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What’s more, Wesleyan Assurance Society, our parent company, is one of the financially strongest and longestserving mutuals in the UK.

Choose Wesleyan Medical Sickness and you choose a Financial Consultant who is as dedicated to your professionas you are.

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Wesleyan Medical Sickness is a trading name of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Ltd is wholly ownedby Wesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham, B4 6AR. Fax: 0121 200 2971. Website: www.wesleyanmedicalsickness.co.uk Telephone calls maybe recorded for monitoring and training purposes.

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TRIAGE 3

THE MAGAZINE FOR JUNIOR DOCTORS

Presenting HistoryJuniorDr is a free lifestyle magazine aimed at

trainee doctors from their first day at medical

school, through their sleepless foundation

years and tough specialist training until they

become a consultant. It’s proudly produced

entirely by junior doctors - right down to

every last spelling mistake. Find us quarterly

in hospitals throughout the UK and updated

daily at JuniorDr.com.

EditorAshley McKimm, editor@juniordr.com

Editorial TeamMichelle Connolly, Matt Peterson,

Muhunthan Thillai, Andro Monzon

Newsdesknews@juniordr.com

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especially if they bring you out in a rash. ©

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Get involvedWe’re always looking for keen junior doctors

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name in print (handy if you ever forget how

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ones). Check out JuniorDr.com.

Life and death IN THE HANDS OF DOCTORS

“As the UK struggles to save £20 billion from the NHS by the year 2014 could exporting our patients overseas for treatment be the answer?”

Ashley McKimmJunIoRDR EDIToR-In-ChIEf

ST3 PSyChIATRy

What’s inside

040914181920

21LATEST neWS

Sun, SEA AND SURGERy

WHEN DOCTORS ARE ExpECTED TO kiLL

SECRET DIARy OF A CaRdiOLOGY SPR

WEEkEND WARD eSCaPe

Batman GETS A CHECk-Up

HOSpITAL COnfidentiaL

A t 11am on December 8th convicted murderer Kenneth Biros was executed in the US state of Ohio. For the first time, in a move away from

the traditional ‘triple cocktail’ injection, executioners administered a single dose of thiopental sodium - the same drug used in the UK to euthanise pets.

Biros was pronounced dead at 11.47am.Ohio had abandoned the ‘triple cocktail’ in Sep-

tember after the botched execution of Romell Broom when the 18 attempts made to find a useable vein failed. Controversially a doctor was called to assist a distressed Broom after he himself had tried to help executioners find a useable IV site.

The involvement of doctors in executions remains a contested issue. In our main feature ‘When doctors

are expected to kill’ (page 14) Michelle Connolly looks at execution via lethal injection in the US and the argu-ments for and against medical involvement.

Staying overseas, but this time looking at prevent-ing death, ‘Sun, Sea and Surgery’ (page 9) analyses the increasing trend for medical treatment abroad. Last year UK residents spent over £130 million on procedures from hip replacement to valve surgery.

Attracting health tourists is becom-ing a booming industry for develop-ing economies. We look at Thailand where one hospital has installed a Starbucks and pizzeria as part of their ongoing push to attract Westerners.

Brits are being wooed abroad in cam-paigns by organisations such as the Singaporean government which described our ageing population as a ‘great potential to be tapped into’. As the UK strug-gles to save £20 billion from the NHS by the year 2014 could exporting our patients overseas for treatment be the answer?

While you contemplate these dilemmas may the JuniorDr team wish you a relaxing Christmas and a productive start to 2010. Look out for the new bigger JuniorDr with expanded clinical content in March.

nEWS PuLSE4

tell us your news. email team@juniordr.com or call 020 7193 6750.

E arlier consultant input is needed for emergency patients according to an independent inquiry which analysed

the care given to those who died within 96 hours of hospital admission.

The report from the NCEPOD (Nation-al Confidential Enquiry into Patient Out-comes and Death) found that one in five emergency patients were diagnosed by FY and ST1-3 doctors despite some patients having complex conditions requiring urgent senior input. At night this number increased to one in four.

The research found a clinically impor-tant delay in the first review by a consul-tant in one in four patients. The report rec-ommends that clinical need should direct access to consultants:

“Consultant advice should be sought according to the patient’s clinical condition, not the time of day,” said Dr James Stewart one of the authors.

“Our report states that juniors should have 24 hour access to consultant advice. Juniors should not be timid in seeking senior advice.”

DNAR ORDERS

The inquiry which analysed the care received by over 3,000 patients who died in acute hospitals also found that junior doc-tors are inappropriately signing one in five DNAR orders. This is despite the GMC stance that a ‘senior medical member of the

team should record fully any advance deci-sion not to attempt to resuscitate a patient’.

Junior doctors were also found to be tak-ing surgical consent despite lacking ‘suf-ficient knowledge’ to inform patients ade-quately. The report suggests that senior doctors are taking consent and a junior signing but in this case it recommends doc-umenting that the discussion took place.

The Chairman of NCEPOD, Profes-sor Treasure, recommends that junior doc-tors should be better equipped to deal with emergency patients:

“For a very sick patient the first and last doctor they are likely to see is a junior - so be prepared to ask the questions, get a plan from the consultant, document it, be sure to update it, and communicate it at handover,” he said.

“Don’t get out of your depth - ask for help. If it’s a ‘do not attempt resuscitation’ decision, get the boss involved in good time and make sure the patient and family are in the picture. That way the patient gets the care that’s appropriate for them.”

www.ncepod.org.uk/2009report2/Downloads/

DAh_report.pdf

yvETTE MARTyn

ONE IN FOUR pATIENTS SUFFER FROM deLaY in COnSuLtant RevieW

PATiENT sAfETy

1 in 4 patients (24.9%) had a clini-•cally important delay in their first consultant review.

1 in 5 emergency patients (20%) •were diagnosed by junior doctors during the day.

1 in 4 emergency patients (25.1%) •were diagnosed by junior doctors during the night.

1 in 5 DNARs (21.8%) were signed •by junior doctors.

kEy STATS

Professor Tom TreasureThE ChAIRMAn of nCEPoD

“Don’t get out of your depth - ask for help. If it’s a ‘do not attempt resuscitation decision get the boss involved in good time.”

CARInG To ThE EnD? A

REvIEW of ThE CARE of

PATIEnTS Who DIED In

hoSPITAL WIThIn fouR

DAyS of ADMISSIon

M ost patients rely on their own past expe-rience or that of family and friends when choosing where to go for an out-

patient appointment rather than official infor-mation sources such as NHS Choices, accord-ing to a survey by The King’s Fund.

Only four percent said they had looked at the NHS Choices website when choosing a hospital despite two-thirds having internet access. A fur-ther 13 per cent used the advice of their GP to judge a hospitals’ performance.

“This survey shows there is still some way to

go before choice is fully embedded in the NHS. Patients recognise that the quality of care is an important factor when deciding which hospital to attend,” said Dr Anna Dixon, report co-au-thor and Director of Policy at The King’s Fund.

“However, currently they are not actively comparing hospitals or using performance data to select the highest quality provider, instead they continue to rely on their own experience or the advice of their GP.”

Cleanliness, quality of care and the standard of facilities available were the three most impor-tant factors that influenced patients’ choice of hospitals. Travel costs and car parking were only seen as ‘somewhat important’.

