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TRIAGE 3

THE MAGAZINE FOR JUNIOR DOCTORS

Presenting HistoryJuniorDr is a free lifestyle magazine aimed at trainee doctors from their first day at medical school, through their sleepless foundation years and tough specialist training until they become a consultant. It’s proudly produced entirely by junior doctors – right down to every last spelling mistake. Find us quarterly in hospitals throughout the UK and updated daily at JuniorDr.com.

Team LeaderMatt Peterson, team@juniordr.com

Editorial TeamYvette Martyn, Ivor Vanhegan, Anna Mead-Robson, Michelle Connolly, Muhunthan Thillai, Rob Bethune

JuniorDrPO Box 36434, London, EC1M 6WA

Tel - +44 (0) 20 7 193 6750Fax - +44 (0) 87 0 130 6985team@juniordr.com

Health warningJuniorDr is not a publication of the NHS, David Cameron, his wife, the medical unions or any other official (or unofficial) body. The views expressed are not neces-sarily the views of JuniorDr or its editors, and if they are they are likely to be wrong. It is the policy of JuniorDr not to engage in discrimination or harassment against any person on the basis of race, colour, religion, intelligence, sex, lack thereof, national origin, ancestry, incestry, age, marital status, disability, sexual ori-entation, or unfavourable discharges. JuniorDr does not necessarily endorse or recommend the products and services mentioned in this magazine, especially if they bring you out in a rash.

© JuniorDr 2011. All rights reserved.

Get involvedWe’re always looking for keen junior doc-tors to join the team. Benefits include getting your name in print (handy if you ever forget how to spell it) and free sweets (extra special fizzy ones). Check out JuniorDr.com.

What’s inside

040912

14

15

172630

LATEST NEWS

ANimAlS IN TRAINING

HOW TO RUN A QuAlity improvEmENt projEct

Qi CASE STUDIES

LEARNING TO lEAd

colAlifE

DR fAirytAlE

courSES AND CONFERENCES

coNNEct pEoplE, SHARE KNOWLEDGE, IMpROvE CARE

It’s easy to reinvent the wheel, it’s even easier to re-invent a flat tyre ~ misquote, Sir Muir Gray

A t the beginning of most patient encounters there is a junior doctor. That junior doctor understands far more intimate-ly than anyone else what a patient is experiencing, and can

identify what challenges and fears may present along the journey. Often it is the junior doctor who makes the most significant deci-sions on behalf of the patient, and who has the biggest impact on patient outcomes.

So why aren’t junior doctors more involved in the quality improvement process? In some cases there is a lack of opportuni-ty, with audit focusing on data collection instead of being part of a change process. In others there is a lack of time, with rotations being fleeting and support to introduce an innovative idea poor. However, the strength of being a junior doctor lies in rotating through hos-pitals and communities, and being able to share best practice ideas.

At the core of effective quality improvement is the need for col-laboration and dissemination of ideas to truly reach a tipping point of change, improving patient care and experience but also job sat-isfaction for junior doctors. In this quality improvement issue of JuniorDr, co-produced with The Network, we share some ways to run a quality improvement project and offer examples.

The Network was established at the end of July 2010 as an online community connecting medical students, doctors and other health-care professionals to improve the quality of care in the UK and beyond. With over 1,400 members representing clinical, non-clin-ical and allied health professionals across all grades, up and down the country and internationally, the value of The Network lies in the ability of members to share the quality improvement work that they are doing.

NHS professionals have been using Facebook, LinkedIn and Twitter for years now as a medium to communicate and exchange thoughts and ideas. The Network takes social media a step further by providing the latest in case book and blog technology to inter-act with like minded individuals and explore the innovative ideas of your colleagues.

Read our QI section in this issue, then join The Network today at www.the-network.org.uk and explore the endless possibilities of being connected.

Rob bEThunE – The NeTwork

nIkkI kAnAnI – The NeTwork

nEWS PuLSE4

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

T he vast majority of doctors are uncon-vinced of potential benefits of the potential benefits of government

plans for the NHS in England, according to an Ipsos MORI poll of BMA members.

The survey of 1,645 respondents found widespread concern about plans to increase competition even among the minority of doctors who are generally supportive of the changes.

Almost nine in ten (88%) think it is likely that the reforms will lead to increased competition between providers, but only a fifth (21%) believe this will improve the overall quality of NHS care.

Two thirds (67%) think closer work-ing between general practice and hospitals would improve the overall quality of patient care but only a third (34%) believe it likely that the reforms will lead to this.

In terms of the impact on their own roles, three fifths of respondents (61%) think it likely that the reforms will lead to them spending less time with patients.

“This survey shows that the govern-ment can no longer claim widespread sup-port among doctors as justification for these flawed policies,” said Dr Hamish Meldrum, Chairman of Council at the BMA.

“While there are widely differing opin-ions, with many still to decide, there are a number of key issues where the majori-ty have very clear concerns. The govern-ment simply cannot afford to dismiss this strength of feeling amongst the group they are expecting to lead much of the change.”

Overall the survey suggests that doc-tors attitudes to the reform fall into three distinct groups: a third (33%) are broadly opposed, around a fifth (18%) are broadly supportive, and just over a third (36%) say they are waiting to see what happens.

There are also mixed views about the impact of the proposed system of GP-led commissioning. Two thirds (66%) agree it will increase health inequalities and half (49%) that it will reduce the quality of patient care.

www.bma.org.uk

DOCTORS THINK NHS REFORMS bRING morE riSkS thAN bENEfitS

NHS

NHS

NHS REFORMS forciNg gpS iNto rEtirEmENt

M ore than half of GPs planning to retire in the next two years blame the NHS reforms as the reason for

them going, according to a major new sur-vey of 18,000 GPs by the BMA.

After age, NHS reform was the second commonest reason given for GPs planning to retire in the next two years (56%).

According to the BMA, if these results were extrapolated the survey suggests that in the next two years, approximately 6,700 GPs across the UK plan to retire - with approximately 3,700 saying that NHS reforms were a factor in their decision.

Dr Laurence Buckman, Chairman of the BMA’s GPs Committee, said:

“I’m not surprised, for example, to find

that two thirds of GPs are worried about how the new consortia will operate when you consider the laissez-faire approach that the government has taken to planning the new arrangements so far.”

“Staff are leaving Primary Care Trusts in droves and those that are left are spending their time and energy creating PCT ‘clus-ters’ instead, without any certainty about their long-term future. In many areas, GPs are being left to get on with it while many of the key questions, such as how groups will be determined geographically, are left unan-swered and still not determined by law.”

www.bma.org.uk

Hamish MeldrumChAIRmAn of bmA CounCIL

“The government simply cannot afford to dismiss this strength of feeling amongst the group they are expecting to lead much of the change.”

other key findings from the survey include:• Respondents believe it is important for

other professional groups to be involved in consortia - with hospital consultants and public health doctors the most important and local councillors the least important

• Three-quarters of Gps do not believe consortia should be paid performance-related bonuses (often referred to as the ‘quality premium’) for commissioning

• Around seven in ten are concerned about the potential conflicts of interest within the Health bill, both for the impact this could have on their relationship with patients and because of their role as commissioners as well as providers

• Approximately two thirds do not think consortia will be appropriately skilled or supported to run the NHS effectively

T he majority of medical students feel they lack the skills and legal knowledge to chal-lenge poor clinical practice and promote

better patient care, according to research pub-lished in the Journal of Medical Ethics.

The survey of 1,154 UK medical students found that confidence was notably low in the areas of the Coroners Act and working in court room settings. Only in the knowledge areas of consent, assessing mental capacity and confidentiality did students feel confident.

“If young doctors do not feel confident, they are unlikely to challenge poor practice or show lead-ership in promoting better patient care through using legal rules and an understanding of how law relates to and underpins good medical practice,” say the authors.

“Structured law teaching is required through-out qualifying programmes, and that this needs to be reinforced and practised in clinical attachments and continuing professional development, other-wise, knowledge and skills, even when acquired, may decay.”

Students felt they knew more about the legal principles relating to negligence than to the NHS complaints procedure. The authors suggest more time and emphasis needs to be put on legal skills in the formal medical curriculum and that these need to be practised and honed during clinical training.

www.gmc-uk.org/recordings

MED SCHOOLS fAil to tEAch NEcESSAry lEgAl SkillS FOR MEDICINE

TraiNiNG

M ost new training programmes designed to widen access to medicine in the UK are failing to increase the diversity of medi-

cal students, according to a study published in the BMJ.

It shows that although historic under-represen-tation of women and of minority ethnic groups has been redressed, a large proportion of medical students still come from the most affluent socio-economic groups in society.

Recent years have seen major initiatives to broaden the demography of the UK medical stu-dent population, but it is unclear whether new programmes, such as graduate entry and founda-tion entry courses, have achieved this.

Researchers at the University of Birmingham looked at whether new routes into medicine have produced more diverse student populations. They found that students on graduate entry courses were, as would be expected, significantly older than stu-dents on traditional courses and were more likely to define themselves as white (84% v 70%).

Two fifths of students on traditional courses declared their parental occupation to be higher managerial and professional compared with 27% of students on graduate entry courses.

In contrast, only 23% of students on foun-dation programmes (where entry is restricted to under-represented groups) defined their ethnicity

as white and only 8% defined their background as higher managerial and professional. However, the numbers of places available on these courses are small.

