The lying doctor

By: Matthew Quinn Published: 27 February 2013 DOI: 10.1136/sbmj.f932 Cite this as: Student BMJ 2013;21:f932 The Dying President and the Lying Doctor: The Fate of FDR Peter Carson Book Guild Publishing 17.99; ISBN 976-1-84624-748-8 Rating: **** Respond to this article As a doctor, is it ever morally justifiable to lie toor indeed, foryour patient? This is one of the questions put before us in Peter Carsons book, The Dying President and the Lying Doctor: The Fate of FDR , which examines the maelstrom of mystery and lies surrounding the health of the United Statess longest serving presidentFranklin D Roosevelt (FDR). Described by Carson as Americas greatest wartime leader, FDR served as president of the US from 1933 to 1945. He played a fundamental role in ensuring the entry of the isolationist US into the second world war and in determining the fate of post-war Europe. He died from a bleed to the brain early into his fourth term as president in 1945, in mysterious circumstances. To further the intrigue, his medical records had disappeared from a hospital safe within 48 hours of his death.[1] The main focus of the book is FDRs fourth and ultimately fatal term in office, which he stood for despite being in the throes of extreme heart failurea fact kept hidden from the public. No competent doctor would have recommended the stress of standing for president after his diagnosis, and the public was unlikely to have re-elected to a fourth term a president suffering from severe heart failure. This leads Carson to discuss two intriguing questions: How much was FDR told about his condition? And how much should the public have been informed about his health? The lying doctor of the title is Admiral Ross McIntire, who was personal physician to FDR throughout the latters time as president. He was responsible for telling massive lies to the press about the presidents health. He also rejected the standard treatment . . . of digitalis and rest for heart failure, out of fear the news of FDRs ill health would leak out and weaken his position on the international stage. McIntire even appointed a cardiologist to FDRs care, whobizarrelywas instructed not to talk to his patient about his heart failure, raising the question of what medical advice was given to the president regarding his condition. Carson conjectures that McIntire must have decided not to advise the avoidance of nervous and physical strain, standard advice in heart failure at the time, as that would effectively mean telling Roosevelt he was not fit for the job (of president). McIntire also repeatedly told the public that the president was in excellent health, even publishing a book in 1946 giving a fictitious account of the presidents health in the run up to his death. Carson suspects that it was McIntire who removed Roosevelts medical records from the hospital safe, as they would have contradicted the book andworseuncovered the presidents ill health and the associated public deception. Apart from being an example of gross malpractice, McIntires actions also raise the question of disclosure how much do we as the public have the right to know about the health of our leaders? This issue remains highly relevant. For instance, before the 2008 US presidential election, John McCain released 1200 pages of his medical records to prove his fitness for presidencycompared with a one page letter exhibited by Barack Obama. This gulf serves to underline the inconsistencies present even today in medical disclosure by public figures.[2] Another fascinating aspect of Carsons book is the exploration of the what ifs? of medical treatment. For instance, Carson explores the implications of Winston Churchills heavy reliance on cigarettes and alcohol, and muses whether he used them as a crutch to support him through the stresses of leadership. Effective or not, would he have made the same decisions if he had followed medical advice and given up his habits? Would we be living in the same world if he did? The book is a fascinating read and raises intriguing questions concerning the ethics of confidentiality and the potentially catastrophic effects of patient mismanagement. Carsons well researched novel is an ideal read for anyone with an interest in medicines role in shaping world historyor indeed, in the simple tale of a man who overcame debilitating illness to become one of the greatest leaders of the 20th century.

Writing a medical case report Case reports have fallen out of favour, but they still have a role to play

By: Aimun A B Jamjoom, Ali Nikkar-Esfahani, J E F Fitzgerald Published: 13 January 2010 DOI: 10.1136/sbmj.b5274 Cite this as: Student BMJ 2009;17:b5274 Responses to this article (34) In this article: Boxes:

Box 1: Famous case reports Box 2: Evidence needed5 Given the unpredictable and challenging nature of medicine, many medical students will have come across a patient who has not been a textbook case. The patient may have presented in an unusual way, had a strange new pathology, or reacted to a medical intervention in a manner that has not been seen before. The publication of these novelties and curiosities as case reports has for many centuries been a fundamental way of sharing knowledge and conveying medical experience, and throughout history there have been famous case studies that have helped shape the way we view health and disease (box 1). There are those who argue, however, that case reports are increasingly irrelevant in current medical practice and education.[1] Their obscurity and rarity appeal only to the specialised few, and they add little to everyday medical practice. Their anecdotal nature lacks the scientific rigour of large, well conducted studies, and they have therefore fallen down the hierarchical ladder of medical evidence (box 2). Sadly, many medical journals now refuse to publish case reports. Top Box 1: Famous case reports Top Multiple myeloma William MacIntyre and Henry Bence-Jones contributed greatly to our understanding of multiple myeloma by recording the effect of this disease on Thomas Alexander McBean. They found that Mr McBeans urine was abound in animal matter. It is owing to this observation that the protein found in urine of patients with multiple myeloma is called Bence-Jones protein.[2] Top Mental health disorders Sigmund Freud, best known for his psychoanalysis and theories of the unconscious mind, also had a special interest in recording the case histories of his patients. Many of his case reports helped further our understanding of a number of mental health disorders, such as obsessive compulsive disorder (rat man), dissociative disorder (Anna O), phobias (Little Hans) and post-traumatic disorder (wolf man).[3] Top Dysphasia Brocas area, the speech production centre in the brain, was named after Paul Pierre Broca, a French physician and anatomist. He made his discovery while studying the brains of dysphasic patients. The first patient that he examined was nicknamed Tan because of his inability to say any word apart from Tan, which he repeated over and over. On postmortem examination Broca discovered that Tan had a fluid filled cavity in the left hemisphere caused by syphilis and concluded that this area is responsible for speech production in humans.[4] Top Box 2: Evidence needed[5] Category IEvidence from at least one properly randomised controlled trial Category II-1Evidence from well designed controlled trials without randomisation Category II-2Evidence from well designed cohort or case-control analytic studies, preferably from more than one centre or research group Category II-3Evidence from multiple case series with or without intervention or dramatic results in uncontrolled experiments Category IIIOpinions of respected authorities, based on clinical experience, descriptive studies, and case reports, or reports of expert committees. Despite their limitations, case reports still have a role to play in furthering medical knowledge and education. Their ability to flag up novelty means that they are still used to identify emerging pathologies. Case reports also hold valuable educational worth as brief clinical caveats. Many people find abstract medical knowledge easier to remember when linked to a patient. Different areas of medical education such as physiology, pathology, pharmacology, and anatomy are brought together in case reports and help students and doctors to develop a more holistic approach to patients.

Top Should I try and write a case report? Case reports help students gain a deeper understanding of a medical topic, but they also act as an excellent introduction to academic writing. Doing a literature review, structuring a manuscript, and learning how to submit and revise your article are skills worth developing early on. In addition to this, a published case report is a contribution (though small) to medical science and a way to get your name in print; it is also something that can be put on your curriculum vitae and help you stand out in future job applications. Top How do I go about finding a suitable case to report? As a medical student it is difficult to know when a case is unique or interesting enough to warrant reporting, and it is therefore important to make the most of help from your seniors. If youre in a clinic or on the ward and you hear a consultant mention that a case is rare, or that theyve never seen one like it before, its worth inquiring whether you could write it up as a case report. If you dont have the good fortune of coming across any suitable cases it is also worth asking if any of the senior doctors have cases that you could help them research and write up. Top Preparation When you have found a suitable case it is vital to do a number of tasks before you can start putting pen to paper. Top Literature review A literature review on a medical database such as PubMed, Ovid, or Medline can be used to check if there have been any similar cases; this helps you gauge how rare your case is. Top Liaising with doctors in charge It is very important to discuss writing a case report with the senior clinician in charge of the patients care. Not only must you gain their permission, but they will also help to provide guidance and advice. In addition, it is also worth discussing the case with clinicians of other specialties (such as pathology, radiology, and microbiology) who have played a role in the patients care. Top Gaining consent Check the journal guidelines carefully. It is extremely important to gain written consent from the patient if you wish to include pictures or clinical details from which they may be identified. During the consent process you must explain why you wish to share their case with others, the risks and benefits of doing so, and you must answer any questions they may have. Get senior help for this. Top Data collection When you have done your literature review, liaised with the senior doctor, and gained consent from the patient you can start bringing your patients case together. This involves finding his or her medical notes, laboratory results, imaging, and any other relevant material. Top How do I structure a medical case report? The basic structure of a medical case report is as follows: AbstractThis section is read by people trying to decide whether they wish to go on and read your full

case report. It is therefore vital to keep it concise (no more than 150 words) and snappy, and to encompass all the important aspects of your case, particularly highlighting what this adds to medical knowledge. Case reportIn this section you are presenting your patient to the reader. This should include a concise history and any relevant examination and investigation findings. It is important to include any relevant negatives based upon the potential diagnoses, but do not clutter this section with unnecessary detail. DiscussionWhen you have presented your case to the reader you are expected to put it into context in the discussion section. Here you give information about the condition or intervention in question, such as the basic epidemiology, pathophysiology, clinical presentation, investigations, and treatment. As you paint this picture it is extremely important for you to show how your case has differed from the norm and how this is contributing to medical understanding. Top Where can I get my case reports published? Given the reluctance of many journals to publish case reports these days, where are you to turn when you wish to share your newly written up experience of an interesting case? Fortunately, the vastness of cyberspace has allowed for the development of a new breed of medical journal. A number of new online journals such as BMJ Case Reports(www.casereports.bmj.com), Cases Journal (www.casesjournal.com), the Journal of Medical Case Reports (www.jmedicalcasereports.com), Radiology Case Reports(www.radiology.casereports.net/index.php/rcr), and the Journal of Dermatological Case Reports(www.jdcr.eu) allow the publication and dissemination of notable case reports. These allow doctors from all over the world to share their experiences of new and interesting cases. Although still in their infancy, these journals have the potential to act as large case banks that allow doctors to search for cases similar to ones that may be puzzling them, to help guide their management.

Arteriovenous fistulas Increasing numbers of patients with renal disease make knowledge of these vital

By: James P Hunter, Noelle Njeru, Michael L Nicholson Published: 05 March 2013 DOI: 10.1136/sbmj.f311 Cite this as: Student BMJ 2013;21:f311 Responses to this article (2) In this article: Figures: Junior doctors and non-renal secondary care doctors are encountering patients with renal disease in greater numbers than before. Many of these patients will have arteriovenous fistulas for haemodialysis. Arteriovenous fistulas, in which a vein is joined to an artery, are created surgically. After the procedure there is a substantial increase in blood flow and blood pressure through the vein, which dilates, arterialises, and can then be cannulated with dialysis needles to facilitate haemodialysis. Fistulas can be created using native veins or a prosthetic graft. Prosthetic grafts are used when all native veins have been exhausted. The rise in numbers of patients with renal failure is largely due to an ageing population with increasing rates of diabetes.[1] [2] In the United Kingdom, about 75% of patients with end stage renal failure will begin treatment with haemodialysis, and up to 40% will start treatment via central venous catheters. [3] These catheters have disadvantages that include high rates of infection, high rates of dysfunction, and damage to the central veins due to stenosis and occlusion. A fistula has the advantage of being done as a day case procedure under local anaesthesia and with a low early complication rate. The National Kidney Foundation guidelines state that 80% of patients beginning haemodialysis should dialyse via a native arteriovenous fistula.[4] [5] Fistulas must be looked after carefully to ensure that patency is retained for as long as possible. This requires knowledge of common complications such as fistula thrombosis, steal syndrome, infection, and swelling of the arm. The aim of this article is to provide an overview of arteriovenous fistulas for medical students and junior doctors. Top

What is an arteriovenous fistula? An arteriovenous fistula is surgically created to facilitate haemodialysis by anastomosing a vein to an artery. The creation of an arteriovenous fistula produces an arterialised venous channel, which has the combined advantage of the venous large diameter and the arterial high blood flow. The ideal arteriovenous fistula has the following features: Blood flow of at least 300 mL/min Large diameter, which facilitates venepuncture Sufficient length to allow two dialysis needles to be insertedone needle is arterial and the other venous Created by a simple and quick operation, preferably under local anaesthetic Good long term patency rate Central venous catheters and prosthetic grafts as access for dialysis have less favourable long term patency rates and higher complication rates than native arteriovenous fistulas. Figure 1 shows a fistula that is ready to be used for dialysis, and figure 2 shows the flow of blood through an arteriovenous fistula. 1 2

Fig 1 Mature right brachiocephalic arteriovenous fistula ready to be used for dialysis

Fig 2 Blood flow through an arteriovenous fistula. Arterial blood flows from the artery into the fistula and back into the circulation. Note the ligated vein preventing the development of venous hypertension Many patients undergo multiple fistula procedures during their time on haemodialysis. Typically, the nondominant arm is used first, and wrist fistulas are performed before elbow fistulas. Once all suitable native veins have been exhausted a prosthetic graft is used as the conduit. Top Fistula care for junior doctors Top Examining a fistula A fistula should be examined if the patient has new symptoms or has voiced concerns about their fistula. Such symptoms might include pain, swelling, enlargement, or difficulty in dialysing. To detect abnormalities, an awareness of the normal variation in fistulas is important. On inspection, fistulas range from being only just visible (fig 1), through to aneurysmal and unsightly (fig 3). A normal fistula will have smooth, unbroken skin (apart from the most recent needling sites) and should not be erythematous or inflamed. A palpable thrill (the tactile sensation of turbulent blood flow) should be present, and the fistula should be soft and non-tender. On auscultation, an audible bruit (the whooshing sound of turbulent blood flow) should be heard along the length of the fistula. 3

Fig 3 Aneurysmal fistula. Such fistulas look unsightly but have a negligible risk of rupture unless infection and skin necrosis are present Top Looking after a fistula Patients with arteriovenous fistulas are present increasingly on hospital wards, and many doctors are uncomfortable with their management and what is permissible in terms of venepuncture and cannulation. The general principles of fistula care extend beyond just looking after the fistula to include protecting the renal patients venous real estate. Such care ensures that veins suitable for future fistulas are safeguarded. This means, where possible, limiting venepuncture and cannulation to the dorsum of the hand and ideally avoiding venepuncture and cannulation in the same arm as an arteriovenous fistula.. Patients with arteriovenous fistulas usually realise the importance of fistula care and will often be forthright in telling healthcare workers what not to do with their fistula. Their views should be respected. Top Dos, donts, and myths about fistulas The ideal site for phlebotomy is on the dorsum of the hand of the arm without a fistula. This is not always possible, however, and there is a misconception that phlebotomy cannot be performed on the same arm as a fistula. There is no risk to fistula patency and no risk of damaging the fistula if phlebotomy is

performed from a vein distal to the fistula on the same arm. Furthermore, there is no concern about damaging veins for future fistula use because the next fistula will always be more proximal, not more distal, to the existing fistula. Phlebotomy from sites proximal to the fistula on the same arm is not advised because it requires placement of a tourniquet across the fistula, which should be avoided. For a critically ill patient, the dos and donts with fistulas are different. If a patient is peri-arrest and urgent blood tests are required, then phlebotomy from a fistula should be considered. A central venous sample from the femoral vein should be attempted first. However, if central venous sampling is impractical or difficult then venepuncture directly from the fistula using a 21-gauge (green) needle can be performed. It is a straightforward procedurethat is what the arteriovenous fistula was designed for in the first placeand is done by palpating the thrill and, much like an arterial stab, introducing the needle directly into the fistula. Once the blood has been collected and the needle removed, five minutes of direct pressure over the needle site will usually be sufficient for haemostasis. Many doctors will be uncomfortable inserting a needle into a fistula, but a delay in investigation and treatment, particularly if the patient is hypotensive for a prolonged period, can result in thrombosis and loss of the fistula. As a simple rule of thumb, intravenous cannulas should not be inserted into the arteriovenous fistula itself. This is because tributaries of the vein used to create the fistula, which were not ligated at the time of surgery, become arterialised and offer poor delivery to the circulation. Additionally, patients who have had multiple fistulas on the same arm will have impaired venous drainage and placing an intravenous drip could lead to substantial arm oedema. However, in a patient with haemodynamic compromise requiring urgent delivery of drugs or intravenous therapy, placing an intravenous cannula in a vein on the dorsum of the hand in an arm with a fistula should be considered in the absence of other options. Top How to manage complications of arteriovenous fistula formation Arteriovenous fistulas should be created at least six months before the need for dialysis, in anticipation of reaching end stage disease. Such patients can be found on general medical or surgical wards with health issues unrelated to their fistula. Furthermore, such patients are often encountered in final examinations at medical school. With these patients, remember to examine both arms carefully for current and failed fistulas and scars from previous arteriovenous fistula surgery. To score highly, inspect the jugular and subclavian regions for scars from previous dialysis catheters. Remember that such patients might also have had peritoneal dialysis catheters, transplant surgery, and a parathyroidectomy for renal hyperparathyroidism, and so the abdomen and neck should also be inspected for scars. Additional interventions are performed in up to 80% of new fistulas in the first year.[6] One problem after formation of an arteriovenous fistula is the high primary failure rate, which is up to 40% for radiocephalic fistulas and is due either to failure of the fistula to mature or to fistula thrombosis.Knowledge of potential complications in the early stages of fistula maturation after surgery can give a junior doctor the confidence to refer the patient to specialist care or reassure the patient appropriately. Top Thrombosis Fistula thrombosis is the commonest cause of fistula loss in an otherwise functioning arteriovenous fistula and should always be treated seriously. Immediately after thrombosis the patient often has pain over the fistula. The absence of a thrill on palpation and absence of an audible bruit on auscultation are diagnostic of fistula thrombosis. However, clinical examination can yield variable findingsfor example, a pulse might still be palpable, even in a completely occluded fistula, and this is due to transmission from the artery through the soft thrombus. Thrombophlebitis often follows in the first few days after thrombotic occlusion of a fistula, and on examination the fistula might appear erythematous and is often firm and tender. If thrombosis is suspected, an urgent duplex ultrasound scan will confirm the diagnosis. However, such investigation should not delay referral to the appropriate specialty for advice and further management. The renal team is the most appropriate first point of contact if local policy is unclear. After referral by the renal or surgical team, interventional radiologists will perform a percutaneous thrombectomy and perform an angioplasty on any stenosis, and this usually retains fistula patency Top Arm swelling Oedema after fistula formation is common. Postoperative swelling immediately around the site of surgery in the absence of signs of infection often occurs and usually improves within two weeks and does not require specialist review. Arm swelling distal to the fistula is due to impaired venous drainage or venous hypertension. Most patients with arm swelling after fistula formation will improve as the collateral circulation accommodates the venous return. Temporary arm swelling is not an indication for specialist