The survey of patients was based on four case study areas across England. It found that 60 per cent of respondents were satisfied with the amount of information they were provided with, 22 per cent did not want any information and 14 per cent would have liked more.

www.kingsfund.org.uk

pATIENTS DON’T USE OffiCiaL data WHEN CHOOSING A HOSpITAL

NHs

T he growing use of smart drugs or ‘nootro-pics’ to boost academic performance could mean that doctors sitting exams will face

routine doping tests in the future, suggests an article in the Journal of Medical Ethics.

The non-medical use of methylphenidate and amphetamine is already as high as 25 percent on some US college campuses, particularly in col-leges with more competitive admission criteria, according to the authors.

“It is apparent that the failures and inconsis-tencies inherent in anti-doping policy in sport will be mirrored in academia unless a reasonable and realistic approach to the issue of nootropics is adopted,” says Vince Cakic of the Department of Psychology, University of Sydney.

Despite raising many dilemmas about the legitimacy of chemically enhanced academic per-formance, these drugs will be near impossible to ban, says Cakic.

Nootropics were designed to help people with cognitive problems, such as dementia and

attention deficit disorder, but students with a looming deadline are using drugs such as modafinil (Provigil), methylphenidate (Ritalin), and amphetamine (Dexedrine) says Cakic.

For boosting memory retention, there’s brah-mi, piracetam (Nootropil), donepezil (Aricept) and galantamine (Reminyl). To get a bit more get up and go, there’s selegiline (Deprenyl). The impact of these drugs is as yet “modest”, says Cak-ic, but more potent versions are in the pipeline.

“The possibility of purchasing ‘smartness in a bottle’ is likely to have broad appeal to students seeking to gain an advantage in an increasingly competitive world,” he says.

jme.bmj.com

‘aCademiC dOPinG’ COULD SpARk ROUTINE URINE TESTS FOR ExAMS

TrAiNiNG

Dr Anna DixonDIRECToR of PoLICy AT ThE KInG’S funD

“This survey shows there is still some way to go before choice is fully embedded in the nhS.”

Case Studies in

Complete eBook (978-0-203-856871):

£22.00

Case Studies in

Complete eBook (978-0-203-85686-4):

£22.00

nEWS PuLSE6

Seven out of 10 care home residents are subject to drug errors, suggests research published in Quality and Safety in Health Care. The study of 55 care homes locat-ed in West Yorkshire, Cambridgeshire and central London found that drug er-rors were made in seven out of 10 cases, with the average number of mistakes just under two for each resident. Contributo-ry factors included doctors who did not know the residents, or had insufficient background information.

www.qshc.bmj.com

60 percent of US medical schools have reported having to deal with unprofession-al content posted by their medical students online, according to research published in JAMA. Incidents ranged from profanities about the course and staff, to frank breach-es of patient confidentiality on social net-working sites and blogs. Most were giv-en an informal warning but three medical schools reported dismissing students after they had posted unprofessional material.

www.jama.org

Antibiotic prescribing for respiratory illness should be standardised across Eu-rope to help reduce resistance, say experts in the largest study of its kind published in the BMJ. The EU funded Network of Excellence GRACE project found that antibiotic prescribing for LRTI ranged from 21% to nearly 90% across the EU. There were also marked differences in the choice of antibiotic. Amoxicillin ranged from 3% of prescriptions in Norway to 83% in England.

www.grace-lrti.org

Eight out of ten (84%) doctors be-lieve the public has become more suscep-tible to health scares, according to a poll published in BMA News. Examples giv-en included a London specialist regis-trar in anaesthesia who said pop star Mi-chael Jackson’s death had led to patients expressing concern about the use of the anaesthetic drug propofol. 80 per cent of doctors did not believe the government was doing enough to rebut scare stories.

www.bma.org.uk

De-Facedbook

Errors in elderly treatment

Standardise to stop resistance

Health gets scarier

p atients who die in hospital in the United States are almost five times as likely to have spent part of their

last hospital stay in the ICU than patients in England, according to research from Columbia University.

The study, which compared the two countries’ use of intensive care services, also found that of all hospital discharges only 2.2 percent in England had received intensive care, compared to 19.3 percent in the U.S.

“In England, there is universal health care through the NHS, and there is also much lower per-capita expenditure on intensive care services when compared to the U.S.,” said Dr. Hannah Wunsch, assis-tant professor of anesthesiology and critical care medicine at Columbia University and lead author of the study.

“The use of intensive care in England is limited by supply to a greater degree than it is in the U.S., and there are consequent-ly implicit and explicit decisions regarding who gets those limited services. We wished to examine what different decisions are made.”

England currently has one-sixth the number of intensive care beds available per capita that are available in the U.S. The study, published in the American Jour-nal of Respiratory and Critical Care Med-icine, also noted that medical decisions in England are generally considered to be the direct responsibility of the physician, rather than that of the patient or the patient’s sur-rogate decision-makers as it is in the U.S.

ajrccm.atsjournals.org

pATIENTS IN US 5 TIMES MORE LIkELy TO SpEND LaSt daYS in iCu THAN pATIENTS IN ENGLAND

NHs

TrAiNiNG

T he GMC has updated its guidance for doctors working in a pandemic this month. ‘Good Medical Practice,

responsibilities of doctors in a national pandemic’ outlines the standards of prac-tice expected of doctors if their work is affected by an outbreak.

The guidance recognises that a pandem-ic can break out regionally and allows those most affected to work flexibly to provide assistance where it is most needed.

Key adjustments include:An allowance for doctors to work out-•side their normal field of practice so long as they are able to do so safely.Doctors running research programmes •are asked to consider whether to in-terrupt them during a pandemic.Patient care prioritisation will be •based on clinical need and on the pa-

tient’s likely capacity to benefit. For example, young people should not be given automatic priority over adults.No formal duty to report concerns •about resources, equipment or insuf-ficient patient services, other than in exceptional circumstances.

“Should a complaint be made against a doctor working under the strain of a pan-demic, the GMC will take into account the circumstances under which they were work-ing,” said Jane O’Brien, GMC Head of Standards and Ethics.

“However, it is important to note that all doctors should be ready to explain how and why they altered their practice if called upon to do so.”

www.gmc-uk.org

GMC UpDATES PandemiC GuidanCe

M edical students are to be offered man-agement training under a new scheme launched by The British Association of

Medical Managers (BAMM).BAMMdot will train students who are inter-

ested in management careers within the health service, through Begin To Lead - a junior spin-off from BAMM’s acclaimed Fit To Lead training

programme. It will be organised to fit around students’ existing academic commitments.

“With public interest in the management of the NHS at an all-time high, we’ve seen an increase in interest from medical students who are keen to learn about medical management and pursue careers in clinical leadership,” said Professor Jenny Simpson OBE, Chief Executive of BAMM.

“We’re looking forward to being able to provide medical students with opportunities and training that will meet their needs exactly, in order to provide insight into management careers within the health service and increase their understanding of clinical leadership, so that, come graduation, they are completely pre-pared to begin the first steps of their careers.”

BAMMdot members will also receive advice, invaluable networking opportunities, regular policy updates and material.

www.bamm.co.uk

MEDICAL STUDENTS TO GET manaGement tRaininG

MEDiCAL sTUDENTs

TrAiNiNG

N ewly qualified medical graduates are poorly prepared to work as junior doc-tors say their senior colleagues, according

to the results of a survey published in the Post-graduate Medical Journal.

Senior doctors were asked to score how well prepared their FY1 trainees were to work as doc-tors six months after they had graduated from medical school. Using the GMC ‘five point’ scale for competency the juniors scored below three on 48 of the 70 items. For clinical and practical skills only six of the 20 were above the midway point.