“Evidence of the advantages of increasing diver-sity is emerging, but the implementation of ‘new’ admission routes to the profession does not seem to be bringing significant change,” say the authors.

“In both the US and UK, the most success-ful programmes to increase student diversifica-tion seem to be those based on explicit affirmative action, yet these programmes are not universally welcomed among the public or the profession.”

www.bmj.com/cgi/doi/10.1136/bmj.d918

NEW TRAINING pROGRAMMES fAil to WidEN divErSity IN MEDICINE

MEDicaL STuDENTS Knowledge you need in an INSTANT!

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Order your copy online now

Jnr Dr advert.indd 1 07/03/2011 12:11:40

nEWS PuLSE6

N ew GMC guidance on taking clinical photos and video came into effect on the 9th May with the aim of protect-

ing patients from recordings that invade their privacy.

Making covert recordings of patients and using mobile phones to record consultations are two of the areas covered in ‘Making and using visual and audio recordings of patients’. The document sets out what doctors must do when recording patients for any purpose, including treatment, research, education or public media.

“Doctors often face a number of dilemmas when making recordings of patients and it can be difficult to strike a balance between sup-porting training, education and research and protecting the best interests of their patients,” said Ros Levenson, Chair of the GMC’s Stan-dards and Ethics Committee.

“The increase in using new technologies, such as camera phones and webcasts, can make this even more challenging. This revised guidance

should help them make the right decisions.” TV and radio production teams who

record patients are also required to be aware of the revised guidance as doctors involved in a programme have a duty to make sure patients’ rights to privacy and confidentiality are prop-erly protected and be satisfied that consent has been obtained.

www.gmc-uk.org/recordings

NEW GUIDELINES FOR vidEoiNg ANd photogrAphiNg pATIENTS

GMc

S urgeons who drink a lot the day before theatre appear to have impaired skills when performing surgery, according to

research published in the Archives of Surgery.The study by researchers at the Royal Col-

lege of Surgeons, Dublin aimed to determine the effects of previous-day excessive alco-hol consumption on laparoscopic surgical performance.

They found that compared to the control group those who consumed ‘excessive’ alcohol the previous day displayed worse performance in all three measures - time, errors and econo-my of diathermy.

“In the two studies we showed persistent det-rimental performance effects the day after exces-sive alcohol had been consumed,” they said.

“Given the considerable cognitive, percep-tual, visuospatial and psychomotor challeng-es posed by modern image-guided surgical techniques, abstinence from alcohol the night before operating may be a sensible consider-ation for practicing surgeons.”

Part of the study involved 16 medical

students and eight sur-geons all going out for a night of dinner and drinks. Half of the students and all of the sur-geons were allowed to drink as much alcohol as they want-ed until they felt drunk. The oth-er half of the students were not allowed to drink at all.

The study found that those who had con-sumed excessive alcohol the previous day per-formed their tasks more rapidly during the 9am simulation but with more errors. By 4pm per-formance had returned to baseline levels.

www.archsurg.ama-assn.org

huNgovEr doctorS pERFORMANCE AFFECTED

NHS Young docs prescribe morePatients with risk factors for cardio-

vascular disease are more likely to be

prescribed cardiovascular drugs if they

see a younger doctor, according to re-

search published in the International

Journal of Clinical Practice. According

to the study of 1,078 doctors and near-

ly 10,000 patients, although younger

doctors prescribed more drugs this did

not result in significantly better control

of their patients’ major CV risk factors

than older doctors who were more like-

ly to recommend a change in lifestyle.

http://bit.ly/lp3TRi

Saving smallpoxSmallpox samples stored at the only

two labs which continue to hold speci-

mens will not be destroyed for a further

three years, according to the latest an-

nouncement from the World Health Or-

ganization (WHO). The WHO debated

in May whether to recommend destroy-

ing the only remaining samples held in

Atlanta, USA and the other near Novo-

sibirsk, Russia. The USA, Russia and

many industrialised nations successful-

ly argued that we need the samples for

research. Smallpox was declared eradi-

cated in 1980.

www.who.int

Shortage of academicsA shortage of medical academics is

threatening to undermine the UK’s vital

clinical research base and leave some

medical schools struggling to teach

their students, according to the BMA.

The number of medical academics fell

to around 3,100 in 2010, down from

the estimated 4,963 in 2000, according

to the Medical Schools Council. They

warned that the situation may get worse

as universities continue to cut costs.

www.bma.org.uk

NHS still sickLevels of staff sickness absence in

the NHS vary dramatically across the

country, with the North of England

showing the highest levels, the Audit

Commission has found. It found that

more NHS staff take sick leave in areas

of high deprivation and that junior staff

are also more prone to taking time off

sick than their more senior colleagues.

The report suggested core areas where

the NHS could increase staff produc-

tivity, improve morale and save £290

million.

www.audit-commission.gov.uk

Available now direct from OUP atwww.oup.com/uk/isbn/9780199606481

or from all good bookshops

EVERYTHING THAT MEDICAL SCHOOL

DIDN’T TEACH YOU

July 2011 | 704 pp | 978-0-19-960648-1 | £29.95

4302 OUP Junior Doctor A4 v3_Layout 1 01/07/2011 13:38 Page 1

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ANimAlS IN TRAINING

AnImALS In TRAInInG 9

ANimAlS IN TRAININGScientific advisor to the government, The Royal Society, claim that virtually every medical achievement in the 20th century relied on the use of animals in some way. Today about 50-100 million vertebrate animals continue to be used for medical experimentation each year.

JuniorDr’s Ben Chandler looks at the current use of animals in clinical treatment and their role in medical training.

I watched anxiously as the patient’s sat-urations started dropping, the moni-tors shrieking that the oxygen lev-els were becoming dangerously low.

Urgent action was needed before a hypox-ic cardiac arrest occurred. Intubation or any other intervention via the mouth or nose was impossible. As the tension lev-els rose another doctor undertook a proce-dure often talked about but very rarely per-formed - a cricothyroid puncture.

Using a cannula to enter the airway then ventilating the patient’s lungs with oxygen, the doctor was successful at the first attempt and the oxygen levels rose to a safer level; the immediate threat to life avoided. As the atmosphere calmed an instructor gave extra tips on how to undertake this life-saving procedure. For the ‘patient’ - a live sheep - the morning’s training was far from over.

Using animals for any kind of experi-ment is controversial. The dispute sur-rounding the use of animals for teaching medical students can be traced back over a hundred years. In the early 1900`s Sir Wil-liam Bayliss, an eminent physiologist (and the discoverer of hormones) was accused of

cruelty to animals based on a demonstration he gave to a group of medical students.

During the experiment he had dissect-ed a dog which the Anti-Vivisection Soci-ety claimed was not fully anaesthetised. The dog had also previously been used for

experimentation and both activities were illegal at the time. In the following uproar Bayliss successfully sued for libel.

However the Anti-Vivisection Society were not finished with the issue, and follow-ing a public donation of funds, proceeded

AnImALS In TRAInInG10

to commission a statue of the dog. The monument to the little brown dog became a battle ground for the opposing groups and was a target for numerous episodes of vandalism.

Events came to a head in 1907 when a large group of medical students marched to the monument intent on knocking it down led to full scale riots. The local council unhappy at the costs of guarding the monu-ment pulled it down three years later. It was not until 1985 that a new version of the lit-tle brown dog statue was unveiled and still exists in Battersea Park, London.

ANimAlS iN SimulAtEd trAiNiNg

Until recently trauma training in the USA commonly involved the use of live anaesthetised pigs on which various surgical techniques, such as chest drains and emer-gency airway interventions, were practised. Following the training session the pigs were euthanised with the aim of avoiding expo-sure to any pain that may occur.

Advocates for the use of live animals claim that undertaking a procedure on a warm creature replicates reality more close-ly. The muscle tone, feel of tissues and response to intervention reflect the chang-es seen in a real human patient. Aside from the animal rights issues, critics argue the

differences in anatomy are a huge limitation in the actual surgical experience gained - a view confirmed by at least one clinical trial of candidates learning experience.

In the face of mounting criticism from various groups the number of centres in the United States using live animals as part of their Advanced Trauma Life Support (ATLS) training has now fallen to only 11 out of 280 centres. In the UK the use of live animals for medical training is illegal.

hiStory of SimulAtEd lEArNiNg

Medical simulators were first used in the 1960s. Over recent years their use has become much more widespread and the technology has evolved greatly from the basic ‘Resusci-Anne’ to the latest ‘SimMan’.

Since 2001 the ‘TraumaMan’ system has been approved for trauma training. It has become the most widely used surgical train-er device in the world and over 30,000 cli-nicians are trained with this device annually. TraumaMan consists of a human-like torso, covered with a pliable ‘skin’.

Numerous procedures can be practised on it, including cricothyroidotomy and chest tube insertion. When cut it will mim-ic bleeding and recent upgrades even allow for integration of focused trauma ultra-sound (FAST) scanning into the system. All this technology is not cheap though and a TraumaMan system costs around $24,000 (£15,000 pounds) and to allow optimal use it needs a supply of disposable skins as well.