referral but persistent swelling or disabling hand oedema requires further investigation and referral to the surgical team is advised. Top Steal syndrome Steal syndrome is defined as hypoperfusion of the limb distal to the arteriovenous fistula. Oxygenated blood usually destined for the hand flows preferentially into the fistula causing distal limb ischaemia. Steal syndrome can occur at any time after formation of an arteriovenous fistula, even many years afterwards. It occurs most commonly in brachial artery fistulas and usually affects diabetic patients with small, calcified, and atherosclerotic vessels. Acute steal syndrome immediately after fistula formation might require urgent ligation of the fistula. Mild to moderate symptoms of steal syndrome usually improve as collateral circulation around the elbow matures. Severe steal syndrome with ischaemic rest pain and gangrene invariably requires referral to the vascular access surgeons. Top Infection Overall infection rates in renal patients are higher than in patients without renal failure because of the relative immunocompromised state caused by uraemia. However, wound infection rates after formation of an arteriovenous fistula are still relatively low, with rates of 2-3%.[1] Infection will usually present within the first three weeks after surgery. If the wound is erythematous without discharge and without substantial swelling, oral flucloxacillin or co-amoxiclav are appropriate first line antibiotics. If the wound is discharging or there is swelling or an abscess present, referral to the surgical team for review is indicated. Top Aneurysms False aneurysms, also known as pseudoaneurysms, are aneurysms that do not contain the three layers of the vessel wall. They are usually caused by leakage of blood via a needling defect in the fistula into the surrounding tissue. The result is a pulsatile mass, which is a haematoma being fed by a jet of blood from a defect in the fistula. Although rupture of the aneurysm is rare, the potential for local complications such as compression of adjacent structures, blood loss, and distal ischaemia means that urgent investigation and early intervention are crucial. The patient will present with a rapidly increasing pulsatile swelling overlying the fistula. True aneurysms are common in mature fistulas and, although often unsightly, in the absence of infection or skin necrosis, the risk of rupture is negligible. Nonetheless, referral to secondary care is reassuring for both the patient and referring physician.

Teaching safe consulting Learning to be a safe doctor needs to begin early

By: Paul Silverston, Lara Stewart Published: 05 March 2013 DOI: 10.1136/sbmj.e7791 Cite this as: Student BMJ 2012;20:e7791 Respond to this article Boxes:

Links A BMJ editorial highlighted the importance of teaching medical students to make rational decisions about diagnosis and treatment during patient consultations.[1] Although the importance of teaching communication skills alongside knowledge based skills is well established, a key component of rational decision making is often overlooked: safe practice. Safe practice aims to avoid serious errors in diagnosis and treatment. This can best be achieved by teaching student doctors to place patient safety at the heart of the consultation through adopting safe consulting practices, such as always excluding the worst, first when assessing a patient. For example, it is essential to exclude meningococcal disease when a child presents with a high fever, or to exclude a heart attack when a patient presents with chest pain. One of the authors (PS) has been teaching this

approach to consulting for several years and has received positive feedback from both student and junior doctors.[2] A fundamental concept in safe consulting is an appreciation of the relation between illness and the consultation procedure. Illness is a dynamic process, and this must always be taken into account when making a diagnosis and formulating a management plan. Doctors need to appreciate the risks entailed in making a diagnosis on the basis of an assessment made at a single point in time while the illness is evolving; this applies particularly to student doctors, who will be working in emergency medicine and primary care during their training programmes. Improved access to healthcare and greater public awareness of the symptoms of serious illnesses mean that patients are presenting earlier in the course of their illness, often with symptoms that are not yet disease specific. Safe consulting entails learning patterns of illness that include early presentations of illnesses, as well as later ones. Many illnesses share symptoms, particularly at their onset, so it is important to learn which serious illnesses need to be excluded in these patients and how to achieve this in practice. Diagnostic uncertainty is an inevitable consequence of the dynamic nature of illness. Student doctors can learn how to manage this by using a safety oriented consultation process, in which focused questions, clinical examinations, and investigations are performed specifically to confirm or exclude serious illness. The National Institute for Health and Clinical Excellence guidelines for the recognition and management of serious illnesses emphasise the need to adopt a patient safety centred approach during consulting, such as in the assessment and management of feverish illness in children.[3] Rational decision making and safe management planning should take account of the fact that misdiagnosis and treatment failure might arise from making an assessment at a single point in time while the illness is evolving. Key to safe management planning is recognising the importance of safety netting patients at the end of each consultation. Safety netting covers the possibility that the patients condition might worsen, either because the disease has naturally progressed or because of misdiagnosis or treatment failure. An example is the well established practice of giving patients verbal and written advice about what to look out for when being discharged from hospital after a minor head injury. Safety netting needs to be taught and practised. Safe consulting skills could be integrated into the existing consultation skills teaching, in the same way that communication skills have been included over the past 10 years. In response to an identified need to produce doctors who can communicate effectively, medical schools have incorporated training in communication skills into the undergraduate medical curriculum and ensured that these skills are formally assessed. Currently, up to 50% of the marks in objective structured clinical examinations (OSCEs) are awarded for showing good communications skills. Studies in the United States, Australia, and Europe, including the United Kingdom, have identified the need to introduce patient safety teaching into the undergraduate medical curriculum and to teach patient safety skills as a theme throughout the course.[3] [4] [5] [6] This was highlighted in the 2009 WHO Patient Safety Curriculum Guide for Medical Schools, which 10 medical schools worldwide are piloting. [7] The initial response has been mainly positive.[8]Stefan Lindgren, president of the World Federation for Medical Education, said that patient safety is a core attitude and thus needs to be introduced early. Safe consulting would fit into this curriculum. A 2012 report from the General Medical Council (GMC) showed that complaints against doctors are at record levels, with a 23% increase in complaints received by the GMC over the past year.[9] Poor communication skills have been identified as a major factor in many of the complaints, and this is being tackled within the undergraduate medical curriculum. The challenge for the next decade should be to introduce safe consulting skills training into the undergraduate medical curriculum and to make formal assessment of this compulsory, to encourage safe practice and to reduce the risk of complaints. This could be achieved either by including specific questions relating to safe consulting in all OSCE marking grids or by establishing a separate safe consulting station in the final year examination, at which, in the United Kingdom, a GMC examiner could be present. Passing the safe consulting component of the examination should be mandatory for qualification, in the same way as passing communication skills is now a requirement. Training in safe consulting skills should be an integral part of the medical course, along with anatomy and pathology. Medical educators have a responsibility to our student doctors, and to their future patients, to ensure that they become safe doctors.

Planes, trains, and poor medical students

By: Richard Pye Published: 27 February 2013 DOI: 10.1136/sbmj.f933

Cite this as: Student BMJ 2013;21:f933 Respond to this article Picture Tom: an enthusiastic fourth year medical student at the University of Glasgow; he is of a modest background, has two younger siblings, and receives little financial support from his cash strapped parents. He is therefore fully dependent on the Student Awards Agency for Scotland (SAAS), which provides him with a bursary and student loan. This money covers his rent in Glasgow, utility bills, and general subsistencebarely. He works a part time job at the weekend to make life a little more comfortable. And he gets by as students do: economically, frugally, carefully. Tom is allocated a 10 week surgery rotation at Inverclyde Royal Hospital, 25 miles from his flat in Glasgow. Despite the distance, accommodation is not provided on this placement, and Tom must make the round trip five days a week. This requires a return ticket on the subway (2.60 [3; $4]) and return rail ticket (9.00), totaling 11.40 daily, 58 weekly, and 580 for the whole placement. He also has a 10 week rotation at Hairmyres Hospital (costing 310 in travel), and five week rotations at Wishaw General Hospital (238), the Southern General Hospital (90), and Glasgow Royal Infirmary (60). Tom can expect to spend well over 1000 in travel expenses throughout his fourth year at medical school. He isnt too worried though. Thankfully SAAS provides a bursary for students who incur substantial travel expenses at universitydont they? Imagine Toms dismay when he learnt that SAAS has scrapped the travel bursary for medical students, leaving him and others in a similar position considerably worse off over the academic year. With money already tight, he is concerned, and considers his options: increasing his hours at work to the detriment of study time; taking out an expensive commercial loan; or borrowing from his parents. Although Tom is fictional, his story is based on fact, and his circumstances are regrettably common. Medical students across Scotland are affected by this abrupt change to the funding system, and many will struggle to fill the budgetary gap. Elective placements abroad might be cancelled; study and free time lost to a part time job; and further debt racked up in private loans. The circumstances are different in England, Northern Ireland, and Wales, where medical students remain eligible for bursaries to cover travel to clinical placements, although they now face the prospect of mammoth tuition fee repayments on graduation. Internationally, the provision of travel expenses to medical students varies, but many students abroad are likely to face the same budgetary difficulties as those in Scotland. In the United States, students are often reliant on gaining competitive scholarships to fund living expenses and cover their notoriously expensive tuition fees. I believe that travel expenses are crucial in ensuring cash strapped students can fully commit themselves to their studies and are not put at an academic disadvantage. Moreover, extra financial support may alleviate the need for private loans, reducing the burden of debt carried into the future. But for medical students across Scotlandand others around the world in similar situationsmaking that expensive daily pilgrimage to hospital, the financial outlook remains bleak. The long awaited first pay cheque cant come quickly enough. Medicine, interrupted

By: Isobel Weinberg Published: 05 March 2013 DOI: 10.1136/sbmj.f1209 Cite this as: Student BMJ 2013;21:f1209 Respond to this article Heroism is an overused word, but there is something heroic about Ryuki Kassais description of watching the 2011 Japanese tsunami flood towards the hospital he was working in. The earthquake was a terrible onethe strongest one that I have ever experienced. We could see the water coming to the foot of the hill. There was nothing to do but keep working. But how can medicine keep working in the midst of chaos? Medicine in the developed world has become inevitably and irretrievably technological. We rely on laboratories, scanners, and diagnostic tests, and,

more fundamentally, on the electricity and infrastructure that keeps them ticking. How can doctors continue when all that isquite literallyswept away? Rebecca Ghanis feature on p 10 gives some clues. What determines whether healthcare systems stay together or fall apart? Its the little things, suggest the doctors she interviews. One GP explains how her practice kept functioning after the New Zealand earthquake because their organisation had the doctors mobile phone numbers and so could text them crucial updates. By contrast, as Kassai explains, in Japan, general practices and small hospitals couldnt cope, and their closure caused terrible chaos. Patients with all kinds of problems presented to tertiary hospitals. In the rush to treat people who were seriously injured, those with everyday problemspregnant mothers, chronically ill peoplewere left without care. Does the idea of working in these kinds of circumstances terrify you? Or do you secretly feel a flash of excitement at the thought of having to step up to the plate? Despiteor perhaps because ofthe primitive conditions and desperate situation, some medics find a kind of purpose in a crisis. One of our personal views this month (p 42) is by Hannah Kirsch, a medical student whose routine ward rounds were interrupted when Hurricane Sandy hit New York City and she went to work in a storm relief shelter. The sadness and the solidarity she saw that night reminded her why she wanted to be a doctor. Despite the brief paper notes and hand mixed amoxicillin, she writes, what we did that night felt like a purer form of medicine. If this resonates with you, Guy Rughanis Careers article (p 24) looks at how to forge a career in crisis medicine. Finally, this month saw the publication of the Francis report: the outcome of the inquiry into one of the greatest scandals in the history of the NHS. Stories of patients at the Mid Staffordshire Trust being denied water and lying in soiled bedsheets have been repeated into infamy. See p 20 for our round up of the reports recommendations and implications. Calls are already being made for change at all levels of the medical profession: medical school recruiters are being asked to consider traits such as compassion when selecting future doctors (p 4). The message for medical students and junior doctors is clear: anyone who has concerns about a patients welfare is obliged to raise them. Mark Porter, the head of the BMA, said: We must no longer accept the attitude that [raising concerns] is someone elses job.

Make no mistake

By: Isobel Weinberg Published: 11 December 2012 DOI: 10.1136/sbmj.e8151 Cite this as: Student BMJ 2012;20:e8151 Responses to this article (1) Everybody makes mistakes. But those made by doctors tend to have more severe consequences than most. Consider the story of Gary Brandeland, discussed in this months Careers article, Making a mistake (p 26). Twenty years ago, his patientJoydied after a caesarean section in which the nurse anaesthetist intubated her oesophagus and forgot to attach a pulse oximeter. This doubtless changed things irrevocably for Joys family, but Brandelands life was also changed. To this day, Im still amazed at how other peoples lives just continued as if this event never happened, he wrote. In our article on p 18, four senior doctors write about errors theyve made while caring for their patients. They focus on what they learnt from their mistakes. Simon Eccles writes, Within two weeks of my first registrar post, Id made an error that nearly cost my patient her life . . . My biggest lesson was that as a registrar you dont know as much as you think you do. Their message is clear: we can prevent errors in medicine if we design safe systems and take opportunities to learn from mistakes. This has become the focus of the patient safety movement. Why should medical students care about safety? Liam Donaldson answers exactly that question in his contribution to the feature. Medical students are important in patient safety, he says, not only because they are tomorrows doctors, but also because they can play an important role in spotting and surfacing risks . . . and occasionally challenging unsafe practiceshouldnt you clean your hands, sir, before examining that patient? But this kind of attitude takes bravery. And results arent always encouraging. In her article on whistleblowing (p 14), Nicole Needham cites the stories of three studentsall of whom wanted to be quoted anonymouslywho tried to raise issues about bad practice theyd seen on the wards. In all cases, their concerns were dismissed. Despite this, it is worth keeping faith. After all, as Nicole Needham

explains, doctors and medical students have a professional obligation to point out poor practice when they see it. Other articles in our medical mistakes cluster this month include an interview with Lucian Leape (p 28), who left a career in surgery to spearhead the patient safety movement, and a review of a new book which says we still have a long way to go in making hospitals safer (p 43). Also this month, Gemma Petts and colleagues write about what happens at an autopsy, and how medical students who get the chance to see one should approach the experience (p 33). It is no longer routine for medical students to see a postmortem examination, but we asked some of those who had to write about it (p 12). They found the experience a valuableif distressingone. Finally, if youve recently begun learning in a clinical environment full time and are feeling bewildered, our careers article (p 21) will help. Henry Murphy explains how to make the most of your time and plan study effectively. To prepare for objective structured clinical examinations (OSCEs), he says, you need to practise examinations continually and push yourself out of your comfort zone. Just dont make a mistake.

