Top time for Hot Water in 2012?

“Personal profiles on Facebook and other social-networking sites are a trove of inappropriate and embarrassing photographs and discomfiting breaches of confidentiality. You might expect that from your friends and even some colleagues — but what about your doctor?” Time Magazine

This is current news in 2012, but if you look at the date of publication of this time article, it’s September 2009. Although this was published over two years ago, we think medical students are going to be coming under increasing scrutiny as the year unfolds.

It’s happened before, in the UK…

Remember people playing the lying down game? Roll back to Swindon, UK. A number of junior doctors were suspended for what many medical students and doctors considered hijinks: posing for photographs whilst lying down in unusual places. See our example of the latest MRI-PET scanner here:

It’s happening now…

A research paper from 2010 looked at a small group of medical students in Liverpool, UK. Over half had witnessed unprofessional behaviour by their colleagues on social media.

Dr Amy Cunningham, a lecturer from Cardiff University recently highlighted on Twitter and her blog about doctors using slang on social media, e.g. referring to ‘mad-wives’ instead of midwives. For her efforts, both she and the doctors in question were both applauded and criticised by healthcare professionals and different elements of the national press.

Help is at hand…

If things seem a bit blurry and you dont know who to turn to for advice, fear not – as we have compiled a handy list of references:

• From Your Institution – Check if you have guidelines at your University, and follow them!
• From Professional organisations
• From the MPS: The pitfalls of social networking
• From the BMA: Using social media: practical and ethical guidance for doctors and medical students
• From the AMA: Social Media and the Medical Profession: A guide to online professionalism for medical practitioners and medical students.
• Help From Within – We think ‘use your moral compass’ is a great adage. See the moral compass example of one experienced GP below.

Advice from an experienced user of social media

One of our medical professionals says this:

“I use this principle. If I wouldn’t be happy with any of: my mother, friends, work colleagues, peers, nurses, receptionists, patients, friends of patients, children of patients, professional licencing bodies, line manager seeing it, don’t post it. Do not post anything relating to your workplace, patients, or patient care online. If you have a grievance, use formal channels.”

What about anonymity online, protected tweets, protected postings?

“Just be careful. Is it worth risking your professional status over such minutia? The security of these areas is becoming increasing difficult to police. Don’t go there.”

Happy – and safe – tweeting in 2012!

F1 is luck of the draw – F2 is up to you!

By now, three weeks into the job it seems that most of our F1’s, whilst they may not have found their feet completely per se, have managed to work out the various tricks in order to survive, and most importantly serve the particular whims of their consultant.

Photo by barelyanythingAlthough in my experience, and my brief presentation to the new surgical F1’s yesterday, when I say working out the tricks to survive… what I mean is how best to divide their time between making sure that Mr Philips, their one and only patient, has had enough paracetamol to cover his headache whilst he waits for his op, and more importantly how to switch on the TV in the mess.

The surgical F1 jobs in the hospital can be really mixed bags, and it entirely depends on your consultant. One surgeon will micro manage his patients down to individual drug doses, whilst another will be content to NEVER STEP ON THE WARD, only interacting with patients when they are under anaesthetic. The point of this being that as a surgical F1 you need to address how best to use your time.

The Firm system is still in place for surgical teams and that gives the week to week ward work a different pace to medicine. In surgery you can be snowed under with patients and jobs one week, but until your surgeon is “On Take” next, every patient who is discharged is off your list and won’t be replaced. Thus its quite feasible you may end shortly before the next “On Take” of having only one remaining patient to look after – USE THIS TIME!

Surgeons love an audience, if it is your thing use the time you have when the wards are quieter to get into theatre, ask can you assist, of if an exceptionally complex op, just ask to observe, its unlikely they’ll say no. Talk to your consultant as a human being (they might not be, but give it a try) there will always be opportunities, whether it’s getting in on a paper, or helping with a simple audit, but you’ll have to go hunting for them.

Your surgery rotation is a great time to plump up your ePortfolio

Now I’ve banged on about this hellish piece of electronic dictat before but it does have its uses. You might find yourself loath with an unearthly contempt your present job, be that colorectal surgery, respiratory or dermatology. If so your ePortfolio is your golden ticket out.

If you get enough bells and whistles hanging off this electronic annoyance you will be able to have your picks of the jobs for F2, and I cannot emphasise this enough. As a medical student, when you selected your jobs, you chose things you thought might be interesting, or that you might possibly want to have a career in.

