Answers to Last Week's Questions

A motor impulse from the cerebral cortex to the left quadriceps synapses on ventral horn cells in the spinal cord. True

Clinical Relevance: Cell bodies of lower motor neurons innervating voluntary muscle are found in the ventral horn. Disease of these cells e.g., poliomyelitis causes paralysis of voluntary muscle.

In adults the right main-stem bronchus is steeper than the left. True

Clinical relevance: Inhaled foreign bodies more often pass into the right main bronchus.

Key Questions in Public Health and Primary Care

Three key questions should be asked about a health care intervention:

Can it work? (Efficacy)
Does it work? (Effectiveness)
Is it worth it? (Efficiency)

Ask yourselves these three questions for every intervention you are asked to endorse.

Adapted from Anna Glasier, Lothian Primary Care NHS Trust

How To Do Just About Anything

There is a belief that while you can learn some skills, such as how to use a computer or drive a car, there are some which you either have or you don't have. The same is often thought about doctors: some seem to have a knack for diagnosis, are extraordinarily adept at practical procedures, or have a natural bedside manner. It was these kinds of beliefs that prompted a group of Californian psychologists in the seventies to ponder the question, "Why do some therapists have consistently excellent results with patients, while others do not?" They looked for the answer to this question by studying three of these excellent therapists: Milton Erickson, a psychiatrist and hypnotherapist; Fritz Perls, cofounder of Gestalt; and Virginia Satir, a family therapist. When they had distilled the factors that were essential for success, they named the resulting framework "neurolinguistic programming." They called the process "modelling," and from there came the premise: "If somebody can do something, anybody can. You just need to know how."

In this excellent article: http://careerfocus.bmj.com/cgi/content/full/335/7617/77-a, Anita Houghton shares a formula for success. See www.workinglives.co.uk

Who Moved My Cheese?

Change happens (they keep moving the cheese).
Anticipate change (get ready for the cheese to move).
Monitor change (smell the cheese often so you know when it's getting old).
Adapt to change quickly (the quicker you let go of old cheese, the sooner you can enjoy new cheese).
Change (move with the cheese).
Enjoy change (savour the adventure and enjoy the taste of new cheese).
Be ready to change quickly and enjoy it again and again (they keep moving the cheese).

From S. Johnson. Who Moved My Cheese? London: Vermillion, 1999.

Welcome to Medical School!

The Superior Doctor

The superior doctor prevents illness.
The mediocre doctor attends to illness.
The inferior doctor treats actual illness.

Chinese Proverb

Do you agree? Have your say....

Learn Dermatology the Easy Way

This site contains colour pictures and a short accompanying description. Although this is a relatively small collection, there is enough material here for a quick revision course on common and not-so-common dermatological conditions: http://medicine.ucsd.edu/clinicalimg/skin.html

Free Online Medical Ethics Course

A new free online course in medical ethics has been launched by the World Medical Association in cooperation with the Norwegian Medical Association. See http://lupin-nma.net/index.cfm?m=2&s=1&kursid=143&file=kurs/K143/intro.cfm for free access. A diploma is provided to all those completing the course.

Spotting the Sick Child

Children have many minor illnesses as they grow up and it can be hard to tell what is wrong with them. They need a different approach from adults and many health professionals are anxious about assessing children. This comprehensive interactive DVD is designed to help health care professionals spot children with serious illness.
Authored by: Dr Ffion Davies, MRCPCH, FFAEM. Consultant in Emergency Medicine
Presented by Dr Ffion Davies, Dr Mark Porter, Prof Tim Coats, Dr David Whittington, Dr John Criddle and Dr Malik Ramadhan.
Not free but a very reasonable price: http://www.ocbmedia.com/product-42-SpottingtheSickChild.html

Learning Statistics Online

Like it or not, statistics forms an essential part of the medical literature. As competition for training jobs gets harder it is becoming essential to have publications in your curriculum vitae. A basic understanding of statistics is vital for deciding the right research methods and analysing results.