Controversies in care

By: Isobel Weinberg Published: 05 February 2013 DOI: 10.1136/sbmj.f524 Cite this as: Student BMJ 2013;21:f524 Respond to this article Hospitals bribed to put patients on pathway to death, screamed one recent Daily Mailheadline. Now sick babies go on death pathway, was another. The death pathway in question is the Liverpool care pathway (LCP), a clinical tool for caring for dying patients. It offers a framework for suspending unnecessary treatment and prioritising the patients comfort. But the Daily Mail has claimed that the doctors in the UK are killing patients to meet targets by using the pathway to withdraw feeding. Euthanasia by the back door, they have termed it. Our article on p 11 criticises the media coverage, and points out how at odds it is with the Daily Mails previous stance on dying well. In the media hysteria, doctors have defended the pathway. Our editorial (p 9) takes a balanced look at end-of-life care pathways, advocating their use but pointing out that even experienced doctors may struggle to recognise when a patient is dying. Katherine Sleeman and Emily Collis write that, Care on the LCP will only be as good as the health care professionals providing it. Their education article (p 28) is a comprehensive overview of care for dying patientsimportant for medical students who will suddenly be tasked with this as junior doctors. Moving from care to palliation can be difficult, they say. But it is needed if we are going to provide a high standard of care and meet individuals needs. There is more than one way to die well, they write. What will it be like, watching your patient die? We asked medical students and junior doctors to write about their recollections of the first patient they saw die (p 12). If youve found this distressing to witness, youre not alone. Our authors experiences were broad, but the impact it had on them was consistent. I imagined the patient with fuller cheeks and out of a hospital gown, and felt devastated, writes one junior doctor. Elsewhere in the magazine, Elizabeth Elmsely writes about the struggle to provide good healthcare to people with albinism in Tanzania and other African countries (p 20). Although this might sound niche, albinism has a particularly high prevalence in Tanzania, and pale skin combined with a lack of education on the dangers of the sun mean that skin cancers are endemic. So dermatology training and treatment centres have been set up to improve the situation. The problem? People with albinism struggle to attend the clinic. They are routinely persecuted and maimed because of a superstitious belief that their body parts can be lucky talismans and so live most of their life in hiding. Elmsely writes about the slow improvements that are under way.

Some things never change

By: Isobel Weinberg Published: 16 November 2012 DOI: 10.1136/sbmj.e7405 Cite this as: Student BMJ 2012;20:e7405 Respond to this article Medical students consider themselves special. We like to think that we are set apart from other students by our onerous course and the responsibilities that lie ahead. Has becoming a doctor always been like this? In his feature, Toby Pitts-Tucker takes a look at the history of medical education (p 12), starting with students who learnt from Hippocrates in ancient Greece, and progressing through to the medieval universitiesin which students endured three hour lectures. Much has changed since then, starting with the curriculum. Medical students in ancient times were taught that diseases resulted from imbalances between bile and phlegm, which seems nonsensical now. On the other hand, plenty has stayed the same. Medical students through the ages have endured long periods of study and heavy memorisation. Whats more, medical students have always believed they have it tough. The time I should spend at lectures and in study I am driven to waste in begging from door to door. Perchance I get a dirty scrap of bread which a dog would reject, or I may get fusty beans, bits of skin or gristle, or sour wine, wrote one student in 15th century Bologna. On reflection, perhaps they did have it tough. One surprisingly recent innovation in medical education is the exam. Although examinations now seem an omnipresent feature of medical school, the idea of testing students on a recognised curriculum didnt take shape until the middle ages. But assessments have persisted. And, if youre aiming to be a junior doctor in the UK, there is a new test on the horizon. The Situational Judgement Test (SJT) is the latest addition to the Foundation Programme application. In their Careers article (p 22), Siobhan Fitzpatrick and Paul ONeill discuss the rationale for moving to this system of assessment. Mahibur Rahman (p 25) explains how students should tackle these questions to maximise their score. As he explains, the SJT has the potential to have a bigger impact on your application than previous educational attainment, degrees, publications, and prizes combined, so it is worth spending time preparing. After all, as Helen Jaques reports in News (p 4), this year the foundation programme was oversubscribed once again. If youd like to make your medical education a bit unusual, have you thought about trying your hand at medical journalism? This month, we open applications for the Clegg scholarship (p 24). Its a two month internship in the BMJ offices for medical students, and will allow you to have a go at writing, editing, or anything else that interests you. Now that would make an exciting change.

Pills, pills, pills

By: Isobel Weinberg Published: 18 October 2012 DOI: 10.1136/sbmj.e6523 Cite this as: Student BMJ 2012;20:e6523 Responses to this article (1) How good is your prescribing? Not very good at all, if statistics are to be believed. Junior doctors make nearly a fifth of prescribing errors; just 35% of medical students have filled in a drug chart more than three times before qualifying. The blame is being laid at the feet of inconsistent and inadequate clinical pharmacology teaching in medical schools. One pharmacology professor described teaching in French medical schools as insufficient, uncoordinated, and likely to get worse. (p 10) The British Pharmacological Society and the Medical Schools Council have proposed a solution: a UK prescribing exam which all medical graduates would have to sit in their final year to qualify. By asking students to answer practical questions based on real life prescribing scenarios, the test aims to prevent underqualified graduates slipping through the net. Pilots have gone well; the test will be optional this academic year and may be compulsory after that. If implemented, a prescribing assessment would be quite a change in UK medical education. But do we need what would amount to, for the first time, a national qualifying exam? Emilie Green examines the arguments in favour and against in her feature (p 10).

If the thought of a prescribing exam makes you quake, then help is at hand. Georgia Woodfield and colleagues have produced Practical Prescribing, a guide to common errors (p 34). Pharmacology teaching, they say, focuses on choosing a drug to prescribe, but often the knack is knowing what not to give. With this in mind, they provide an accessible guide to important contraindications. For instance, a patient with hyperkalaemia must have potassium supplements crossed off their drug chart. Sounds absurd? It happens, the authors say. And they give plenty of other warnings which arent so intuitive. Does memorising prescribing information still seem too onerous? After all, wouldnt life be easier if, rather than having to learn and prescribe a raft of drugs, there was one wonder pill that could be dispensed over and over? Enter the polypill, a combination of six drugs including a statin and an ACE Inhibitor, to be taken as a preventative measure by all those with risk factors for cardiovascular disease (or, more controversially, by everyone over 55 years). The idea was conceived by professors Wald and Law in 2003, but, as Tom Fahey and Emma Wallace explain in their editorial (p 8), the polypill has struggled to make it into clinical practice. So, its time to give your prescribing skills an upgrade. Will you be dutifully reaching for your textbooks or crossing your fingers for the introduction of the polypill?

Welcome to the grindstone

By: Isobel Weinberg Published: 07 September 2012 DOI: 10.1136/sbmj.e5534 Cite this as: Student BMJ 2012;20:e5534 Respond to this article Summer is fading fast, and a new academic year looms. As medical students wipe dust from battered textbooks and shuffle reluctantly back to lecture halls and wards, they will be experiencing a mix of emotions. A new term brings excitement, optimism, but alsofor someapprehension at returning to the grind. We all know how taxing the demands of medical training and clinical practice can be. The statistics are shocking but no longer surprising: healthcare workers have higher rates of depression than other professionals; one in 15 doctors experiences drug or alcohol dependence at some point. How do medical students cope with the strains of their workload? We all have different ways. Binge drinking is generally cited as one of the more prominent copingor rather, not copingstrategies, with inebriated medical students supposedly spending weekends cluttering the hallways of emergency departments that theyll have to work in on Monday. At least, so says student folklore. But are medics the hard partiers they fancy themselves to be? Or has the apparent booze culture been cooked up by a combination of irresponsible MedSoc advertising and medical student bravado? Emma Rourke considers medical students relationship to alcohol in her Life article (p 20). If medical students arent boozing for consolation, are they turning to other illicit substances to keep up with the pace of their studies? Weve all heard rumours of so called cognitive enhancement, where psychiatric drugs are used off label. The hearsay is tantalising: modafinil will banish tiredness, methylphenidate (Ritalin) lets you concentrate. Meher Lad argues that medical students have a special duty to consider the ethics of these uses: not only do we have to decide if we are going to take these drugs, but if we are willingone dayto prescribe them (p 18). But if some medical students pop pills to work longer and later, while others drink their sorrows away, there is always a third sort. The gamers. You know their kind: when exams loom, theyll cope by putting in extra hours on the X-Box or Nintendo Wii. In his feature, Rhys Davies sticks up for these procrastinators, looking at the possible value of video gaming to medicine (p 14). This month, we also take a look at medical leadership. Despite enduring criticism for being a somewhat nebulous concept, leadership is gaining prominence in medical schools and postgraduate training. Aniket Tavare and Peter Lees discuss this trend (p 10), while Varo Kirthi and colleagues offer advice for career minded students who want to stay ahead of the leadership curve (p 22) and Toby Pitts-Tucker makes a personal plea for the necessity of leadership (p 42). Whether leadership features on your medical schools curriculum or not, I wish you luck with the strains of the coming academic year, regardless of whether your coping strategy of choice is vodka, Adderall, or Super Mario Bros.

Junior doctors in an acute care setting Better practical training and supervision are needed

By: Gary Smith Published: 26 March 2012 DOI: 10.1136/sbmj.e1331 Cite this as: Student BMJ 2012;20:e1331. Responses to this article (5) The General Medical Councils (GMC) Tomorrows Doctors lists 16 outcomes, all of which medical students must achieve by the time they graduate . . .in order to be properly prepared for clinical practice and the Foundation Programme . . . .[1] One of these is the provision of immediate care in medical emergencies that is, acute care, which includes the ability to assess and recognise a patients severity of illness, diagnose and manage acute medical emergencies, and provide life support. A separate outcome is the ability to prescribe drugs safely, effectively, and economically. It is worrying that the authors of a review of 10 studies describing the educational impact of UK medical school training on graduates preparedness to begin clinical practice have reported that graduates perceive themselves to be less well prepared in acute care and prescribing than in the other 14 outcomes. [2] All 10 studies used questionnaires, face to face interviews, or focus groups. Four studies could not be included in the quantitative analysis of graduates self perceptions or those of their professional colleagues.[2] The remaining six provided quantitative assessments of preparedness from 12 groups of graduates and eight groups of the graduates professional colleagues. The validity of data provided in these is uncertain, as only 17 of 20 assessments provided questionnaire response rates and almost half of these had rates below 50%.[2] Data from one of the included studies pre-date 1990[3] and their relevance could be questioned, given changes in medical education, patient case mix and clinical working environments since then. Excluding this study, the total numbers of graduates and their professional colleagues providing opinions on which the review authors conclusions are based are 1051 and 705, respectively, over seven years.[2] The opinions of such small groups may not necessarily represent those of the wider graduate population or their professional colleagues. Nevertheless, there is a common theme of perceived poor preparation in acute care running through all 10 studies. So why should newly qualified doctors feel this way? The management of acutely ill or deteriorating patients is complex and stressful.[4] Clinical scenarios often develop rapidly, and fears of poor patient outcome, error, complaint, and litigation are common. Doctors are often required to integrate a varied and large amount of information, while concurrently treating a patient who has no diagnosis. Many newly qualified doctors report difficulty in transferring their considerable theoretical knowledge to practice.[5] Although they feel confident that they can describe what they should do to treat a given condition, they often freeze in emergency situations because they have never been taught how to do it. For some, their expectations and the perceived expectations of their senior colleagues create a tension between the desire to ask for help and the worry that this will be seen as a mark of failure.[6]Similarly, tension can exist between the desire to help an acutely ill patient and the fear that doing the wrong thing could worsen the patients condition and outcome.[5] Perceptions do not always reflect reality; but is there evidence that newly qualified doctors really arent equipped to manage acutely ill patients? Most is circumstantial. More than half of patients admitted to intensive care units from wards receive suboptimal care which, at least in part, has been delivered by newly qualified staff.[7] Junior doctors often provide emergency care that . . .would be improved by greater consultant input and supervision . . . .[8] The early death rate for patients increases in the week immediately after the changeover of junior doctors.[9] Patients are also less likely to be treated promptly and are more likely to die if they are admitted to hospital at the weekend, with the chances of survival being better where more senior doctors are on site.[10] Studies have shown that some trainee doctors possess poor knowledge of aspects of acute care,[11] and in the latest review,[2] the healthcare staff working alongside newly qualified doctors appear to judge them as less well prepared in acute care than in the other Tomorrows Doctors outcomes. It is easy to suggest that research is required to evaluate if, how, and to what extent under-preparation in acute care influences new graduates performance and patient outcomes. Whatever the results, is it acceptable for the least experienced clinician still to be the first responder to a sick or deteriorating patient? The concept of patients being attended by the right person . . . first time is accepted for medical admission units,[12] so why not apply this principle to general hospital wards? The GMC is explicit that students who are unable to provide immediate care in medical emergencies . . . must not be allowed to graduate with a medical degree . . . .[1] Ensuring that every medical student is taught the practical aspects of how to manage the most common medical emergencies, and is assessed to be competent at the bedside, is not only time consuming but perhaps unachievable at least before graduation in the current educational model. Perhaps we should accept that graduation from medical school does not currently equip newly qualified staff to deal with medical emergencies. Doing this would

lead hospitals to face the fact that, for patient safety reasons alone, urgent care should be provided by staff that have been properly and appropriately trained to provide it.

Widening access to medicine for under-represented groups Defining under represented is far from straightforward

By: Chris McManus Published: 29 May 2012 DOI: 10.1136/sbmj.e3407 Cite this as: Student BMJ 2012;20:e3407 Responses to this article (1) Diversity matters in universities. As in natural ecosystems, variation and interactions underpin innovation and resilience. As Robert J Sternberg says, Without diversity, the intellectual life of a [university] campus is constricted. People may come to believe that their own point of view is the only sensible one, or even the only one.[1] Different medical schools can produce graduates with different outlooks,[2] but creating effective diversity is difficult. Widening participation, according to the Higher Education Funding Council for England, means that people with the potential to benefit from successful participation in higher education should have the opportunity to do so, which is vital to creating a fairer society, improving social mobility, and supporting economic growth.[3] Student diversity, however, which relates to access and participation, inevitably depends upon which applicants are selectedalthough obviously selectors can choose from those who apply. Nor does diversity among entrants always result in diversity of interaction, as students with similar backgrounds tend to associate more closely than do those from more diverse backgrounds,[4] and the result is sometimes a college that looks diverse on paper, but is not as diverse in terms of actual student interactions.[1] The emphasis in medical student selection has traditionally been on academic attainment, which has been shown to be a valid selection criterion,[5] although recently there have been concerns about grade inflation, undue influence of secondary schooling, and over-represented private sector students underperforming at university.[6] In 2006, a consortium of UK medical schools introduced the UK clinical aptitude test, UKCAT, which aimed to predict performance in medical school and beyond, and to increase the diversity of medical students, but whether or not UKCAT predicts medical school performance is unclear.[7] Tiffin and colleagues[8] have now published an important but statistically complex prospective cohort study of UKCATs impact on widening access. Their study looked at the outcome during selection of 8459 applicants who made 24844 applications for entry to UK medical schools in 2009. The 22 consortium members used UKCAT differently, allowing a comparison of UKCATs effectsseven schools used UKCAT strongly, taking only those students who passed a threshold score; nine schools combined UKCAT with other information as a weighted factor; and six schools used light-touch UKCAT, for borderline cases. The results strongly suggest that schools using UKCAT have broader access, with threshold schools admitting more candidates from low socioeconomic backgrounds. Knowing what the study actually means is more difficult. Firstly, is UKCAT itself responsible for widening access? Not necessarily. Even if applicants received random lottery numbers for admission into medical school, then schools that selected students solely using those lottery numbers would have wider participation, as any potential bias from other selection processes, such as educational achievement, would be excluded. The entrants would then be a random, representative sample of applicants. An additional and difficult problem is defining under-represented groups. In the published study, somewhat unexpectedly, men are a disadvantaged category because they are less likely to be accepted, and there is clear evidence that females are over-represented in medical school intakes, compared with the UK population.[8] Those dual principles are clear, if debatable, particularly because not all categories in the study met them: for instance, non-white applicants were over-represented30% of medical students are non-white compared with 17% of the population. Especially contentious is the group who have low academic attainment, defined as below the median level of medical school applicants (grades of ABB at A level (secondary school) in these data), whom the study shows are less likely to be accepted. As an argument for disadvantage, though, this is surely wrong. Would it also mean that, for example, unfit people are disadvantaged in selection for the Olympics 100 metre final? The meaning of UK population as discussed by the authors is also problematic, when (in England and Wales) 59% do not take A levels and 5% have no GCSEs.[9] Should all such attainment levels be represented (and if they dont apply, should we seek them out?). If reflecting population proportions were really such an unassailable ideal in selecting medical students then why dont medical schools do it properly? As a thought experiment, consider a scheme whereby each year medical schools offer places to a randomly selected 8000 people. Young and old, men and women, rich and poor, honest and criminal, sane and insane, and bright and less able, all would be

present in population proportions. If few medical educators would subscribe to that process, it presumably is because most recognise that educability and suitability are key attributes of competent medical professionals Population proportions alone clearly cannot determine policy on admissions. That is why the Higher Education Funding Council for England talks instead of equality of opportunity and of ensuring success in programmes of study. Whether groups with low academic attainment actually do become successful, competent doctors, or perhaps instead continue to underperform, is the key empirical question here, which is now beginning to be explored,[10]and the answers will have important implications for selection and healthcare. Outcomes, therefore, matter as much as intakes. Widening access needs to reconcile possible benefits from a broader spectrum of students, with possible risks from technically less able doctors. The inevitable calculus of equity and efficiency[11] is ultimately not statistical, but political.[12]

