FYISSUE 11 i

MEDICAL CARE IN A TROUBLED WORLD Médecins Sans Frontières at the front line in con ict and disaster

ALSO INSIDE A CAREER IN EFFECTIVE AN MDDUS 08 ACADEMIC MEDICINE 10 COMMUNICATION PUBLICATION 02 • • PHOTO: RON CATHRO Welcome to your FY Joanne Curran ASSOCIATE EDITOR: Dr AnnePartt-Rogers EDITOR: switched to 24/7care? Our to die,soisittimehospitals surgical patients are more likely research suggests weekend eld onpage6.Thelatest explains more about this growing many ways. Dr Michael Moneypenny helped improve patient safety in and theirlinkto medicalerror has best results. following key rulesto get the highlights theimportance of medical researcher DrAllanGaw scientic discovery. Onpage5 di­erent kind,intheeldof your literary skills. highlight thebenets of rening magazines andother mediaand get involved withwritingfor blogs, On page4,Ilookat how you can are many other funopportunities. vital skillfor ourwork, butthere Communicating e­ectively isa year orrstyear asajuniordoctor. will bebusy startingyour nal scorching summer, many of you IN themiddleof a(mostly) discretionary as set out intheMemorandum andArticlesof Association. MDDUS isnot aninsurance company. Allthebenets of membershipof MDDUSare Scotland No5093at Mackintosh House,120Blythswood Street, Glasgow G24EA.The FYi ispublishedby TheMedicalandDental Defence Unionof Scotland, Registered in News Welcome FYi The studyof “humanfactors” And to inspiration of a Editor Dr AnnePartt-Rogers consequences. leg painwithtragic deals with a case of misdiagnosed on page8. might befor you. Findoutmore career inacademicmedicine intriguing scientic questions–a to answer someof themost challenge that o­ers thechance those seekingalessdangerous organisation onpage12.For more aboutthisremarkable safety. Adam Campbellndsout zones at great riskto theirown deliver care involatile con–ict Sans Frontières often have to o­er advice onpage10. Experts from theMaguire Unit sure you are really listening? complaints. Sohow canyou be most common sources of patient communicate are amongthe article onpage7investigates. www.mddus.com [email protected] w: 08452702034 e: t: Glasgow G2 4EA 120 Blythswood Street Mackintosh House MDDUS FYi Editor CORRESPONDENCE: www.jtcp.co.uk J. ThomsonColour Printers PRINT: www.cmyk-design.co.uk CMYK Design DESIGN: Our casestudyonpage14 Doctors withcharityMédecins The ways that doctors COVER PHOTO i : PETER : C ASAER

improvements andchange.” including managersandmedicaldirectors, to “bring aboutfurther for theirfuture career. trainees (79percent) thought thepostwould bevery useful oruseful but thegure isuponlastyear’s 69percent. Thevast majorityof 87.9 percent. Surgical trainees are theleastsatised at 77.1percent, same asinprevious surveys. They gave anaverage satisfaction score of were supervisedby someonewhowas competent to doso. over 80percent satised withtheirtraining and90percent saying they “rarely”. this happeneddaily, weekly ormonthly withtherest saying ithappened have felt forced to work beyond their competence. Ofthese,afthsaid monthly basis.Justover halfof the6,000GPtrainees surveyed saidthey clinical problems beyond theircompetence orexperience onaweekly or 2013, aresponse rate of 97.7percent. while onein10saiditwas “very heavy”. Around athird of trainees describedtheirdaytime workload as“heavy” T L POOR Edinburgh, Glasgow andLondon. training standards for thethree UKRoyal Colleges of Physicians in Training Board. Theboard isresponsible for setting andmaintaining £169 they pay eachyear to theJoint Royal Colleges of Physicians four UKsurgical royal colleges. on Surgical Training. Thecommittee managessurgical training for all against taxableincome the£185 ayear they pay to theJoint Committee and HMRevenue andCustoms. to anew taxdealbetween theRoyal College of Surgeons of Edinburgh TRAINEE OF T ONG RAINEES National training survey 2013, www.tinyurl.com/gmc2013 The GMCsaiditplansto work withthoseinvolved inmedical training, GP trainees remain themostsatised withtheirtraining, whichisthe Despite theseconcerns, overall satisfaction remains highwithjust Other results showed 15percent of trainees felt forced to cope with A total of 52,797trainees responded to theNationaltraining survey RAINEES Medical specialtytrainees willnow benet from taxrelief onthe The move meanssurgical trainees willnow beableto claimback

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SPECIALTY TRAINING ‘LIMITS DOCTORS’, SURVEY FINDS

MORE than half of trainee doctors and new GPs think the current specialty training programme limits doctors’ potential. Criticism for the Modernising Medical Careers (MMC) programme emerged in the latest BMA survey of doctors who graduated in 2006. The BMA has questioned the 431 graduates each year as the cohort was the rst to follow the MMC pathway. Of the 372 doctors who responded to the 2012 survey, 54 per cent agreed or strongly agreed that the programme limited the potential of doctors. They highlighted duplication of placements, di®culty changing specialty and previous clinical experience not being taken into account as the main problem factors. The majority of respondents (84 per cent) wanted more –exible specialty training placements while 72 per cent believed taking time out of specialty training to work in a non-training post was stigmatising, with 59 per cent feeling the same about taking time out for family reasons. A further 47 per cent also believed there is a stigma associated with changing specialty after foundation training. The BMA said this nding was “particularly concerning” due to the expected shortfall in GP trainees and oversupply of hospital specialty trainees. Despite the criticism, only 12 per cent of those who responded to the survey said their specialty training so far had not allowed them to develop their career to the best of their ability. Chair of the BMA’s Junior Doctor Committee Ben Molyneux branded the MMC “a mixed bag”, adding: “We have reduced the amount of –exibility in the system and it’s really slow progress to change things in the right way”.