Mannequins have numerous advantages over using animals - they have human ana-tomical landmarks, give a more reproducible

learning experience and they are much more portable, allowing courses to be run almost anywhere, without the need for animal facilities.

doctorS AgAiNSt ANimAl uSE

Some of the most vocal criticism of ani-mal use in medical education comes from doctors in the form of the Physicians Com-munity for Responsible Medicine (PCRM). Founded in 1985, the organisation has 9,000 doctors in its membership. As well as opposing animal experimentation it also promotes vegetarianism. The PCRM exerts pressure on numerous universities and hos-pitals using email based campaigns to high-light ongoing animal cruelty.

John Hopkins Medical School is one of PCRMs current targets. Regarded as one of the top medical schools in the US it remains one of the only medical schools where live animals are used for teaching. During the students surgical placement they have the opportunity to attend a surgical skills ses-sion using live anaesthetised pigs. The ses-sion offers students the chance to suture wounds and operate on various organs, however pressure is now mounting on the university to abandon this practice.

In February this year a criminal com-plaint was filed with the state attorney claiming that the university ‘should be held criminally liable for cruelty to animals’ and requesting an investigation to halt the live animal component of the school’s medical student curriculum.

Two former students along with the PCRM were behind the action. Dr John

N ot all medical interactions with animals involve painful experi-

ments. Some animals have demon-strated great abilities not only for companionship but to help patients cope with health conditions.

Guide Dogs Although references to dogs

helping guide visually impaired people can be found in texts dat-ing back hundreds of years, the first modern training scheme for guide dogs appeared in Germany dur-ing the first world war to aid veter-ans injured during battle. Over the next 40 years the idea caught on throughout several other countries.

Guide dogs take around 8 months of training

and there are

around 4500 in service in the UK. Two guide dogs in the USA were credited with saving their own-ers lives in the 2001 attacks on the World Trade Centre with both lead-ing their owners down 70 flights of stairs to safety.

Seizure alert dogsTrained to help look after their

owner following or during a sei-zure, by either alerting helpers, get-ting the phone or even by stopping their owner from falling. Some dogs may even develop the ability to recognise signs that their owner is about to suffer a seizure.

psychiatric Service DogDogs that are trained to rec-

ognise symptoms of psychiatric

problems such as hallucinations, and give companionship to peo-ple suffering from diseases such as schizophrenia.

Hearing dogTrained to recognise certain

noises, such as alarms, sirens or even somebody calling their own-ers name.

Monkey HelpersCapuchin monkeys have proved

to be suitable as companions for mobility-impaired patients. Ca-puchin monkeys are a suitable size and with a playful nature and ability to undertake practical skills that other animals would not find possible.

hElpful ANIMALS

AnImALS In TRAInInG 11

W ould you ever consider injecting a product taken from a pig’s intes-

tine into a patient then reversing its effects with a syringe full of fish sperm? Believe it or not these are just some of the wacky products we use in everyday medicine. Ben Chandler takes a trip to the pharmaceutical zoo, to uncov-er some of the strangest uses of animal parts he can find.

pigsPigs have the misfortune of having

similar sized organs to humans and be-ing readily available. Porcine tissues are already used throughout numerous fields of medicine and the humble pig is felt to

be one of the best candidates for future production of organs for transplant in-to humans. Among the many porcine derived products include:

Heparin - One of the oldest drugs still in current use, heparin was initially ex-tracted from dogs liver. Controversy was sparked in the USA in 2008 when a number of patients suffered adverse effects from heparin with numerous deaths. When the drug was traced back to its sources it was discovered that some of the heparin was extracted from pig intestines on small unregulated farms in China. A potentially extremely expen-sive lawsuit is ongoing.

Insulin - Although newer insulin for-mulations are human insulin, porcine insulin is still available. It only differs from human insulin by a single amino acid - another example of how geneti-cally similar we are to pigs!

Pig skin - Aside from being a key ingre-dient in pork scratching production, pig skin is also used in some special wound dressings.

MaggotsObservers noted over a hundred years

ago that maggots did a great job of clean-ing wounds and that soldiers who had maggots in their wounds seemed to be more likely to survive. The invention of penicillin stifled interest for a while but with the advent of drug resistant bacteria maggots are back.

LeechesAnother medieval sounding treatment

that is also making a comeback. Leeches have been used for over 3,000 years and modern medicine still finds them useful. Historically leeches were used to treat ma-ny ailments but today their use is main-ly in plastic surgery to extract blood from swollen grafts. Unlocking the components of leech saliva has also given a new range of anticoagulant medications.

SalmonPossibly the most surreal use of an an-

imal product. Protamine sulphate is de-rived from salmon sperm and it is used to reverse the effect of heparin. It is asso-ciated with some nasty side effects when injected.

beesHoney has been used as a medicine for

thousands of years, and recently has been shown to have antibacterial properties. It may even be a useful weapon against MRSA.

Pippin, spokesperson for PCRM is quot-ed at the time as saying that “animal use at Johns Hopkins is inhumane and violates Maryland’s anti-cruelty statute”. Despite being faced with this criticism the direc-tor of surgery at John Hopkins University has so far refused to withdraw the pig based training lab.

militAry SErvicE

Trauma and surgery are not the only spe-cialities that use live animals for training procedures. In the US live ferrets have been used in paediatric training programmes for practising tracheal intubation, and live rab-bits for paediatricians to learn chest tube insertion. Pressure is mounting on all of these hospitals to stop such practices.

As more medical schools and hospitals stop using live animals in trauma training the focus has shifted to the US military and its use of live animals. As recently as 2009 the US military were using 8,000 live ani-mals a year for training during which the animals would suffer severe injuries for medics to cope with.

Other animal use within military train-ing includes the use of monkeys exposed to chemical agents to observe the clinical signs and response to treatment. The PCRM has obtained videos of this practice via freedom of information acts and posted them on the internet, increasing public awareness.

thE ExpEriENcE

Our ‘patient’ died at the end of the train-ing session. It was given a lethal injection by the attending veterinary anaesthetist having

shown no signs of distress or pain during the procedures.

Seeing this type of training first hand left me with mixed feelings. Using live animals for surgical training is illegal in the UK and my description of the experience is based on time spent overseas.

Anaesthetising a sheep to allow train-ing is extreme and requires serious justifi-cation. However some procedures and the stressful circumstances in which they may be needed cannot be replicated as well on a mannequin and a live anaesthetised animal may provide the best learning opportuni-ty. The sheep used for this training was also used to provide blood for the microbiology

department and following euthanasia it was used for surgical training and research.

As new working time directives cur-tail the amount of time spent in training for junior doctors, exposure to true emer-gencies is reducing and high quality emer-gency training becomes more important. More acceptable alternatives already exist for much of the training that is done on live animals. As simulator technology con-tinues to evolve the use of live animals will be increasingly difficult to justify but in the mean time some continue to argue that the UK is ignoring an important educational resource too soon.

ThE nEW bRoWn DoG by

nICoLA hICkS, ERECTED

In bATTERSEA PARk In

1985

Animal Assisted TherapyA wide range of treat-

ments based around spending time with an-imals. Recent evidence has suggested that spend-ing time in “animal as-sisted therapy” may help with treatment of autism, and it is often undertaken to help with many other ailments. Although many types of animal have been used, some of the most common include hors-es (hippotherapy), dogs and dolphins - and even elephants.

StrANgE mEdicAl productS FROM ANIMALS

mAnAGEmEnT12

HOW TO RUN A QuAlity

EStAbliSh A tEAmThis is crucial, you cannot do it alone.

Most of us do four or six month placements and this is often not enough time to run a project. Get a team of 6-10 people who can rotate whilst running the project through-out the year and you’ll find things much easier.

You’ll need as many pairs of hands as possible as good data collection is crucial and you need to make this easy and feasi-ble for yourself. You can often get by with a little help from your friends but working in a team also makes it fun and gives you immediate motivation as your colleagues and friends will hold you to account.

dEvElop A StructurE to thE projEctIt is useful from the outset of the proj-

ect to set specific targets. This will help focus your mind and enable everything to be done by the end of the year. Below is an example of a timeline for a series of Founda-tion One projects in the South West - one of which is described in a bit more detail later.

The collaborative feature of this timeline is particularly important. If there are oth-er groups in your hospital running quality improvement projects then make sure you have collaborative sessions with them. This will help all of you to learn from each other as well as providing motivation and support.

thE modEl for improvEmENtThere are a multitude of tools for

improving quality of systems (Lean and Six Sigma are examples) but the most tried and tested model for healthcare is The Model

for Improvement. I will describe it in more detail below using a current F1 quality improvement project as an example, but the diagram below shows the outline - make your aim, measure the thing you are trying to improve and then run a series of tests of change (the plan-do-study-act cycle).

AimWhat is it you want to improve? It is real-

ly important to carefully define this at the start to help you develop a deeper and more profound understanding of the system. Our example project was trying to improve the effectiveness of weekend handover. They wanted 95% of jobs that were handed over to the weekend team to be completed by Monday morning.

mEASurE‘Data, data, data’ goes the drumbeat of

a quality improvement project. Without it you will not be able to see if your changes are an improvement - but more importantly by getting really good data you will devel-op profound knowledge that will allow you really see what needs changing.

Profound knowledge is often underesti-mated. We see problems on the surface and think solutions are obvious and often we just go ahead and implement them. These simple change efforts are often unsuccessful because we do not really understand the sys-tem we are dealing with.