A man with a human bite to the finger

By: Kartika Selvam, Kuen Chin, Alok Misra Published: 05 March 2013 DOI: 10.1136/sbmj.e7296 Cite this as: Student BMJ 2012;20:e7296 Respond to this article In this article:

A 29 year old man presented to the emergency department with increasing pain, redness, and swelling of his right middle finger. Two weeks previously he had been bitten during an alleged assault, but had not sought medical attention. Examination of the digit showed a discharging sinus at the distal inter-phalangeal joint level on the dorsal surface, with swelling, localised erythema, tenderness, and reduced active and passive motion (30 degrees active and passive flexion compared with 45 degrees on the opposite side). 1 2 Systemically, the patient was apyrexial and had normal vital signs. Routine investigations showed a normal white cell count, a C reactive protein of 52 (normal range: < 5 mg/L). He had two radiographs takenanteroposterior and lateral. The lateral radiograph is shown. Top Questions (1) What does the radiograph show? (2) Based on the case history and radiograph, what diagnosis does this patient have? (3) What other investigations may be helpful? (4) How might this patient be managed? (5) What are the possible complications of this presentation? (6) What are the micro-organisms typically isolated in a bite injury? Top Answers (1) This is a lateral radiograph of a right index finger, showing soft tissue swelling, osteopaenia (shown by increased radiolucency), metaphyseal rarefraction, cortical destruction, loss of joint space, and joint destruction. These findings are suggestive of osteomyelitis, which is an infection of the bone or bone marrow that complicates 1-6% of hand infections.[1] During early infection, <5% of patients will

demonstrate changes on plain radiographs; however, this rises to 90% by three to four weeks.[2] False positives include healing stress fractures and benign or malignant bone tumours.[2] (2) The patients history of a human bite and no treatment suggests that he is at high risk of developing infection. A human bite in the finger would lead to a breach in skin integrity and introduction of microorganisms into the wound. With close proximity of the wound to soft tissues (skin, tendon), bone and joint, infection spread occurs readily in the digit, leading to cellulitis, tenosynovitis, osteomyelitis, and septic arthritis.[3] Pain, erythema, swelling, and reduced range of movement in the patients finger suggests that there is cellulitis and tenosynovitis. Radiographical findings with features described in question 1 show evidence of osteomyelitis and septic arthritis. (3) Blood tests including white cell count, C reactive protein, and erythrocyte sedimentation rate, though non-specific, are common but useful baseline levels to obtain as markers of response to treatment. [1] Plain radiographs are mandatory for further investigation. If radiographic findings show no indication despite strong clinical evidence, other types of imaging including computed tomography, magnetic resonance imaging, and bone scans can be carried out. Computed tomography scans highlight periosteal new bone formation, cortical destruction and sequestra or involucrum in later stages.[2] The sensitivity of magnetic resonance imaging, with gadolinium enhancement, is 92-100% and is reserved where previous investigations are inconclusive.[2] Abnormal marrow is detectable early (T1 weighted images) in osteomyelitis.[3]Rarely used investigations such as bone scans (99m-Tc MDP), detect early infection (focal hyperemia, hyperperfusion, and uptake) with high sensitivity and, if white cell labelled, high specificity, too.[2] Microbiology culture of a bone biopsy or sub-periosteal aspirate obtained on the operating table would isolate the organisms to confirm the diagnosis and guide antibiotic treatment.[4] (4) After a bite injury, the tetanus status should be determined and a booster dose offered to patients who are not immunised or whose vaccination status is unclear.[3] Human viral transmissionfor example, HIV1, hepatitis B, hepatitis C, and herpes virusesis possible and post-exposure prophylaxis is recommended if risk concerns exist.[3] Surgical debridement and wound washout is the first-line treatment in the management of deep seated infections and human bite injuries. Surgery permits the submission of tissue samples for investigation (microbiology and histology) and definitive diagnosis.[1] Any remaining tissue is irrigated, to washout residual contaminants and debris. Further intra-operative debridement and washout may be required until infection resolution.[1] Complex tests, such as computed tomography, magnetic resonance imaging, and bone scans, should not delay this intervention. Empirical broad spectrum intravenous antibiotics to cover skin and human oral flora should be started pending microbiological results.[3] [4] In our department, coamoxiclav is the antibiotic of choice. Longer term treatment requires conversion of the antibiotics to the sensitivities of the isolated micro-organism or micro-organisms.[1] The type and duration of antibiotic (or antibiotics) should involve discussion with a microbiologist. Patient factors including co-morbidity and adequacy of debridement can also affect antibiotic choice and duration of treatment. Good bioavailability, bone penetration, and low toxicity are important considerations in prolonged oral courses (usually four to six weeks).[3] [4] (5) Infected bone can weaken, causing pathological fractures. Partial tendon, nerve, vessel, or bone injury might become apparent only after surgical exploration.[4] Immunosuppressed patients risk systemic sepsis, including toxic shock syndrome.[4] Pain, joint stiffness, and finger deformity commonly follow surgical management in osteomyelitis. [1] Despite adequate management, up to 30% of patients with osteomyelitis will have recurrent infections.[1] Amputation can provide relief from these complications.[1] (6) Human saliva is highly infective. All human bite wounds should be considered infected and can contain up to five different strains of micro-organism.[3] A common isolate (25%), exclusive to human saliva, is eikenella corrodens, a gram negative, facultative anaerobic rod. Other bacteria include and haemolytic streptococci, staphyloccus aureus, staphyloccus epidermidis, and corynebacterium.[3] Top Patient outcome The patient declined surgical intervention although he had all the above complications. Empirical intravenous antibiotic treatment was started on microbiological advice. Despite careful counselling about the likely poor outcome of this single approach, the patient declined surgery and self discharged from hospital. Kartika Selvam, foundation year 2 doctor1, Kuen Chin, registrar1, Alok Misra, consultant 1 1plastic surgery, Wexham Park Hospital, Slough, UK Correspondence to: kselvam@doctors.org.uk Competing interests: None declared. Patient consent obtained. Provenance and peer review: Not commissioned; externally peer reviewed.

After the storm

By: Hannah Kirsch Published: 27 February 2013 DOI: 10.1136/sbmj.f949 Cite this as: Student BMJ 2013;21:f949 Respond to this article Boxes:

Links By my third year of medical school, wearing a white coat every day had lost its lustre, and I had become discouraged by the increasingly fervent screeds against becoming a doctor. From blog posts by former doctors to dire political predictions about the future of healthcare, it seemed that a career in medicine could no longer provide me with the satisfaction Id hoped for. And then, two weeks from the end of my pediatrics rotation, Hurricane Sandy slammed into New York City. I spent a physically and emotionally exhausting four days helping to evacuate patients from our two teaching hospitals. Once that was over, I sought to stave off my grief by working overnight at a high school turned evacuation shelter in one of the hardest hit areas with one of the surgeons who supervises me. I expected to be handing out a few ibuprofen tablets for headaches and drifting off to sleep. Instead, I experienced a 12 hour microcosm of the patients who flow in and out of our hospitals every day. One woman complained of pain who, on further questioning, felt utterly alone in her attempts to care for her children on her husbands salary. Her home was now in pieces. Teenage boys came with insulin syringes belonging to various members of their family to be stored in the same medical refrigerator that held pink bottles of methadone. Feverish toddlers arrived, cradled in their exhausted mothers arms. Then there was the woman who was faced with an intensely personal and difficult decision about her health and future. She started to cry silently in the converted office that was the shelters clinic. She told me how making this decision would have been hard even in the comfort of her now waterlogged home. My teachers had always extolled the value of silence, and I realised the truth of that statement holding this womans hand. That night, I stopped thinking of myself as a medical student or a future specialist. I forgot to think of the surgeon I was with as someone who is constantly evaluating me. I neglected to recall that, often in medicine, writing notes at the computer takes precedence over spending five more minutes with a patient. Instead, I remembered that I want to be a doctor. That statement should be trivial; after all, Ive spent three years at medical school. Yet that night in a converted high school was one of only a handful of moments in which I have felt that desire with total conviction. The solidarity among disaster victims freed me to spend my time with anyone who needed an analgesic, a syringe of insulin, or a caring touch from a stranger. Despite the brief paper notes and hand mixed amoxicillin, what we did that night felt like a purer form of medicine. Of courseand thankfullythe opportunities born of disaster do not last. My classmates and I will return to our disrupted routines, and the refugees I met will return to their homes and their regular doctors. What will last in me is the full embrace of what this profession means. I will remember the people who did not need a student or a surgeon, but who did need someone to look them in the eyes, smile, and spend a few minutes with them as if they were the only patients we had ever had. It will keep me wanting to be the best possible doctor despite the fatigue and paperwork and politics: remembering that overnight shift where I was able to do so much with so little.

Everybody Lies

By: Sidra Maqsood Published: 15 October 2012 DOI: 10.1136/sbmj.e6284 Cite this as: BMJ 2012;20:e6284 Responses to this article (1) Before I started medical school, the small insight into doctor-patient relationships I acquired came from

medical television dramas. House was a particular favourite. The protagonist, Dr House, is a resolute misanthrope who contradicts the customary benevolent depiction of the medical profession with his notorious slogan, Everybody lies. As an aspiring medical student, in awe of Houses genius, I assumed he was fibbing a little himself with this generalisation and dismissed it as an illustration of his unique cynical charm. Yet, as I progress through medical school, I realise that he was giving some honest advice. A typical scenario is that you approach a patient with smiles and enthusiastic professionalism, introduce yourself, and obtain consent to talk. You carefully and patiently dissect the patients story, translating it into medical terminology. You empathise and discuss the effect of the illness on their lives, all the while maintaining open and calm body language. After performing a relevant examination, you thank the patient and leave. You walk towards the nurses station with a spring in your step, confident you have obtained a detailed history. You reach for the patients notes, certain that all that will be required is a cursory review. Flicking through the recent notes, you are struck with disbelief as you scan a three page list detailing a complex medical historyall of which the patient had completely failed to mention. It is at this point that I envision a hobbling Dr House, gruffly snarling, Well, duh . . . what did you expect? Everybody lies. In such situations, students are liable to perceive the encounter as a personal affront. This is disheartening at a crucial stage in medical education, when essential history-taking experiences are being acquired. Self doubt and frustration could reduce a students confidence when clerking patients in future.Ironically, experiences at medical school can be at odds with the inherent principles of medicine; at particularly stressful times of the academic year, it is an environment that necessitates some self absorption. Drowning in a swirl of deadlines and revision, students can become selfish; it is often easy to dismiss difficult clinical encounters without attempting to reflect and learn from the experience. Students should remember that, in encounters between medical students and patients, the student is benefitting most from the interaction. Consequently, it should come as no surprise that some patients are hesitant to divulge all instantly, especially when the person asking the questions has no involvement in their care. At the same time, there could be circumstances where the patient is embarrassed, or confused about their medical history and therefore inclined to avoid the truth. So, the next time a similar situation arises, do not be disheartened by the apparent duping. Take a moment to consider the patients reasons for keeping schtum, and be appreciative that someone has freely volunteered their time to speak to you without demanding anything in return.

Bitten by the bug

By: Michelle Hall Published: 07 November 2012 DOI: 10.1136/sbmj.e7150 Cite this as: Student BMJ 2012;20:e7150 Respond to this article So, Im a hypochondriac. A self confessed hypochondriac. I have hypochondriasis about being a hypochondriac. But I was sure. I was scratching, my skin was burning, and no amount of antihistamine was curing it. I had scabies. It had started when I went to visit friends in their student house. I was told that two of the friends had experienced a rash and that they put it down to a couch in their rented accommodation. Of course, my skin started to crawl. I tried to be vigilant, but, because of the shortage of beds in the house, I had to share with one of my friends, who kept me awake all night with incessant scratching. I returned home and the nightmare began. What started as one or two small bites on my hands began to take over my entire body. One by one, they appeared on my legs and arms, and eventually on my stomach, chest, and back. The itching was horrendous. My skin was on fire. I scratched until I bruised. I visited the doctor. He was 75% sure that this was scabies. I returned home with my prescription and a large dose of shame. Stigma is attached to this disease. People often associate it with dirtiness. I know, I had the same misconceptions. I had to notify all my contacts. Starting with the friends Id stayed with who already had rashes. Then my family. None of them had had any symptoms, but blanket cover with permethrin is advised.[1] I started receiving text and picture messages from other friends wondering why they were itchy, and did

this look like scabies? My mind was going into overdrive, playing the blame game. Which one of these people had given it to me and whom had I given it to? What were people going to think of me? After all, the only thing all these people had in common was me. Did everybody blame me? It wasnt until I paused to look at the whole picture that I thought: could this be true? The only person I had close contact with was the friend with whom I had shared the bed. I had had no close contact with my other friends. They had had no contact with each other. I had only become particularly itchy when I realised that somebody else also had a rash. Did we all have scabies? Or was this a case of mass hysteria? None of the doctors that any of us had seen had taken skin scrapings for definitive answers. Cases of mass hysteria in the literature include the laughing outbreak of Tanganyika,[2] and more recently in Mexico, where schoolgirls found themselves unable to walk properly, and were feverish and nauseated. [3] No physical cause was found for any of these cases. The Diagnostic and Statistical Manual of Mental Disorders 4th ed defines mass hysteria or epidemic hysteria as shared symptoms [that] develop in a circumscribed group of people following exposure to a common precipitant. That common precipitant was me. I was the only connection between everyone exposed. I must point out that no other person shared my mass hysteria theory. Perhaps I was making excuses as I did not want to admit that I had scabies, a highly contagious and socially stigmatised disease. As I write this, everybody has been treated, and yet I am still scratching, and wondering. Was this a case of scabies or mass contagion? Well, Im a hypochondriac, so it is, of course, both. Michelle Hall, foundation year 1 doctor 1Warrington Hospital, Cheshire The view from the other side

By: James Conlon Published: 18 December 2012 DOI: 10.1136/sbmj.e8317 Cite this as: Student BMJ 2012;20:e8317 Responses to this article (2) As a junior doctor working in a busy teaching hospital, I have become accustomed to arriving at work in the morning and being greeted by a barrage of requests from the nursing staff. Last Thursday morning I noticed that the questions seemed slightly different: When did you last have a drink? Whos your next of kin? Can you provide a urine sample? It was a day of surgery admissions and I, for a change, was a patient. As I was escorted towards the operating theatre, a corridor which I have traversed countless times during the previous 12 months, I realised that the tables had turned and I was no longer in a position of control. Even with the added benefit of a medical background and the knowledge that my procedure was associated with negligible risk, the sense of feeling powerless was a novel and unnerving one. The trust a patient must have in people who they have never met before is great, a concept which is at the core of medical practice. I have been in operating theatres hundreds of times, but to be lying on the table rather than standing next to it felt completely different. If anything was to go wrong, there would be nothing I could do and I trusted the ability of the surgeons, anaesthetists, and nurses to look after me during the procedure. This combination of implicit trust and a sense of being powerless is something which I will be better able to empathise with when discussing impending treatments with anxious patients in the future. If all went well, there was no reason why my operation should have any particular significance to anyone involved in my care that day. By contrast, for the vast majority of patients, an operation is a significant life event. The disparity between the view of the patient and the clinician, when considering the personal significance of the event, is clear and should not be forgotten. Lying in a hospital bed, away from the concerns of everyday life, I found that my senses seemed hyperacute. The patient notices everything. Small characteristicssuch as clothing, language, or mannerismsall take on an added importance and may positively or adversely affect the patient experience. The opportunity to take the patients perspective turned out to be an unexpected learning experience, and an invaluable one. It allowed me to empathise better with the people I treat. Its something I wont forget when caring for patients in future. James Conlon, foundation year 2 doctor 1Accident and Emergency Department, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK

The disaster medics Planning a career in crisis medicine

By: Guy Rughani, James Smith Published: 04 March 2013 DOI: 10.1136/sbmj.f1145 Cite this as: Student BMJ 2013;21:f1145 Respond to this article In this article: Boxes:

Box 1: Disaster medicine training programmes Box 2: Gaining experience at medical school for a career in disaster medicine Links In recent years an international effort has been made to formalise the work of doctors treating people caught up in manmade or natural disastersso called disaster medics. In 2006 the American Board of Physician Specialties certified disaster medicine as a specialty. Disaster training aims to prepare doctors for chaotic situations in the field so that their medical skills can to be used to the maximum.[1] Concepts of triage, planning, and efficient team working are critical to smooth running healthcare in challenging locations. The European Society for Emergency Medicine views the specialty as an extension of emergency medicine, but with the added complication of a paucity of resources in terms of location, hospital facilities, equipment, and medical personnel.[2] Although the United Kingdom has no disaster medicine courses, centres in Europe and America offer specific training programmes, mainly to postgraduates (see box 1). Top International origins Much of the knowledge base of the specialty has come from the work of organisations like Mdecins Sans Frontires (MSF). MSF is a non-governmental organisation, consisting of medical and non-medical staff, which aims to provide emergency aid to people affected by armed conflict, natural or manmade disasters, epidemics, and to those excluded from healthcare.[3] Bart-Jan Bekker is the head of human resources (field) at MSF in London. Bekker is responsible for the recruitment, development, and retention of international staff for MSF field projects. I first met MSF when I was in Bosnia in 1995 working as UN peacekeeper, says Bekker. The culture of MSF impressed me. They tried to make a difference in places other organisations didnt reach, and with minimum means. Often there are only five or six international MSF staff working with hundreds of local professionals. I applied to work for MSF and to my surprise I was accepted. I wanted a job that would allow me to be more useful and make a bigger contribution to society, rather than simply increase company profits. For more than a decade Bekker has served in missions to Sierra Leone, Afghanistan, Liberia, Congo, and Burma. I love the adventure aspect of working for MSF, says Bekker. You get the opportunity to go to places you would otherwise never go, and in circumstances that are extraordinary. I would be lying if I said that I never felt in dangerthere are certainly some tricky moments. Fortunately though, we have good security management and security protocols in place. We dont opt to work on the front line, but front lines are not static, so we occasionally find ourselves in hairy situations. Having experienced staff on the teams helps at these times to help get you through it. MSF describes its work on the ground as projects. Staff are sent out for a period of time to work on a project, and that time is termed a mission. The result is that staff rarely go out as groups to the projects, but go out as individuals on a mission to join an existing project and team who all have different end dates for their mission. On average, the missions are nine months in length. We are very keen for new people to get involved because there is a fair bit of turnover, says Bekker. Some people just come and do one mission and then go back to their normal lives. On average we need 30% new people each year. The other 70% are longer term staff who are vital for continuity and to show the new recruits the ropes.