ALL TRAINEES FIND JOBS PHOTO: ETIENNE MENEAU ALL trainee doctors have been given jobs after spending months on a waiting list. DRINK FROM THE VEIN The nal 33 reserve list applicants were allocated places on July 8. It was conrmed last October that oversubscription to the Foundation FRENCH sculptor Etienne Meneau has created an unusual range Programme had left 295 trainees without jobs. In April and May, 98 of bio-tableware, including this eye-catching vein-shaped glass reserve list applicants were found a job with a further 138 allocated the decanter which holds a full bottle of wine. Other pieces include following month. drinking glasses inspired by the human heart. Anatomy fans can nd The remaining posts have now been allocated more than two weeks out more at the-strange-decanter.blogspot.com or order directly ahead of schedule after the UKFPO ran an additional batch allocation. from [email protected] UKFPO national director Professor Derek Gallen welcomed the move and said it meant all trainees would be ready to start their foundation training on time. TRAINEES CAMPAIGN FOR SAFE SHIFT WORKING FUNDING BOOST FOR JUNIOR doctors have taken their campaign for safer shift working to the Scottish Parliament following a Channel 4 documentary highlighting the issue. TRAINEE INITIATIVES Surgical trainee and chair of the BMA’s Scottish Junior Doctors AN APP to help confused patients and a tablet- Committee Tom Berry was among those who met with politicians to based surgical training kit are among nine trainee-led discuss the issue. He was also featured in the documentary, broadcast in projects to receive funding from Health Education March, in which he demonstrated how the e­ects of a 10-day working England. pattern of shifts a­ected his ability to do even basic tasks. A broad range of programmes led by trainee He said: “Much progress has been made to reduce working hours over doctors shared the £100,000 cash pot as part of HEE’s the past 20 years and although the introduction of the European Inspire Improvement project under its Better Training Working Time Directive has driven down the volume of hours that junior Better Care programme. doctors work, it has also led to an increase in shift working patterns Among the winners was the educational and which can have risks for health and performance.” bedside “Confusion App” from Selina Sangha and FY2 Ingrid Sepp also attended the meeting. She said: “Going from Christy Gardner of North Cumbria University Hospital nights to days twice in a two week period is exhausting. I usually nd it Trust, while Mohsan Malik and Ali Bahson of Guy’s and St Thomas’ takes me two weeks to feel human again after a set of nights.” Hospital NHS Trust devised a mobile, tablet-based surgical training kit. The event was hosted by Labour shadow health minister Jackie Baillie Tim Robbins, Petra Vojtechova and Shirish Dubey of University MSP. She said she was concerned by the issues raised, adding: “I have Hospital Coventry and Warwick NHS Trust aimed to improve patient decided to ask for Audit Scotland to investigate the working hours of our safety during the August changeover with their “Avoiding Grey junior doctors. We need an independent investigation to allow those Wednesdays” shadowing and peer mentoring project. with concerns to come forward and speak without fear of repercussions See the full list of winners at www.tinyurl.com/cbbdj7m for their careers.” 04 FYi • Writing

O you have a –air for writing? Maybe you’re already to online courses, try out topics such as HTML and web involved in a creative writing club or have published design to learn about creating your own website. D in a journal, whether medical or extracurricular. The ability to communicate e­ectively in written form Extra earning for presentations, referral letters or other clinical Writing can be a useful way to earn money documentation is vital for junior doctors. But there are as projects tend to be short with –exible many other fun opportunities. Here are some tips to get working hours. Consider signing up started. to a freelancing site such as Guru or Elance to nd and bid for new Cultivate your creativity projects on topics from writing There are many ways to improve your writing health tips for websites to skills, from blogging to reading groups at your trivia quizzes. It’s usually free library or online. Carry a notebook to jot down although they’ll take an admin ideas, and keep one by your bedside too. fee of around 10 per cent. For Check out some of the most popular blog speedy payment, register platforms – WordPress, Tumblr or BlogSpot, your bank or Paypal details an o­shoot of Google. They allow you to at the same time. If you have design backgrounds, monitor site visitors suitable blog content, you and tag key words. For inspiration on writing can also monetise your blog by topics and to connect with others, sign up to adding adverts such as Google the Daily Post or Weekly Photo Competition AdSense via BlogSpot. Check the on WordPress. Following the blogs of webpage terms and conditions for like-minded people can be a great way to what makes a marketable blog. broaden your horizons and learn more about your chosen eld, particularly for scientic Stay ethical advances and elective destinations. This is probably the most important consideration for trainees as unprofessional conduct could lead to a complaint to the Be inspired General Medical Council. Remember that everything you write It’s often said that the best way to pick up new writing ideas may be permanently recorded, so avoid defamatory comments, is to read voraciously. While this is di®cult to maintain during plagiarism and obscure abbreviations, check spelling and grammar, nals and junior doctor years, some people enjoy reading books and respect patient condentiality at all times. Some sites will request on study breaks, while others keep you remain neutral on political and up-to-date with medical news via religious aspects, unless you are writing the web or newspapers. Test your for a particular society or group. lateral thinking skills with crosswords The GMC’s Good Medical Practice and wordsearches, and design free has more detailed guidance on this “word clouds” from sites like www. topic. One key point states: “When wordle.net. There are also some great communicating publicly, including online courses – Dundee Libraries, THE POWER speaking to or writing in the media, you for instance, o­er free access to over must maintain patient condentiality. 200 topics including proofreading and You should remember when using copyediting and technical writing. OF THE PEN social media that communications intended for friends or family may Get published become more widely available.” The Although there’s no guaranteed way Many doctors write for magazines, GMC highlights the importance of being to get published, you can achieve this books or the web – but what’s honest about your experience, without doing research (although qualications and current role, being this may not count towards UKFPO involved? FYi editor and medical writer sure to “make clear the limits of your applications). Many medical journals Dr Anne Partt-Rogers investigates knowledge and make reasonable accept book reviews, but check with checks to make sure any information the journal before reviewing as they you give is accurate.” may have a specic book in mind. If you see an interesting case on the wards then ask your senior (and secure the patient’s informed consent) Fancy a career in medical writing? if you can write it up for the education section. Your writing doesn’t have If the idea of a fast-paced environment combining word-wielding and to be medically related – you can enter a poetry or writing competition or scientic knowledge appeals to you, think about medical writing as write for your local faith group newsletter or sports club magazine. a career. This will be easier as you gain experience but you may miss the patient contact. A qualication or knowledge of business and/or Become tech-savvy journalism will help, as will a PhD or Masters. Check out the Association The world is becoming increasingly digital and it’s well-advised to move of British Pharmaceutical guidelines and International Society for with the times. Whether it’s designing a new medical app or editing an Medical Publication Professionals’ regulations, and visit the MedComms e-book, you can pick up new skills and increase your medical knowledge Networking website to sign up for careers days. at the same time. You can nd projects for e-books on freelancing Finally, get in touch with us at [email protected] if you’d like to write websites, just pick a subject that interests you. Uploading to platforms an article or media review – we’d be delighted to hear from you! such as Amazon Kindle tends to require Microsoft Word only. You can design a front cover either on the Kindle site or using Word features and convert online to jpeg on sites such as Zamzar.com. If you have access Anne Par tt-Rogers is an FY1 doctor and editor of FYi FYi 05 Research •

THE BUSINESS OF DISCOVERY Inspiration is vital in scientic discovery – but so also are rules. Medical researcher and writer Dr Allan Gaw o­ers insight into how we must channel our sense of wonder

