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Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double spaced
Students sitting ®nals: ready to be house of®cers?
As a ®nal year medical student, I was particularly interested by the report from Mr Goodfellow and Dr Claydon (October 2001 JRSM, pp. 516±520). They showed that in eight core clinical skillsÐnamely, venous cannulation, venepuncture, rectal examination, nasogastric intubation, suturing, arterial blood sampling, urinary catheterization and performing an ECGÐmany ®nal year medical students had little or no experience. The lack of teaching in these skills needs to be addressed. Although many teaching hospitals now have clinical skills rooms with mannequins on which students can practise, there is no substitute for the real thing. All of the skills discussed are applied in operating theatres and anaesthetic rooms every day and I suggest that the operating theatre environment is an ideal place for medical students to learn themÐnot only because of the large number of these procedures but also because supervision would be mainly by consultants. At present most medical students will not spend much time in theatre during surgical attachments. I surveyed 25 of my ®nal year colleagues who had just ®nished a general surgery attachment. The average amount of time spent in theatre was one day per week. Of this sample, only 8 students said that they had spent any time in the anaesthetic room when at medical school. I therefore wonder whether a new type of clinical attachment could be set up called `theatre medicine'. This could be a month long, during which the students would spend all their time in the operating theatre and anaesthetic room. Along with the clinical skills bene®t of such an attachment, students would get to see many different operations, which will put them in a more knowledgeable position for when they have to seek patients' consent for surgery as junior doctors.
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On one occasion, I, a former teacher of psychiatry in Shef®eld, noted that one woman, 4th or 5th year, was greatly steamed up. My psychiatric background suggested I look into what troubled her and she told me how the A&E sister had insisted on her taking blood from a patient when she had never done it before. My education background made me wonder how this could be and I asked the other students, who explained that they had all done it when they took blood from each other for biochemical and physiological investigations. I went back to her to ask how she had missed all this but her response was: `Yes, but they were students; this was a patient'. Incidentally, since 1982, Shef®eld had had a three-part preregistration year of four months each of medicine/ psychiatry/surgery for a small number of students to ensure the acquisition and practice of an important skill, interviewing. Philip Seager 9 Blacka Moor Road, Dore, Shef®eld S17 3GH, UK. E-mail:
[email protected]
Mr Goodfellow and Dr Claydon suggested that the competence of medical students in practical procedures could be improved by introduction of skills laboratories and logbooks. I fully agree about skills laboratories and there is suf®cient evidence to support them1,2. However, I disagree with the use of logbooks. As acknowledged in the paper, most logbooks simply testify that a procedure was performed and do not certify competence, although this de®ciency could be overcome by asking the doctor to grade competence as good, average or below average. I would also suggest that logbooks cause additional stress to many students and become a major preoccupation. Even if doctors' evaluations were conscientiously done, the logbooks might offer a temptation to student fraud3,4. After training in a skills laboratory, students should be assessed on models with an objective structured clinical examination (OSCE) before practising on real patients.
LETTERS TO THE EDITOR
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Vassilis Vassiliou University College London Medical School, London WC1E 6BT, UK E-mail:
[email protected]
Daniel M Sado Southampton University Medical School, Southampton, UK. E-mail:
[email protected]
How reliable are questionnaires about what skills medical students learnt in Shef®eld, or anywhere else? Shef®eld used to have a system of social tutorial groups for studentsÐ perhaps they still doÐin which a student from each year is linked with a medical school staff member for social and support activities. This might mean gathering for a meal, going out to the theatre, etc. It was an opportunity to meet students of other years, to learn what is in store, and to meet staff on a social rather than teaching footing.