Top Mission impossible? Being away for lengthy periods of time can make working for MSF a challenge, attracting a certain demographic. It depends on the person, but I have never found it too difficult coming home and leaving again, says Bekker. I find that I can adjust quickly back to home life. Sometimes people find it difficult when returning because their home environment doesnt understand what theyve been through. There is quite a lot of support for these people, but it is still tough. Going away all the time is not terribly conducive to relationships and family life. Because of all of this, the majority of MSF recruits are either at the younger or older end of the spectrum, with the middle age group who have careers and families relatively under-represented. We have people from their mid-20s at the beginning of their careers who dont have a family yet to those over 70 who are looking for new challenges. The mix of people, the camaraderie and teamwork really attracts me, comments Bekker. Each MSF mission requires a range of staff. About half of personnel on an MSF mission are non-medical. Administrative, logistical, technical, financial, and coordinating staff allow the medical staff of medics, surgeons, dentists, nurses, midwives, biomedical technicians, mental health specialists, and pharmacists to work as efficiently as possible, says Bekker. The whole operation has become much more specialised, so there is potentially a role for almost every medical specialty. Concerns for some considering work in the disaster medicine or humanitarian fields are the ethical aspects of overseas aid. The humanitarian sector is largely unregulated, raising concerns of well meaning but ultimately harmful medical intervention.[4] After the 2004 tsunami, for example, commentators criticised short term visits by volunteers attempting to fix complex and chronic problems and the undermining of local practitioners by a flurry of foreign medics imposing better methods.[5] In short, says Bekker, there is currently no regulation, but the sector is becoming more and more self regulating. I think MSF is slightly different from many other humanitarian organisations because we can only take GMC registered staff, so there is some quality assurance there. The way we go about things is very professional and we have the benefit of many years experience. Top Who would suit a job disaster medicine? We look for people who are well informed: people who know what they are doing and what they are letting themselves in for, says Bekker. MSF wants fully registered medics who have lots of clinical experience, so the people we get are often those who have worked for a few years after graduating and registering. Because we want people to be as useful as possible and have limited resources, we cant take people when they are fresh out of university. That goes for all the other professionals we employ too. Some training in tropical medicine or infectious diseases is important, and if people havent done these courses we tend to get them to complete them before coming out to projects. Although disaster medicine courses help doctors to become more aware of the logistical and other nonmedical aspects of working in difficult locations, comments Bekker, a lot of it you just pick up in the field, and there are enough experienced staff to allow you to do that. Also, many of our missions are not necessarily disaster work. For example, our HIV/AIDs, tuberculosis and nutrition programmes would not benefit from a specific training in disaster medicine. Top Opportunities for interested students For students or junior doctors interested in working for MSF, the Friends of MSF organisation is a good place to find out more about a career in disaster medicine. James Smith is national president of Friends of MSF. Born from the collective passion of medical students in Sheffield in 2004, Friends of MSF has evolved into a network of over 40 groups across the UK and Ireland, says James. Our groups regularly engage with a range of high priority advocacy campaigns: improving access to essential medicines, raising the profile of neglected diseases, and highlighting sub-standard paediatric

nutritional substitutes, among others, comments James. The Friends of MSF also organise talks from doctors who have recently returned from the field and liaise with similar initiatives in South Africa, Canada, the United States, and institutions across Europe. Although MSF does not offer elective placements, proactive students can do much within their timetabled medical placements to prepare for a possible career in disaster medicine. Box 2 gives some tips for areas to explore. Top Box 1: Disaster medicine training programmes

European Master in Disaster Medicine: mix of online and in person teaching:www.dismedmaster.org/ National Disaster Life Support Foundation run a series of courses in the US for disaster training: www.ndlsf.org/Courses Top Box 2: Gaining experience at medical school for a career in disaster medicine Undertake infectious disease training or placements Undertake your elective in the developing world. You need to show that you have some experience working in challenging resource poor environments Learn a languageknowledge of foreign languages will increase your appeal to international aid organisations. The languages particularly useful to MSF are French, Spanish, Portuguese, Arabic, and Russian Do psychiatry and GP placements: the importance of mental health management in disaster regions is being increasingly recognised. MSF recruits psychiatrists and looks for doctors with excellent communication skills Get experience in the emergency department: the basics of triage and critical care management can be honed during these placements. Try and volunteer to work on the front line in the emergency department to master the basics Do an obstetrics and gynaecology placement: obstetric emergencies are particularly common in the developing world. Projects or extra placements in this subject are highly valued Gain experience in paediatrics: most of MSFs patients are children. Research the effects of malnutrition on development and familiarise yourself with common presenting complaints Expand your current learning by considering each topic from an international perspective Adapted from MSFs information for medical students. Read more atwww.msf.org.uk/medicalstudents

Caring for a dying patient The shift from cure to palliation can be a challenge for doctors

By: Katherine E Sleeman, Emily Collis Published: 19 February 2013 DOI: 10.1136/sbmj.f322 Cite this as: Student BMJ 2013;21:f322 Responses to this article (3) In this article: Tables: Figures: Boxes:

Useful resources Every year, more than half a million people die in the United Kingdom, and over half of these deaths occur in hospital. Junior doctors are often required to care for dying patients,[1] and assessment and management of these patients are essential skills.[2] [3] [4] The importance of good end of life care, both for the patient and for their family, is increasingly recognised. Sadly, many people dying in hospital continue to have unmet needs, and, in the UK, more than half of complaints referred to the Healthcare Commission (the Care Quality Commissions predecessor) concerned the care of dying people.[5] Acquisition of the basic skills required to care for people who are dying can improve the patients and their familys experience of death, while also enhancing the safety, efficiency, and satisfaction of the junior doctors work. Top

Recognising dying Doctors are notoriously poor at prognosticating, and recognising that a person is dying is a skill that develops over time. In the patient who is close to death, clinical signs such as reduced consciousness level, respiratory changes (for example, Cheyne-Stokes breathing), and cardiovascular changes (for example, peripheral vasoconstriction) are common. For the patient and his or her family to have time to express their preferences for end of life care, however, recognition of dying must occur earlier. The last weeks of life for most people are characterised by a progressive physical decline, frailty, lethargy, worsening mobility, reduced oral intake, and little or no response to medical interventions. These changes can be subtle and can first be identified by nursing staff, allied health professionals, or family members. In cancer, which characteristically has a smooth downward trajectory in the last few weeks, death can be easier to predict than in non-cancer diseases such as chronic obstructive pulmonary disease and heart failure, which are characterised by relapses and remissions. Similarly, death from frailty or dementia can be difficult to predict because patients can live for a long time with a very poor level of function, making the dying phase difficult to distinguish (fig 1). 1

Fig 1 Disease course of malignant versus non-malignant disease process In the acute hospital setting, where patients are often being intensively managed and reversibility is unclear, it is impossible to predict with complete certainty which patients will not survive an admission. The onus on clinicians is to identify patients in whom dying is a possibility, and make advance care plans, including treatment escalation decisions, in advance of a potential terminal deterioration. The AMBER care bundle is a tool designed to facilitate this process, by promoting communication, advance care planning, and team working, alongside active treatment.[6] The AMBER care bundle is a key component of the national end of life care programme for transforming end of life care in acute hospitals.[7] Top Assessment of a dying patient The recognition that a patient is deteriorating irreversibly, and is therefore dying, heralds a shift in the focus of careaway from disease, treatment, and cure, and towards the patients needs and priorities. The assessment of the dying patient aims to identify the patients current physical, psychological, social, and spiritual needs, and to develop strategies to meet them. Assessment of unconscious or non-verbal patients requires close attention to physical signs such as facial expression, movements, and breathing, as well as discussion with the family and nursing team. Top Management of a dying patient Most UK hospitals use the Liverpool care pathway (LCP) (or an equivalent pathway) to care for dying patients.[8] The LCP is a multidisciplinary template, which was developed to translate best practice for care of the dying from the hospice to the hospital setting. The template provides prompts to guide physical, psychological, social, and spiritual care. Inappropriate interventions such as blood tests and routine observations are stopped, and care is focused on four hourly reviews of physical symptoms, comfort, and dignity.[9] The LCP does not determine careit provides a series of prompts and considerations that might be relevant at the end of life. Care on the LCP will only be as good as the healthcare professionals providing it. Nevertheless, the LCP has been suggested as a model of good practice by the Department of Health, the General Medical Council, and the National Institute for Health and Clinical Excellence.[2] [4] [10] The recommendation to start the LCP should be made on the basis of multidisciplinary agreement that there is no reversible cause for the patients deterioration, and that the patient is likely to be in the last hours or days of life. The LCP is not a treatment; it is a framework for good practice, and therefore written consent is not required. However, identifying that someone is dying, and changing a plan of care accordingly, should be discussed with the patient where appropriate, and always with the relative or carer. The LCP has come under fire in recent months, with newspapers equating it to euthanasia by the back door and accusing hospitals of using the LCP to kill patients.[11] It has been reported that the LCP requires food and fluids to be withdrawn. In fact, the LCP states that all patients should be supported to eat and drinkfor example, by spoon feedingfor as long as possible. However, it is common for patients to have a period at the end of life where reduced consciousness limits their ability to take food and fluids orally. Provision of nutrition and hydration by tube or drip is considered in law as a medical treatment, and whether or not to provide them should be determined on a case by case basis, by weighing up the potential benefits, such as improved comfort, with the burdens and risks, such as peripheral oedema and bronchial secretions. The views of the patient and family, including any religious or cultural context, should be considered, and the benefits, burdens, and risks of clinically assisted nutrition and hydration should be discussed with them.[12] All patients should receive regular mouth care to keep their lips and

tongue moist. Patients on the LCP should be seen daily by the medical or surgical team. A full multidisciplinary team review should occur if the patient improves; if concerns are expressed about the management plan by the patient, a family member, or member of the multidisciplinary team; or if it has been 72 hours since the last assessment by the multidisciplinary team. The LCP is not irreversibleif the patient improves, the LCP can be discontinued. As always, any change in plan should be discussed with the patient where possible, and always with the relative or carer.[4] Top End of life prescribing There are three general principles of prescribing at the end of life: (1) Stop non-essential drugs. In general, this means stopping all drugs that are not providing a symptomatic benefit. For some drugs, such as statins and antihypertensives, this is fairly clear. Other medicines, such as antiepileptics, would usually be continued for as long as the patient can manage to take them. Antibiotics are usually stopped, but can be continued if it is thought that they are providing symptomatic benefit. (2) Convert essential drugs to the subcutaneous route, especially in patients who are having trouble swallowing tablets, and in those who might have poor oral absorption or nausea and vomiting. Regular drugs are usually delivered via a syringe driver, a continuous subcutaneous infusion pump that runs over 24 hours. Continuous subcutaneous infusion pumps are ideal at the end of life because the subcutaneous route is relatively non-invasive, doses can be titrated easily, and several drugs can be combined in one pump. (3) Anticipatory prescribing. Irrespective of current symptoms, all dying patients should have an analgesic, an anxiolytic, an antiemetic, and drugs to reduce bronchial secretions available on the as needed side of their drug chart, so that there is no delay responding to a symptom if it occurs. Top Physical care At the end of life, physical care is guided more by patients symptoms, such as breathlessness, than by signs, such as respiratory rate or oxygen saturations. However, understanding the cause of symptoms helps guide their treatment, and focused physical examination to elicit relevant signs remains important. The most common physical symptoms at the end of life are pain, breathlessness, agitation, nausea and vomiting, and constipation. Up to 96% of dying patients experience pain.[13] Although often feared, particularly by patients with cancer, pain is also common in non-malignant diseases.[13] The VOICES survey, the first national study of bereaved families, reported that only 33% of relatives of patients who died in hospital said that pain had been completely relieved, compared with 60% of patients who died in a hospice.[14] Opioids, usually morphine sulphate, are the mainstay of pain relief at the end of life. The LCP documentation includes simple algorithms to guide opioid prescription (fig 2). For more complex pain control, including advice on increasing doses, opioid dose conversions, and opioid use in renal or liver disease, useful resources include the ward pharmacist and hospital palliative care team. 2

Fig 2 Algorithm for control of pain at the end of life, adapted from the Liverpool care pathway. CSCI=continuous subcutaneous infusion Breathlessness is a distressing and common symptom reported at the end of life. Opioids have been shown to improve the sensation of breathlessness,[15] and the doses used are generally smaller than those used for pain. The exact mechanism by which low dose opioids alleviate breathlessness is unknown, but is likely to be distinct from the mechanism by which inappropriately high doses of opioids cause respiratory depression. Studies have shown that opioid titration reduces respiratory rate and the sensation of dyspnoea, without substantial changes in PaO[2] or PaCO[2].[16] A systematic review of benzodiazepines for breathlessness in advanced disease showed a non-significant trend towards beneficial effect.[17]Nevertheless, for patients who are breathless and anxious, benzodiazepines can be useful.[16] The role of oxygen therapy in breathlessness is unclear, but a trial of oxygen therapy is reasonable in patients who are hypoxic and breathless. Non-pharmacological interventions, such as directing a fan towards the face, can also be useful. Most patients show fluctuant changes in conscious level towards the end of life, with generally increasing drowsiness. Some patients show signs of physical restlessness, delirium, and agitation, which, if severe, are termed terminal agitation. Terminal agitation might be a symptom of physical, psychological, or existential distress. A diagnosis of terminal agitation requires that reversible conditions have been

excluded (table 1). Thereafter, most patients respond to benzodiazepines (for example, midazolam 2.5-5 mg as required). Occasionally antipsychotics (for example, levomepromazine) or barbiturates (for example, phenobarbital) are needed, but specialist advice should be sought in this circumstance.

Reversible causes of agitation at the end of life Possible causes Drugssteroids, benzodiazepines Drug or alcohol withdrawal Cancercerebral metastases Metabolic hypercalcaemia, hypoglycaemia, hyperglycaemia Constipation Urinary retention Pain Suggested investigations Review current drugs Review social history and drug history (prescribed/non-prescribed) Review relevant scans and signs of focal neurology Review most recent blood results, check capillary blood glucoseConsider repeating bloods if prognosis >72 hours Examine abdomen and review bowel history Examine abdomenBladder scan Suggested treatments Consider reducing dose or ceasing Consider benzodiazepines or appropriate drugs Consider subcutaneous dexamethasone if prognosis >72 hours Consider treating abnormal capillary blood glucose

Consider rectal suppositories Consider urinary catheter

Observe for non-verbal signs of painfor Prescribe appropriate example, grimacing, writhing, moaningDirect analgesia questioning if conscious Oxygen saturationsRespiratory rate Take temperatureUrine dipstickExamine chest Consider oxygeneg, 2-4 L/min via nasal cannula Consider antibioticseg, oral suspension

Hypoxia Infection

It is a common misconception that drugs such as opioids and sedatives hasten death when given at the end of life, and that this practice is justified by the doctrine of double effect. This doctrine states that if doing something morally good has a morally bad side effect, it is ethically justifiable to do it providing the bad side effect was not the primary intention. Although the doctrine is widely cited with respect to opioids for relieving pain at the end of life, there is no reliable evidence that in appropriate doses to alleviate symptoms, opioids or sedatives shorten life.[18] Nausea and vomiting are common features in many advanced diseases. Although vomiting can be tolerated by many patients, relentless nausea is profoundly debilitating. There are many causes of nausea and vomiting at the end of life: physical causes (bowel obstruction, constipation), biochemical causes (hypercalcaemia), drugs (chemotherapy, opioids), and central causes (brain tumour). The appropriate antiemetic is chosen based on an understanding of the likely cause (table 2), and also consideration of other symptoms (for example in a patient who is nauseated from hypercalcaemia and agitated, levomepromazine could be used to treat both symptoms). Occasionally, antiemetics need to be combined, and specialist palliative care advice should be obtained.