ISCOVERY is a rather magical word, don’t may merely be a coincidence. Scientic method ‘wonder’. you think, evoking voyages on high, protects against the power of coincidence. But, RCTs are not without their problems. D uncharted seas, the delving into ancient, What if these people were receiving the same The example given above, while scientically dusty libraries and the witnessing of previously drug because they all su­ered the same sound, may present signicant ethical unseen marvels at the end of a microscope symptoms related to their cancer, a cancer they problems. If we really believe a drug might lens. had developed before they had ever been cause cancer is it right to expose people to that When it comes to scientic discovery, prescribed the drug? How can we resolve this? risk only to satisfy our curiosity? Of course not, however, there are rules. If we ignore them we We can employ a range of observational tools, but it is not our curiosity that is at stake. If the do not discover – we only think we have – for but none will be conclusive. drug has important clinical e­ects that could science is about revealing truth through a The denitive way to test the hypothesis – benet many patients, we must be sure when process that does its best to ensure we don’t that the drug causes cancer – is to conduct a using it that we are not unwittingly causing delude ourselves. Rather like the archaeologist randomised controlled trial, or RCT. Here, a more harm than good. The only way we can we have evolved a simple set of tools to scrape and brush away the layers of confusion in order to reveal the answer, and our most important tool is the concept of “control”. “ If we are to discover the truth of cause and So often we read headlines about how a drug has caused a cancer. These stories are e ect we must nd a new way of thinking” convincing because they appeal to our basic human need to nd a link between cause and e­ect. Something happens and then group of people are randomly assigned to prescribe with condence is if we have the something else happens, so the rst event receive the drug or a matching placebo. By data to back it up, and the highest quality data must have caused the second. If our primitive concealing from both participants and will be derived from a well conducted RCT. ancestors forgot to pray to their gods and their researchers the treatment allocations, we Discovery is wonderful, but it is also di®cult. child died, it was obvious what had happened. perform a so-called “double-blind” study and Those who wonder need to be taught how to We like to think we are more sophisticated, but eliminate as much bias as possible. We will then channel that sense: they need to learn how to in truth we still have cavemen’s brains and are follow the participants, checking them for signs ask the right questions, how to design still dangerously vulnerable to the fallacy of of cancer. If our study is large enough and long strategies to answer those questions, how to post hoc ergo propter hoc – after it, therefore enough we will be able to compare the two conduct studies with rigour, and within the law, because of it. If we are to discover the truth of groups. Only if the number of cancers in the and how to tell the world of their discovery. A cause and e­ect – i.e. did the drug really cause drug group is signicantly higher can we cycle of discovery that begins with a thought, a the cancer? – we must resist this way of condently conclude the drug has a causal role question, a moment of wonder should end thinking and nd a new and perhaps less in the cancer’s development. with a revelation that we can all share. For intuitive approach. An example may help. This methodology is regarded by many as discovery belongs to us all – it has allowed us to If 10 people have developed a rare form of one of the most important advances in feed our hungry, light our cities, cure our cancer we look for reasons. We rst look for medicine in the 20th century. Without RCTs we diseases, and it has allowed us to walk from our characteristics they share: where do they live, are operating in the half-light, with only caves and step on the Moon. what do they eat, what drugs do they take? observational studies and anecdote to guide The rst piece of common ground we discover us. The scientic rigour applied within the RCT Dr Allan Gaw is a clinical researcher and may be the cause but, equally, it may not; it allows us to ‘know’ where before we could only writer in Glasgow 06 FYi • Risk

“HUMAN FACTORS” AND MEDICAL ERROR

Medicine has learned much from other high-risk industries such as aviation and o­ -shore drilling. Dr Michael Moneypenny explains how the study of “human factors” can enhance patient safety