“The findings give cause for concern,” say the researchers. “Senior doctors perceived that the undergraduate medical degree had not adequate-ly prepared F1s for practice, especially in clinical and practical skills.”

Basic respiratory function tests, prescribing, and more advanced communication skills were some of the areas where juniors performed poorly.

They scored well on basic communication skills and how to ask for help, prompting the

authors to wonder whether medical schools had ‘gone too far in emphasising risk management and, perhaps inadvertently, helplessness’.

The study at two major teaching hospitals in the East Midlands of England called for more opportunities for ward based experiential learn-ing and for senior doctors to be more explicit about what is expected of FY1 trainees.

pmj.bmj.com

MEDICAL GRADUATES ‘POORLY PRePaRed’ TO bECOME DOCTORS

Professor Jenny Simpson OBEChIEf ExECuTIvE of BAMM

“We’ve seen an increase in inter-est from medical students who are keen to learn about medical manage-ment and pursue careers in clinical leadership.”

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T he Wellcome Image Awards recognise the creators of the most informative, striking and technically excellent images.

In this image by Paul Appleton finger-like structures in the small intestine of a mouse have been cropped at the tips and stained with fluorescent dyes to distinguish between different components of the cells. The cell nuclei are blue, while the red stain shows actin,

a protein that covers the surface of each villus.The images are on display in the Wellcome Collection from 14

October 2009 to spring 2010.

www.wellcomecollection.org

Used with permission. Credit Wellcome Images.

VILLI IN THE SMALL INTESTINE, by pAUL AppLETON WELLCoME iMAGE AWArDs 2009

not long ago the term ‘medical tourist’ was used to describe unscrupulous patients entering the uK to obtain free treatment on the nhS. Today, in contrast, it is used to describe the thousands of British citizens who flee the long waiting lists to seek

private healthcare abroad. JuniorDr’s Michelle Connolly looks at the surge of medical tourists travelling abroad for sun, sea and surgery.

b ut the UK is catching up, according to research by analyst Mintel. Their survey suggests that 12 per cent of Britons would consider surgery abroad because of the substantial

savings - costing up to eighty per cent less in some cases - com-pared to private treatment in the UK. Dental surgery is the most common overseas procedure with around 20,000 Brits travelling to favourites such as Hungary and Poland for a better smile at around £2,500 a time.

Cosmetic surgery comes a close second with 14,500 of us shelling out for facelifts, breast augmentation and liposuction at a cost of £50 million each year. Those wishing to skip NHS waiting lists for elective surgery, the most frequent of which are joint replacements and cataract surgery, make up a further 10,000 patients spending £36 million.

Word-of-mouth is one of the main drivers for overseas treatment. International medical facilities are promoting good service and reward schemes to encourage ex-patients to recommend to friends. Jacqueline Wilson, a 48 year old Herefordshire housewife travelled to Gdansk in Poland for tooth veneers after first getting quotes from British dental surgeons.

“Poland was nearly three thousand pounds less than the price I was quoted in Harley Street and I combined it with four-day spa holiday too,” she said. “The hospitals were clean, the operation fast and the staff were very pleasant and spoke English. I’d recommend the experience without question.”

Selling surgery

Foreign governments and private firms have begun to rea-lise the potential of medical tourism. Brits are being wooed abroad by development agencies such as the Singaporean government’s Singapore Medicine, which describes the UK’s ageing population as “a great potential to be tapped into”.

Intermediary brokers are one of the big drivers for overseas treatment in what is a difficult process for potential patients to negotiate themselves. Dipa Jethwa, from the London-based Taj Medical Group, explained how they try to simplify medi-cal treatment abroad for clients:

“We liaise with the patient’s NHS consultant to obtain their clinical records. We then arrange flights, visas and their admission to hospital.”

While the mainstay of treatment is joint replacement oper-ations, Taj Medical is also benefiting from the obesity epi-demic. “We are seeing an increase in the number of patients, particularly from the US and Canada requiring gastric band-ing surgery.”

And it’s not just small brokers that are benefiting from the public’s new acceptance of private treatment overseas. High street tour operators such as Thomas Cook have realising the potential and have established partnerships with agencies like Taj Medical.

Because of these new medical expectations centres in coun-tries targeting medical tourists are no longer typical hospitals - they are ‘resort hospitals’ with enticing names such as Kuala Lumpur’s ‘Palace of the Golden Horses’.

Thailand’s Bumrungrad hospital is the number one inter-national hospital in the world treating some 450,000 medical tourists annually. To accommodate Westerners it has a specially built Starbucks in the reception and a pizzeria upstairs.

Thailand’s Bumrungrad hospital is the number one international hospital in the world treating some 450,000 medical tourists annually.

Whether it’s for a hip replacement, valve surgery or a simple rhinoplasty medical tourism is booming. Last year alone some £130m was spent on medical tourism procedures outside the UK. However, Britons are still in the Ryanair league compared to countries like the United States where 150,000 Americans jet off each year for long-haul procedures in countries as far away as India, Thailand, Argentina and Malaysia.

BMA Careers Servicescomprehensive | impartial | tailored | confidential

www.bma.org.uk/careerservices

PROFESSIONALDEVELOPMENTWORKSHOPS Is your career wilting away as you try to keep up with yourday-to-day responsibilities?Develop your true potential by attending one of our interactive professionaldevelopment workshops.

These CPD approved workshops will focus on issues specific to junior doctors,to enhance and nurture your development as a medical professional.

Join the BMA today to take advantage of significant BMA member discounts on all workshops.

Book online now, as spaces are limited.

Little or no aftercare on your returnOften questionable quality of blood transfusionsWeak malpractice laws meaning redress is difficult and malpractice awards

abroad are capped at a much smaller amountDraining away of medical services from local population in order to

serve the touristsThe British Transplantation Society has warned medical tourists

considering China that they might be receiving the organs of executed prisoners

mediCaL tOuRiSm dOWnSideS

ADvERT

Americans driving the market

Americans lead the way in medical tourism partly because of the baby boomer generation and also because of sporadic healthcare cover. With 45 million Americans uninsured over-seas treatment is the only way to avoid huge medical debts. Last year, the average healthcare expenditure for a family of four exceeded the total annual earnings of a minimum wage worker for the first time.

Howard Staab, a 56 year-old carpenter from North Car-olina has become the industry’s poster boy. His local hospi-tal demanded a $50,000 deposit from him for a mitral valve replacement before warning him that the cost of treatment could rocket to $200,000. He got change from $10,000 for a pig valve in New Delhi - and also a trip to the Taj Mahal.

Differences in doctor’s salary partly explain why such con-siderable savings can be made. The average salary of a US fam-ily doctor is $161,000, compared to just $35,000 in India.

India

With four doctors for every 10,000 people, compared with 27 in the US, India is hardly a healthcare model to be copied.

Yet India is now seen to be leading the world as a medical tourism destination - with the finance minister calling for the country to become a ‘global healthcare destination’.

Efforts have been made to improve infrastructure to help smooth the arrival and departure of medical tourists. Import duty on medical equipment has been slashed and the gov-ernment has introduced a special medical visa which permits tourists to stay in the country twice as long as before. As a result India’s medical tourism industry is set to balloon to $2 billion by 2012, according to a joint report by the consultan-cy McKinsey and the Confederation of Indian Industry.