REFERENCES
1 Bradley P, Bligh J. One year's experience with a clinical skills resource centre. Med Edu 1999;33:114±20 2 Fox R, Dacre J, Mclure C. The impact of formal instruction in clinical examinations skills on medical student performanceÐthe example of peripheral nervous system. Med Edu 2001;35:371±3 3 Rennie SC, Crosby JR. Are tomorrow's doctors honest? Questionnaire study exploring medical students' attitudes and reported behaviour on academic misconduct. BMJ 2001;322:274±5 4 Paton J. Cheating at medical school. Main impact of cheating is on clinical work. BMJ 2001;322:298
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It was of some concern to me that the medical students questioned in the preliminary study, to identify a group of `core skills' they would need regularly in their house of®cer year, did not include basic life support or any form of airway management. Perhaps these most important and fundamental of clinical skills were not perceived as likely to be regularly needed during the preregistration year. Or do we have a more worrying explanationÐa perception that dealing with a cardiopulmonary arrest is purely the responsibility of the `crash team' or that our anaesthetic colleagues will always be able to appear instantaneously? Nimesh N Patel Department of Otolaryngology, Northwick Park Hospital, Harrow, London HA1 3UJ, UK
Mr Goodfellow and Dr Claydon attribute the lack of basic clinical skills in ®nal year Shef®eld students to a traditional `®rm' setting in which no time was allocated to acquiring these skills. There may, however, be another factor. In 1991, Glasgow University tried to address the issue of de®cient clinical skills by altering its curriculum from bedside teaching and formal lectures to a `®rm' system resembling that in Shef®eld. The class of 1991 had been exposed only to the old system whilst the 1993 graduates had been taught exclusively in the `®rm' setting. We surveyed the two Glasgow cohorts anonymously when they attended their preregistration introductory lecture. The questionnaire was similar to that of Goodfellow and Claydon with the omission of suturing and nasogastric tube insertion. There were no signi®cant differences between the two year-groups. In Table 1 we present these results alongside those reported from Shef®eld, and it seems that Shef®eld students are much less experienced in two skillsÐ phlebotomy and electrocardiography. We suggest that these differences may re¯ect a change in the ensuing decade Table 1 Comparison between Shef®eld and Glasgow ®nal year medical students
Clinical skill
Glasgow ®nal year students (1991)
Glasgow ®nal year students (1993)
122/163
111/205
90/195
(75%)
(54%)
(46%)
Shef®eld ®nal year No. of procedures students performed (1999)
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whereby house of®cers have been relieved of some of these duties (for example, by cross-skilled nurses) and opportunities for students have diminished. David S Sanders Iman A F Azmy Departments of Medicine and Surgery, Royal Hallamshire Hospital, Shef®eld S10 2JF, UK E-mail:
[email protected]
Training for necropsy
In the JRSM, last year, Baron1 lamented the decline of the necropsy. As a senior house of®cer in histopathology working in a district general hospital, I have managed to attend only four post-mortems in the past twelve months. Most of my colleagues in this region are in a similar predicament: Royal College of Pathologists training requirements for the ®rst-year trainee include twenty post-mortem examinations. What can be done to improve matters? Do we need to perform necropsies at all? Rutty and colleagues2 looked at the ability of pathologists to predict a cause of death from the available clinical history without conducting a postmortem examination, and found an error rate between 61% and 74%. This was not acceptable to replace coroner's necropsies. According to Home Of®ce statistics, deaths reported to the coroner now account for one-third of all deaths in England and Wales, having risen from 130 000 in 1970 to 201 000 in 1999. In 1999 62% of the total referrals underwent post-mortem examination under the legal authority of the coroner3. These examinations could provide valuable opportunities for histopathology trainees and are widely used for this purpose in North America. Maintenance of regional databases of post-mortem examinations in hospitals without trainees could enable trainees on day release to attend or perform post-mortems. This would be a good way to use a dwindling resource for training. Another, and underexplored, approach is to use simulators. Simulator software is available on several pathology websites, but its usefulness needs to be evaluated properly. The Royal College of Pathologists must address this issue of training, or trainees will be emerging with serious skill shortages. Mary Jones Department of Histopathology, Barnet and Chasefarm NHS Trust, En®eld, UK
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IV cannulation
55
89%
81%
86%
Venepuncture
540
48%*
88%
93%
Rectal examination
55
25%
36%
38%
Arterial blood gas
53
49%
53%
58%
Catheter
53
28%
26%
33%
Electrocardiogram
53
48%*
87%
92%
*P50.0001; chi-squared analysis of student numbers; Shef®eld vs Glasgow
E-mail:
[email protected]
REFERENCES
1 Baron JH. Clinical diagnosis and the function of necropsy. J R Soc Med 2000; 93:463±6 2 Rutty GN, Duerden RM, Carter N, Clark JC. Are coroner's necropsies necessary? A prospective study examining whether a `view and grant' system of death certi®cation could be introduced into England and Wales. J Clin Pathol 2001;54:279±84 3 Allen R. Statistics of deaths reported to coroners: England and Wales 1999. Home Of®ce Statist Bull 2000;8:1±15
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Amputations at the London Hospital, 1852±1857