GREAT teacher of mine, Dr David Gray, once told me “de ne or die”. What Internal modi ers External modi ers then are “human factors”? There are A Emotional state Design of equipment numerous de nitions out there, some simpler than others. Concentration on task Support from senior The UK’s Clinical Human Factors Group Expertise with task Training (CHFG) describes it as: “Enhancing clinical performance through an understanding of the Ability to communicate Rota intensity e­ ects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that minimise (never “eliminate”) human errors making is one useful way to start “error- knowledge in clinical settings.” as well as minimising their e­ ects. One may proo ng” your work. This doesn’t lend itself to being easily wish to divide the modi ers into internal and As trainee doctors, you might also  nd memorised, so if we apply the KIS (keep it external. (See the table above). yourself trying to remember 10 di­ erent things simple) principle then the term “human factors” An appreciation of human factors can help us to do – again increasing the likelihood of may be de ned as: understand what internal and external modi ers mistakes. The human brain can only have are a­ ecting our abilities. It may also allow us to seven or eight things at its forefront at any one 1. All the things that a­ ect human see which modi ers are potential causes for time, so consider drawing up a checklist to give performance mistakes and allow us to redress these. yourself a visual reminder. 2. The  eld of study of all the things that There are many more tips and techniques a­ ect human performance. The value of simulation available and applying these human factors Attending courses at a simulation centre concepts in your practice will make you a better Performance modi ers may help you identify internal modi ers doctor. Whenever you are carrying out a task there contributing to your mistakes. Video-assisted will be internal and external modi ers of your debrie ng allows you to re– ect on your performance. As I sit here writing this article performance. With the help of a facilitator Recommended watching: these include: the uncomfortable wooden chair and your peers, you may learn where your CHFG video, Just a routine operation - www. I’m sitting on, the distractions through the strengths and weaknesses are. In situ tinyurl.com/fyichfg window, the copy deadline and lack of sleep. simulation involves using the mannequins in They might also include: the type of computer the workplace; this is where external modi ers BBC Horizon programme: How to Avoid and word processing software I’m using and may be discovered such as lack of equipment, Mistakes in Surgery (available on YouTube) that I’ve had breakfast and two cups of tea. lack of support, organisational blind spots, etc. If you think back to your last insertion of an intravenous cannula you may be able to Getting started Recommended reading: identify the human factors which a­ ected your You can start applying the lessons of human • Sidney Dekker, The Field Guide to performance such as tiredness, number of jobs factors research today. An important  rst step Understanding Human Error still to do, audience (including the patient), is accepting that we are all human and will number of attempts already made, familiarity inevitably make mistakes no matter what stage • Rhona Flin et al, Safety at the sharp end with the technique, lighting, and so on. Until we are at in our careers. recently, in medicine anyway, the idea that your Ask yourself: where are your strengths and • Atul Gawande’s books: Complications, performance is a­ ected by these modi ers was weaknesses (and how might you  nd out Better and The Checklist Manifesto neither much appreciated nor understood. about them)? What can you do to address The  rst change which occurred was an these? What are the things in your workplace • Alissa Russ et al. “The science of human appreciation that medicine is a high-risk industry; which may lead to human error? Who can you factors: separating fact from  ction” in BMJ in the UK thousands of patients are killed or talk to in order to remove or minimise these Quality & Safety - harmed every year due to mistakes made by risks? Human factors provides us with the www.tinyurl.com/ndk4mcz healthcare professionals. Once this had been vocabulary to talk about what is going wrong acknowledged, the lessons learned and and the tools to mitigate this. • Charles Vincent, Patient Safety vocabulary from other high-risk industries, such Self-awareness in your day-to-day work will as aviation, o­ -shore drilling and nuclear power, help you admit when you are tired, stressed or were adapted and translated into healthcare. distracted. These human factors increase the Dr Michael Moneypenny is a consultant risk of making a mistake, and are particularly anaesthetist and expert in the eld of Analysing factors relevant in situations where you are required to human factors in healthcare. He is also How then can “human factors” help us avoid make complex calculations in drug dosages or director of the Scottish Clinical Simulation medical error? Through the study of what equipment settings. Centre a­ ects human performance we can try to Taking time to double-check your decision- FYi 07 Analysis • SURVIVING THE WEEKEND research studies suggested that hospital service could be implemented even in today’s Research suggests weekend death rates rise at the start of August, with tough economic climate. surgical patients are more likely one study saying rates go up by as much as Of those who opposed a 24/7 service, most to die, so is it time hospitals eight per cent. were worried about the cost while some were Last summer NHS medical director Sir concerned that spreading the workload might switched to 24/7 care? Bruce Keogh admitted publicly for the  rst mean fewer sta­ would be available at any time that the “killing season” does in fact exist one time. DENTIFYING trends within patient death and that measures were being put in place to Primary care has also taken centre stage in rates has long been a preoccupation of address the problem. the debate as the government has proposed Iresearchers. The European Working Time Directive returning the responsibility for out of hours The latest study, published in the BMJ, (EWTD) has also caused controversy since its care to GPs. The Urgent and Emergency Care suggests patients who undergo surgery introduction in 2009. Designed to end the Review by Sir Bruce Keogh, published in June, towards the end of the week are more likely to practice of excessive working hours, it limited calls for a better co-ordinated urgent care die than those earlier in the week. doctors’ average working week to 48 hours. system. His vision includes “decision support Researchers from Imperial College London However this had the knock-on e­ ect of from a patient’s own GP practice and hospital looked at all non-emergency surgery restricting training time and impacting on specialist nurse/team seven days a week”. Sir Bruce has said a forum has now been established to “develop viable  nancial and clinical options to help our NHS provide more “ Patients were 44 comprehensive services seven days a week.” per cent more likely Some hospital units are already ahead of the argument and are to die if undergoing delivering 24/7 care. The issue has been a hot topic within the Royal College of Paediatrics and surgery on a Friday Child Health for the past three or four years. than a Monday” The Royal Free London Foundation NHS Trust has been providing consultant delivered care since 2007, where undertaken by the NHS in England in 2008 to continuity of care due to increased sta­ consultants, rather than junior doctors, 2011. Among the four million operations, they handovers. provide the bulk of clinical frontline care. noted more than 27,500 deaths in the 30 days A survey by the Royal College of Surgeons Writing for the BMJ in June 2013, consultant following surgery, making the average risk of in 2010 found that 80 per cent of consultant paediatrician Dr Susie Gabbie describes how death 0.67 per cent. surgeons and 66 per cent of surgical trainees this is achieved through a variety of di­ erent Concerns were raised about the signi cant said patients were less safe because of the shifts. She says 12 hour day and night shifts variation over the week, with the lowest risk directive. cover the emergency department from 9am to attached to surgery performed on a Monday. In Add to this the statement in March 2013 by 9pm, while separate consultants cover contrast, patients whose operations were the head of the Care Quality Commission (CQC) inpatient wards and clinics. Duty consultants carried out on a Friday were 44 per cent more David Prior who warned of a crisis in urgent are closely involved with all patients through likely to die than on a Monday. Those care. He said: “If we don’t start closing acute direct supervision of junior doctors and undergoing surgery on a weekend were 82 per beds, the system is going to fall over. hands-on care. cent more likely to die than on a Monday, Emergency admissions through accident and She highlights several advantages: although the relative number of weekend emergency are out of control in large parts of “Patients receive direct consultant input at all operations was low. These  gures include the country … That is totally unsustainable.” times. Care is not reduced at weekends or out deaths both during the patient’s hospital stay This prompted renewed calls for the NHS of hours. No child is more than four hours from and after discharge. to consider 24/7 healthcare provision, where consultant review, and in reality most patients The researchers said the  ndings could be hospitals would be expected to o­ er the same are seen much more promptly, complying fully linked to various factors, including a poorer level of service around the clock, rather than with royal college standards…Trainees are also quality of care at the weekend, or that reducing cover at weekends. under close consultant supervision at all patients admitted or operated on at the This has been a recurring topic in times.” weekend are more severely ill than those healthcare debate in recent years. A poll of She also believes the unit is “more or less admitted during the week. more than 1,000 GPs and secondary care cost neutral” thanks to various factors This is not the  rst time research has doctors conducted by doctors.net.uk in March including performing fewer investigations and highlighted trends among death rates. 2012 found 59 per cent agreed hospitals admitting fewer children. For years, the August change-over – when should operate on a 24/7 rolling weekly While it seems 24/7 care is possible, it trainee doctors start their new jobs – has been schedule. Respondents suggested that if the remains to be seen exactly how plans will referred to by a variety of alarming names, current workload was spread equally over progress in our rapidly changing NHS. among them the “killing season” and “black seven days and the premium salary for Wednesday”. These tags emerged as various weekend working were scrapped, a seven day Joanne Curran is an associate editor of FYi 08 FYi • Career

THIRST KNOWLEDGEFOR Foundation doctors following an AFP have An academic career is perfect for doctors with plenty dedicated time set aside for academic of courage, curiosity and determination activities, the nature of which will depend on the AFP itself. AFPs vary signi cantly between foundation schools. Most of the dedicated USHING the boundaries of knowledge foundation doctors the chance to develop skills academic time will be during the second year of and seeking answers to important in research, teaching and leadership/ foundation training (F2), but some P questions are all in a day’s work for management in addition to the basic programmes arrange additional activities a clinical academic. This varied  eld o­ ers competences outlined in the curriculum. during F1. Trainees may have a four-month endless opportunities for those interested in While this is a very useful programme, it is academic placement in F2, day-release research, teaching and management. not the only way of entering the  eld. There throughout the year, or a combination of the Whether you have ambitions to be the next will be other opportunities during your career two. chief medical o® cer, enjoy spending hours in a to develop academic skills and an AFP is not a The UKFPO strongly advises applicants to laboratory or have a burning desire to take part pre-requisite for securing a research fellowship research the AFPs on o­ er and apply for those in research projects that have the potential to or other academic post. that best suit your interests. Most foundation change the way disease is diagnosed and The UK Foundation Programme O® ce’s doctors organise a project for their academic treated, then a career in academic medicine (UKFPO) Rough Guide to the Academic placement which forms the main focus of the could be for you. Foundation Programme o­ ers a very useful AFP. The options are varied. Some doctors Academic work is usually undertaken in overview. It says there are currently around choose a lab-based project leading to a addition to work in clinical practice, o­ ering the 450 AFPs available each year across the UK, scienti c publication while others might opt for chance for “the best of both worlds”. accounting for just over  ve per cent of UK a clinical quality improvement project with the foundation programme places. There is great aim of improving patient care. Entry and training variety between AFPs, with some focusing on The UKFPO highlights a number of desirable The route into an academic career involves traditional academic pathways such as qualities in trainees seeking an academic career. considerable commitment and will require more research and teaching, while others focus on Candidates must be able to demonstrate that skills than an intercalated BSc can provide. This areas like leadership and management, quality they understand what the career involves and be will likely mean undertaking a higher research improvement and even health informatics. All competitive and successful with “something on degree (MD/PhD) alongside your clinical programmes have the same common purpose; their CV that stands out” such as distinctions, training. they enable foundation doctors to develop prizes etc. You must demonstrate an interest in One popular postgraduate route is via their clinical skills whilst simultaneously your chosen specialty, have a passion for the AFP Academic Foundation Programmes (AFPs) supporting the development of key skills in programme and good clinical abilities as AFP which operate across the UK. These give other areas of medicine. trainees are expected to gain all of the foundation www.mddus.com