Effect on the NHS

Many expected the boom in medical tourism to lead to a reduction in UK private healthcare prices - instead the effect has been largely an efflux of medical tourists. Fiona Harris, head of personal markets at BUPA, the UK’s largest private healthcare provider, denies that their business is threatened by the boom in medical tourism:

“Sometimes BUPA customers will seek treatment abroad where it is not available in the UK; in these cases we meet the equivalent UK costs of the treatment.”

Social costs

Often the last thing a patient planning an operation over-seas considers is the affect on the local community but it’s one of the key concerns that objectors raise. Many fear an internal brain drain whereby doctors leave small rural prac-tices to work in better equipped urban centres that cater for medical tourists.

Anil Maini, director of corporate development at the Apol-

lo Hospitals group - India’s largest medical tourism organisa-tion - doesn’t deny this is the case:

“There is an internal brain drain but there are enough doc-tors available to serve both rural and urban populations,” he says. “Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less, than they earned in the West.”

There are many who believe medical tourism hails the beginning of a much broader overhaul in the world’s health-care systems - the advent of medical outsourcing. Outsourc-ing means that it won’t be the patient who decides to travel for treatment, it will be your insurer or government who sends you abroad to save money. Just as manufacturing and call cen-tre operations were relocated to countries such as India health-care is likely to follow.

REfEREnCES

Burkett L (2007). Medical tourism. Concerns, benefits, and the American legal perspective. J. Leg. Med. 28: 223-45.

“Doctors who had gone overseas are now returning to India, even though they earn a fraction, maybe twenty times less than they earned in the West.”AnIL MAInI. DIRECToR of CoRPoRATE DEvELoPMEnT. APoLLo hoSPITALS GRouP, InDIA.

The medical tourism industry is worth $100bn – growing at 15 - 20 per cent per yearSouRCE: ERnST AnD younG

The average procedure in India is one-tenth of the cost in the US.Singapore is a more expensive destination but the savings are still large - a liver transplant which costs $300,000 in the US is just $150,000 in Singapore.

COSt COmPaRiSOnS

PArTiAL HiP rEPLACEMENT

India $4,500•US $18,000•

fULL HiP rEPLACEMENT

India $3000•US $39,000•

orTHoPAEDiC sUrGEry

India $4500•US $18,000•

KNEE sUrGEry

India £8000•UK (Private) •£20,000

GALL bLADDEr sUrGEry

India $7500•US $60,000•

fIGuRES ARE APPRoxIMATE. ThEy Do noT InCLuDE TRAvEL AnD ACCoMMoDATIon CoSTS.

An honest mistake?Cutting a few corners or embellishing a training application might seemharmless, but it could leave you in hot water, says Sara Williams

When applying for jobs, many young professionals openlyadmit that they have exaggerated achievements on their CVs,relaying similar justifications: “But everyone does it, don’tthey?” This could land a junior doctor in a lot of trouble. In theBBC’s Apprentice, Lee McQueen famously landed the top jobdespite lying on his CV, but Dr McQueen would not have beenso lucky.

All doctors are expected to be truthful and medical regulators takeevidence of any dishonesty very seriously, whether it be making falseclaims about qualifications and experience to get a job, plagiarism orsigning fraudulent certificates.

Lying on applicationsThe pressure of on-call commitments, combined with the ever-increasing competition for training posts, may lead some individuals to take “short cuts” when completing their application forms.

However, trusts would usually consider dishonesty on an applicationform as a disciplinary matter, which could subsequently lead totermination of a doctor’s contract of employment. If a doctor intentionallymakes a false representation in order to gain a financial advantage, he or she may be guilty of a criminal offence under the Fraud Act 2006.

In the 2007 GP application process, the GMC saw a number of caseswhere junior doctors were accused of plagiarism on application forms.This led to sanctions ranging from warnings through to erasure fromthe medical register. Many of the doctors involved had reproducedmaterial from websites, with others being found to have copied fromtheir colleagues.

Why is dishonesty such a danger to doctors?Good Medical Practice advises that you must be honest andtrustworthy when signing forms, reports and other documents. It alsorequires you to make sure that any documents you write or sign arenot false or misleading. This means that you must take reasonablesteps to verify the information in the documents, and must notdeliberately leave out anything relevant.

You may encounter families who don’t want certain information visible on the death certificate, but you have a legal and professionalobligation to complete the certificate truthfully.

Falling under this category is the requirement for any junior doctor to inform the GMC if they have accepted a caution, been chargedwith a criminal offence, or if they have been found unfit to practise by a professional body anywhere in the world. It also includes therequirement to take up any post that has formally been accepted.

Whilst it is clearly best to avoid any suspicion altogether, if you do find yourself being accused of plagiarism or dishonesty, it is importantthat you contact MPS to obtain advice at an early stage. The earlierwe are involved, the better the chances of mitigating any damage to your career.

ScenarioST1 Dr T is in the second week of his surgical training. Following a successful cholecystectomy, Dr T is delegated the responsibility of writing up the operation notes from the surgery. He gets to workimmediately, but in his haste he forgets to write up the postoperativeinstructions for hourly urine output monitoring, and continues to workthrough his list of patients.

A few hours later the patient experiences problems so he visits heragain, and finds that there has been no monitoring of urine output. He realises the mistake on the records. Dr T alters the records toinclude what he had previously omitted. Dr A, a registrar, saw Dr Talter the record.

Dr A confronts Dr T about his actions, but Dr T pleads with him not to say anything. Dr A calls MPS for advice. A medicolegal advisersuggests that Dr A raise the matter with Dr T’s consultant orsupervisor. Dr A does this, and Dr T receives advice and a warningfrom his consultant, who addressed it as a training issue. If his actions were to be repeated, Dr T could face disciplinary action.

Survival tips

If you are uncertain, double-check your work with a senior.

Take steps to verify what you are saying. Never sign a form unlessyou have read it and you are absolutely sure that what you aresaying is true.

Probity means being honest and trustworthy, and acting with integrity.

Be honest about your experiences, qualifications and position.

Be honest in all your written and spoken statements, whether you are giving evidence or acting as a witness in litigation.

You must be open and honest with any financial arrangementswith patients and employers, insurers and other organisations or individuals.

Assume that all records will be seen by the patient and/or others,eg, GMC, the courts.

Useful links

GMC, Good Medical Practice (2006) paragraphs 56-76 –www.gmc-uk.org/guidance/good_medical_practice/index.asp

BMA, –www.bma.org.uk/ap.nsf/Content/mafees~cremation?OpenDocument&Highlight=2,death,certification

MPS, Playing fast and loose with the truth, Casebook (Vol 17, No 1) – www.mps.org.uk

MPS professional support and expert advice

For more information call 0845 718 7187Or visit www.mps.org.uk

24-hour medicolegal emergency advice line

Medicolegal publications – Casebook and New Doctor

Risk Management materials includingmedicolegal booklets

Online resources including factsheets andcase scenariosEducational support through discounts with leading publishersLargest international defence organisation

The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. MPS0956

MPS0956 Junior Doctor - Dishonesty.qxd:Template - Junior Doctor 1/12/09 13:01 Page 1

DEATh PEnALTy14

A key point in the debate for death by lethal injec-tion occurred when California postponed execu-tions indefinitely after doctors refused to partici-

pate. They became opposed after a judge’s ruling stated that doctors would have to physically intervene if the condemned person appeared to be in pain.

Doctors would therefore have been expected to tell prison officials whether the prisoner needed more sedation, or possibly even to administer more drugs. “Any such intervention would be medically unethical,” the anaesthetists replied in a statement. “As a result, we have withdrawn from participation.”