This brief article by Munier Hossain summarises a few excellent free online resources to teach yourselves statistics: http://careerfocus.bmj.com/cgi/content/full/335/7621/119. Learn and enjoy!

What Books Should I Buy?

Don't buy anything until you have checked this out!: http://respectablequack.blogspot.com/2007/09/books-bloody-books.html

Attention Year 3 Students: Clinical Examination Videos

St. George's Hospital Medical School in London has produced a number of very good videos outlining basic clinical examination.
Cardiovascular System: http://www.youtube.com/watch?v=dp5m2tXHDmA&mode=related&search
Respiratory System: http://www.youtube.com/watch?v=hWGzi5h2UR8&mode=related&search
Abdominal Examination: http://www.youtube.com/watch?v=AktNxbiTO0I&mode=related&search
Thyroid Gland: http://www.youtube.com/watch?v=3EnLqNaRPZM&mode=related&search
Hope you find these useful.

Clinical Quiz: Chronic Heart Failure

Discover how much you know about this disease in our true-or-false quiz
1. Hypertension is the most important cause of chronic heart failure worldwide. True/False
2. A raised jugular venous pressure or presence of a third heart sound will always be seen in heart failure. True/False
3. The most obvious symptom of chronic heart failure is dyspnoea. True/False
4. About one in five patients with left ventricular systolic dysfunction (LVSD) will have an abnormal resting ECG. True/False
5. Brain natriuretic peptide is not a sensitive marker for heart failure, but has high specificity. True/False
6. Radionucleotide ventriculography is more precise than echocardiography. True/False
7. MRI and/or computerised tomography will be key techniques in future heart failure assessment. True/False
8. ACE-inhibitors should be used before beta-blockers in patients with reduced LV systolic function. True/False
9. Eplerenone can be used in spironolactone-intolerant patients. True/False
10. In dyspnoea and fluid retention, frusemide is preferable to bumetanide, as it offers improved gut retention and less gout. True/False
11. LV systolic dysfunction is linked with increased mortality, which can almost always be attributed to eventual pump failure. True/False
12. Cardiac resynchronisation therapy will eventually reduce LV end diastolic volume, which will result in reduced LV dimensions and improved LV ejection and prognosis. True/False
13. One-year mortality in cardiac transplants is around 5%. True/False

Answers 1. True - At least 50% of UK patients have it. Ischaemic heart disease (IHD) with previous myocardial infarction is the most common cause in the developed world.
2. False - These strongly suggest heart failure, but their absence does not rule it out.
3. True - Patients also complain of fatigue, peripheral fluid retention, reduced appetite and weight loss. Symptoms such as chest pain in IHD or palpitations in tachycardia may be present.
4. False - This is seen in most patients with LVSD, along with abnormalities such as Q waves suggesting previous infarction, left bundle branch block, atrial fibrillation and LV hypertrophy.
5. False - It is actually very sensitive, but as it is also raised in conditions such as COPD, it loses specificity.
6. True - It is more reproducible than echocardiography. However, patients are exposed to ionising radiation with the injection of a nuclear tracer.
7. True - MRI is excellent in assessing cardiomyopathies and IHD. Availability is the main limitation in use of these techniques.
8. False - Historically this was the practice, but recent evidence provides no support for either as the starting management. Patients with reduced LV systolic function should be on both drugs, barring contraindications.
9. True - It now has a UK licence for symptomatic LV dysfunction post-acute MI. However, use with caution, as hyperkalaemia is a significant side-effect.
10. False - Bumetanide offers this advantage over frusemide. If fluid overload persists, loop diuresis can be complemented with a thiazide.
11. False - Although pump failure is a factor, a large proportion of the increased mortality is due to arrhythmic sudden death.
12. True - CRT paces both the septum and lateral LV wall via the coronary sinus and stimulates the septum and lateral wall simultaneously, providing maximal cardiac output.
13. False - Early mortality of transplant is about 20%. The number of patients with a predicted annual mortality greater than 20% is falling dramatically.
Reference Cormack A, Brady A. Update 2007; June; 19-28

How Do You Help This Patient?