Q&A Dr Thomas Kelley Project leader with the International Consortium for Health Outcomes Measurement, Boston MA; UKFPO academic adviser.

What is attractive about a career in academic medicine? Academic medicine is broad, from cellular research to clinical trials to working at the level of the health system. It gives you the opportunity to think about some of the greatest challenges that we face from managing dementia to developing new models of healthcare delivery. Naturally this is challenging and immensely stimulating. You get to be innovative and creative and dene where you’re going to focus, how you’re going to investigate a particular problem and once investigated, how this will be translated into a solution. This has the potential to have an enormous, positive societal impact. You get to meet interesting, brilliant people who challenge your programme outcomes in reduced time. university contracts, with terms and conditions thinking. You get to talk about your work, More advice can be sought from your that may di­er from those o­ered by the NHS to debate with people, to convince dedicated academic supervisor who will junior doctor contract. people that what you’re doing makes oversee academic work and provide feedback. Again, it is important to note that neither sense. Ultimately, it is the challenge, the intellectual stimulation and the potential the ACF nor SCREDS are the sole, or even impact that I nd most attractive. Specialist training predominant, ways of obtaining experience and On completion of academic foundation training, training in academic medicine. Look for What challenges do academic there are many available options which di­er opportunities in your area by contacting your clinicians face? across the UK. For trainees in England, the local research and development o®ce or The intellectual challenge, as described above. However, this is positive. The next step is usually to enter an academic consider organising your own research project negative challenge is that you have to clinical fellowship (ACF) for up to three years while completing clinical training. University decide where to focus. You cannot be with entry at ST/CT1-4. This is followed by up websites will also have details of funded brilliant at everything. Do you continue to four years in a clinical lectureship position research posts while organisations such as the with clinical medicine or not, for (entry at ST3 or above), before achieving the Wellcome Trust o­er research funding. example? There can also be challenges with getting academic posts as they are Certicate of Completion of Training (CCT). very competitive. These schemes are co-ordinated by the Moving forward National Institute of Health Research (NIHR), The opportunities for working within academic What do you consider the most important but many UK charities and funding bodies also medicine are varied. Doctors may choose to personal characteristic in a good provide additional personal fellowship take up a post as a senior lecturer, consultant/ academic physician? schemes. Support for clinical academics is honorary senior lecturer or pursue a senior Resilience. Whether this means bouncing back from not getting the academic available from professional bodies including the clinical fellowship. Notable clinical academics position you wanted or not getting the Royal Colleges. include chief medical o®cer Professor Dame results you wanted/hoped for in an Scotland opted not to follow the ACF Sally Davies, and the immediate past director of investigation. scheme and set up its own system, the Scottish the Wellcome Trust (and current Chief Scientic Clinical Research Excellence Development Adviser) Professor Sir Mark Walport with What is your most memorable experience so far? Scheme (SCREDS). The entry point is from ST1/ many more in the elds of medical education Getting the job that I always wanted and CT1 and can last up to the entire duration of and scientic research. Many agree these are then really struggling to get the US work specialty training. Posts are funded by NHS exciting times for clinical academics with great visa to turn the dream into a reality. Education for Scotland and Scottish –exibility in choosing which path to follow. universities. They typically average around 80 Is there any advice you could give to a nal year or FY trainee considering per cent clinical time and 20 per cent academic Joanne Curran is an associate editor of FYi academic medicine? time, with –exibility according to your career Don’t think of academic medicine as only stage. More information is available on the NES Sources: lab based or clinical research churning website at www.tinyurl.com/pdn4smd • Rough Guide to the Academic Foundation out papers. It is broader than that. I am, The BMA website provides a useful Programme, March 2013, UK Foundation for example, about to start working at a healthcare institute set up by Harvard overview (link below) which explains that there Programme O®ce - www.tinyurl.com/lclp5ft (ichom.org), where we work with are “di­erent opportunities available at the healthcare organisations around the various levels of seniority, and the nature of • BMA – Academic training in Scotland at world to develop outcome measures for academia means that careers may not follow www.tinyurl.com/op5gyqv disease management. I think this has the an established or set pathway.” It also potential to really improve the quality of highlights that, unlike in England, all medical • Medical Careers - www.tinyurl.com/ patient care. academic training posts at specialty level are ohmjylo 10 FYi • C ommunication SENDING THE RIGHT M E E S S A G

How doctors communicate with their patients is a common cause of complaints. Experts from the Maguire Communication Skills Training Unit o­ er some practical tips and advice

ATIENTS want to be treated by skilled and knowledgeable clinicians but this by itself is not su® cient. Patients also want to be treated with Structure of an assessment humanity, dignity and respect; they want to be fully interview (Maguire model) informed, supported and listened to so that they can make meaningful and informed choices about their care. Introductions In 2012 the General Medical Council report, The State of Names and role P Reason for the consultation Medical Education, revealed there were proportionally more Time boundary complaints about doctors than any other healthcare professional. Two of the top three complaints involved communication: Gathering information ine­ ective communication (including failure to respond to Background information concerns, provide appropriate information and listen) and lack of History of the illness including patient’s perspective and concerns respect (including rudeness, failure to respect the patient’s dignity Assessing current situation and work in partnership). Current concerns What steps can we take to deliver best practice? Impact on life Coping responses Structuring the conversation View of the future Evidence suggests that one of the simplest things we can do is to structure our consultations. The aim is to gather all information Information giving and plan of action Tailor information and concerns, from the patient’s perspective, before we give any Share decision making information. This aids the disclosure of concerns. As soon as we Negotiate plan of action provide any information and advice to patients, patient disclosure is reduced and we hear fewer concerns. The Calgary-Cambridge Closing consultation model is useful, as is the Maguire model (see box, Summarise Screen for further questions or concerns right). Both allow the doctor to direct and optimise the – ow of Check how patient is left feeling information between patient and doctor.