Now you know the reality of those jobs good or bad. A well filled ePortfolio is your ticket out of your personal Hell onto the ward you wish you were working on – Remember a bad job on F1 is the luck of the draw, getting the best job for you and your career is entirely down to that electronic hoop jump, so learn how to make it work for you, and grasp whatever extra time you have.

Finally take heart, its payday next week – but more on that later!

Well we survived week 1, and (almost) as importantly so did all of our patients! Congratulations, and if you felt that you (almost) didn’t survive that first week – DON’T WORRY TOO HARD. IT WILL GET BETTER

Now I’m not going to tell you that soon life will be grand, consultants will come to love you, and they will invite you to their summer BBQ and introduce you to their eldest daughter – they might, but that would be unlikely (and rather irregular to boot!).

The biggest issue I had when starting as an F1, and I have seen it repeated in the new F1s this week, was a lack of confidence. Let’s all be honest, despite being absolutely no different from 2 weeks ago, you now are, at least to the outside world, a real doctor.

But what does this actually mean? – basically now, when someone, probably a nurse, asks you what drug you would give to a patient for problem x, rather than just being an academic exercise, that person will then ask you to write it on a drug chart AND THEN ACTUALLY GIVE THAT DRUG TO A LIVING, BREATHING PATIENT.

Photo by Carter ComicsI think I must have checked the dose of aspirin at least 10 times in my first week as an F1!! Oh heck I knew it was 75mg once daily, but was I sure, was I completely confident? Thus I kept on checking – what was I expecting I don’t know? It wasn’t as if it would have changed since the morning!

I found that it is was lack of confidence, combined with the realisation that this isn’t just a paper test anymore which made me very tired by the end of my first month – getting it wrong now matters!

When I started on the ward as an F1, I very quickly made friends with our ward pharmacist, largely because of the number of errors I would make on the drug charts. She would come and find me – and putting on her best “stern and disapproving face” would ask if I really meant to give the patient a certain dose, and ask what I thought might be better – she was (and still remains) absolutely fantastic and couldn’t maintain her “stern” face for long, simply because she knew that I was new, and although I wasn’t getting it right as often as a I should – I was TRYING.

REMEMBER AS LONG AS YOU’RE WORKING HARD, THE WHOLE WARD TEAM WILL SUPPORT YOU! You are not alone, despite what it might feel like.

Ok… this week’s top 5 tips

1. Trust the nursing staff. Some have been there longer than the consultants, they will help steer you and guide you when you find yourself alone on the wards – this will be particularly important when you are on nights or on call – remember the nurses control the flow of biscuits and chocolate so be nice, and say PLEASE and THANK YOU.

2. Don’t be frightened of leaving the ward. Sometimes a department (mainly radiology) will be exceptionally busy, and no one can answer the phone – everyone hates a ringing phone, so walk round to the department. You’ll get to know the people on the other end of the line, and I guarantee you that you’re scan requests will be more easily accepted.

3. Call for help often and early. Try not to get stressed when you don’t know what’s going on. You might be a doctor now, but for the first couple of weeks you’ll be barely more than a grunt. Your job is to carry out your seniors instructions. If nursing staff are telling you that a patient as a problem and you don’t know what to do, call for help. No one will expect you to know everything from day one – Ok Dr Satan the Consultant might – but he is in the minority.

4. Accept you WILL make mistakes. You are human, and you will learn through trial and error, but don’t worry, the nurses, and the “stern looking” ward pharmacist are normally exceptionally, and they’ll normally catch things, and show you where you went wrong. Don’t beat yourself up when you do.

5. Start work on your ePortfolio NOW. It’s a pain in the neck, many would describe it as a waste of time. Personally I don’t do well with reflective learning either, BUT IT IS COMPULSORY. In several months you’ll have to think back over the things you have done, and try and remember what was important, if you do it now – i) its easier, ii) you’ll forget less things, iii) life will get more stressful when you are trying to fill in the other parts of the ePortfolio, so start the reflective bit NOW.

Look our for james’s next blog post – the trials of week 2.

Can you film patients without telling them?

Well the answer is, of course a resounding no, and even more so in a number of simple scenarios and clinical situations which are covered by the new guidelines on the making of patient audio/visual recordings. So the UKs General Medical Council, are issuing new advice to doctors which comes into effect on the 9th of May 2011 for the United Kingdom. The guidance relates to the making of audio or visual recording in the UK. This updates previous guidance and intends to cover the audio and visual recording of patients, the general principles of which are of course  intended for doctors but highly relevant to doctors in training.