THE CASE
An anxious 44-year-old female patient has booked an emergency appointment to see you, her GP. She says she discovered a lump while in the shower two weeks ago, and although she had been worrying about it, it took her a while to pluck up the courage to see you. Examination reveals an enlarged axillary lymph node on her left side, and you explain that she will need urgent referral to a specialist breast clinic. She pleads with you to find a female consultant, but you can find none. She breaks down in tears, distressed at the thought of seeing a male breast cancer specialist. What do you do?
THE GP's VIEW
This patient has expressed a (not unusual) specific request to see a female specialist and even though there appears to be none listed as available locally, I would respect her needs and look for ways around this. For example, the local consultant may have a female SpR who could see and assess her, or may have a female locum who occasionally works with him and is due again soon. So it is worth talking to the local specialist, checking whether he has had this problem before, and if so, how it was resolved. Alternatively, she may be willing to pay privately and go further afield. I would offer her the choice of the nearest female breast specialists and inform her of the approximate costs that she would need to consider, including any further investigation or surgery that may result. There may be more serious issues behind the request, so it is essential to offer her the opportunity to express concerns and reasons as to why she is so adamant. There may be cultural reasons or religious beliefs, but I would want to allow her time to talk about previous experiences that may have affected her. Many women are simply shy of showing intimate areas to male doctors and will go to some length to avoid it. But there could be reasons from her past, such as abuse as a child, or spousal pressure or abuse, which are relevant in this case and which she may wish to talk about. With the pressure on GPs to provide for patient choice in all aspects of care, we could try applying to the PCT for special funding for her to go out of area, but experience warns me not to be too optimistic. Also, I would expect this to take quite some time, which (considering our possible diagnosis) we do not have. If all these efforts do not produce a result, I would ask the patient what she would like to do, or whether she has an answer herself. For example, she may be aware of a female specialist to whom we could refer privately, or local charities that may help her with costs. I would make it clear that I am trying to help her, but that the NHS does not allow for full patient choice over every aspect of their care. This is an increasing dilemma as greater ranges of drugs and therapies stretch NHS resources. Even if it is the case that she reveals a history of abuse, we might have no other option than a local male NHS specialist or her paying privately in order to have more choice. Should she choose the local male specialist, I would want to make sure she feels supported in that decision and the outcome.
Dr Gill Jenkins, a GP in Bristol

THE SPECIALIST'S VIEW
Obviously she's worried and understands the importance of rapid assessment. It could be a breast primary, a lymphoma or something less serious. In any case, she needs a mammogram, ultrasound, blood tests and a biopsy. I would stress the importance of teamwork here. It is not going to be a single person who deals with her in the hospital. Persuade her that male doctors can be just as empathetic as women and breast surgeons now are usually very different from the days of Lancelot Spratt. They have been trained to communicate much better. She will see a breast care nurse and almost certainly obtain counselling. Explore what her worries are and try to reassure her. She needs sorting out and the local breast care team would be the best first port of call. Encourage her to take a friend or relative with her for the first visit. The pathology result may well be available there and then, as many hospitals operate one-stop clinics so the treatment plan can be given immediately. This really is much better than weeks of uncertainty. If all this fails, refer her to a female breast surgeon in London privately. Getting such an opinion will, of course, cost her money, but will be quick and she can still go back to the local team if, as is likely, she needs further treatment. Trying to get your PCT to sanction a referral like this on the NHS is likely to delay things. Patient choice just doesn't run that far.
Prof Karol Sikora, professor of cancer medicine, Hammersmith Hospital, Leeds