Lethal injections were suspended as a result. Michelle Con-nolly looks at the role doctors for JuniorDr.

WHAT’S LEGAL?

Lethal injection under United States federal law states that ‘the punishment of death must be inflicted by continuous, intravenous administration of a lethal quantity of an ultrashort-acting barbiturate in combination with a chemical paralytic agent until death is pronounced by a licensed physician accord-ing to accepted standards of medical practice.’ In it’s simplicity lethal injection simulates a medical procedure - the intravenous induction of general anaesthesia.

THE pROCEDURE

Once the prisoner has been strapped to the table the arm is swabbed with alcohol. Two 14-gauge catheters, the largest com-mercially available, are inserted, one in each arm. The second is a backup, in case the primary IV. fails. Both catheters are flushed with heparin to prevent clots forming inside.

All condemned prisoners are given the opportunity to make any final statement they wish, and then, on the warden’s signal the drugs are administered.

Sodium thiopental (at 14 times the normal dose) is used to induce anaesthesia, pancuronium bromide is the substance used to paralyse the respiratory muscles and potassium chloride is administered to induce ventricular fibrillation.

Even without inducing VF death would still follow by asphyx-iation. Death typically takes 8-10 minutes and is pronounced

WHEN DOCTORS ARE ExpECTED TO kiLL– ADMINISTERING A LETHAL INJECTIONAt exactly 11pm on the 21st September 2006 forty-eight year old Clarence Hill was strapped to the table at Starke Prison, Florida. The warden gave the signal and a cocktail of lethal drugs was pumped into his veins. At 11.12pm the ECG flatlined and Hill was pronounced dead.

Hill’s execution went ahead despite his lawyers arguing that the lethal injection is inhumane. Many doctors in California agree and believe the method of lethal injection, supposedly painfree, does cause the condemned pain and should be banned.

1 Administering lethal drugs

2 Maintaining injection devices

3 Supervising technicians

4 Prescribing lethal drugs

5 Selecting intravenous access sites

6 Inserting IV lines

7 Monitoring vitals

8 Pronouncing the prisoner dead

The American Medical Association (AMA) specifically condemns the involvement of doctors in state-sanctioned executions. It cites eight acts constituting direct involvement:

INVOLVEMENT OF DOCTORS

DEATh PEnALTy 15

on asystole. A coroner then signs the death certificate and the procedure is complete.

With the IV lines, a cardiac monitor and a medical doctor on standby the execution room is not dissimilar from an acute medical ward. The direct telephone line to the Department of Justice in Washington is perhaps the only giveaway - the Presi-dent is the sole authority able to grant last-minute clemency.

‘INHUMANE ExECUTION’

The claim of the lethal injection being the most humane form of capital punishment, is disputed by many.

Leonidas Koniaris, professor of surgical oncology at the Uni-versity of Miami, Florida, writing in The Lancet, suggests evi-dence that judicial execution by these means is not as humane as death penalty proponents have claimed.

Researchers obtained post-mortem toxicology reports from four of the 36 states killing prisoners via lethal injection. The results indicated that levels of sodium thiopental were lower than those required for surgical anaesthesia. Even more surpris-ing was that in 43 percent of cases levels were consistent with consciousness.

Determining consciousness levels in prisoners who are paral-ysed and who will not be resuscitated is both difficult and debat-able. This lack of certainty has however prompted the American Veterinary Medical Association to ban the use of neuromuscu-lar blocking agents, such as pancuronium bromide, when put-ting animals to sleep.

THE INVOLVEMENT OF DOCTORS

The involvement of doctors varies considerably with 35 of the 38 death penalty states that rely on lethal injection allowing doctors to participate, and 17 states requiring it. Participating

doctors are required to ensure that the Eighth Amendment of the US Constitution, which prohibits ‘cruel and unusual pun-ishment’ is upheld.

It was a doctor who pushed the syringe in Illinois’s first lethal injection execution and in Nevada, doctors are required to examine the condemned for good venous access and to pre-scribe the fatal drugs.

Some states, such as Illinois and South Dakota, have attempt-ed to de-medicalise the death penalty with laws decreeing that the assistance of death does not constitute medical practice. South Dakota’s death penalty statute states that “any infliction of the penalty of death … may not be construed to be the prac-tice of medicine.”

THE ARGUMENT FOR MEDICAL INVOLVEMENT

Despite the reluctance of medical professionals to involve themselves many feel their presence is essential for the welfare of the prisoner. Each step of the execution procedure from the dosing of fatal drugs to the pronouncement of death ideally requires a medical practitioner.

Where doctors are unavailable these tasks are performed by trained ‘technicians’ but as Koniaris and his team point out the worst toxicology reports were obtained from states that employed teams qualified only at technician level.

Death row inmates often have poor vascular access as a result of intravenous drug use or obesity and it is here that the skills of doctors are particularly useful. In Georgia one of the three doc-tors present in the execution chamber during procedures is an expert in vascular access.

Many also use the argument view that healthcare personnel transform the executions from a terrifying to peaceful environ-ment alleviating pain or giving the illusion that pain is being alleviated.

THE ARGUMENT AGAINST

Firstly doctors argue that they were not asked whether they agreed with the medicalisation of the death penalty prior to its re-introduction in 1976.

Many doctors oppose the execution process on ethical grounds. The president of Georgia’s medical school, in a letter to the prison warden, condemned the involvement of doctors saying their presence in the chamber ‘compromised their rela-tionship with the inmate population.’

“Even more surprising was that in 43 percent of cases in those four states levels were consistent with consciousness.”

“The worst toxicology reports were obtained from states that employed teams qualified only at technician level.”

More significantly in June 2006, the American Society of Anaesthesiologists sent letters to its 40,000 members urging them to ‘steer clear of any participation in execution.’

Missouri officials then sent nearly 300 letters to anaesthetists in the state and in Illinois to ascertain their ‘willingness to par-ticipate in execution’. To date not a single recipient has said they would so it seems the Society’s call is being heard.

In a further development the following month North Caro-lina’s state medical board banned doctors from participating in state executions.

CHOOSING TO pARTICIpATE

Despite what appears as widespread reluctance by the medi-cal profession to participate in lethal injections many doctors are still willing to assist in state execution.

An American Medical Association survey found that 19

percent would inject lethal drugs and 41 percent said they would perform at least one of the eight acts (see table)2. Many individ-uals balance their clinical responsibility against their duties to society and agreed to their involvement. Many also wanted to provide a ‘painless’’ death and were concerned with the expertise of the technician-level staff.

In a case that caused particular furore among the medical profession, the governor of Kentucky, who is a doctor, signed the death warrant of a prisoner with an IQ of 74. Executive counsel John Roach said Dr Fletcher did not violate the Ameri-can Medical Association guidelines and that in signing a death warrant, he is in ‘no way participating in the conduct of an execution’.

Doctors still refuse to be present in the execution room in California. Their role in administering lethal injections across the United States is still uncertain - but executions continue in the other states.

StaRke PRiSOn, FLORIDAdeath ROW CeLLS

A Death Row cell is 6x9x9.5 feet high. Florida State Pris-on also has Death Watch cells to incarcerate inmates await-ing execution after the Governor signs a death warrant for them. A Death Watch cell is 12x7x8.5 feet high.

LaSt meaLPrior to execution, an inmate may request a last meal. To

avoid extravagance, the food to prepare the last meal must cost no more than $40 and must be purchased locally.