Once we have this knowledge then the changes are usually clear. Remember H.L. Mecken’s words ‘For every problem there is a solution, simple, elegant - and wrong’.

We have to be able to show that our solu-tions do make a difference so we plot our data on a run chart. In our example project the team collected data on how many jobs were being completed on a weekend (they sampled this data) and plotted the initial data before any tests of change on the graph below. As you can see they did this on five separate occasions to ensure the accuracy of their data.

thE plAN-do-Study-Act-cyclE (pdSA)Now you have your background data

collection and a deeper and more profound understanding of the system (weekend handover in our case) you are ready to make some changes. These are done in the form of a PDSA cycle.

The PDSA cycle is as simple and intui-tive as it sounds; come up with a plan, trial it out on one day, study the effect and act upon the result. One of the keys is to trial

(WHILST WORKING FULL TIME AS A JUNIOR DOCTOR)

Effecting change in the NHS as a junior doctor can be a daunting experience. With limited power, influence and time it can seem an almost impossible task.

Yet, as a junior doctor we get a unique insight into how we can improve patient care. In this article The Network’s Rob Bethune offers a few helpful suggestions that can help facilitate change.

fIG 1 - ThE moDEL foR ImPRovEmEnT

fIG 2 - Run-ChART

As junior doctors we are in a unique position to see the problems and affect the

solutions.

mAnAGEmEnT 13

improvEmENt pROJECT

the change over a short time period in one area. If it works you can spread it but if it doesn’t and needs refining then you can do that easily.

If you implement your idea widely from the beginning (as we have seen so often in healthcare!) and you get it wrong it is expen-sive both in terms of time and resources to undo it. Make your first tests small.

In our example (see the next run chart below) they did several PDSA cycles, improving the handover sticker in the notes as well as unifying the Excel spreadsheets used to pass the information on.

Through a series of small scale changes

with continuous data collection the effec-tiveness of weekend handover increased dra-matically (and for the managers out there - this was free!).

Improving the systems in which we work is crucial to improving the care we give to our patients. As junior doctors we are in a unique position to see the problems and affect the solutions.

rob bETHuNE, SuRGICAL REGISTRAR, SEvERn DEAnERy

ACknoWLEDGEmEnTS. Izzy mARk AnD JoAnnE hookER AnD ThE REST of ThE WEEkEnD hAnDovER GRouP AT noRTh bRISToL nhS TRuST, foR ThEIR DATA.

fIG 3

– Run

ChART

ExAmPLE

A lthough ‘quality’ is discussed widely in many professions and

industries, (the word is includ-ed some 360 times in Lord Darzi’s much cited NHS Next Stage Review Final Report1), it remains a slightly evasive concept.

The focus on quality has been ap-parent in healthcare for much of the 20th century and is both political (used by different professions to ad-vance their particular interests) and subjective (dependent on who is as-sessing it and what values and con-sensus are used).

The popular definition of quality in healthcare that now dominates was produced by the Institute of Med-icine and Committee on Quality Health Care in America (2001); this portrays safety, effectiveness, patient-centeredness, timeliness, efficiency and equity as the six ‘pillars’ of qual-ity in healthcare.

Simply evaluating quality repre-sents just one end of the quality con-tinuum which includes quality assur-ance, and quality improvement. The latter, popularised by a number of quality improvement evangelists in the late 20th century (such as W.E. Dem-ing and Philip Crosby), had its roots in managerial and industrial sectors be-fore being applied to healthcare.

Perspective is also important: a key distinction is that between patient quality and professional quality. In the former, the patients’ perception of a service could be deduced by counting complaints, or rating service attributes for example. When professional qual-ity is considered, the professionally as-sessed needs of patients represent the standard which should be met.

So, whether you are trying to mea-sure it, assure it, or improve it, quality in healthcare is a slippery but increas-ingly relevant force for improvement.

WHAT IS QuAlity?

mEDICAL STuDEnTSImPRovInG CARE14

Qi CASE STUDIESWHaT WaS THE ProbLEM?

Fast track protocols are now well es-tablished for elective surgery, and early discharge is becoming the vogue. This removes the need for additional blood tests (C reactive protein and coagulation screens) in the early post operative peri-od as ‘screening’ tools in place of bedside assessment. However, these are request-ed frequently and unnecessarily, impos-ing extra burden on busy pathology labs, and at significant cost.

WHaT cHaNGES DiD you MakE?

An intervention was designed through Pathology and IT, with con-sultant approval. We introduced a noti-fication on the computerised blood re-questing system to remind surgical house officers of test indication, and to make

recent results quickly accessible before requesting serial tests. We also provided junior doctor education.

HoW DiD you DEMoNSTraTE aNy DiffErENcES you MaDE?

We collected a prospective database of 114 patients under surgical specialties over two months and performed audit, intervention, and closure of the cycle. We demonstrated a significant 54% and 56% reduction in requesting of CRP and coagulation screens respectively. This did not affect safety: average length of stay did not differ significantly (3.7 and 3.6 days respectively), and 10.5% had com-plicated recoveries in both groups.

WHaT arE your coNcLuSioNS?

Hospital costs of CRP= £5.37;

coagulation panel = £8.34. Based on 57 patients/month, this infers potential sav-ings of approximately £36,000 per year. This improves accuracy for detecting complications by reliance on clinical ex-amination and reduces burden on pathol-ogy labs. Indeed, this offers significant cost savings through a front line interven-tion without compromise in patient care.

WHaT LESSoNS HavE you LEarNT THaT couLD HELP oTHErS?

Established practice can be changed through simple intervention. This achieves significant improvement, and IT provides an effective instrument to realise this change.

UNNECESSARY bLOOD TESTING

aiMS:95% of discharge summaries to be

of high quality and be completed with-in 24 hours of patient discharge by the end of our F1 year.

obJEcTivES:

Responsibility for discharge sum-maries often falls to Foundation Doc-tors. We recognised the importance of this communication with primary care in patient safety. By studying the system and process of producing discharge sum-maries, and engaging everyone involved (from ward clerk to GP), we sought to improve this part of our jobs and serve our patients better.

METHoDS:

We divided our project into Quality and Timeliness. To evaluate Quality we devised a 12-part questionnaire that was completed online by a GP and a Consul-tant using a 5-point rating system. Using data from IT managers, Timeliness was

assessed by comparing the Cerner ‘time of discharge’ with the time the electronic discharge summary was completed. We met regularly to create rolling data logs, monitor progress and discuss the next innovation.

SoLuTioNS:

• Feedback from local GPs on what constitutes a high quality discharge summary was distributed to our Foundation colleagues.

• We collaborated with IT managers to improve the electronic discharge summary system.

• All discharge summaries were read by a team Consultant.

• We asked juniors to involve seniors in the discharge summary process by specifically asking on the ward round, ‘the diagnosis/differentials’ and ‘details of follow-up’.

• We made sure Registrars had log-in details for the discharge summary sys-tem to spread responsibility for com-

pletion and ensure operation notes were entered.

coNcLuSioNS:The percentage of discharge summa-

ries being sent out within 24 hours of discharge increased from 35% to 90%. The overall rating of quality in our dis-charge summaries improved by 26%.

• We learned that whilst systems are of-ten imperfect as Foundation Doctors we are in a prime position to identify problems and implement change.

• We learned the importance of en-gaging clinical and non-clinical col-leagues, from GP’s to ward clerks, to facilitate improvement.

• We took away a sense of pride that a small group of Foundation Doc-tors could make a significant dif-ference to the care our organisation provides.

F1 DOCTORS MAKING bETTER DISCHARGE SUMMARIES

Dr Anish N Bhuva, F2 DoctorHillingdon Hospital

Dr Dermot Mallon and Dr Andrew Hamilton, Musgrove Park Hospital

foR moRE CASE STuDIES AnD To PoST youR oWn vISIT AT WWW.ThE-nETWoRk.oRG.uk.

mEDICAL STuDEnTSImPRovInG CARE 15

A s a junior doctor you can devel-op your leadership competencies by being proactive and consciously

assuming greater responsibilities around leadership activities; the Medical Leader-ship Competency Framework provides a range of practical examples of opportuni-ties for learning and development.

Establish clinics, participate in manage-ment meetings and volunteer to undertake additional leadership responsibilities; closely observe selected role models in order to iden-tify effective leadership behaviours; attend a postgraduate leadership course so as to gain exposure to unfamiliar scenarios and new theoretical models and identify your person-ality and leadership styles by completing self-assessment questionnaires.

Additional opportunities for leadership development, both pre- and post the transi-tion to consultant grade are outlined below and learners are encouraged to blend learn-ing opportunities. Each development tool and method has its own advantages and disadvantages and the right approach will depend upon individual and organisational circumstances and goals.

oPPorTuNiTiES for LEaDErSHiP DEvELoPMENT

• Action learning - working as part of a small group of peers or an ‘action learn-ing set’ to address real life problems, de-velop solutions and take action

• Coaching - a time-limited, goal-orientat-ed, one-to-one developmental relation-ship based on real work issues

• Developmental work assignments - learn-ing from ongoing work initiatives and in-tegrating these experiences with each oth-er and strategic organisational imperatives

• Mentoring - a long-term, open-ended, one-to-one developmental relationship in which a senior colleague supports the personal and professional development of a junior colleague

• Leadership within a team - motivating team members, leading through change, confronting poor performance, delivering results (by achieving objectives) and en-couraging and supporting the profession-al development of team members

• Networking - creating interdepen-dent and often mutually beneficial relationships;

• Self-directed learning - taking responsi-bility for finding, managing and assess-ing one’s own learning eg. basic internet research, reading leadership books and journal articles, attending and contribut-ing to networks and forums

• Shadowing - provides opportunities to observe and understand an unfamiliar part of a system without being required to act

• Workshops and masterclasses - time-limited learning sessions focused on spe-cific topics which provide opportunities to gain up-to-date information, develop particular skills and to share learning; workshops delivered by experts in their field are called masterclasses

Developmental experiences are likely to have the greatest impact when they can be linked to or embedded in your ongo-ing work. You should adopt a cumulative approach to learning, considering basic concepts and local systems early on in your training and complex concepts and wider systems when more established.