THE ETHICIST'S VIEW
There is an interesting mix of the practical and the ethical here. I think most people would probably agree that the request to see a female consultant in these circumstances is a reasonable one. There may be cultural or ethnic factors at play, which might reinforce the legitimacy of the request. As Dr Jenkins points out, there may also be a history of abuse or of psychosexual difficulties that might contribute to the patient's anxiety. In these circumstances, it would therefore be appropriate to try, as far as reasonably possible, to comply with her request. If a female consultant cannot be found - and I do not think there is a positive obligation on the NHS to provide one - then alternatives, such as a slightly more junior female specialist, could be offered. In the absence of a duty to provide a female consultant, however, it will be for the patient herself to make a decision between the available options. Overall, though, efforts should ordinarily be made to meet reasonable requests. Having said this, the idea of the 'reasonable' is inevitably a vague one, subject to change over time and between cultures. Behind the notion of medical professionalism lies the idea of scientific impartiality - an approach blind to the gender, or any other personal attribute, of the treating professional. Although in reality such neutrality may be difficult to achieve, the attractions of such an approach become much clearer when faced with requests that are less 'reasonable', such as for doctors of specific ethnic origin or sexual orientation. It was not that long ago, after all, that homosexuality was a criminal offence in the UK.
Dr Julian Sheather, senior ethics adviser at the BMA

Estimated Pevalence of Dementia in Malta

Dr. Abela, Consultant Geriatrician at Zammit Clapp Hospital, and colleagues, report that the estimated number of individuals with dementia in the Maltese islands is 4,072. This figure is expected to almost double by the year 2035. Dementia is a serious, common, world-wide neurodegenerative disease associated with severe loss of cortical brain. It is a major predictor of morbidity and mortality in the elderly costing the health services more than cardiovascular disease and cancer put together.

The Malta Health Sciences Research Database lists the abstracts of health studies conducted in the Maltese Islands. Look it up on the sidebar.

So, Why Do You Want to be a Doctor?

I'm sure you have thought about this, long and hard. Read: http://student.bmj.com/issues/07/09/life/310.php
What are YOUR reasons? Have they changed since you started medical school?

Picture Quiz

All you new Year 2 students (and new Year 3!!), check out this Neuroanatomy picture quiz: http://student.bmj.com/issues/07/09/education/326.php
Any questions? Ask here.

To Be a Medical Student Today

Check out this article: http://student.bmj.com/issues/07/09/editorials/298.php
What has it been like for you so far? What advice do you have for incoming pre-clinical/clinical students?
Post your answers here

What Textbooks Should I Buy?

Knowledge of Anatomy is essential to the practice of medicine. The Department of Anatomy's website (see link) lists a number of textbooks that may assist you in your journey. I would like to encourage current and past students to share their experiences here regarding textbooks and other resources they found most useful.

Abstinence Only Programmes

This study was a systematic review of 13 randomised and quasi-randomised controlled trials of abstinence-only programmes that enrolled about 15 940 US youths. The programmes examined aimed to prevent HIV only or both pregnancy and HIV. Trials evaluated biological outcomes (incidence of HIV, sexually transmitted infection, pregnancy) or behavioural outcomes (incidence or frequency of unprotected vaginal, anal, or oral sex; incidence or frequency of any vaginal, anal, or oral sex; number of partners; condom use; sexual initiation). Compared with various controls, no programme affected incidence of unprotected vaginal sex, number of partners, condom use, or sexual initiation.
Conclusion: Programmes that exclusively encourage abstinence from sex do not seem to affect the risk of HIV infection in high income countries, as measured by self reported biological and behavioural outcomes.
Read the related articles and rapid responses that followed it's publication on the link.
Post your comments here.

Cinemeducation

All Medical Students are cordially invited to the KSU Common Room on Wednesday September 26 at 2pm for a screening of "The Doctor" starring William Hurt. This will be followed by a discussion regarding various aspects of professionalism raised in the movie.

See you there!

Read New York Times Review at http://query.nytimes.com/gst/fullpage.html?res=9D0CE1DC1439F937A15754C0A967958260

View Videos:

Laryngeal Cancer: http://www.youtube.com/watch?v=aeHiG0swB9I&mode=related&search
Vocal cords 1: http://www.youtube.com/watch?v=iYpDwhpILkQ
Vocal cords 2: http://www.youtube.com/watch?v=JrullzgEYmU&mode=related&search