Working with cues To optimise either model of assessment, it is essential to be cue- focussed, as behind each cue may be a concern which needs to be Patients tend not to immediately and clearly disclose all their identi ed. concerns even if we ask them to, instead they hint at worries and concerns to determine if the healthcare professional is interested. De nition of a Patient Cue An important skill is therefore the ability to recognise and A hint or clear expression of a negative emotion (verbal, respond appropriately to patient cues. At each step in the model vocal or non-verbal) which would need exploring to check the doctor needs to recognise the patient’s cues and link their for the presence of an underlying concern response to the cue. Communicating in this way about the issues www.mddus.com

that matter to the patient, detected via the cues (whether they information is given. Being empathic throughout is crucial. are worries the patient came with or worries resulting from new information given), allows the concerns and needs of the patient Handling di cult questions to be identied and addressed appropriately. Di®cult questions or demands are often best treated as cues. Answering di®cult questions may lead to breaking bad news or Which cues? giving uncertain information. Typical questions can be “How long Gathering information do I have?” “I am going to die, aren’t I?” Is it bad?” The key principle It isn’t always feasible or practical to explore every cue but it is is to rst acknowledge the importance of the question, then important to work with key cues that help to elicit the patient’s explore the question before giving information that addresses it thoughts, feelings and concerns. (“explore before explain”). By exploring the question, the patient’s There is evidence that the acknowledgement and exploration perceptions and concerns can be identied which will allow the of the rst patient cue (verbal or non-verbal) is crucial because question to be answered appropriately. there is a 20 per cent decrease in cues provided by the patient if the rst cue is not acknowledged or explored. Subsequent cues to Breaking bad news work with are the strongest ones (which healthcare professionals Bad news needs to be given in a way that allows the person to tend to avoid). If in doubt, summarise the cues and ask the patient understand and manage what is being said to them and in a to prioritise. Working with the strongest cues and rst cue (verbal way that allows them to express their fears and concerns before or non-verbal) will optimise disclosure of concerns. any information and advice is given. This means it needs to be delivered slowly in small chunks and with compassion. The Giving information doctor also needs to actively elicit the patient’s new concerns Working with cues is also important when giving information and and feelings (being guided by the patient’s cues) before moving negotiating decisions with the patient. Acknowledgement of a into information giving and discussing and negotiating treatment patient’s cues increases the amount of information the patient is options. able to recall and increases their ability to make decisions. Cues are a useful way of gauging patients’ reactions to what Improving skills we say. These cues might include nods which may suggest Learning to communicate e­ectively through experience alone agreement or understanding, but could also include frowns, has been shown to be ine­ective when compared to other agitations, blank expressions or reduced eye contact, all of which methods. Although a sound knowledge base and observation of may imply confusion or distress with what is being said, or good practice may facilitate change, experiential workshops which disagreement with a decision. give participants a chance to practice, will optimise and maximise the ability to acquire, hone and maintain new skills. Key communication skills To be sure of their meaning, cues need to be acknowledged, Summary claried and explored (ACE) using the skills below. A patient-centred approach using a structure for the consultation Using skills in context, i.e. to acknowledge and explore cues, (“gather before give”), and facilitative skills linked to cues will: signicantly increases the disclosure of signicant information optimise disclosure of patient concerns, allow patient preferences from the patient and is key to a patient-centred approach. to be heard, increase the likelihood of the patient understanding and recalling information, and participating in treatment decisions. A patient-centred approach is the key to best practice. It will Skills to Skills to clarify increase the likelihood of the patient feeling satised with their acknowledge and explore care and feeling they have been treated as an individual with their • Reflection • Open focused wishes respected. It will also allow doctors to deliver tailored care • Paraphrase questions with less risk of non-concordance with treatment. • Summary • Educated guesses Summary of useful patient centred skills • Actively elicit patient’s perspective and all concerns (gather Showing empathy and being supportive information) Being empathic helps the patient to feel understood and cared • Verbally acknowledge concerns by summarising and for, and acknowledging emotions (cues) signicantly increases empathising information recall and enables the patient to process decisions • Obtain permission to give information more clearly. • Pause frequently when giving information • Obtain permission to give further information Empathic statements: examples • Check for new concerns and acknowledge • I can see how upset you are. • Negotiate a plan • You sound upset, am I right? • Empathise throughout • It sounds overwhelming. • You say you are coping but I am getting the sense that you are nding it really hard. (Pause) Further reading Assessing Patients with Cancer: the content, skills and process of assessment, Cancer Research UK Publication: (2nd ed 2008) Dicult situations [email protected] Managing di®cult communication situations normally refers to handling strong and di®cult emotions exhibited by the patient Silverman J., Kurtz S., Draper J. (2008) Skills for communicating or relative but it can also mean being asked di®cult questions, with patients (2nd edition), Radcli­e publishing: Oxford or when patients or relatives make inappropriate demands. In all these situations the key is to work with the cues. Strong emotions Dr Claire Green, Nicky Scho eld and Alison Fellows are need to be acknowledged, not ignored or minimised, and the trainers with the Maguire Communications Skills Unit, The concerns driving the emotion elicited and explored before any Christie School of Oncology, Manchester 12 FYi • Prole

IN THE LINE OF FIRE Doctors with Médecins Sans Frontières risk their lives to provide care in the most extreme settings. Adam Campbell nds out more about this remarkable organisation

F HOLLYWOOD were to make a lm about Republic of Congo last year. In both cases, Tomas and then again in preparation for the humanitarian aid doctors, there would be events took a turn for the unexpected. anticipated electoral chaos. guns, lots of them, and plenty of blood too, “Haiti was meant to be a fairly simple, stable “It was a di®cult time – a lot of the no doubt. There would be border-crossings rst mission,” she says, “but it turned out to be surrounding NGOs were pulling out because of at night with a local guide, life-saving quite complex, because this was just before the deteriorating security situation, so people operations in a dusty cave lacking in the cholera hit, before the elections in December started coming to us.” Imost basic resources, and a rock-hard –oor on and we were also preparing for the coming In the Congo, Angeline was in charge of an which to steal a few hours’ sleep. Meanwhile, hurricane.” outreach project supporting two clinics in the helicopters would rain down rockets and bombs Her regular duties involved delivering care mountains near Kitchanga. Based just 50 km onto the surrounding area, the explosions from a bus-cum-clinic in a camp controlled by away, her weekly three-day visits would punctuating conversations among the medical gangsters and also working in a clinic set up on nevertheless involve a six-hour road trip taking sta­. a golf course owned by the actor Sean Penn medical supplies and a small supervisory team And despite Hollywood’s reputation for to the clinics. hyperbole, this would not be an exaggeration. She had got used to dealing with the Indeed, this is exactly what has been associated security issues – “I had never spoken happening in the recent con–ict in Syria, where to anyone holding a gun before” – when the surgeons from the humanitarian charity con–ict suddenly escalated, and the Médecins Sans Frontières (MSF) have been subsequent displacement of people raised the working under the most extreme conditions to medical stakes further. treat the horrendous casualties of a modern “In one of the areas there was a refugee war. camp of about 20,000 people, so we had to set But there are other types of care going on up a cholera treatment unit. There were cases too – perhaps less dramatic, certainly no less of measles as well. I had never even been part important – in this organisation of 25,000 of a measles vaccination campaign and people providing emergency aid to the needy suddenly here I was in charge of one! It was and dispossessed around the world, including really intimidating.” eight million outpatient consultations and over 70,000 surgical procedures a year. And whatever the circumstances, be it a con–ict “ It was meant to be a simple rst mission - situation, a cholera epidemic or a devastating earthquake, the requirements for medical sta­ but then a cholera epidemic hit and we had are usually the same: medical know-how, of course, but also an ability to keep a cool head to prepare for a hurricane.” when all around are losing theirs and the best-laid plans are going wildly o­-course. (later, she would move to a primary care clinic Political resistance Facing danger attached to the paediatric hospital). But events By contrast, the intimidation encountered by Dr Angeline Wee, a GP from Singapore, has meant she was suddenly involved in setting up Dr Johann McGavin, who is now a trainee GP done two missions with MSF, one of seven a new cholera treatment centre in Port-au- in Brighton, during his nine-month mission months to post-earthquake Haiti and one of Prince, as well as a number of 24-hour to Zimbabwe was of a di­erent nature nine months to the con–ict-torn Democratic emergency centres, rst ahead of Hurricane altogether. There, he was working mainly to www.mddus.com