Choosing an antiemetic at the end of life Cause of nausea and vomiting Centralfor example, raised intracranial pressure Biochemical Chemotherapy Bowel obstruction Antiemetic Haloperidol 1.5 mg once dailyCyclizine 50 mg three times a day Haloperidol 1.5 mg once dailyLevomepromazine 6.25 mg once daily Ondansetron 4 mg twice daily Cyclizine 150 mg/24 hours in continuous subcutaneous infusionHaloperidol 3-5 mg/24 hours Consider hyoscine butylbromide for colic Further considerations Consider dexamethasone 8 mg once daily

Cause of nausea and vomiting

Antiemetic in continuous subcutaneous infusion

Further considerations

Gastric stasis Cause unclear

Metoclopramide 10 mg three times a day Haloperidol 1.5 mg once dailyLevomepromazine 6.25 mg once daily

Discontinue if colicky pain

Constipation is common in dying patients because of immobility, poor diet, dehydration, weakness, and drugsfor example, opioids. Assessment of constipation should include the patients normal bowel habit, when the patient last opened his or her bowels, what the last bowel movement was like (hard/soft), and any associated symptoms (abdominal cramping, nausea, vomiting). In general, constipation is best treated with a combination of a stimulant and a stool softener (for example, senna and docusate sodium). If the patient is unable to take oral laxatives, rectal intervention with suppositories might be appropriate, depending on the balance between benefit and discomfort of the intervention. Patients who are close to death often develop audible respiratory secretionsdeath rattlecaused by the patients inability to clear the throat normally. This is often of more distress to the family than to the patient. Repositioning can help. First line drug treatment is usually an antimuscarinic, such as glycopyrronium or hyoscine butylbromide. An alternative is hyoscine hydrobromide, though this has the disadvantage of crossing the blood-brain barrier, potentially causing sedation. These drugs all cause a dry mouth, and extra attention should be paid to mouth care. Top Social care The social assessment of a dying patient should focus on family support and identification of carers or dependants. Patients in whom death is not imminent and who are alert enough to converse comfortably can be asked sensitively about their preferred place of death, so that a rapid discharge can be arranged if appropriate. Questions that might be appropriate include, How do you feel about being in hospital at the moment? It is essential to pay close attention to patient cues to guide how far a patient wishes to engage with advance care planning. If prompted by patientsfor example, by a worry about their affairsit might be appropriate to ask if they have made a will, and, if necessary, to facilitate this. Many hospital palliative care teams have specialist social workers who are invaluable under these circumstances. The insight of the patients family, and their wishes or concerns, should be elicited. Family members might have questions and concerns about practical matters after their relatives deathfor example, what will happen to the patients body, and how to arrange a funeral. The hospital bereavement office can be a useful source of information. Identification of family members who might be particularly at risk in bereavementfor example, young dependants, and those with young children, other recent bereavements, or mental health issuescan allow pre-emptive social work support. Confidence about who would benefit from the input of a specialist social worker develops over time, and senior advice is likely to be helpful for junior doctors. Top Psychological care In the unconscious dying patient, extreme anxiety can manifest as agitation, and if no reversal is possible, benzodiazepines are usually effective. In patients who remain conscious, gently exploring their fears and concerns can help address any anxiety. Questions could include, Whats the worst thing for you at the moment? and Is there anything in particular that is worrying you? Sometimes making an educated guess can be useful. For example, Many patients fear that as they become less well their pain will increaseis this something that worries you? You could then give appropriate reassurance that this is not something that we would expect to happen. Patients might voice other fears about the dying process itself and are generally reassured to be told that for most people it is simply a process of gradually becoming more drowsy, taking to bed, and speaking and eating less. It is not possible to fully understand a patients psychological concerns after a single meeting. This happens over time, through ongoing, open, and honest conversations with the patient and family, and discussion with the multidisciplinary team. If a patients anxiety or agitation does not improve, the specialist palliative care team can often provide additional psychological support.

Top Spiritual care Spirituality becomes very important to many patients at the end of life. Identification of a strong faith can help guide appropriate chaplaincy support, and might influence care after death. For many people, however, spirituality encompasses much more than religion. Asking open questions such as, Where do you find strength? or How do you make sense of what is happening? and How do you feel about the future? can be a useful and non-confrontational way of finding out more about a patients spirituality. Irrespective of religious faith, hospital chaplaincy teams can provide spiritual support if needed. Top End of life communication Communication is the cornerstone of good end of life care. Junior doctors are understandably often concerned about communicating with dying patients and their relatives, and should develop their communication skills through observation, simulation, practice, feedback, and reflection. Although junior doctors are not expected to break bad news to patients, being present while senior colleagues have these conversations is invaluable experience. When embarking on a sensitive conversation, start by considering the environment in which the conversation will be held: Is there adequate privacy? Can you be heard? Are you likely to be disturbed? It is useful, too, to try and ensure that a nurse is present for the conversation, to support the patient and to provide continuity. Always ascertain how much information the patient wants (Are you the sort of person who likes all the information?), and modify your responses accordingly. Start by checking what the patient or relative understands about the situationthis often makes the rest of the conversation much easier. In general, leave time for the conversation (try to give your bleep to a colleague), dont try to force it according to your agenda, and be sensitive to cues. Ask open questions, particularly about what their worries or concerns are, and dont be afraid to use the words death and dying sensitively, because use of ambiguous language may lead to confusion. If a patient asks a difficult question, be prepared to say you dont know, but ensure you bring back a senior colleague to complete the conversation. Together with the nursing staff, ensure that the patients family have all the practical information that they need. For example: Do they need to adhere to visiting hours? Can they stay overnight? Is there a kitchen they can use? Discuss with relatives how they would like to be informed of a change in the patients condition. For example: Would they want to be called in the middle of the night? Top Resuscitation In patients who are deteriorating from an incurable disease, for whom there is no reversibility, and who are expected to die within days or weeks, cardiopulmonary resuscitation is almost certain to be futile. In this situation, an advance decision not to attempt cardiopulmonary resuscitation (DNACPR) helps to ensure that the patient dies in a peaceful and dignified manner. The DNACPR decision is the responsibility of the medical team, but should be discussed with the patient (if appropriate), and his or her next of kin. It is important to reassure the patient and family that a DNACPR decision applies only to cardiopulmonary resuscitation, and it does not imply that other treatments will be withdrawn or withheld. Top When to involve the palliative care team Almost all acute hospitals now have a specialist palliative care team. The team usually consists of clinical nurse specialists, doctors, social workers, and chaplaincy support. The general medical or surgical team is expected to provide basic end of life care to patients, with support from the specialist palliative care team if there are symptoms that are difficult to control, extreme psychological distress, or a complex social situation (for example, if there are young dependants). Most palliative care teams will see any hospital inpatients according to need, rather than according to diagnosis, and increasingly they see non-cancer patients. Most teams can be contacted for telephone advice, one-off assessment, or ongoing support. Top A challenge for doctors All junior doctors will care for dying patients at some point. There is more than one way to die well, but the minimum requirements are excellent communication, recognition of the dying phase, and attention to psychological, social, and spiritual distress in addition to physical symptoms. The shift from cure to

palliation can be challenging for doctors at all levels, but is necessary to achieve a dignified and peaceful death for the patient, and consequently reduce family suffering in bereavement. As Dame Cicely Saunders, founder of the hospice movement, said how we die remains in the memory of those who live on. Top Useful resources

Map of Medicine guide on end of life care in adults. Contains useful, well referenced, flow diagrams around care of dying patientswww.mapofmedicine.com/newsandevents/newsarchive/2010/endoflife Palliative Care Adult Network guidelines. Detailed electronic resource on palliative care generally. Includes an opioid dose calculator and syringe driver drug compatibility resource. iPhone app available http://book.pallcare.info/ e-Learning for Healthcare modules on end of life care. Over 150 modules on end of life care including advance care planning, assessment, communication skills, and symptom managementwww.elfh.org.uk/projects/end-of-life-care/

Should doctors accept gifts from patients? Large gifts can raise conflicts of interest

By: Julian Sheather Published: 17 December 2012 DOI: 10.1136/sbmj.e8300 Cite this as: Student BMJ 2012;20:e8300 Respond to this article In 2011 Huguette M Clark, a reclusive copper heiress died, leaving her nurse $30m (18.6m; 23m) in her will; she also left her doctor $100000. Should they have accepted the money? Large bequests of this kind raise two questions. The first is whether doctors and other health professionals can accept such gifts or bequests; the second is whether they should. In the UK, the first question can be quite easily dealt with. NHS employees are not allowed to accept substantial gifts from patients and there the matter rests: small gifts of pens or diaries, insubstantial tokens of gratitude are fine, but the sums of money involved must be insignificant25 is the ordinary ceiling.[1] Doctors who are not directly employed by the NHS, such as GPsit is not always realised that GPs are contractors to the NHS, not employeesand doctors in private practice, can accept gifts or bequests without limit to the amount. Predictably then, most of the calls I receive on this subject are from GPs and their question is not whether they can accept gifts, but the ethical question of whether they should. This is more complex. On the one hand they dont want to offend their patients by refusing well intentioned gifts, and consequently damaging the doctor-patient relationship. On the other hand, they can be anxious about the impact, real or perceived, that the promise of large sums of money might have on that relationship. Although small gifts expressing gratitude, such as chocolates or a bottle of wine, are unlikely to be problematic, when it comes to larger gifts we are in the realm of conflicts of interest. These arise where factors ordinarily external to the clinical encounter bring pressures to bear that might not be in the best interests of the patient. Unlike their colleagues in private practice, doctors working in publicly funded healthcare have to an extent been insulated from direct financially driven conflicts of interest, although successive NHS reforms are changing this. The anxiety of a GP suddenly confronted with the promise of a large bequest is therefore understandable. How should we proceed? In Good Medical Practice the General Medical Council makes two relevant statements: You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you.[2] You must not ask for or accept any inducement, gift or hospitality which may affect or be seen to affect the way you prescribe for, treat or refer patients.[3] They both straightforwardly prohibit doctors in any way encouraging or persuading patients to give or to lend money and no reasonable person would argue with that. The second raises the conflicts of interest question: the possibility that any substantial gift or bequest might have an impact on clinical objectivity. Importantly, perceived conflicts of interestseen to affectare considered on a par with actual ones, so doctors need to think carefully about how their actions are perceived, even where they believe their choices or decisions are not influenced by external factors. The guidance also points out that both patients and their doctors have interests that need to be considered here. It is conceivable that the offer of money from a patient may not be an entirely disinterested act. It could be offered with the anticipation

of favourable treatment. It could also be an invitation to the doctor to take more than a professional concern. Offers of money can therefore put pressure on professional boundaries and doctors need to be cautious. Should a doctor agree to receive a gift, or to being a beneficiary to a patients will, several things need to be borne in mind. Doctors should make it clear to patients from the outset that the gift will in no way influence their care. If a doctor has been made a beneficiary of a will, he or she should not be involved in assessing the capacity of the person making it. If an assessment of capacity is needed it should be undertaken by a doctor with no financial interest in the outcome. Many doctors are not aware in advance that they have been made a beneficiary and there is nothing to stop doctors accepting bequests, bearing in mind the GMCs guidance about perceived conflicts of interest. One approach that some GPs take to substantial gifts or bequests is to set up a fund to improve patient services. Although wary of introducing a more sombre note, at the back of some minds will be the memory of Harold Shipman, the GP whose serial killing was brought to a halt when he was caught forging the will of an older patient. Shipman was a terrible, solitary exception, but his case reminds us of the vulnerability of some patients and the trust that doctors still overwhelmingly enjoy. Subsequent to the revelations over Shipman, regulations were introduced relating to GPs accepting gifts from patients or their relatives. [4] GPs have to keep a register of gifts from patients or relatives that have a value of 100 or more unless the gift is unconnected with their services. The register should include the donors name and the amount of the gift. Medical practice, like life more widely, is full of conflicts of interest. They cannot be entirely eradicated. Where conflicts of interest arise in their practice, doctors need to consider if they can be avoided. If they cannot they need to be managed. This will always be a matter of judgment, but openness, transparency, and a focus on the best interests of patients are central.

Interpreting head computed tomography scans Familiarity with certain cross sectional cuts will simplify interpretation

By: Adam Marcus, Hani Marcus, Ramez Kirollos Published: 05 March 2013 DOI: 10.1136/sbmj.f871 Cite this as: Student BMJ 2013;21:f871 Respond to this article In this article: Figures: Boxes:

Box 1: Common indications for CT head scans* Box 2: Hounsfield unit (HU) scale (approximate values) for various substances Box 3: Differential for ring enhancing space occupying lesion Box 4: Glossary Links Computed tomography (CT) scans of the head are investigations that are commonly requested, particularly when an acute brain injury such as trauma or stroke is suspected. Junior doctors often find interpreting CT scans of the head daunting. The complex anatomy of the brain might be unfamiliar, making it difficult to recognise and localise lesions confidently. In this article we review normal brain anatomy, describe a systematic approach to reviewing scans, and illustrate important and commonly encountered pathologies. Top Requesting a CT scan of the head CT scans are available in most hospitals but are quite expensive investigations and carry a high dose of ionising radiation. The use of these scans must therefore be clinically justifiedthat is, a result (positive or negative) will aid diagnosis or alter the management of a patient. The UK Royal College of Radiologists publishes regular guidelines on the indications for CT head scans (box 1), and most radiology

departments encourage doctors to discuss equivocal cases with them directly. CT scans of the head are usually performed without intravenous iodine contrast medium unless an infection or tumour is suspected. Top Box 1: Common indications for CT head scans* Acute head injury Acute stroke (CT scan as soon as possible to rule out intracerebral haemorrhage, although features of ischaemia might not yet be present) Acute subarachnoid haemorrhage Space occupying lesionsfor example, tumour or abscess (contrast enhanced scans indicated) Hydrocephalus *Adapted from the Royal College of Radiologists referral guidelines[1] Top Anatomy of the brain The brain is encased by part of the skull termed the neurocranium, which protects it from injury. The neurocranium consists of the thick skull base below and the flat bones that form the skull vault above. Surrounding the brain are the meninges, which consist of three layers: from superficial to deep, these are the dura mater, arachnoid mater, and pia mater (fig 1). The space between the arachnoid and pia mater, the subarachnoid space, contains cerebrospinal fluid. The pia mater is closely invested with the brain surface, and the arachnoid mater bridges across gyri (brain ridges) leaving spaces filled with cerebrospinal fluid. In certain regions the arachnoid and pia mater are widely separated; these cisterns contain several important structures such as the blood vessels of the circle of Willis. 1

Fig 1 Layers of the brain, skull, and meninges The brain itself has three main components (fig 2): the cerebrum, the cerebellum, and the brainstem. The cerebrum contains several paired lobes including the frontal, parietal, temporal, occipital, and hidden insula lobes. Deep within the cerebrum lie the paired thalami and basal ganglia (including the caudate nucleus, globus pallidus, and putamen). The cerebellum consists of the cerebellar vermis in the midline, the hemispheres on each side, and the flocculonodular lobe below. The brainstem consists of, from rostral to caudal, the midbrain, pons, and medulla. 2

Fig 2 Major structures of the brain Reflections of the dura mater divide the brain into compartments. The falx cerebri and falx cerebelli divide

the cerebrum and cerebellum into left and right sides. The tentorium cerebelli separates the cerebrum, above, from the cerebellum and brainstem below. The diaphragma sellae separates the cerebrum, above, from the pituitary below. Buried within the brain is the ventricular system, containing cerebrospinal fluid (fig 3). Most cerebrospinal fluid is generated within the ventricles. Cerebrospinal fluid flows from the lateral ventricles, through the foramina of Monroe, into the third ventricle, through the narrow cerebral aqueduct, and into the fourth ventricle. Circulating cerebrospinal fluid eventually exits the ventricular system through the foramen of Magendie (medial) and the foramina of Luschka (lateral) into the subarachnoid space before being absorbed by the arachnoid granulations. 3

Fig 3 Ventricular system Top Understanding CT head scan cuts Recognising the anatomy on head scans is helped by familiarity with several important cross sectional cuts of the brain (fig 4).[2] Figure 5 shows the locations of the cuts, which are always parallel to the skull base. The left side of the scan represents the right side of the patient (analogous to viewing the brain from below, looking up from the patients feet). 4 5

Fig 4 Various cross sectional cuts of the brain make characteristic shapes When assessing tissues, remember that CT scans use x rays in a similar manner to plain radiographs. The Hounsfield unit (HU) scale, which is named after Sir Godfrey Hounsfield, who helped develop CT scanners, describes radiodensity (box 2).[3] Bone, calcification, and contrast appear hyperdense (white). Air, fat, and cerebrospinal fluid appear hypodense (black). Brain tissue appears grey (isodense). Blood can be confusing because its appearance varies according to its age: acute blood is hyperdense, subacute blood

is isodense, and chronic blood (several weeks old) is hypodense. Box 2: Hounsfield unit (HU) scale (approximate values) for various substances -1000 (appears black on computed tomography imaging)air -90fat 0water 5 cerebrospinal fluid 30white matter 40 (appears grey on computed tomography imaging)grey matter 50-70acute blood clot >1000 (appears white on computed tomography imaging)bone X The frontal and temporal lobes of the cerebrum can be identified anteriorly, and the brainstem and cerebellum posteriorly.