COntaCtWhen a death warrant is signed the inmate is put under

Death Watch status and is allowed a legal and social phone call. While on Death Watch, inmates may have radios and televisions positioned outside their cell bars.

florida Department of Corrections

DEATh PEnALTy

STARKE PRISon, fLoRIDA ExECuTIon RooM

PICTuRE: fLoRIDA DEPARTMEnT of CoRRECTIonS

16

WHEN DOCTORS ARE ExpECTED TO kiLL– ADMINISTERING A LETHAL INJECTION

HISTORy OF THE LethaL injeCtiOn

Lethal injection was first considered in 1888 by a New York doctor writing in the journal Medico-Le-gal. Initially this was not for humane reasons but to rob the prisoner of the hero status which was attached to hanging. He suggested the injection of 6g of mor-phine. The idea didn’t catch on and New York state introduced the electric chair instead.

In the UK the British Royal Commission on Cap-ital Punishment looked into lethal injection back in the 1950s but following pressure from the BMA decided against it.

Lethal injection in its modern form was the brain-child of Stanley Deutsch, an anaesthesiologist at the University of Oklahoma. In response to the state sen-ator’s 1977 request for a cheaper alternative to repair-ing the dilapidated oak electric chair, Dr Deutsch recommended barbiturate as a ‘rapid, pleasant way to bring about unconsciousness’ followed by a muscle relaxant to bring about an ‘extremely humane’ death. Texas became the pioneering state for lethal injection as a form of capital punishment. It was doctors who watched as the drugs were pumped into the veins of a 40 year old African-American. He was dead with-in minutes and the procedure was deemed a success. Since then over over 700 men and women have been executed by lethal injection in the USA alone.

DEATh PEnALTy

Junior doctors: pitch your ideas for improving patient safety

Junior Doctors are invited to pitch ideas for improving patient

safety to be considered for presentation at the 2010 junior

doctors: agents for change conference. If you have an idea for

an initiative concerning patient safety which you believe could

make a significant improvement within a clinical setting, or you

have experienced success in improving patient safety, you are

encouraged to submit your idea.

Deadline for submissions: 15 March 2010. For more information and

submission details visit:

bmj.com/campaigns/juniordoctors

Junior doctors: agents for change

Monday 7 June 2010 Hilton London Metropole Hotel, London

17

REfREREnCES

Koniaris LG, Zimmers TA, Lubarsky DA and Shel-don JP (2005). Inadequate anaesthesia in lethal injection for execution. The Lancet. 365: 1412-1414.

Groner JI (2002). Lethal injection: a stain on the face of medicine. BMJ 325: 1026-1028.

farber nJ, Aboff BM, Weiner J, Davis EB, Boyer EG, ubel PA (2001). Physicians’ willingness to par-ticipate in the process of lethal injection for capital punishment. Ann Intern Med. 135: 884-888.

WEEkEND WARD ESCApE TO

MADriD

SECRET DIARy18

* names have been changed to try to keep our cardiology SpR in a job - though she’s doing a pretty good job of trying to lose it without our help!

MoNDAy If you’ve been following this column then you’ll know that

Douglas, my boss and mentor, recommended I take a Fellowship overseas before settling down as a consultant. He suggested Mel-bourne but I chose California. That was how I ended up cramming my face full of ultra low fat skinny blueberry muffins at 6am every day as we started rounds. It’s also how I ended up spending Friday mornings on the beach learning how to surf. Not a bad life.

Monday was pretty dull. James (think Hawaiian surfer dude) was the attending on the wards. He is surprisingly meticulous for someone who wears faded jeans and an Aloha shirt and makes sure that all the patients have plans for the week. I spend the afternoon doing an echo list before finishing some paperwork and heading home for an early night. My apartment has a great view of the Pacif-ic but it also has ‘Showtime’ which is a combination of Sky Mov-ies, cable and every other type of great TV, so I end up spending the night drinking a glass of Californian red and watching seasons pre-mieres of shows I have never heard of.

TUEsDAy Angio list this morning. The attending in charge is Suzie, a young

woman not much older than myself, and like all the cardiologists here she is pretty meticulous. Perhaps the constant fear of litigation is what drives them. Everything is heavily supervised, especially the complicated case that we start with. There is a window on the sec-ond floor with a small gallery and a professor talks through what I’m doing with a group of medical students.

The case goes smoothly and we soon start another and then another. The pace of work is frantic but unlike back home every-thing seems to run exceptionally smoothly. The assistants and nurs-es are eager and willing to help, the equipment is always ready and in perfect working condition, and the computer systems to help us do our job are first rate. I guess this is what it would be like if they privatised the NHS.

WEDNEsDAy Early rounds again and then a morning of teaching. The stu-

dents here really know their stuff and some of their questions leave even me thinking for a moment before I can compile an answer. After lunch I see some ward patients and spend an hour catching up on emails.

I go out with some of the other residents in the evening and we hit a couple of bars in the centre of town. My colleagues don’t usu-ally drink a huge amount and I find myself getting blank stares when I suggest a third round. Still, they all buy into it and we end up moving onto a gothic club where we look decidedly out of place. The bouncers laughed at us when they let us in and most of the patrons keep out of our way but we end up dancing all night and I crash back in my flat sometime around 2am.

THUrsDAy I feel decidedly unwell as we start rounds a mere four hours later

but I look significantly better than some of my colleagues who don’t stay out late very often. It takes several coffees and a double bacon roll (the lady in the canteen looks at me as if I’m mad when I order

this instead of the skinny muffin everyone else is having) before I feel better. After lunch I leave the building with Suzie and we go downtown to the weekly inner city clinic that the hospital runs as part of its charity outreach programme.

Most of the patients have standard stuff but towards the end we find a man in his forties who is really sick. He has no cardiac history but has been getting chest pains and shortness of breath for a few weeks and is now in crushing pulmonary oedema. Suzie looks anx-ious when he tells us what we already know - that he doesn’t have any health insurance. We tell him that he has to get checked into a hospital and suggest the local one where they will look after him immediately. He doesn’t want to pay for an ambulance so a friend agrees to drive him there.

After clinic, I go out for dinner with Suzie and we talk about his case. If he had turned up in the UK he would have had a battery of blood tests, a chest x-ray, an echo and a cardiac MRI within an hour of setting foot through the door. If we had found something stent-able the chances are that we would have done an angio tonight and sorted it out. By tomorrow morning he would have been in coro-nary care eating a skinny blueberry muffin like everyone else.

friDAy Wave rounds today which means surfing at dawn for the whole

team. We meet for breakfast in a hut on the beach and sit in our usual corner table as we do a paper round of our patients. As we talk, Suzie walks to the juice bar to order some more drinks and makes a call on her phone as she does. When she comes back she tells us that the man from yesterday died early this morning. It turns out he did get to the hospital but aside from an ECG and some blood tests he didn’t have much else as they were too stacked up with patients. He arrested a couple of hours ago and they couldn’t revive him.

There’s a silence after she finishes as we all look at each other. James explains to the students that based on the clinical story he may have died anyway but as he does so he gives Suzie and I a look that says otherwise.

My six months are nearly up and as I reflect on this in my apart-ment that night. I wonder which system I’d rather practice in. The NHS has many faults but, like the army, they leave no man behind. However, what’s the point in training to be a cardiologist in the developed world if you can’t treat some of your patients in the best possible way using the best technology? Is it better to treat all your patients to a good degree or treat some of them to a fantastic degree whilst leaving some of them with nothing?

I’m not sure that I know the answer to that any more.

SECRET DIARy OF A CaRdiOLOGY SPR

WHErE To sTAy?