Regular, accurate and honest appraisals, grounded in the Medical Leadership Com-petency Framework, can offer insight in-to your leadership strengths, abilities, gaps and developmental needs as you progress in your career. Seize opportunities to re-flect, individually and with colleagues, and

to promote deep learning as a means of real-ising positive changes in your thinking and behaviour. When confronted by a new lead-ership framework or approach it is helpful to ask “how does this apply to my situation” and “how can I do things differently in the future?”.

A significant temptation for a newly ap-pointed consultant is to accept every leader-ship role and opportunity that is offered; this approach, however, is an inappropriate use of resources, limits teamwork and team de-velopment, fails to foster the skills of others and may increase levels of stress. Conversely over-delegation risks establishing unrealistic expectations and stretching individuals be-yond their competencies to the detriment of patient care and team well being.

Dr Michael HobkirkMichael is the Lead Consultant for Chichester Child

and Adolescent Mental Health Service and the Specialist Advisor for Leadership Development at the

Royal College of Psychiatrists.

ReferenceNHS Institute for Innovation and Improvement,

Academy of Medical Royal Colleges (2010) Medical Leadership Competency Framework, 3rd edn.

http://www.institute.nhs.uk/images/documents/Medical%20Leadership%20Competency%20Frame-work%203rd%20ed.pdf (accessed 30th April 2011).

LEARNING TO lEAd FROM JUNIOR DOCTOR TO CONSULTANT

Many of the challenges facing new consultants in the emerging NHS lie in the realm of leadership and yet junior doctors often report feeling unprepared to lead.

The time when the sole function of a doctor was to provide clinical care has passed.

Summary•LeadershipisakeycomponentofyourprofessionaL

deveLopmentandanongoingprocess

•refLectuponyourLeadershipcompetenciesandLearningneedsusingthemedicaLLeadershipcompetencyframeworkasaguide

•therearenumerousinformaLandformaLopportunitiesforLeadershipdeveLopment;

•strikeabaLancebetweentakingonnewroLesanddeLegatingworktoothers.

mEDICAL STuDEnTSImPRovInG CARE16

AgENtS FOR CHANGET he past 10 years have seen a strong

focus on increasing the quality of healthcare in the NHS, with billions

of pounds invested in improving the servic-es provided to patients. This investment has resulted in wide scale improvements, such as the large reductions in waiting list sizes and rates of hospital acquired infections.

In 2008, the 60th anniversary year of the NHS, Lord Darzi’s NHS Next Stage Review titled ‘High Quality Care for All’ described quality in three dimensions to help define excellent healthcare. These three dimen-sions are patient safety, patient experience and clinical effectiveness.

Coupled with this challenge it is esti-mated that the NHS must save £20billion - equivalent to 20% of its current annual bud-get - over the next four years so that it can afford to pay for these new services. As such, cost has now switched from simply being a financial issue to now being an ethical issue that affects all those who work in the NHS.

iMProviNG froM THE froNTLiNEFaced with arguably its toughest chal-

lenge yet the NHS has been looking to find those people with the skills, knowledge and expertise already working in the system to meet this challenge whilst also maintaining standards and improving quality.

Understanding that there are 55,000 junior doctors currently working in the NHS and that junior doctors lead 80% of ward based activity (Tooke Report, 2007) there has been growing recognition of the increasingly important need to engage junior

doctors in building a more efficient and sus-tainable NHS.

One such initiative is Agents for Change - a partnership established under the lead-ership of the NHS Medical Director at the Department of Health and the BMJ. Its pur-pose is to engage and enable junior doctors to lead from the frontline to improve the qual-ity and safety of care provided to patients.

Agents for Change works in collaboration with a number of partners to help junior doctors gain the skills to improve their local care for patients. In the past, these organ-isations have included the National Patient Safety Agency, the King’s Fund, the NHS Institute for Innovation and Improvement and the NHS Confederation.

Last year Agents for Change held two national conferences, the first focussed on safety improvement, and the second on quality. In addition to formal conferences, Agents for Change also run a series of semi-nars and workshops. Most recently, ‘Junior Doctors: Innovating from the front line’, was held at the 2011 NHS Innovations Expo at the Excel Arena in London. These seminars engaged junior doctors through showcasing inventions by award winning young doctors and outlined methodical approaches with which to improve healthcare systems.

Agents for Change conferences have also attracted international interest. In Novem-ber 2010, ‘Agents for Change: collaborating for quality’, a pioneering event – the first to bring together junior doctors and senior managers to explore more effective methods of working together - was streamed live on

the internet and watched by a large number of international medical students.

As a direct result of this conference, Agents for Change launched the publica-tion of the ‘7 key recommendations for how junior doctors and managers can collabo-rate to improve quality’ at the International Forum on Quality and Safety in Healthcare, in Amsterdam, April 2011. This contained the agreements arrived at by the 200 senior managers and junior doctors who contrib-uted to the conference.

ENGaGiNG PaTiENTS, iMProviNG carE

Agents for Change is currently planning its next series of events beginning on the 4th November 2011 with the ‘Engaging Patients, Improving Care’ conference in partnership with the Health Foundation. This event will place patients at the very centre of the qual-ity improvement process with junior doctors working in partnership with patients to help shape and improve the delivery of healthcare. The conference will also include a series of Quality Improvement Masterclasses which will provide further context of the changing environment within the NHS.

To find out more about Agents for Change and to register for forthcoming conferences and events, please visit agentsforchange.bmj.com.

Ahmad Moolla, Agents for Change

Junior doctors rising to the quality improvement challenge

mEDICAL STuDEnTSImPRovInG CARE 17

A pproximately 20% of children die in Africa before their 5th birthdays from preventable diseases such as dehydra-tion or diarrhoea – a mortality rate that has not significantly

changed in three decades. But this may be all about to change.Children in developing countries will soon have local direct

access to essential medicines through a transformative initiative called ColaLife. ColaLife founder Simon Berry had the idea of using the Coca-Cola distribution network as a means of getting much needed supplies out to the people that really need them.

The ColaLife ‘AidPod’ fits between bottles in crates and is designed to carry essential medicines such as oral rehydration salts. This is sold wherever coke is - in every market, shop and at every street corner - for the price of an egg, it will be transforming access to medicines for those most in need.

Starting with a blog post and then a Facebook group called “Let’s talk to Coca-Cola about saving the World’s Children” Colalife soon had over 15,000 friends. And Coca-Cola heard: just three months after putting the idea live on the internet, meetings were set up with leading executives in the company and the idea of ColaLife will now become a reality later this year.

Hearing about the campaign on-line, a group of students from King’s College London went to meet Simon at an Innovations talk at the Royal Society of Medicine. Five weeks later the team of 15 flew out to Uganda to lead the largest research project for ColaL-ife to date.

Collectively travelling over 1000km by bicycle to ensure the most rural communities were reached, 656 mothers were inter-viewed, 62 schools were visited and every Coca-Cola sales point en-route was mapped out and the stock in all 16 health clinics in the Northern region was recorded.

With enough data and feedback to make the final tweaks to the design and business model, funding has now been secured to run

the first ColaLife pilot in Zambia this year. However, this is just the beginning: “The success of the pilot will pave the way for us to repeat and scale this project throughout Africa and the developing world,” says ColaLife founder Simon Berry.

Soon, local people will be able determine the contents of the AidPod’s that arrive in their communities and be empowered to treat their own children. Maybe then, we will be able to curve the mortality trend and not lose another child from easily preventable diseases simply because life-saving medicines were not available.

To find out more or to follow the campaign visit www.colalife.org

Claire Matthews, 3rd Year Medical Student King’s College London

HOW TO REDUCE child mortAlityCould Coca-Cola and Facebook have found the answer?One of the great pleasures in life is knowing that you can buy a bottle of Coke virtually anywhere in the world. So why is it, that if Coca-Cola can reach the remotest villages on the planet, children are still dying from inadequate distribution of simple medical treatments?

SImon bERRy. PhoTo by ThE RuGby TImES.

PhoTo by TIm DEnCh.

PhoTo by TIELmAn nIEWouDT.

“ColaLife is a really imaginative, practical and worthwhile project which aims to help save people’s lives.”Hilary Benn MP

IMpROvING cArE

mEDICAL STuDEnTSImPRovInG CARE18

D APS (Doctors Advancing Patient Safety www.daps.org.uk) is an organisation set-up at the beginning of 2009 to empower junior doctors in making improvements in

patient safety and care within their clinical environments. DAPS has over the past two years extended its activities to

include a website, a student safety forum, a publication for report-ing errors and its most innovative activity to date, the Improve-ment Programme.