provide HIV and TB care to a group of 25,000 Clockwise from left: Dr Johann McGavin treats a a really, really hard time,” says Liz, who has patients who had been displaced through a patient in an MSF clinic in Zimbabwe; Dr Angeline done missions as a nurse in Sri Lanka and Sierra deliberate government policy called ‘Operation Wee at an MSF outpatient clinic in Haiti; and Dr Wee Leone. with outreach worker Gilbert at a refugee camp in Murambatsvina’. the Congo A diploma in tropical diseases is a Meaning ‘Clean out the Trash’, the policy prerequisite, languages – particularly French had displaced 250,000 people from Harare to and Arabic – are a denite advantage, and MSF an area with no water, no electricity, a very low pragmatism; and expectation management. “I prefers international sta­ who can commit to employment rate, little food and shelter, and a think the most important one was expectation 9–12 months per mission. lot of crime and sexual violence. management, which was the cure for Planning is essential, then. As Angeline Wee The Zimbabwean government was not frustration, disappointment and burnout,” says says: “It cannot be an impulsive decision. All in particularly keen on the presence of NGOs. “It Johann. all, I had been planning this for nine years. You was like walking through treacle,” says Johann, Johann underwent this rst mission at the really need to know what you’re getting into who, unusually for an MSF volunteer, was age of 28, after his foundation training, which and pick up the necessary skills. From what I working with his ancée. “We had a lot of is the earliest possible with MSF, whereas have seen, people who are more experienced challenges with the local hospital because we Angeline, who went to Haiti at 31, was further and with management skills tend to do better. were made to do a three-month introductory along in her career, already working as a GP It’s not easy for someone coming out of medical period under supervision and that included a after switching from respiratory medicine. school – you really need a steady head.” lot of paperwork and obstruction. It was And then there’s the question of security. challenging in a rather insidious, undermining, Careful planning Volunteers may not all be –ying into a war quiet way, not like in other countries.” Despite the di­erences in their experience, zone, but a mature attitude to risk is Upon arrival they had been briefed to be both discovered that a lot of the work required indispensable, says Liz Bowen. very careful about what they said. “I felt very from the 4,000 MSF international volunteers, “We want people who are considered and oppressed being there, not being able to really who are sent in to support 20,000 locally thoughtful. What experiences have they had of vent, to my partner at any volume, to my employed nationals, is supervisory. being in an insecure situation and how did they friends, certainly not to any Zimbabweans and It is something that Liz Bowen – an MSF manage it? And what is their thought about not even over the phone to my parents in human resources manager in charge of eld where they’re going? Obviously the media England, in case that was being listened in on.” sta®ng – is keen to emphasise. “It’s important portrays a certain angle, but often it’s not that The experience brought him very low and to understand there is a strong supervisory and exciting at all. But they are unstable contexts, he even considered giving up. “But then you training element,” she says. “It’s not that you so they might change. If we get people who say remembered that if you gave up because of won’t do any hands-on work – sometimes you I only want to go and work somewhere stable frustration with the government, it was the have to, because there aren’t any other sta­ then we wouldn’t accept them.” poor people who were going to su­er.” there – but you’ll always be managing some The reverse is also unacceptable – and here Johann developed a survival toolkit to help sta­ and they deserve to have somebody who the Hollywood version might well diverge from him get through the di®culties with the has an idea about managing groups.” the reality: “You don’t want somebody who’s authorities and those arising from treating a Typically, among refugees, those most at completely gung-ho, thinking ‘Oh I don’t mind steady and insistent stream of 500 adult and risk are children and young people, closely about danger.’ We would reject a person like paediatric HIV patients a day between one followed by pregnant women. For this reason, that immediately.” doctor and 14 other clinicians in a hugely says Liz, young doctors looking to get into this under-resourced facility. kind of work should get as much exposure as Adam Campbell is a freelance journalist Called HOPE, it stood for humility and they can to paediatrics, obstetrics and and regular contributor to MDDUS humour; open-mindedness; patience and gynaecology. “Pregnant women refugees have publications 14 FYi • Case study A SORE LEG

Day 1 Mary attends her local GP surgery complaining of pain in her Sonicaid detects a faint signal from the posterior tibial legs. She is a 48-year-old mother of two children, obese arteries in both legs. He also measures the ABPI (ankle/ and a heavy smoker with a history of excessive alcohol use. brachial pressure index) and con rms a reading of 1.0 – i.e. Mary is seen by Dr G who records a history of pain in no obvious circulatory impairment. Mary’s blood pressure is both legs over a period of three weeks made worse during 180/120. walking and relieved with rest. The pain is worse in the left Dr G records a preliminary diagnosis of peripheral leg with “tingling pins and needles”. Mary has also noticed vascular disease (PVD), given Mary’s history of pain on some swelling in the left leg but says this is improving. exertion and the absent peripheral pulses. The doctor Dr G examines the legs and  nds some soft oedema in prescribes nifedipine for the high blood pressure and PVD the lower left leg but no other abnormality. There is no calf and later refers her to a local consultant cardiovascular tenderness and Homan’s sign (to detect DVT) is negative. physician. Blood tests taken at the consultation show signs Arterial pulses are not palpable on the feet but use of a of impaired liver function consistent with alcohol excess.