Like any capital city staying in Madrid is expensive. Visiting at the weekend does let you take advance of reduced rates when all the business travellers have left. Try the centrally located Petit Palace Are-nal (Calle Arenal) approx £60 a room. If you’re still waiting for your paycheck you could try the Barbieri Internation Hostel (Calle Barbieri), just a short walk from the centre, which offers double rooms from under £30. Or if you’re planning a really special weekend away you could splash out on Hotel Santo Mauro (Calle Zurbano) - the choice of residence for the Beckhams at £250 per night.

EATiNG

Tapas will become addictive whilst in Madrid. Pop into a bar, order a drink, and nibble the night away with the locals - it’s how they can stomach drinking until the early hours of the morning.

The top tapas treats can be found at Juana la Loca (Plaza Puerta de Moros) or Alhambra (Calle Victoria) which offers a more lively experience with heavy music and a younger crowd.

For a more sedate sit-down meal con-sider La Viuda Blanca (Calle Campo-manes) which offers a modern take on Spanish cuisine.

KEy ATTrACTioNs

Palacio Real - Arguably the most impressive building in Madrid with fan-tastic gardens which are perfect for a spot of lunch. There are 3,000 rooms to the Royal Palace, many of which you can wander through.

El Teleférico de Madrid - This is a 10 minute cable car ride that departs from the park behind the Royal Palace. It’s a great way to see the city from afar and also ends at a welcome restaurant.

Prado Museum - This is Madrid’s most popular tourist attraction and claims to have a higher concentration of masterpieces than anywhere else in the world. At any time there are 1,500 works of art on display out of an impressive col-lection of 9,000.

Parque del Retiro - Retiro means retreat and is the most popular park in Madrid. With a large lake, monuments and shaded areas it’s the perfect place to relax after stomping around the Prado - which is conveniently situated close to the main entrance.

NiGHTLifE

Plaza de Toros de Las Ventas - Whether you are amazed or are appaled

by bullfighting it’s certainly a big part of Madrino culture and increasingly popu-lar. Tickets can cost from a few quid to over fifty depending on where you sit in this massive 25,000 seater stadium with the action kicking off from 7pm.

Casa Patas (Casa Canizares) - Fla-menco is the other great Madrino pas-sion and certainly worth an evening’s viewing. Casa Patas offers one of the more authentic experiences. Entrance is approximately £25 and includes a com-plementary drink.

Find the full Madrid guide at JuniorDr.com

With bullfighters, women who dance clapping metal cymbals and huge 30 inch plates of paella there’s no doubt Madrid sees itself as a macho city. hardly a place

for a relaxing weekend away you may think. Wrong, Madrinos also have a strong reputation for enjoying themselves ... you just have to let them take the lead.

WEEkEND WARD ESCApE TO

MADriD

KEy fACTS

POPULATION - 2,905,100•

LANGUAGE - SPANISH•

CURRENCy - EURO•

MADRID IS EUROPE’S HIGHEST CITy •

(2,100 FEET)

hoSPITAL MESS20

BatmanI t is a dark winter’s night at my surgery and the last appointment of the

evening. The clinic is deserted and cost-saving measures have meant that only a single flickering light remains on. Suddenly, creeping from the shadows of the waiting room, a dark figure emerges. Dressed almost total-ly in a form-fitting reinforced suit with his head covered in a frightening mask I can make out the outline of a man - or possibly something more supernatural. At first he says nothing, then quietly, somewhere between a whisper and a threat, his voice rasps “Doctor, I have an itch...”

LARyNGITISNo-one should have to live with a voice that hoarse without seek-

ing medical help. Although there are many causes for this dysphonia, inflammation of the larynx would be the most obvious - likely due to a simple viral infection or overuse of the vocal cords. I would recommend a combination of gargling, menthol inhalation, air humidifiers and sim-ple rest. If the problem persists I will make a referral to our local voice therapist Dr Joe Kerr.

ERyTHROpOIETIC pORpHyRIAPerhaps the main reason for “Batman” only appearing at dusk is photo-

sensitivity to sunlight. In all cutaneous porphyrias, photosensitivity pres-ents as bullous eruptions occurring on sun-exposed areas. The recom-mended treatment is actually prevention by avoidance of sunlight and use of sun-protective clothing. A firm diagnosis could be made by testing for porphyrins in plasma, urine, and stool; which would be elevated to lev-els higher than those in other porphyrias. This would however necessitate Batman removing his uniform which in itself would be a difficult task.

HISTOpLASMOSISQuite why this “Batman” chooses to spend the majority of his time in a

cave teeming with bats is beyond the limits of this consultation. However, it is common knowledge that bats carry various diseases including rabies, the Hendra virus and Ebola. What is less well known is that their excre-ment, called guano, has the fungus histoplasmosis capsulation present in a high enough quantity to cause histoplasmosis - an infectious disease caught by inhaling the spores. Around 10 days after exposure many sufferers com-plain of flu-like symptoms including dry cough, headache, impaired vision and muscle pains. Some cases, however, are more serious often resembling tuberculosis and can be fatal without treatment. My recommendation would be to have the whole cave fumigated and install better ventilation.

ATTACHMENT DISORDERWhile obtaining a family history I uncovered that during his ear-

ly childhood both Mr and Mrs “Batman” were murdered. It is well known that failure to form normal attachments to primary care giving figures in early childhood can lead to problematic social expectations and behaviours - particularly emotional dysregulation, self-endanger-ing behaviour and hyper-vigilance. Although treatment is difficult in these cases, a narrative-therapeutic approach may allow “Batman” to open and explore other aspects to his personality rather than sticking to this Dark Knight persona.

Assessed by Gil Myers

MEDICAL REpORT

1 Name associated with paradoxical rise in JVP with inspira-

tion (8) 3 Purified cardiac glycoside extracted from foxglove

(7) 5 Fourth cranial nerve (9) 6 Proton pump inhibitor; ‘Los-

ec’ (10) 7 Paediatrician’s name associated with testing a drop

of blood to exclude phenylketonuria (7) 8 FK506, immunosu-

pressant discovered by the Japanese (10) 9 His syndrome is

rheumatoid arthritis with pneumoconiosis; treated with steroids

(6) 12 Inflammation of the wall of a vein (9) 13 This ligament

forms the floor of the inguinal canal (8) 16 Cell type of carci-

noma of the bronchus with darkly staining nuclei and scanty

indistinct cytoplasm; in porridge (3) 19 satellite of Saturn; first

cervical vertebra; collection of maps (5) 20 A rare and rela-

tively benign form of muscular dystrophy of pelvis-girdle type

with better prognosis than Duchenne’s dystrophy; Wimbledon’s

youngest men’s singles winner (6) 23 Disease associated with

spirochaete Borrelia burghdorferi; sounds like a citrus fruit (4)

ACross:

DoWN:

2 Kidnap; moving a limb or other body part away from the

midline (6) 4 Terminal organ of the lower limb; 12 inches (4)

10 High potassium (13) 11 Lobe of the brain behind the fron-

tal; contains sensory cortex and association areas (8) 14 Whit-

ish crescent shaped area at the nail base (6) 15 Group of

mammals considered by some as vermin; ulcer associated with

basal cell carcinoma (6) 17 Itching (8) 18 What you aim for;

red blood cells with central staining, a ring of pallor, an outer

rim of staining e.g. in liver disease, thalassaemia and sickle cell

disease (6) 21 Coldplay classic; this fever is an infectious dis-

ease of tropical Africa and Southern America transmitted by Ae-

des mosquito (6) 22 Rod shaped bacterium (8) 24 Name as-

sociated with the plantar reflex (8) 25 Flat circumscribed area

of skin or an area of altered skin colour (6)

You can find the crossword solution by searching for ‘crossword answers’ at www.juniordr.com.