The Improvement Programme took place on the 21st January 2011 where seven junior doctors from the UK travelled to Lahore, Pakistan to work with seven junior doctors there to carry out qual-ity improvement projects.

The programme was organised under the auspices of DAPS and the Government of Punjab which is the largest of the four provinces of Pakistan. The team was allocated to carry out its work in Services Hospital, which is located in Lahore and is the main tertiary centre within the local area. Services Hospital is a govern-ment hospital but also has an allocation for private patients.

COLLAbORATING FOR SAFETY

The first and second days of the programme were largely dedi-cated to introductions, forming three groups which would carry out the intended quality improvement projects and engaging in a walk-round of the hospital with the intention of looking for areas in which there were potential hazards in patient care. After high-lighting a number of areas the team decided to focus on three par-ticular areas of care which they developed over nine days.

The first group focused on two specific infection control issues

which they had found sorely lacking. The first was hand hygiene and the second was the reuse of oxygen masks. The team observed that there was little or no adherence to simple hand-washing by either staff or patients which was particularly serious given the high patient load as well as the vast number of relatives who were allowed in the ward to act as attendants to the patients due to low nursing staff levels.

Oxygen masks were being re-used from one patient to another with minimal effort of sterilisation between use despite the fact that the previous patient may have been suffering from active respiratory tuberculosis.

The group made a number of positive interventions which included organising the allocation of alcohol wash to each ward, producing an educational leaflet about infection control for doc-tors and nursing staff, designing posters for patients and staff about the importance of hand-washing and assigning a house offi-cer on each unit to act as the lead for infection control.

The second group focused on the resuscitation trolleys in the hospital, which were not being used for their designed purpose. The vast majority of them were being used as general pharmacy stores and others were placed in inaccessible locations, which was of great concern given that there were five cardiac arrests per day on the medical wards.

The aim of the team was to redesign the trolleys so that they functioned as a crash as well as an emergency trolleys. They designed a bespoke tray, which was used to hold medications in slots in con-trast to the free-floating medications in the drawer. Testing their new tray against the old system demonstrated that the time taken in obtaining four emergency medications was halved. The group also designed a checklist which was to be checked on a daily basis.

The third group focused on discharge medications. At least 50 percent of patients in Services hospital were found on survey to be illiterate and so there was a question over medication compliance. Discharge letters were either handwritten or typed in English and given the illiterate population, comprehension of the medications was extremely limited.

The group designed a new medication discharge form which used symbols to represent the different times of the day. Surveying this form with the patient demonstrated that there was much bet-ter understanding of the symbols, which would naturally lead to an increase in compliance.

FUTURE pLANNING

All three groups made a presentation on the penultimate day to the rest of the hospital which was extremely well received - with some of the local consultants expressing an interest to further take up the work.

The team also had the opportunity to take a day out of the pro-gramme to see some of Lahore’s historic sights as well as visiting the famous Wagah border between India and Pakistan to watch the changing of the guards ceremony.

After the departure of the British doctors the Pakistani doctors have continued to make improvements in their clinical environ-ment and continue to stay in contact through a Facebook group.

DOCTORS ADvANCING pAtiENt

oxygen masks were being re-used from one patient to another with minimal effort of sterilisation between use despite the fact that the previous patient may have been suffering from active respiratory tuberculosis.

The programme was an extremely useful venture with the feed-back being unanimous as to its role in promoting quality improve-ment and empowering junior doctors to take it up. DAPS is due to run the programme again in January 2012.

If you would like to participate in the programme in January 2012, please contact info@daps.org.uk

Imran QureshiSpecialist registrar in Medical Microbiology & Virology

Founder of DAPS

DOCTORS ADvANCING pAtiENtSAfEty

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CAREERS20

WRITING cASE rEportSFor most junior doctors their first experience of publication will be writing a case report. bMJ Case Reports Editor-in-Chief, Seema Biswas, offers some advice on perfecting your write-up.

W riting up a memorable case with your team is a valuable learning experience. It is the opportunity

to research more about a case, search the medical literature, look up and compare clinical guidelines, ask probing questions about the pros and cons of management decisions and, most of all, assert your point of view in the medical literature.

As evidence based medicine standards go case reports are level 5 evidence (below clin-ical trials and case series) but case reports do have their place. We learn from our discus-sion of cases we manage every day. It helps to discuss unusual presentations, complex symptoms, ethical or practical challenges, near misses, pitfalls and how complications may present and are dealt with. The debate is an educational one and case reports are an ideal educational resource for real case based discussion.

A common perception is that only rare or novel cases are worthy of publication. In fact, we learn far more from common cases that present in an unusual way or common management pathways that meet an impasse or result in an unexpected outcome.

My advice for writing up a case are to find one with valuable educational lessons for junior doctors or medical students. The patient may be someone you meet as a student or junior doctor, or a patient you looked after on a medical student elective. Take any clinical pictures you need to illus-trate your points and then write-up the case using the following structure:

Summary: Try to project the lessons of value and points of interest so that these are immediately apparent to someone reading your report. You may choose to type this section last as your report takes shape but this will be what captures the attention of your audience.

Background: This is essential informa-tion that sets the scene and explains why certain symptoms or complications may have arisen during the course of illness.

Case presentation: For most of us this is frequently the easiest section to begin writ-ing. This is an outline of everything that happened to the patient from the time of presentation to discharge. This is ideal for you to type as you are most likely to have completed most of the case note entries

yourself and merely need to consult your notes. Be sure to include all relevant results and write these in full using international-ly recognised units explaining any abbre-viations, e.g. “The patient was hypotensive with a blood pressure of 130/80 mmHg and had developed neutropenic sepsis with a WCC, white blood cell count, of 2.1 x 109/l”

Investigations: This is where radiologi-cal images illustrate your results and good pictures are extremely effective.

Differential diagnosis: Rather than list-ing these, what is crucial is to demonstrate is how differential diagnoses were formed and diagnoses excluded as the patient was worked up. Clinical reasoning is fascinat-ing as an entity in itself, but case reports are a brilliant opportunity to demonstrate how diagnoses are teased out through clin-ical problem-solving. This is where case reports really come into their own and earn their place amongst the medical literature.

Treatment: As an editor, the best case reports present the case, investigations, diagnosis and treatment as an honest and reasoned process where management deci-sions are explained clearly. Clinical judg-ments and treatment plans, therefore, make immediate sense, especially to a doc-tor of a different specialty.

Outcome and follow up: These give the clearest idea of the progress of a case. All too often this is neglected as inpatient teams may be disconnected from outpa-tient care. This information is crucial, however, and tracking a patient’s progress after discharge is, of course, excellent prac-tice for the inpatient team.

Discussion: There is no need for the discussion to be a summary of all the lit-erature about a particular clinical problem. Focus on points that make the case notable and where lessons can be learned; this may be a mechanism of injury, a pitfall in the interpretation of investigations, the suit-ability of appropriate clinical guidelines, necessary departures from these guidelines or their adaptation in a particular scenario, the management of challenging complica-tions … there are innumerable possibilities!

Learning points and take home mes-sages: These are essentially your final conclusions and serve to crystallize your

thoughts on exactly why you think this case is of value and what we can learn. You may find this very effective in focus-ing your thoughts when you begin typing the case report.

The patient’s perspective: This may be a most enriching contribution. I would urge you to involve patients in the process from the beginning as this is likely to result in a well-rounded account and the process of obtaining consent for images and publica-tion is rendered more meaningful.

As an editor, it is often writing style or grammar that fail to do justice to a case report. A well-written case with clear learn-ing points is likely to be published. In modern medical portfolios where publi-cation is essential for job applications and continued professional development writ-ing up notable cases is both an educational and career ‘no brainer’.

“Writing up notable cases is both an educational and

career ‘no brainer’.”

Wesleyan Medical Sickness is a trading name of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Ltd is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham, B4 6AR. Telephone calls may be recorded for monitoring and training purposes.

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fInAnCE22

Focus on Finance - in association with Wesleyan Medical Sickness

AN INTERvIEW WITH pROFESSOR pArvEEN kumAr

Why did you go into medicine?

One of the reasons I decided medicine was a great career is that it combines sci-ence with caring for patients – both of which I was passionate about and still am. Medicine has so many facets and also gives you an enormous choice of jobs within the speciality. Ultimately, it’s very fulfilling and certainly helped me to achieve what I wanted to do with my life.

How did I get into teaching?

I just love to teach. There are so many different ways of teaching depending on where you are, for example, on the wards or in out-patients. Students learn in dif-ferent ways and part of the excitement of teaching is to find the correct method, lev-el and interests of the students. Medical students are such resilient people – they’re very bright and very motivated. They also ask the most penetrating questions which sometimes make you think ‘well actually I never really thought about that!’

I’m always impressed with the differ-ent activities that medical students do in their day to day lives. Some of the students I have met are doing all sorts of things, including raising hundreds of thousands of pounds for RAG every year. Some of my students are doing a lot of charity work here and abroad in their holidays and I really admire their ability to juggle lots of activities.

What was the inspiration behind writing Kumar and Clark Clinical Medicine?