Mr Chaloner (August 2001 JRSM, pp. 409±412), commenting on the use of chloroform in the Crimean War, suggests that the wounded who were transported to Scutari to have operations performed there would have been less likely to die as a result of anaesthesia than those who were operated upon in the ®eld soon after their injuries, because they would be less likely to be hypovolaemic (if they survived the journey) and better able to withstand the depressive effects of chloroform. In the of®cial report the ®gures for the administration of chloroform are poor and only a few deaths are recorded1. One young soldier having a minor operation became violent and almost certainly died of cardiac arrest due to ventricular ®brillation. In the French ArmyÐmore than ten times the size of the British ArmyÐno deaths due to anaesthesia were reported in 25 000 cases; careful instructions about its administration were issued2. Since the time of Larrey, it was the custom to perform amputations as soon after injury as possible, because a recently wounded soldier fared better. The ambulances volantes allowed operations to be performed at or near to the front line. In the British Army, just over 1500 received chloroform3. At the beginning of the war there were no ambulances. For this and other reasons, amputations were not always performed as quickly and there is no evidence that the army surgeons received speci®c instructions in the use of chloroform. The transport to Scutari, which took several days, could well have increased the chances of hypovolaemic shock and infection, and therefore of death, before or soon after arrival, as Mr Chaloner suggests. D D C Howat Flat 10, 40 Wimpole Street, London W1G 8AB, UK
REFERENCES
1 The Medical and Surgical History of the British Army during the War against Russia in the years 1854±1856, Vol 2. London: Harrison, 1858 2 Scrive G. Relation MeÂdicale de la Campagne d'Orient. Paris: Libraire Victor Masson, 1854±81:81 3 Howat DDC. French and British anaesthesia in the CrimeaÐa comparison. Proc Hist Anaesth Soc, 1998;24:29
Requests for vasectomy: counselling and consent
Mr Harris and Mr Holmes (October 2001 JRSM, pp. 510± 511) are correct in stating that an unwanted pregnancy following a vasectomy failure due to late recanalization `can have devastating social and ®nancial consequences'. But their advice that it is suf®cient to warn the patient that the (average) risk of such failure is `about 1 in 2000 cases' is, I
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believe, ¯awed in two respects. First, it leaves unanswered what sensible advice can be given to a patient who asks what can be done to reduce this risk. Secondly, the term `vasectomy' includes a range of proceduresÐfrom the removal of several centimetres of vas (with wide separation of the ends) through division of the vas and separation of the ends by tissue interposition1 to diathermy of the intact vas resulting in an obstructed segment less than 2 mm in length2. The risk of recanalization when the diathermy technique is used must be far greater than the average quoted, and therefore the advice given will be incorrect (and so any consent improperly obtained). Because of the rarity of recanalization an individual surgeon cannot calculate the risk for the procedure that will be used. But surely the British Association of Urologists ought by now to have collated the results of a large enough number of surgeons, grouped by the type of `procedure called vasectomy' that they use, for a statistically valid estimate of the risk for each procedure to be made. Patients would thereby be better informed and so able to choose a less risky procedure if they wished, and the profession might be less at risk from litigation2,3. Roger Hole Wynd House, Hutton Rudby, North Yorkshire TS15 0ES, UK
REFERENCES
1 Gingell JC. Late failure of vasectomy. BMJ 1984;289:318 2 Hole R. Late failure of vasectomy. BMJ 1984;289:318 3 Hole R. Vasectomy procedures and fertility. Lancet 1994;344:415
Nephrotoxicity in the elderly due to co-prescription of ACE inhibitors and NSAIDs
The report by Dr Adhiyaman and others (October 2001 JRSM, pp. 512±514) of renal failure after co-prescription of angiotensin converting enzyme (ACE) inhibitors and nonsteroidal anti-in¯ammatory drugs (NSAIDs), together with ®ndings on renal function in elderly heart failure patients1, should invoke even greater vigilance in the era following the RALES study (which reported survival bene®t from co-prescription of spironolactone and ACE inhibitors in heart failure). Already there are reports not only of deterioration in renal function but also of hyperkalaemia complicating co-prescription of ACE inhibitors, spironolactone, and NSAIDs3,4. Spironolactone aggravates the impairment of potassium excretion in renal failure. NSAIDs are liable to impair potassium excretion in their own right, because they can induce hyporeninaemic hypoaldosteronism, which, in turn, impairs renal potassium excretion5. Selective cyclo-oxygenase-2 (COX-2) inhibitors also seem to carry some risk of nephrotoxicity, as judged by anecdotal reports of acute renal failure associated with rofecoxib6 and
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celecoxib7, so these drugs may differ little in this respect from conventional NSAIDs. Perhaps the time has come for indiscriminate prescription of NSAIDs to be used as an indicator of clinical underperformance. O M P Jolobe Department of Adult Medicine, Tameside General Hospital, Ashton-under-Lyne OL6 9RW, UK
REFERENCES