Day 7 Day 12 The surgery receives a call from Mary’s husband requesting a home visit. Mary attends the surgery for an A locum – Dr K – attends the patient who is complaining of a painful emergency appointment and is purulent cough, and chest and shoulder pain associated with breathing. seen this time by Dr G. She is still She has a fever and auscultation reveals suspected pleurisy. Dr K notes su­ ering from cough with blood- Mary’s history of left lower leg pain and swelling. He makes a diagnosis stained sputum. Dr G  nds that her of respiratory infection but also records: “? PE/DVT”. breath sounds are normal though Mary is prescribed amoxicillin and is advised to contact the surgery if she claims her chest is still very there is no improvement over the next two days – at which time Dr K will sore. Dr G tells her to keep taking arrange for an ECG and VQ scan (to rule out pulmonary embolism). the antibiotics and come in again if the infection is not settling.

OUR months later the surgery receives a letter from solicitors F acting for Mary’s family alleging clinical negligence in her care against Day 19 both Dr G and Dr K. MDDUS, acting for Dr Just before bedtime Mary K, commissions medical reports on the collapses at home. Her husband case from both a primary care expert and calls 999 but the ambulance team a consultant vascular surgeon. is unable to resuscitate her and The primary care expert  nds Dr G at she is pronounced dead at 2310 fault for not considering more seriously hours. A post mortem determines the possibility of DVT at the initial the cause of death as pulmonary consultation. The use of Homan’s sign is embolism consequent with deep criticised as it has fallen out of favour in vein thrombosis. The pathologist ruling out DVT. A call to a local vascular also reports swelling of the left surgeon would have con rmed PVD was leg. unlikely in light of a normal ABPI and that referral to an outpatient clinic would have been appropriate to assess the

cause of the presenting complaint. PHOTO: ZEPHYR/SCIENCE PHOTO LIBRARY Another opportunity was missed when Dr K attended the patient at home. Dr K to hospital for a VQ scan.The consultant’s Key points had considered the possibility of pulmonary opinion was that had Mary been referred • Always weigh up potential risks/ embolism but adopted a wait-and-see earlier and treated with controlled outcomes involved in not referring a approach which was unduly risky given the anti-coagulation therapy this may have patient. possible outcome. A third chance to act prevented extension of the pulmonary was missed when Mary again attended embolus and subsequent death. • Do not ignore inconvenient signs that Dr G at the surgery with blood-stained MDDUS advisers and lawyers discuss may counter an “obvious” diagnosis. sputum and continuing chest pain, but the options with Dr K and decide the best decision was made to persist with antibiotic course of action is to settle the claim out • Maintain a high index of suspicion in treatment although there was su® cient of court with costs shared with Dr G’s respiratory symptoms combined with clinical uncertainty to warrant admission medical defence organisation. leg pain. notion that humanlife persistsonlywithina popular science. Inthe text he expands onthe which falls unashamedlyinto thecategory of of London. Environment Medicineat University College of theCentre for Aviation Space andExtreme and expert inspace medicine,beingco-director But heisalsoadoctor, lecturer inphysiology one-o­ documentaries andHorizon episodes. presenter of Extreme A&Eandoccasional KEVIN Fong is bestknown from TVasthe MDDUS Review by JimKillgore, publications editor, paperback (dueout 24October 2013) Hodder &Stoughton: £20hardback; £8.99 the Limits of the Human Body Extremes –Life, Death and Book Review: www.mddus.com Source: @qikipedia prosthesis was carriedoutintheUS1962. rst successful enlargement usingasilicone breast wool andpara‘n, often withdisastrous results. The tried makingbreast implants outof honey, glass,ivory, called for clearer calorielabellingonmenus. than at other outlets. Harvard University researchers have Diners at Subway were more likely to underestimate calories with underestimates getting worse asportionsincrease. content of theirmealsby anaverage of 200calories, words. who clenchedast were better ableto recall alistof Montclair State University researchers found those the opposite sideof your bodyabout90seconds later. Clenching onehandincreases activityinthebrain on those thoughts that are onthetipof your tongue. the a¶icted. the word written onanamulet that was to beworn by Serenus Sammonicus,doctor to theRoman emperor, had by a2ndcentury doctor whowas tryingto treat malaria. BOTCHED BEAUTY FAT FOOD BRAIN BOOST MAGIC CURE OUT THERE Extremes, hisshortbutengagingnew book And itthiscore interest that isthesubject Albert Brooks; 1997 Spader, Kyra Sedgwick,HelenMirren, Directed by Sidney Lumet, starringJames Pick: Fast food dinersunderestimate thecalorie Source: omg-facts.com The rst known useof “abracadabra” was

Makingast could helpyou remember DVD -CriticalCare Early20thcentury surgeons have the numerous talesof survival (ornot) at simplicity butwhat brings thetext to life are are explained withelegant lecturer asphysiological concepts serious illness. and incatastrophic trauma and and cold andpressure, inlow gravity body responds at extremes of heat He thenexplores how thehuman to histraining asananaesthetist. space medicineat NASA, inaddition school andlater asaresearcher in career – astrophysics thenmedical subject by rst tracing hisown interest. boundaries that excites Fong’s ability to cope. Itislife at these envelope andourphysiology rapidly losesthe composition, gravity. Stray outsidethat – temperature, pressure, atmospheric narrow envelope of environmental conditions medical greed, incompetence andamorality. (Brooks) isthepersonication of modern relevant. Smug,whisky-swillingDrButz patient care, thisbitingcomedy remains increasingly prominent factors inNHS At atimewhencost cutsandprot are of their terminally illandcomatose father. and hisght withtwo halfsisters over the care it follows resident DrWerner Ernst(Spader) system. Basedonthenovel by Richard Dooling, the heartof thissatire ontheUShealthcare END-OF-LIFE care isoneof themany issuesat No doubt Fong isatalented In Extremes hedevelops the WHAT AREWELOOKING AT? Stumped? Theanswer isat thebottom of thepage a litany of money-motivated attacks. learns to defend hishelplesspatient against cynical andunlikeable astherest buteventually The womanising Ernstinitiallyappearsas squeeze every lastcent outof hispolicy. likely agonisingly extend hislife in order to should hebetaken illthehospitalwould himself hasnoinsurance, reasoning that him to betreated. Butzthenexplains he patient isadequately insured before allowing He takes great painsto ensure Ernst’s and wonder. well-written science bookrichwithcuriosity whose heartstopped for three hours,and the Norwegian skiersubmerged inanicyriver escapes aery crash burnt beyond recognition, extremes –apilot intheBattle of Britainwho Extremes isacracking read, a cocoon”. surround ourphysiology like a using technology andscience to “the themeof rapid advance, book isalsoabouttechnology – its resilience,” says Fong. The “its fragility, itsfractal beautyand context for anexploration of life, centrifuge at NASA. strapped inahigh-G the notorious vomit comet or and inintensive care, –ying in working asadoctor inA&E Fong’s own experiences Most of allthough These stories provide the Activated platelet, SEM platelet, Activated Back for more FYi WHAT ARE WE LOOKING AT? LOOKING WE ARE WHAT • PHOTO: SCIENCE PHOTO LIBRARY 15 FYi summer 2011_FYI DPS 26/07/2012 10:42 Page 16

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