When I was a medical student there was this textbook which was so difficult to fol-low – it was verbose, ambiguous and unfo-cussed. I used to read a paragraph and think ‘should I be giving this drug or should I not give it?’ – an important distinction if it was a life or death case! I promised myself that when I “grew up” I would write the defini-tive textbook. Well, I think we got pretty close. It came about when Dr Clark, who was my supervisor for my research at the time, heard that I’d agreed to write a chap-ter for a new textbook that was being com-piled. He suggested that we should write a new book as I had ‘gone on and on about it for so long’ and offered to help. Two-and-a-half years later, having worked every week-end, holiday and spare moment, we actu-ally produced the first edition of Kumar and Clark’s Clinical Medicine. We never thought that we would still be writing it over 20 years later; it is currently in its 7th edition and is used around the world. A humbling thought but also a great respon-sibility in keeping it up to date.

What in your view are the challenges facing young doctors?

There are of course many different chal-lenges. A key one for students these days is the huge debt they might have, which can be as much as £35,000. This figure will certainly rise with the increase in universi-ty tuition fees. Not only do students have large debts but they have less time to earn money because they don’t have as much spare time or the same amount of holidays as students in other courses. As they prog-ress in their career, doctors may get mar-ried and have children so they will have a

huge number of financial commitments as well as trying to learn to be a good doctor.

What can young doctors do to alleviate these challenges?

There’s a lot to think about and clearly they need to take advice where they can. I think in terms of their education, obvious-ly young doctors should work hard but also they should play hard because it’s impor-tant to have a good work/life balance.

There’s a worry now that some young doctors might not find a job. In the past doctors always had ready made positions but now there may not be a job in a particu-lar speciality or it may require a young doc-tor to relocate, which can be very difficult if they have a family. I really think this is an area where doctors will need good advice.

One other thing young medics should consider is joining member organisations. The Royal Society of Medicine is a great institution (I would say that, wouldn’t I, as I am President!) that runs lectures on all sorts of topics. It also provides young doctors with a strong support network and an opportunity to mix with consultants or retired members who can offer the wisdom of their experience.

Professor Parveen Kumar is an influential figure in the medical profession. You may know her as co-editor of “Kumar and Clark’s Clinical Medicine”. She is also a Profes-sor of Medicine and Education and Consultant Physician and Gastroenterologist, as well as President of the Royal Society of Medicine and a member of the Wesleyan Medical Sickness Advisory Board. We caught up with Professor Kumar at the Royal Society of Medicine and got her views on everything from coping with student debt to the importance of having fun!

It’s important to have fun; if you’re not having fun then forget it and leave. Medicine is difficult enough anyway and if you have fun you’ll hopefully have a super career, I have certainly enjoyed mine and still do - even at my

ancient age!

The best tip I can give to doctors is to work hard, be honest and

show humility.

fInAnCE 23

The British Medical Association is another good organisation. It looks after the professional and personal needs of doctors and can help with legal advice if required.

How did you get involved with the Wesleyan Medical Sickness Advisory board?

I was very honoured to be asked to be part of the Wesleyan Medical Sickness Advisory Board. It’s a great organisation and offers a fantastic service to doctors of all ages across all specialities. I wish I’d had Wesleyan when I was a medical stu-dent because they give you strong finan-cial advice as you move from being a med-ical student to becoming a junior doctor and then a consultant. There are always going to be financial headaches so it’s useful to have someone to talk to that understands the specific challenges doc-tors face and can provide real help.

What would be your top career tips for a successful medical career?

The best tip I can give to doctors is to work hard, be honest and show humility; I abhor arrogance. If you make a mistake own up to it; it’s part of becoming a bet-ter doctor. Of course you must have the knowledge and this does mean hours of study and seeing patients.

The second tip is to ask for help as there

Finally, it’s important to have fun; if you’re not having fun then forget it and leave. Medicine is difficult enough anyway and if you have fun you’ll hopefully have a super career, I have certainly enjoyed mine and still do - even at my ancient age!

Specialist financial services for doctors

0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk

• Savings and Investments

• Retirement Planning

• Life and Income Protection

• Mortgages

• Motor, home and travel insurance

Wesleyan Medical Sickness and Wesleyan for Professionals are trading names of Wesleyan Financial Services Ltd, which is authorised and regulated by the Financial Services Authority. Wesleyan Financial Services Limited is wholly owned byWesleyan Assurance Society. Registered No. 1651212. Head Office: Colmore Circus, Birmingham B4 6AR. Telephone calls may be recorded for monitoring and training purposes.

Motor, home and travel insurance is arranged by Wesleyan for Professionals.

Focus on Finance - in association with Wesleyan Medical Sickness

AN INTERvIEW WITH pROFESSOR pArvEEN kumAr

The above information does not constitute financial advice. If you would like more information or need general financial advice, you can call Wesleyan Medical Sickness on 0800 107 5352 or visit www.wesleyanmedicalsickness.co.uk

is no point bottling it up because it will not help a situation. There are times when young doctors may be struggling due to work pressures or they feel that their job is not going as well as they would like. They mustn’t be afraid to ask for advice - there are lots of people who can help.

24

I sla is now an F2 in Aberdeen. A few years ago, during her final year at med-ical school, Isla got into some trouble on a night out with friends. She was

celebrating getting her final results, so had spent most of the day in the pub.

By midnight she was a tad worse for wear so decided to go home. On the way to hail a taxi she spotted her now ex-boyfriend outside a nearby club kissing another girl. Isla saw red and leapt at them, shouting and screaming. A police car spotted what was going on and before Isla knew it she had been arrested and had to spend the night in a cell.

The following morning Isla was allowed to leave without charge, but had to later accept a fiscal fine for breach of the peace. Isla wanted to put the incident behind her so did not declare the incident on her GMC application. She already had an F1 job and her CRB check had already come back fine.

Isla had a fantastic F1 year and she fully registered with the GMC, but the incident came back to bite her in her F2 year. Anoth-er CRB check flagged up the incident and she was formally disciplined by her hospi-tal, who also informed the deanery and the GMC. The GMC discovered that she had failed to declare her fiscal fine on either of her applications to the GMC. Isla was then called to a fitness to practise hearing.

MPS stepped in to represent Isla at the GMC and she was given a formal warning that would stay on her record for five years. She also faced significant difficulties at her trust, where she could easily have been dis-missed for her failure to accurately com-plete the job application. Isla learnt the hard way and her F2 year was marred by her dishonesty.

According to Dr Chris Godeseth, Med-icolegal Adviser at MPS, the GMC takes probity very seriously. He says: “Unfortu-nately, a number of medical students and junior doctors will find themselves in a situation similar to this. Although med-ics are famed for their “work hard, play hard” ethos, they must be aware that their

behaviour outside the clinical environ-ment, including that displayed in their per-sonal lives, may come under scrutiny from the GMC. Doctors’ behaviour at all times must justify the trust the public places in the medical profession, so there is a similar requirement placed on students.”

In this case, Isla failed to declare her cau-tion to the medical school, the GMC, or the trust for whom she had already agreed to work as an F1. All students applying to join the GMC register need to complete a “Fitness to Practise declaration”; she was

AN INCONvENIENT truth

dishonest in hers. While there may not be a strict requirement to declare these issues to your medical school, they will often come to light through the CRB checks performed in later years. But trying to hide or ignore the issue will only make things worse.

Dr Godeseth adds: “The GMC takes any failure to disclose evidence of criminal behaviour very seriously, and often treats this as evidence of dishonesty. If the GMC calls your practice into question it can lead to suspension, which could mean you do not complete medical school at the same time as

Medicolegal Advice - in association with the Medical Protection Society

MPS is often contacted by doctors who are surprised that their attitude and behaviour outside the clinical environment has called their fitness to practise into question. Sara Williams shares the story about what happened to Isla when her deanery discovered a serious black mark on her record.

24

MPS is the leading provider of comprehensive professionalindemnity and expert advice to doctors, dentists and healthprofessionals around the world.

We actively protect and promote the interests of members and believe that education is an integral part of every healthprofessional’s development. As well as providing legal adviceand representation for members, we also offer workshops,conferences and a range of publications designed to aid goodpractice.

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

About MPS

MPS Members who would like more advice on the issues raised in this article can contact the medicolegal advice line on 0845 605 4000.

www.mps.org.uk

The Medical Protection Society Limited. A company limited by guarantee. Registered in England No. 36142 at 33 Cavendish Square, London W1G 0PS.

About MPS info for articles.qxd:MPS Checkup 12/2/10 10:05 Page 1

other graduates from their medical school.”It really is very important that new doc-

tors who find themselves in this situation are open and honest. It’s often very embar-rassing or difficult to do this, but favourable to any initial mistake being compound-ed by taking the wrong approach with the medical school, your trust or the GMC.

This case features in one of a series of pod-casts exploring fitness to practice cases for junior doctors and medical students. Access them here: www.medicalprotection.org/uk/advice-and-publications/podcast

Medicolegal Advice - in association with the Medical Protection Society

“aLTHouGH MEDicS arE faMED for THEir ‘Work HarD, PLay HarD’ ETHoS, THEy MuST bE aWarE THaT THEir

bEHaviour ouTSiDE THE cLiNicaL ENviroNMENT, iNcLuD-iNG THaT DiSPLayED iN THEir PErSoNaL LivES, May coME

uNDEr ScruTiNy froM THE GMc.”