Compiled by Farhana Mann

hoSPITAL MESS 21

Ask for fish fingers instead at:

£4.50 bristol Royal Infirmary, bristol

Expect them to be wrapped in newspaper at:

£2.95 barnet General Hospital, London

Bring your own teabags at:

£1.90 Royal Free Hospital, London

Dose up on those antioxidants at:

95p New Cross Hospital, Wolverhampton

Maybe just stick to butter:

£2.95 Chase Farm Hospital, London

Say cheese at:

£1.95 Warwick Hospital, Warwickshire

Next issue we’re checking the cost of a toothbrush, a cup of tea (small) and a Magnum Classic ice-cream. Email prices to hospitalconfidential@juniordr.com.

W hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of

a PICU incubator things start to take the biscuit. Here’s our regular column of the best and worse hospital essentials you’ve reported:

42” TV with Sky Digital, 10 PCs with Inter-net Access, a plasma information screen, a modern kitchen, two snooker tables and a Fussball table. Complimentary tea, coffee, toast, newspapers and magazines are provid-ed daily and there’s a lunchtime snack bar selling sandwiches, soup, jacket potatoes and snacks, solely for the use of doctors.

JuniorDr Score: ★★★★✩

Fish and chips

Jacket potato with cheese

‘Writing in the notes’ is our regular letters section. Email us at letters@juniordr.com.

Writing in the Notes

the post-Shipman charade

Dear Editor,Harold Shipman has a lot to answer for but the

increasingly intrusive appraisal system brought on

by his evilness is a kneejerk reaction. We know that

under current appraisal methods Shipman would

have been rated a great doctor. As shown in your arti-

cle (Consultants failing to use portfolios properly in

appraisals Iss 14 p5) appraisals are often a pointless

box-ticking exercise. It’s only a matter of time until

another Shipman shows the whole appraisal system

to be a rather expensive charade and casts even more

doubt in the minds of the public. Shouldn’t the DH

focus be on the things we can improve rather than

the things we have no control over?AnonyMouS

SPR SuRGERy

unsticking needle stick reportingDear Editor,

In your article (Most surgeons do not report nee-dle stick injuries Iss 14 p6) you note that only a quar-ter of surgeons report needle stick injuries. My own experience of having had at least two (that I’m aware of!) is that I regarded them as low risk and would not have taken antiretrovirals. This judgment was based on a good knowledge of the risks of transmission of blood borne infections. Reporting them is tedious and inevitably means being corralled into meet-ing with occupational health. A better way forward is improved education of doctors to allow them to make their own risk assessment rather than waiting for them to report.hARRy CRoSSEnST4 GEnERAL MED, noTTInGhAM

how to spot a fresher

Dear Editor,I’ve an additional way to spot a fresher to add to

your list in the last issue (How to spot a fresher Iss 14

p14). It’s to look for the students who have to spend

eight hours in lectures each day whilst balancing a

part-time job in Tescos, Aldi or some other hideous

workplace. Training in medicine is now so prohibito-

ry that it’s putting many good students off and forc-

ing others to compromise their education by slaving

away in part-time jobs. Isn’t it time medical training

is subsidised just like nursing and teaching?

ALICIA PATEL

MEDICAL STuDEnT

Queen’S mediCaL CentRe, NOTTINGHAM

Cup of tea (small)

CLASSIfIED22

Applied Clinical EthicsFebruary - June 2010

Programme:Day 1: Clinical Ethics in Theory and Practice (6 February)

Day 2: Autonomy Issues in Clinical Ethics (27 February)

Day 3: Ethical Issues at the End of Life and the Role of Context in Clinical Practice (20 March)

Day 4: Law and Justice in Clinical Practice (24 April)

Day 5: Sustaining Professional and Ethical Practice in the Clinical Environment (22 May)

Day 6: Moral Dilemmas in Clinical Practice: Oral Presentations and Case Analysis (19 June)

For further information and to book a course please visitwww.imperial.ac.uk/cpd/aceor contact: Marta Kowalewska, School of ProfessionalDevelopment, Imperial College London.Tel: +44 (0)20 7594 6884Email: cpd@imperial.ac.uk

Organised in collaboration with the Department of Primary Care and SocialMedicine, Imperial College London and the Medical Protection SocietyCME / CPD approval sought for

Speakers include: Professor Raanan Gillon (Imperial College London)Professor Michael Parker (Oxford University)Professor Carol Seymour (Medical Protection Society)Deborah Boyle (Royal Free Hospital)Dr Andrew Hartle (St Mary’s Hospital)Dr David Inwald (Imperial College London)Mr Martin Lupton (Imperial College London)Katy Peters (Capsticks Solicitors)Dr Chandak Sengoopta (Birckbeck College)Dr Suzanne Shale (King’s College London)Dr Julian Sheather (British Medical Association)Ronald P. Sokol (Sokol Law Offices)Dr John Spicer (St George’s, University of London)Dr John Tuohey (Providence Medical Centre, USA)Dr James Wilson (University College London)

Directed by: Dr Paquita de Zulueta (Imperial College London)Dr Daniel Sokol (Imperial College London)

6 x 1-Day Professional Training on Saturdays at Imperial College LondonFor hospital doctors, surgeons, general practitioners, nurses, managers andmembers of clinical ethics committees.

Now in its fourth year, the School of ProfessionalDevelopment is proud to present the highly popularpractical modular course for busy practitioners

Testimonials:‘Essential teaching for allclinicians’

‘Would wholeheartedlyrecommend this excellentcourse. One of the moststimulating, thought provokingand well informed courses’

‘Excellent, really made methink’

GET yOUR NEURAL INpUT TO JUNIOR DOCTORS. ADVERTISE HERE. CALL US ON 020 7684 2343.

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Wavelength International are looking for Junior Doctors with a desire to travel, for a variety of excellent training positions in coastal, city & country locations.

The combination of world class healthcare & unique range of lifestyle options makes Australia & New Zealand a great career move.

Our dedicated team give career & salary advice, assist with registration, migration & relocation.

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Relocation and home search specialists

We are always in need of good quality properties for our professional clients. Properties needed from one bedroom fl ats to fi ve bedroom family homes. Our exemplary tenancy selection process delivers professional fully referenced tenants from individuals to families.

Please call Carole or Vickie on 0844 335 6955 www.medicsonthemove.co.uk

A dedicated personal service

MPS professional support and expert advice

� 24 hour medicolegal emergencyadvice line

� Medicolegal publications– Casebook and New Doctor

� Risk management materialsincluding medicolegal booklets

� Online resources includingfactsheets and case scenarios

� Educational support throughdiscounts with leading publishers

There are many benefitsto membership:

The Medical Protection Society is the leading provider ofcomprehensive professional indemnity and expert advice todoctors. MPS offers support to members with legal and ethicalproblems that arise from their professional practice and activelyprotects and promotes the interests of members and the widerprofession.

For more information call 0845 718 7187Or visit www.mps.org.uk

The Medical Protection Society Limited. A company limited byguarantee. Registered in England No. 36142 at 33 CavendishSquare, London W1G 0PS.

MPS is not an insurance company. All the benefits ofmembership of MPS are discretionary as set out in theMemorandum and Articles of Association.

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