Star The star is formed by the suprasellar cistern, which contains important structures such as the blood vessels of the circle of Willis. The uncus, the most medial part of the temporal lobe, forms the lateral borders of the suprasellar cistern on this slice. Note the shape of the fourth ventricle, which resembles a lowercase n.

Happy face The eyes are formed by the frontal horns of the lateral ventricles, the nose by the third ventricle, and the smile, which resembles a lowercase u, by the quadrigeminal plate cistern (often mistaken for the fourth ventricle).

Sad face The eyes are formed by the frontal horn of the lateral ventricles, separated by the thin septum pellucidum, and the frown by the occipital horns of the lateral ventricles.

Worms The lateral ventricles form the worms. In addition, the falx cerebri may be seen within the midline.

Coffee beans The cerebral convexities form the coffee beans. Sulci (furrows) and gyri (ridges) are usually visible, and the central sulcus may be identifiable. In older patients, who have age related cerebral atrophy, they are often quite prominent. In younger patients or in patients with raised intracranial pressure, they might be effaced.

Systematic approach When reporting all imaging trainees should firstly confirm the name of the patient, the date of the scan, and the nature of the imaging. When reviewing scans it is important to do so systematically to avoid missing important features. The method adopted here is to work from the outside inwards, paying particular attention to the anatomy of the aforementioned axial sections.

Bone windows The image viewer software is set to bone window (see box 4 for a definition and fig 6(A) for an example of a bone window) to evaluate for skull fractures.

Extra-axial (outside the brain) The image viewer is then returned to brain window, and the region between the skull and the brain is carefully surveyed to look for extra-axial lesions, such as acute haemorrhage, which are seen as hyperdense. The cisterns are inspected; if they are not apparent they might be filled by blood or compressed because of raised intracranial pressure, resulting in transtentorial herniation (see below).

Intra-axial (within the brain tissue) Next, the brain parenchyma is surveyed for space occupying lesions such as tumours or abscesses.

Ventricular system Finally, attention is turned to the ventricular system. Haemorrhage within the ventricles will tend to collect in the occipital horns because of gravity. Ventricles may appear small, which might occur in raised intracranial pressure, or large, which might be the result of hydrocephalus (see below). When describing pathology it is important to report the characteristics of the lesion itself (such as location, size, shape, and density) and also associated features (such as mass effect). A lesion with mass effect can efface (obliterate) the sulci and gyri of the neighbouring cerebrum. Substantial mass effect can result in herniation of the brain across any of the compartments previously described. Herniation of the cingulate gyrus across the falx cerebri (subfalcine herniation) is often described in terms of midline shift of the septum pellucidum. Herniation of the uncus of the temporal lobe across the tentorium cerebelli (transtentorial herniation) results in effacement or obliteration of the suprasellar cistern. Herniation of the cerebellar tonsils through the foramen magnum (tonsillar herniation) results in crowding and compression of the lower brainstem, though this can be difficult to recognise on CT scans

Pathology Trauma

Skull fracture Several types of skull fractures may occur: these include simple linear fractures of the flat bones of the skull vault; depressed skull fractures, in which broken bones are displaced inwards; and fractures of the thick skull base. To the untrained eye normal suture lines and nutrient canals can occasionally be misinterpreted as fractures. True fractures are usually asymmetric and are often associated with features such as scalp swelling and intracranial air (seen as deep black specks). Opacification of the paranasal sinuses or mastoid air cells can also provide secondary evidence for a fracture. Figure 6 shows a depressed skull fracture of the left parietal bone on the bone window (A) and reconstruction (B). Note the associated overlying left parietal scalp haematoma and intracranial air. 6

Fig 6 CT scan and reconstruction showing a depressed skull fracture of the left parietal bone

Acute extradural haematoma Acute extradural haematomas occur between the skull and the dura mater. As acute extradural haematomas consist of fresh blood clots they are hyperdense. Most are thought to arise from haemorrhage of the middle meningeal artery. High pressure arterial blood strips the dura off the skull, except at suture lines, where the dura is adherent to bone, leading to a biconvex shape. Figure 7A shows a right sided extradural haematoma. 7

Fig 7 CT scans showing extra-axial haemorrhage. (A) Right sided extradural haematoma. Also note the multiple associated intraparenchymal haemorrhages (contusions), particularly in the left temporal lobe and occipital lobe. (B) Right sided acute subdural haematoma. (C) Bilateral chronic subdural haematoma. (D) Subarachnoid haemorrhage

Acute subdural haematoma Acute subdural haematomas occur in the potential space between the dura mater and arachnoid mater. Like acute extradural haematomas they contain fresh blood clots and are hyperdense. Unlike extradural

haematomas, however, subdural haematomas can cross suture lines and have a crescent shape. Figure 7B shows a right sided acute subdural haematoma; note the associated compression of the right lateral ventricle and midline shift.

Chronic subdural haematoma Chronic subdural haematomas also occur in the potential space between the dura mater and arachnoid mater and have a crescent shape. However, in chronic subdural haematomas the collections are hypodense (darker), reflecting old blood. Figure 7C shows a bilateral chronic subdural haematoma. The left sided collection is considerably larger than the right sided collection, with suggestion of associated midline shift. Note that the right subdural collection is more isodense posteriorly, suggesting layering of haemorrhagic products.

Vascular Subarachnoid haemorrhage Subarachnoid haemorrhage occurs within the subarachnoid space between the arachnoid mater and pia mater. The most common reason for spontaneous (non-traumatic) subarachnoid haemorrhage is rupture of an intracranial aneurysm, a potentially lethal condition. Fresh blood clots result in a hyperdense (white) appearance of the subarachnoid space, particularly the deep intracranial cisterns, as aneurysms usually arise from arteries within the circle of Willis. Figure 7(D) shows a subarachnoid haemorrhage with blood completely filling the suprasellar cistern and spreading within the subarachnoid space, including the right Sylvian cistern.

Intracerebral haemorrhage Intracerebral haemorrhage occurs within the brain parenchyma, resulting in a hyperdense (white) appearance within the brain tissue. Figure 8A shows a deep left sided acute intracerebral haemorrhage around the basal ganglia.8 The location of this bleed is fairly typical for haemorrhagic stroke. In this case there does not seem to be substantial associated mass effect and there is no evidence of midline shift or herniation, although these features might be seen in intracerebral haemorrhage.

Fig 8 CT scans showing various pathologies. (A) Deep left sided acute intracerebral haemorrhage. (B) Large right sided cerebral infarction in the territory of the middle cerebral artery. (C) Large intrinsic brain tumour crossing the midline. (D) Right parasagittal extrinsic brain tumour

Ischaemic stroke Acute ischaemic stroke may not be apparent on radiograph for up to 12 hours. Loss of grey-white differentiation of the insula is one of the earliest features that can be identified. If stroke is suspected and the early CT scan looks normal, further imaging may be appropriate. As the stroke evolves, the affected

brain region may appear darker (hypodense) owing to oedema. Although the anterior, middle, and posterior cerebral arteries arise from the circle of Willis to broadly supply the anterior, middle, and posterior cerebrum, their distribution is rather complex (fig 9). The anterior cerebral artery supplies a midline strip of brain, particularly at the higher cuts. The middle cerebral artery supplies most of the lateral surface of the brain. The posterior cerebral artery supplies the occipital lobes. 9 Figure 8(B) shows a large right sided wedge shaped cerebral infarction in the territory of the right middle cerebral artery. 9

Fig 9 Vascular territories of the brain

Tumours Brain tumours might be classified radiologically into intra-axial (arising from the brain tissue itself, which are usually malignant) or extra-axial (arising from outside the brain and pushing against it, which are usually benign). An important feature when assessing cerebral tumours is the presence of contrast enhancement. The blood-brain barrier generally acts to prevent contrast enhancement of intrinsic lesions, but in high grade tumours the breakdown of this barrier results in heterogenous enhancement. In some cases, aggressive tumours with necrotic central components can show ring enhancement. The differential for such ring enhancing lesions in the brain is wide, however, and includes other pathologies such as cerebral abscess (see box 3). Most extrinsic tumours enhance vividly because they lie outside the bloodbrain barrier. Box 3: Differential for ring enhancing space occupying lesion Metastasis Abscess Glioma Infarct (resolving) Contusion or intracerebral haematoma (resolving) Demyelinating disease Radiation necrosis The mnemonic MAGIC DR might be helpful as a prompt Figures 8C and 8D illustrate large cerebral tumours. Figure 8C is an example of an intrinsic brain tumour, probably a high grade glioma, which seems to cross the midline and is associated with considerable surrounding cerebral oedema. Figure 8D is an example of an extrinsic tumour, probably a meningioma, which arises from the falx cerebri.

Hydrocephalus Hydrocephalus is a disturbance in cerebrospinal fluid production, circulation, or absorption leading to raised intracranial pressure.[4] If the ventricles appear large and hydrocephalus is suspected, the brain should be assessed for evidence of high pressure such as effaced sulci and compressed cisterns. Another associated feature is periventricular lucency. In acute hydrocephalus high pressure cerebrospinal fluid is forced outside the ependymal wall (lining of the ventricles) into the surrounding brain parenchyma, leading to a darker (hypodense) periventricular appearance.

Hydrocephalus may be divided into communicating (usually arising from reduced absorption of cerebrospinal fluid) and non-communicating (usually arising from an obstruction in cerebrospinal fluid circulation). In cases of the latter, look at all the ventricles and determine whether there seems to be an obstruction. Figure 10 shows hydrocephalus with large lateral and third ventricles (a rounded nose in the smiley face). Note the evidence of a previous left sided craniotomy (hydrocephalus occurred postoperatively). 10

Fig 10 Hydrocephalus with large lateral and third ventricles Box 4: Glossary Basal ganglianuclei deep within the brain including the putamen, globus pallidus, caudate nucleus,

substantia nigra, and subthalamic nucleus Bone windowsetting when viewing CT head scans which is centred above the usual tissue densities (500 HU) so that bone lesions such as fractures can be more easily identified Brain windowstandard setting when viewing CT head scans, which is centred at the usual tissue densities (40 HU) Circle of Williscircle of arteries that supply blood to the brain Cisternsopening within the subarachnoid space created by a separation of the arachnoid mater and pia mater Cutscross sectional images of the brain Extra-axialwithin the skull, but outside brain tissue Gyrusridge on the surface of the brain Hounsfield unitsscale of radiodensity from -1000 HU (hypodense; black) to >1000 HU (hyperdense; white) Intra-axialwithin the brain tissue Lobesanatomical divisions of the cerebrum including the frontal lobe, parietal lobe, occipital lobe, temporal lobe, and insular lobe (some texts also describe an additional limbic lobe) Mass effectpressure exerted by a space occupying lesion on neighbouring tissue Meningesmembranes that surround the central nervous system, consisting of the dura, arachnoid, and pia mater Neurocraniumpart of the skull containing the brain, consisting of the skull base and skull vault Subarachnoid spacespace between the arachnoid and pia mater, containing cerebrospinal fluid Sulcusdepression or fissure on the surface of the brain Research news: July 2010

Published: 19 July 2010 DOI: 10.1136/sbmj.c3132 Cite this as: Student BMJ 2010;18:c3132 Respond to this article In this article: Figures: Cardiovascular medicine A shunt improves survival for babies with underdeveloped left heart N Engl J Med 2010;362:1980-92 Babies born with the hypoplastic left heart syndrome, an anomaly that affects one in 5000 live newborns, have an incompletely developed mitral valve, left ventricle, aortic valve, and ascending aorta 1 . They survive in the womb because the foramen ovale and a dilated ductus arteriosus allow the right heart to take over the function of running the systemic circulation. However, once born, these babies die of right heart failure within days, unless surgery is performed.

Shunt type and transplant-free survival after 12 months. Adapted from N Engl J Med2010;362:1980-92 The surgical approach to correcting the anomaly comprises three operations. The first operation, the Norwood procedure, is performed immediately after birth and is associated with the highest mortality. The next two operations are performed before 6 months and 4 years of age, respectively. A randomised trial of 549 infants treated in 15 North American centres compared two types of shunts used as part of the Norwood procedure: the classicmodified Blalock-Taussig shuntand a newerright ventricle-pulmonary artery shunt. Transplant-free survival to 12 months after randomisation was better with the newer shunt (74% (202/274) v 64% (175/275)). After that, no differences were seen in the primary outcome between the groups. Further unplanned surgical interventions and complications, which were mostly respiratory, neurological, and infectious, were more common with the newer shunt however. The editorialist (p 2026) praises the surgeons and other teams involved in the trial. The goal line keeps moving thoughNorwood stage I may soon be replaced with a hybrid procedure that combines surgical and endovascular approaches. (From the BMJ 2010;340:c2873).

Stenosis of carotid artery: surgery or stenting? N Engl J Med 2010; doi:10.1056/NEJMoa0912321 One of the largest trials to date confirms what guidelines recommend, that surgery should be preferred over stenting in people with symptomatic stenosis of the carotid artery. How best to treat asymptomatic stenoses remains controversial. In the trial that randomised 2502 patients to carotid endarterectomy or carotid artery stenting, the primary outcomea composite of periprocedural death, stroke, or myocardial infarction, as well as ipsilateral stroke in the four years after randomisationdid not differ between the groups (6.8% v 7.2%, respectively; P=0.51). However, death and stroke were more common in the stenting group, compared with the surgery group, both in the periprocedural period and at four years (periprocedural death 0.7% v 0.3%, P=0.18; periprocedural stroke 4.1% v 2.3%, P=0.01; death or stroke at four years 6.4% v 4.7%, P=0.03). Periprocedural myocardial infarction favoured stenting over surgery (1.1% v 2.3%, P=0.03), but the editorialists (doi:10.1056/NEJMe1005220) argue that periprocedural stroke and myocardial infarction should not be considered equivalent in terms of health implications in the longer term. This is supported by measurements of health status at one year after randomisation: the 36 item short form questionnaire showed impaired health in people who have had periprocedural stroke but not in people with periprocedural myocardial infarction. Still, say the editorialists, individualisation of treatment choices is appropriate. (From the BMJ2010;340:c2873). Mental health New dads get depressed too JAMA 2010;303:1961-9 Having a baby has mental health implications for both men and women. Although we know a fair bit about prenatal and postnatal depression in women, we know precious little about depression in their partners. So researchers trawled through 489 studies to look for prevalence data in men. A pooled analysis of the 43 studies that met their inclusion criteria suggested that 10.4% (95% CI 8.5% to 12.7%) of men are depressed during a partners pregnancy or during the year after the birth. Prevalence peaked three to six months after delivery (25.6%, 17.3% to 36.1%) and seemed to be higher in the United States than elsewhere (14.1%, 10.9% to 18.0%). The headline estimates may not be reliable because of wide variations in both methods and results among different studies, say the authors. But prenatal and postnatal depression in men does seem to be a public health problem that deserves more attention. Parental depression can have serious effects on children. Most studies in the review used self reported scores to measure symptoms of depression. The three studies with more rigorous interview based methods reported lower rates of male depression before and after the birth of a baby than did the studies that used self reporting (4.9%, 3.6% to 6.7%). The researchers found a significant, but modest, correlation between maternal and paternal depression. (From the BMJ 2010;340:c2740).

Nephrology Renal function is an important predictor of cardiovascular and all cause death Lancet 2010, doi:10.1016/S0140-6736(10)60674-5 Renal function is a powerful predictor of mortality. The link between worsening renal function and earlier death was clear for two completely different measures of renal function in a new meta-analysis of published cohorts. In addition, the link was independent of other health indicators and significant for both cardiovascular death and all cause death. Among adults in the general population, risk of death rose steadily with increasing albumin to creatinine ratio (ACR). Even people with microalbuminuria or a trace of protein on a urine dipstick were significantly more likely to die during around eight years of follow-up than people with normal ratios or a clear dipstick (hazard ratio for all cause mortality for ACR 1.1 mg/mmol vACR 0.6 mg/mmol 1.20, 95% CI 1.15 to 1.26 2 ). Estimated glomerular filtration rate was associated with rising mortality below a threshold of 60 ml/min/1.73 m.