25

hoSPITAL mESS26

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

evening. The clinic is deserted and cost-saving measures have meant that only a single flickering light remains on. Suddenly, creeping from the

shadows of the waiting room, a dark figure emerges. Dressed almost totally in a form-fitting reinforced suit with his head covered in a frightening mask I can make out the outline of a man - or possibly something more super-natural. At first he says nothing, then quietly, somewhere between a whisper and a threat, his voice rasps “Doctor, I have an itch...”

lAryNgitiSNo-one should have to live with a voice that hoarse without seeking medi-

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

ErythropoiEtic porphyriAPerhaps the main reason for “Batman” only appearing at dusk is photosen-

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

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

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

AttAchmENt diSordErWhile obtaining a family history I uncovered that during his early child-

hood both Mr and Mrs “Batman” were murdered. It is well known that fail-ure to form normal attachments to primary care giving figures in early

childhood can lead to problematic social expectations and behav-iours - particularly emotional dysregulation, self-endanger-

ing behaviour and hyper-vigilance. Although treatment is difficult in these cases, a narrative-therapeutic approach may allow “Batman” to open and explore other aspects

to his personality rather than sticking to this Dark Knight persona.

Assessed by Gil Myers

MEDICAL REpORT

1 Annoying person (usually male); sudden contraction of a muscle in response to a nerve impulse (4) 2 vibrations or tremors in part of the body, that can be detected by palpation

fo auscultation (8) 3 When belonging to a policeman, this is plantar fasciitis (apparently) (4) 4 Diseased, pathological (6) 5 Analysis of variance between groups, statistical procedure (5) 7 Tumour containing sandlike particles; typical of ovarian cancer (8) 8 Do this e.g. for a table if you want to guarantee it; extra volume of air one could breathe in or out if not breathing to limit of his capacity (7) 10 pes ______ : flat foot (6) 11 Absence or marked impairment of will power, e.g. in schizophrenia (6) 12 ‘Crushing’ this nerve was formerly a treatment option in tuberculosis (7) 13 Apoplexy; you may do it to cats for example (6) 14 Disease of rapid onset or severe symptoms (5)

1 Structure forming framework of the mouth and where teeth attach (3) 4 ___ foot is an infection of the tissues and bones in the feet causing chronic inflammation (6) 6 Any tumout relating to cells of the nervous system (7) 7 Hit from

Nicole Scherzinger; any substance that irritates, damages or impairs functioning of body tissues (6) 9 This suture technique is used when closing contaminated wounds and wounds associated with tissue necrosis; made late (7) 13 A streak or line (5) 15 Localized form of scleroderma, plaques in the skin without internal sclerosis (8) 16 Fancy word for swallowing (11) 17 Yellow pigment of corpus luteum (6) 18 This type of association was described by Freud; no cost (4)

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

Compiled by Farhana Mann

ACRO

SSDO

WN

hoSPITAL mESS 27

Choc-olotta money at:

60p Queen Elizabeth II, Welwyn Garden City

Lighter than your average chocolate snack at:

49p Royal bournemouth, bournemouth

Enough to give you a toothache at:

£3.19 Royal Edinburgh Hospital, Edinburgh

A tooth sparkling price:

£1.49 Crosshouse Hospital, Ayrshire

Stick to a wind-up model at:

£4.99 Whipps Cross Hospital, Leytonstone

Time to recharge at:

£2.99 Crosshouse Hospital, Ayrshire

Next issue we’re checking the cost of sausage and chips, a ball pen and one pint of milk. Email prices to hospitalconfidential@juniordr.com

W hen your hospital food tastes like the remnants of a liposuction procedure and the price bears more resemblance to the cost of a PICU incubator things start to take the biscuit. Here’s our regular

column of the best and worse hospital essentials you’ve reported:

The Mess has a newly decorated lounge, which includes a television and snooker table. Adja-cent to the mess, a quiet area for study is avail-able with PC, printer and Medline Search facility and CD-ROM texts (a laptop and CD-

ROM can also be borrowed). The doc-tors also have their own dining area where Barbara the waitress serves breakfast and lunch. In the restaurant foyer vending machines sell snacks, drinks and chilled foods. The latter may be reheated in the adjacent microwave ovens.

JuniorDr Score: ★★✩✩✩

packet of Malteasers (37g)

4 x AA batteries

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

Writing in the Notes

Save our NhS!

Dear Editor,I was amazed by the facts in your last issue (We

love our NHS - Facts and figures; Iss 20; p9). The

NHS truly is something we should be proud of. I’m

not sure where you got your facts from but if the

UK only spends 3% of its budget on management

costs as opposed to 17% in the USA Andrew Lans-

ley shouldn’t be complaining so much. I was also

staggered that one in 23 people are employed by the

NHS. Maybe we should all get out on the streets

like students did. Save our NHS - it is so special to

everyone.kAREn ThomAS

fy1, noRTh WESTERn DEAnERy

thanks for speaking outDear Editor,

I’ve had to take some time off work recently for health reasons. It has been a struggle managing the process - nevermind dealing with my fears over what my colleagues and the senior staff might think. I’m pleased to say that generally I was treated with the seriousness and respect that was appropriate. This didn’t mean it was an easy process but it certainly wasn’t as bad as my initial fears and apprehensions. I think if more people like Helen Burt (A person-al view; Iss 20; p15) were open about their stories it would help educate the rest of us and hopefully persuade us not to carry on working under fear of disclosing our problems. I’m hoping to go back to work soon and I just wanted to congratulate Helen for having the courage to tell her story.hELEn ST3 PSyChIATRy

trAfford gENErAl hoSpitAl, MANCHESTER

Toothpaste (100ml)

Safety is common sense?

I was shocked to read just how far behind the

US are with regards to working hours compared to

Europe (Reduction in US working hours has little

effect on safety and training; Iss 20; p6). It seems

bizarre that US trainees are debating whether it’s safe

to reduce working hours from 90 per week when the

rest of us are working under 60. Surely any member

of the public with an ounce of common sense would

understand that having a surgeon operating at the

end of a 110 hour week certainly can’t be safe.

SAnJAy SWAmy

LoCum GP, bIRmInGhAm

CLASSIfIED28

The Medical Journalist’s Association brings together medical writers, the media, health professionals, and health charity workers.

> Meetings on major health and medical topics of the day> A forum to meet colleagues> Recognition and cash awards for distinguished work> A website with your own address. Visit www.mja-uk.org> Professional advice when you need it

Wish to join? For more information visit www.mja-uk.org

2012 Specialty Training Recruitment

Get ReadyThe provisional timetable for Round 1 and Round 2 recruitment is as follows:

CT/ST1 Round 1 - August/September 2012 intake• Applications open on 25 November and close on 9 December 2011• First offers issued by 9 March 2012

ST3+ Round 1 (and readvertised CT/ST1 posts) - August/October 2012 intake• Applications open on 17 February and close on 5 March 2012• First offers issued by 25 May 2012

Note: Round 1 includes recruitment to run-through specialties and CT2 for most of the uncoupled specialties. The exception is Anaesthesia - where CT2 posts will be advertised with ST3 recruitment.

Set...Visit the SMT website over the summer for more information on the application process.Subscribe to the SMT e-Newsletter via the website for the latest updates.

Go!http://www.scotmt.scot.nhs.uk

GET YOUR NEURAL INpUT TO JUNIOR DOCTORS. ADvERTISE HERE. CALL US ON 020 7684 2343.

jourNAliSm

From little acorns mighty oaks grow To make sure your career grows strong

and true, and always on an upwards trajectory, join:

The Society for Acute Medicine

“The most important body championing the cause of acute medicine” SAM member, 2011

To join or to find out about the many benefits SAM members enjoy visit www.acutemedicine.org.uk or email sam@rcpe.ac.uk.

rEcruitmENt

AcutE mEdiciNE

CLASSIfIED 29

Experience Drama

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If you’re a qualified Junior Doctor looking to ramp up your career and really enjoy life, we can make it happen. To learn more about this unique opportunity, and to apply, visit

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• Australia• Singapore• MiddleEast

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Leeds9-10 July 2011London16-17 July 2011

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Apply online from Tuesday June 21 www.health.qld.gov.au/medical/rmoinfo.aspApplications close midnight Monday July 18

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EvEnTSDR.Com30

THE MEDICAL COURSE AND CONFERENCE DIRECTORY

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We think they should all be in one place - which is why we launched EventsDr.com as part of the JuniorDr network.

We’re aiming to build the most comprehensive database of medical events. Below you’ll find just a selection of the full listings at EventsDr.com.

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EvEnTSDR.Com 31

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For more information Visit www.mps.org.ukCall 0845 718 7187Email member.help@mps.org.uk

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE

The best protectionMPS members have access to a wide range of benefits designed to help with the legal and ethical problems that can arise from professional practice.

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MPS Educational ServicesWe have developed a range of highly rated publications, workshops, conferences and e-learning resources to help promote good medical practice and minimise the risk of clinical mishaps. More than 4,000 doctors in the UK have already benefited from attending an MPS workshop. www.mps.org.uk/education

Working overseas?MPS has over 270,000 members in more than 40 countries. If you are planning to work overseas we can usually help.

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

Supporting you throughout your careerMPS understands the importance of giving members access to a reliable, high quality service, and a range of educational services designed to meet your needs.

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