GMC guidance from May 2011 on audio and visual records for patients

Helpful excerpts include advice regarding materials for teaching, patients who lack capacity, radiology and endoscopic images, and covert recording of patients by doctors. They include advice such as the following on radiographs:

You may disclose or use any of the recordings listed in paragraph 10 for secondary purposes without seeking consent provided that, before use, the recordings are anonymised; for example, by the removal or coding of any identifying marks such as writing in the margins of an X-ray (see paragraph 17).

The guidance is complex, and the excerpt above can only be taken in the context of the complete document: you can read a PDF of the guidance here, or visit the web pages here.

This is of particular importance to medical students who have a blog, use Twitter and Facebook, and sometimes write reports about their day to day practices: be careful. It supplements the already heavy advice from the GMC on patient confidentiality, ethics, and both formal and informal advice from Medical Indemnity organisations such as the MPS (see their article on ‘tweeting into trouble’ here).

A contributor for Medical Educator is quoted as follows:

This is of course particularly important for students as well as doctors: there are lots of anxieties, for example for using an anonymised chest radiograph for teaching purposes, by a doctor, under the guidance is ‘definitely’ allowed, however the guidance also provides useful information for those considering making audiovisual recordings in different settings. The advice is complex, intended for practising doctors, and carefully tip-toes through what is an ethical minefield. Our advice to any student is: always follow trust and University guidelines, read the GMC guidance, and when it comes to recording any medical images, you should always have the full support and first hand documented supervision of the clinician responsible for the patient prior to considering any audio/ visual recording. In general, unless you are absolutely certain, your GP or consultant is watching you (and documenting it), and you have informed written consent from a competent patient, we suggest keep your iPhone in your pocket and out of the clinic room!

It’s worth researching publications before you start to write. You’re much more likely to get published if you write something targeted at a particular audience or slot, that you know the editor will be interested in.

Don’t send anything in without reading the author guidelines and understanding where it might be placed. And check for word limits – there’s no point toiling for hours over a lengthy Tolstoy-esque manuscript and sending it to the editor of a short health news section – no matter how brilliantly written, they simply won’t have time to read it!

Where to publish

Publications that accept articles from medical students include:

Junior Doctor

New Doctor

Medical Student

Student BMJ

Medical Educator

So, what are you waiting for? Your publishing career is waiting to get started! Let us know any experiences you have had with publishing via a comment on the blog.

1. Using acid to cure a skin infection

Thomas S Fletcher was a surgeon at the Bromsgrove Workhouse, Worcestershire. One of his patients, young Henry Cartwright, died in 1842 after being immersed in potassium sulphate – in an attempt to cure “the itch”, or scabies.

2. Mistaking Tincture of Opium for Rhubarb

Mrs Elizabeth Galloway was suffering from inflammation of the bowels. To aid her recovery, she was given a tincture of rhubarb … Unfortunately, the druggist mixed up the wrong remedy; the cup contained laudanum [Tincture of Opium] rather than rhubarb. Mrs Galloway immediately worsened and the doctor was called… she later died.

3. Choosing the wrong bottle

Mary Ramshaw was knocked down and severely fractured her thigh. Dr Lumley was called, and prescribed both a mixture to take and an embrocation. Mrs Ramshaw’s daughter unfortunately administered the medicine from the wrong bottle and Mrs Ramshaw instantly began to convulse. Ten minutes later, she died. The embrocation she had accidentally been given contained belladonna (deadly nightshade).

You can read about more deadly disasters in the full article here.

The MPS regularly publish case reports as an aid to its members, to alert them to pitfalls that have caught their colleagues unawares.

Have you been privy to any first-term disasters? We would love to hear about them.

Which of these symptoms of hypoadrenalism will distinguish between primary adrenal failure and secondary (pituitary) adrenal insufficiency?

a. Postural Hypotension
b. Weight Loss
c. Fatigue
d. Hypoglycaemia
e. Skin Pigmentation

A 74 year old retired GP, Dr Wallis comes to see you.His wife reports that his memory is not ‘as it was’  however the retired GP dismisses this as ‘nonsense’ and proceeds to tell you about his early research on the use of anti tuberculous medications. His wife is concerned that he may have a brain tumour. The concern about this is that she has read brain tumours can cause memory problems.

