid dependence

Posted in Psychiatry at Mon, 05 Oct 2015 11:39:24


Posts: 73
Joined: 07 Apr 2015

A group of researchers conduct a randomised controlled trial of the drug buprenorphine in opioid dependence.

There are 392 patients in the treatment arm and 382 participants in the control arm. Interviews are conducted at baseline, three months and six months, where each participant is asked if they have used non-prescription opiates over the preceding 14 days.

Their results are tabulated below.

(N = 392)
(N = 382)
N % N %
Baseline 160 47 176 48
3 months 67 20 115 31
6 months 60 18 119 33