Cardiovascular mortality and all cause mortality according to renal function. Adapted from Lancet 2010, doi:10.1016/S0140-6736(10)60674-5 The two measures of renal function seemed to be independent of each othera rising ACR predicted death across all categories of estimated glomerular filtration rate, for example. This means that the two tests provide complementary prognostic information for adults in the general population, says a linked comment (doi:10.1016/S0140-6736(10)60748-9). Both could be incorporated into existing risk calculators and algorithms. The 21 cohorts in this analysis included more than a million people from 14 countries. The findings should help bring renal health to the attention of policy makers and the medical community in general, says the comment. Both groups have ignored the implications of underperforming kidneys for too long. (From the BMJ 2010;340:c2740).

How to make a scientific poster Conference attendees will look at your poster only briefly, so a clear presentation is crucial

By: Fiona Tasker Published: 29 January 2013 DOI: 10.1136/sbmj.f297 Cite this as: Student BMJ 2013;21:f297 Respond to this article In this article: Figures: Boxes:

Websites with examples of scientific posters A scientific poster is an illustrated abstract of research that is displayed at meetings and conferences. A poster is a good way of presenting your information because it can reach a large audience, including people who might not be in your field. It is also a useful step towards publishing your research. Some conferences publish poster abstracts, which then count as publications in their own right. A successful poster captures the viewers attention and communicates the key points clearly and succinctly. One author reviewed 142 posters at a national meeting and found that 33% were cluttered or sloppy, 22% had fonts that were too small to be easily read, and 38% had research objectives that could not be located in a one minute review.[1] Avoiding these mistakes is important to ensure your poster has a positive impact.

Where do I start? If you have completed a project, you will need to research the right meeting or conference to submit your abstract to, if you have not done so already. You might need to ask your supervisor or consultants in the field of your topic for information about relevant conferences at which you can present your work. You will usually be asked to submit an abstract online. The submission guidelines on the website should guide you on how to do this, as well as provide other valuable information such as formatting instructions and deadlines. Your abstract should state why your work is important, the specific objective or objectives, a brief but clear explanation of the methods, a summary of the main results, and the conclusions. I would not recommend adding the abstract to your poster unless this was stated in the conference guidelines because a poster is already a succinct description of your work; use it as an outline for your poster. Follow submission guidelines carefully because they differ among meetings. Start putting your poster together early to avoid the stress of last minute printing queues.

Designing the poster According to the 10-10 rule, attendees spend only 10 seconds scanning posters as they stroll by from a distance of 10 feet.[2] Your poster should be well laid out, with a visual representation preferable to large chunks of text. Diagrams, tables, and photographs aid readability and attract people. Guide the viewerss eyes from one frame to another in a logical fashion from beginning to end. Set up this pattern via a columnar format, so the viewer reads vertically first, from top to bottom, moving across the columns from left to right. 1

An example of a poster. Using information from www.postersession.com Top Text and font Its important to make the writing in your poster clear and easily understandableremember that readers wont give it much time. Use plain language and write in the active voice (We did this, rather than, This was done.) Avoid jargon and acronyms. Use simple language and short sentences. Edit ruthlessly. If its not relevant to your message, remove it. Avoid using uppercase text for more than one sentence because it becomes difficult to read. Keep text to a minimum. Whenever possible, use bulleted text rather than blocks of sentences and leave blank space

around the text and throughout the poster. Use sans serif fonts such as Arial or Helvetica, or fonts such as Times or Times New Roman, which are generally considered to help legibility for posters. If you want a different look, consider Baskerville, Century Schoolbook, or Palatino. The font should be consistent throughout the poster and text should be legible 5 to 6 feet away. Use at least 85 point for the title, 56 point for the authors names, 36-44 point for subheadings, 24-34 point for text in the main body, and 18 point for captions.

Colour Use colour to attract attention, organise, and emphasise, but dont overdo it. Use a maximum of two or three colours and consider people who have problems differentiating colours. One of the most common forms of colour blindness is an inability to tell green from red. Black type on a white background is standard practice, and patterned backgrounds should be used with caution.

Software Microsoft Powerpoint is easy to use and most people have access to it. Lay your poster out on a single slide. There are several other programs that can be used to design a poster, such as QuarkXPress, [3] InDesign,[4] LaTeX,[5] and Scribus (a free download).[6] These programs allow control of text wrapping around images and text flow among associated text blocks. One piece of software specifically targets the scientific poster market: PosterGenius.[7] Layout The title is most effective when it refers to its overall take home message. It should include the scope of the investigation, the study design, and the goal. In general the title should highlight your subject matter, but need not state all your conclusions. It should be about 10-12 words long and the font size should be large, 85 point. If things dont fit, shorten the title; dont reduce the typesize. And remember, titles that are in uppercase lettering are hard to read. The author who was involved most is listed first and the most senior author is listed last. Some posters will have the addresses of the institution to which the authors are affiliated. Break up your poster into sections, much like a scientific article. Label all the sections with titles: introduction, methods, results, conclusion, references, and acknowledgements.

Introduction Write a few brief sentences to identify what is known about the topic, why you did the research, and the aim or aims of your work. This section can also include your hypotheses, which usually go at the end of the introduction.

Methods Explain what you did. For a study involving people, you should explicitly state whether the study was retrospective or prospective, and whether there was randomisation. Your data analysis and statistics used should also be described, including what P value you chose to indicate significant differences.

Results Select the most important results that support your message. Images and graphs say more than words. Tables and figures should be used to illustrate your studys results, and they should be clear, self explanatory, and uncomplicated. They should be numbered, and referred to by number in the textfor example, see figure 1). Make sure figures have a title and a legend. Keep text to a minimum. Graphs and charts should have an appropriate scale and labelled axes. Orient text for graphs horizontally, including labels for vertical axes.

Conclusions Write short, clear statements explaining the main outcomes of the study and why your results are interesting or important. You can also suggest future directions for research that build on your current study

References References should be limited to five, and the font size should be smaller than the poster text. Check on the organisations website for formatting instructions

Acknowledgements Write up a short acknowledgement section to thank those who helped you to complete your research, such as your research group or funding source. You should disclose any conflicts of interests that might exist.

Practicalities Find out if the library based at your hospital site has the facilities to print your poster. Alternatively, you could upload your poster onto an internet site that will print and deliver the poster to you. Some conferences print posters on site so that you can collect them when you arrive. If you do upload your poster online, make sure you set the dimensions on the file to match those in the conference guidelines. If you are travelling with your poster, make sure it is packaged in a plastic tube to protect the paper from getting damaged. If you are travelling by air, you should inform the staff at the check-in desk that you have extra hand luggage so that you do not have any problems taking your poster onto the aircraft.

Presenting the poster When someone stops to look, you should be able to introduce your poster in 10 seconds and that person should be able to assimilate all of the information and discuss it with you in 10 minutes.[2] Some conferences will allocate time for you to present your poster to a small group of colleagues who also have posters in the same category as you. Check the conference website for details. Place a note on your poster board listing the times you will be available by the board for those who would like to discuss the poster outside the formal presentation time. Prepare mini sized poster handouts or handouts of the key points for participants to take away. Make it easy for a conference attendee to contact you afterwards. Have your contact details clearly displayed on your poster and handouts. Posters are a great way to gain feedback from your colleagues and for networking and collaborating, and this should support you in writing up your research for publication. Websites with examples of scientific posters

http://phdposters.com/gallery.php http://www.ncsu.edu/project/posters/NewSite/ExamplePosters.html http://www.writing.engr.psu.edu/posters.html Roper L. Attending professional conferences. Student BMJ 2012;20:e3962. Fiona Tasker, core medical trainee doctor 1Royal Sussex County Hospital, Brighton BN2 5BE Correspondence to: fionatasker@doctors.org.uk Competing interests: None declared. Provenance and peer review: Commissioned, not externally peer reviewed. Fighting the stigma of facial surgery Jayaratnam Jayamohan is a paediatric neurosurgeon specialising in craniofacial conditions

By: Emilie Green Published: 18 December 2012 DOI: 10.1136/sbmj.e6035 Cite this as: Student BMJ 2012;20:e6035 Respond to this article In this article: Boxes: Jayaratnam Jayamohan is a consultant paediatric neurosurgeon at the craniofacial unit of the John

Radcliffe Hospital in Oxford. He was brought up in Liverpool and London, and studied at St Marys medical school in London. Jayamohan and his colleagues appeared on a BBC2 documentary called Childrens Craniofacial Surgery, which followed seriously disfigured children through life changing surgery. The Oxford Craniofacial Unit is one of four specialist centres in the UK that are licensed to undertake complex surgery involving the face and skull. The unit has developed a global reputation for the excellent psychological and practical support provided alongside the revolutionary surgery.

What inspired you to pursue a career in paediatric neurosurgery? I have always been interested in neurology so I was initially going to be a neurologist. I did my elective at Queen Square (The UCL Institute of Neurology), and was alarmed by the lack of treatment options for many neurological diseases. I spent time with the neurosurgeons and thought this is what I want to do. I got into paediatric neurosurgery while I was a trainee, primarily because the patients were so much fun to look after, but also because of the huge breadth of subspecialties within this field.

What is your average day like? My day starts at 7:45 am and finishes around 6 pm. I operate on one or two days each week, spend one day in clinic, and the rest of the time is spent attending multidisciplinary team meetings and doing paperwork. Each day of surgery is accompanied by a huge amount of ward work, which involves explaining diagnoses to families, discussing the operation, and showing them test results. Thats the big difference between paediatrics and adult medicine: there is more interaction with family members when caring for children.

What conditions do you see most often? The craniofacial unit in Oxford is one of four centres in Britain that cares for children with craniofacial conditions. These patients comprise half of my job, and the rest involves children with tumours, hydrocephalus, trauma, spina bifida, and spasticity. Increasingly, antenatal diagnosis is creeping into my remit, which involves discussing options with pregnant mothers whose ultrasound scans have revealed some major abnormality. This is quite stressful but rewarding. You recently appeared in the BBC2 documentaryChildrens Craniofacial Surgery. What were you hoping to achieve? Our primary aim was to increase the publics knowledge about the unusual conditions that we deal with daily. Although children with such conditions can have a good quality of life, they look and behave differently and can therefore be severely affected by societys reaction. You hear horrendous stories where people in the street stop and stare. Once, an adult told one of my patients that they look like a monster. This is not something that children and their families should have to deal with. We were hoping that by demonstrating these children are just children, despite looking different, it might remove some of the stigma. I think it did.

Do you believe it is necessary to remove yourself emotionally from your work? No, I dont think you should, but theres a fine line. You need to be able detach yourself to the point where you can accept that what you do to a child might make them worse. However, you can only logically accept this if your aim is to make them better in the long run. This decision about whats best for the child has to originate not just from clinical but also from emotional and moral factors. So when deciding whether to operate or not, or when talking to families about whether to withdraw treatment, you must keep the child at the forefront of your mind. To do this, I think you need to maintain an emotional link with your patient, but equally you cant let it compromise their treatment.

What has been the proudest moment of your career? Every time you come out of surgery and youre waiting for the patient to come round, particularly if the surgery has been challenging, its a hugely proud moment when they wake up in a good condition. Similarly, when a test confirms that a patient has been cured of a problem, I feel incredibly proud.

Is there anything that you dislike about your job? The thing that I dislike is the unbelievable, relentless grimness of it. Having to tell parents that their child has a malignant condition or that their child is going to die is awful. I have three children of my own, and, since I became a father, it has been even more of a wrench because I always think what must it be like? It makes me feel sick, but, although horrible, its part of my job.

Do you ever miss working with adult patients? No, never. My kids [patients] are just amazing and I love looking after them. I do look after adults in that the patients family are part of the disease. We have to try to keep the mums and dads in one piece while were steadily chipping away at their lives. I guess were sort of psychiatrists for the parents while being neurosurgeons for the children.

What qualities are needed to be a successful paediatric neurosurgeon, and what advice would you give to students wanting to work in this field? In terms of personality, you need to be robust. You have got to be able to interact with children and their families, and make them relaxed. You must be good at handling difficult situations and breaking bad news on a regular basis. You also need to be physically strong to be able to cope with the lengthy operations, which can last up to 12 hours. Its the best job ever, but it isnt for everybody. I advise students to really think about exactly what they would be good at and what they would enjoy. Factors such as what society or families expect should not come into play. Everyone considers their specialty to be the best, which is a reflection of the fact that most medics have managed to find a career that suits them. Thats the great thing about medicine: theres something for everyone. Emilie Green, Clegg scholar, BMJ Its ability not disability that counts A paralympian and anaesthetist

By: Leslie Herbst Published: 26 July 2012 DOI: 10.1136/sbmj.e3963 Cite this as: Student BMJ 2012;20:e3963 Respond to this article In this article: Boxes:

Angelika Trabert Top Angelika Trabert Biographydysmelia caused Angelika Trabert to be born without legs and with only three fingers on her right hand. She is one of the most successful dressage riders in disabled sports. She has competed at international level since 1991 and won at the Paralympics, World, and European Championships. Her medal collection comprises 14 silver and 3 gold medals. She is also a qualified trainer and anaesthetist who works two days a week in a day clinic in Frankfurt Hchst and three days in urban clinics in Offenbach, Germany.

What attracted you to a career in medicine? My passion for horses and big animals attracted me to studying veterinary medicine. I looked into the options available to me, but the prospect of working with small animals didnt appeal. Human medicine seemed a great alternative because it offered such variety and opportunities. Straight after secondary school, I studied medicine. A friend of mine worked as an anaesthetist in the same hospital I was working in, and one day I sat in with her and thought this is what Id like to do.

When and how did you begin horse riding? My passion for horses began at the age of 6. Like every little girl, I was eager to take up the reins to ride. My parents assumed Id quickly lose interest in riding and put me on the back of a pony. Finding a way for me to ride was difficult because my parents had to find special insurance, a sensitive horse, and a teacher. Once all these were sorted out, I started hippotherapy (physiotherapy on a horse), and also took riding lessons on different horses.

Has your riding style changed since you first started? I suppose I was always determined to blend in, which is why I wore my prosthesis when I first started riding. Then in 1985, during my first visit to the US, my riding style and experience changed completely. I met a young girl who had lost one leg to cancer. She rode horses without a prosthesis and encouraged me

to do the same.

How do you balance your riding career with your medical career? Its a tricky one. I constantly need to prioritise. My PhD took me longer than normal because I had to defer exams that clashed with the European Championships and Paralympics. Now, things have shifted slightly, and I am approaching a phase in my life where the riding is more intense. My local trainer and I are working on Project London 2012. Support from him and my stable team is indispensible in maintaining the balance.

Have you ever faced discrimination from patients because of your disability? Patients tend to focus on themselves and dont touch on my disability. Working as an anaesthetist means you get to know people in exceptional situations, and patients usually have major surgeries ahead of them. I have never had any problems, other than perhaps patients asking me why I was walking differently as thats as much as they can ascertain.

Professional horse riding and your job as an anaesthetist are very competitive: what guidance can you give medical students who constantly face rivalry? I think you need to know what you want and also stand up for yourself. If I dont give my horse clear instructions as to what I want it to do, it simply wont react. The same applies for medicine. Ultimately, its all about performancethats how you convince people and win them over. Some days you might not be at your best, and then its difficult to argue conclusively or come up with the smartest solution, but thats only human.

Looking back at your career in sports and medicine, what advice do you have for readers who may want to follow your example? You can only be successful in a competitive career such as medicine if you are balanced. Otherwise you are likely to fall into a trap and become narrow minded, which will have a negative effect on your patients. To do a good job you need to be balanced and content in yourself and also understand your patients. Creating an antipole such as art is healthy because it hasnt got anything to do with your job but helps you regain energy. Its important to stay realistic, though.

Do you have time to live a private life at all? Yes, I do. I have time to do this interview, for example. Unfortunately, my private life did take an unexpected turn in 2005 when my boyfriend died in a plane crash. That caused an extraordinary hole in my life, but I didnt give up. I am fortunate to have some close, very good friends whom I see regularly. They are very important to me. Occasionally, some peers and I go to Africa to practise anaesthetics in the bush for an aid organisation called Mango. I met my new boyfriend on one of our trips to Guinea in West Africa. Long distance relationships have their difficulties, but I believe that you can do anything if you want it.

Do you have a motto? In 1985 I went to the National Paralympic Games in Michigan, USA where a poster caught my eye. It said Its ability not disability that counts. I thought this described my life so well that it became my motto ever since.

14 silver and 3 gold medalswhats next? London, of course. The good news is that my mare and I have won the first two qualification rounds in Mannheim in Germany. We stand a good chance of participating in London 2012. Fingers crossed.