Dr Wallis is frustrated by his wife’s concerns about his memory and mentions she is always meddling in his affairs. In his history his wife tells you he has put on a stone in weight, and fractured an ankle when being run over by a car 12 months ago.

PMHx

Previous history of skin psoriasis, treated with topical preparations only.

Drug history

Vitamin D tablets ordered over the internet (patient unsure of strength, wife believes it to be 1000 international units a day)

Examination

You proceed to examine Dr Wallis to evaluate him for any neurological problems. The examination is as follows.

Observations normal. Normal Cardiovascular, Respiratory and Gastrointestinal Examination

Neurology:

Cranial Nerve Exam

Normal. Fundoscopy normal.

Mental Test Score:

Adapted from Hodkinson HM. “Evaluation of a mental test score for assessment of mental impairment in the elderly.” Age and Ageing 1972;1:233-8

Recent blood tests

What is the most likely diagnosis is this just ‘old age’, and does the patient require any other investigations? You can pick a maximum of 5 answers.

A free subscription is on offer for what we judge as the best ‘free text’ answer to this question!

We were a interested in a report from the The Independent (a leading British newspaper) highlighted the case of one British Medical Student. It relates to students from University College London, specifically the transfer of student information to the United States Central Intelligence Agency (CIA). The case in question is that of Umar Farouk Allmutallab, arrested in the US over terrorism charges from Northwest Airlines Flight 253 on Christmas Day.  To refresh your memory on this, read reports on this here from The Times and here from the BBC. He was, of course the former student and president of the University College London (UCL) Islamic Society. There now seem to be repercussions for other Muslim students studying at UCL.

One British medical student has apparently had personal information passed to US authorities as a result of being a member of the UCL Islamic Society. He was quoted by the Independent on the 1st April as saying the following.

I feel frustrated and outraged. To pass on 900 student details because they were members of UCL Islamic Society is ridiculous. The reason I joined the society was for socio-cultural reasons. I’ve never seen the guy [he's referring to Abdulmutallab]. I wasn’t here when he was at university.

Is does seem a little extreme. One of our main contributors (who happens to be British Muslim) had the following to say.

It seems a little curious that the apparently all the members of what was apparently a fairly mainstream society have been put on a US watch list. Its difficult enough getting through US border control at the best of times, never mind having your name potentially put on a list of potential terror suspects! I guess things need to be kept in perspective, but it does seem a little odd.

UCL were reported to say that no details other than the student names and their email addresses had been passed on. Their student Union said the following.

The police asked the student union to provide details of members of the UCL Islamic Society and the Royal Free and UCL Medical Islamic Society between 2005 and 2008. The union provided the names and email addresses of student members only.

Another contributor to medical educator had the following thoughts…

We certainly won’t be spamming any of our customers with junk or sending out any other sort of unsolicited mail. I can’t help but wonder what sort of spam you might get from the CIA. Could be quite fun really. They are now off our list of potential sponsors for the coming year…

Read to read the whole article here from the Independent, and commented on elsewhere in British Newspapers.We’d be interested in any comments from medical students in the UK or abroad about this.

Medical Educator promises not to pass on your email addresses to other companies/ organisations or third parties, there’s no special box to tick, we just wont do it. This includes the CIA, unless they make us!

Its interesting to find many of the images and descriptions are still relevant today, although some of the descriptions are a little ‘brutal’. To the right you can see handwritten notes by a student along with an image describing the excision of a portion of a rib.

We have concluded 3 things.

1. Medical students revision notes were as illegible 00 years ago as they are today. We can’t decipher much of the revision notes shown here (answers on a postcard). There was one bit that we could read that started with Oh-Oh Oh To Touch And… We haven’t printed the rest out of common decency.
2. Writing in flowing fountain pen certainly adds to the drama of revision notes.
3. Although the 1910 book is of exceptional quality and detail, we reccomend using some of the more up to date texts available. Some of our colleagues have even suggested searching the internet, but we’re not too sure about this and prefer to stick to books!

Thanks to Ms K for the donation of the text, we hope to publish some other relevant diagrams in coming months. William Wheeler died in 1943. A telling comment from his obituary in the BMJ from the same year follows:

He was not only a brilliant operating surgeon, a clinician of much wisdom, and an authoritative writer on surgery, but
a man with a great capacity for friendship.