1 Jolobe OMP. Evaluation of renal function in elderly heart failure patients on ACE inhibitors. Postgrad Med J 1998;75:275±7 2 Pitt B, Zannad F, Remme W, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341:709±17 3 Berry C, McMurray JJV. Serious adverse events experienced by patients with chronic heart failure taking spironolactone. Heart 2001;85:e8 4 Schepkens H, Vanholder R, Billiouw J-M, Lamiere N. Life-threatening hyperkalemia during combined therapy with angiotensin-converting enzyme inhibitors and spironolactone: an analysis of 25 cases. Am J Med 2001;110:438±41 5 Tan SY, Shapiro R, Franco R, et al. Indomethacin-induced prostaglandin inhibition with hyperkalemia: a reversible cause of hyporeninemic hypoaldosteronism. Ann Intern Med 1979;90:783±5 6 Wolf G, Porth J, Stahl RAK. Acute renal failure with rofecoxib. Ann Intern Med 2000;133:394 7 Parazella MA, Tray K. Selective cyclooxygenase-2 inhibitors: a pattern of nephrotoxicity similar to traditional nonsteroidal anti-in¯ammatory drugs. Am J Med 2001;111:64±6
Attitudes to torture
Derek Summer®eld in his review of The Medical Profession and Human Rights (August 2001 JRSM, pp. 420±421), uses your respected journal as a forum for his own agenda of hate. As I understand it, Dr Summer®eld was not present when Professor Dolev allegedly made the statement attributed to him. It is unclear to me on what basis Dr Summer®eld allows himself the liberty to cast aspersions on the former head of the IMA ethics committee by attributing to him such a statement, which Professor Dolev vehemently denies having made. Dr Summer®eld's calumnies, and particularly his decision to publish them in a journal such as yours, lead us to believe that he is less interested in advancing human rights and more interested in slandering and condemning Professor Dolev, the IMA ethics committee and the State of Israel. We would expect a journal of your calibre to check the facts before you allow them to be printed, and not allow your publication, a medical and not political journal, to be used as a forum for the spewing of lies and vili®cation. Yoram Blachar President, Israel Medical Association, PO Box 3604 Ramat-Gan 52136, Israel
Author's reply
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A four-member delegation of the Medical Foundation for the Care of Victims of Torture, London (Helen Bamber,
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Rami Heilbronn, Dr Duncan Forrest, Dr Elizabeth Gordon) can attest that during an interview on 25 November 1999 Professor Dolev said to them that `a couple of broken ®ngers' during the interrogation of Palestinian men was a price worth paying for information. Professor Dolev was then the Head of Ethics of the Israel Medical Association (IMA). This was a moment of honesty which crystallized a position that campaigners had long inferred from the IMA's inactivity on the issue of state torture and the everyday collusion of doctors in the units where this took place. Dr Forrest recorded Professor Dolev's admission last year in a paper in an Amnesty International publication1. The tone and substance of Dr Blachar's letter is sadly familiar to those who have attempted to engage the IMA on these issues over the years: the standard response (when one can be elicited) is that we are motivated by anti-Israeli, and by implication anti-semitic, sentiments. It is worth noting that, in the paper referred to above, Dr Forrest also cited a letter by Dr Blachar in the Israeli newspaper Ha'aretz of 15 November 1999. In it Dr Blachar failed to categorize `moderate physical pressure' as torture (which all human rights organizations have long since condemned as the of®cial euphemism for torture in Israel) and suggested that this might be a suitable response in a `ticking bomb situation' (his words). This, then, is the quality of ethical leadership available to Israeli doctors. The case against the IMA is the most exhaustively documented of any since that brought fruitfully to bear against the Medical Association of South Africa during the apartheid era. Derek Summer®eld CASCAID, South London and Maudsley NHS Trust, London SE1 1JJ, UK
REFERENCE
1 Forrest D. ``Moderate Physical Pressure'' in Israel. Newsl Med Group Amnesty Int (UK) 2000;12(1):1±2
Oesophageal cancer surgery
Mr Britton presents a plausible option for the reorganization of oesophageal cancer services (October 2001 JRSM, pp. 500±501). However, the ®nal sentence undermines the overall plan particularly with respect to the singlehanded or low-volume specialist. The proposed scheme, he says, `does not represent a threat to any specialist in the ®eld provided his or her results withstand local and national review'. A corollary of low caseload volume is that results will be unlikely to be amenable to meaningful statistical review. A large number of years of data will be needed, ensuring a long delay to closure of the audit loop. The way ahead is surely to review operators' processes rather than outcomes of care. Thus,
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participation in effective prospective audit and multidisciplinary discussion of cases are surely clinical governance issues as valid as, and more timeous than, outcome. Regular multidisciplinary team discussion has the further advantage of facilitating peer review of management decisions before they are acted on, and thus might effectively form `pre-prospective audit'. The bene®t to both operator and patient is clear: sanctioning of treatment decisions by a responsible body of peers, based on regional as well as local experience. C C McGuigan Scottish Centre for Infection and Environmental Health, Clifton House, Clifton Place, Glasgow G3 7LN, Scotland, UK
Transition from paediatric clinic to the adult service
Professor David's editorial is timely (August 2001 JRSM, pp. 373±374). Young disabled people currently get a raw deal, not least because of dif®culty using the healthcare system to their advantage. There are two issues that need to be addressedÐthe transition from a specialist paediatric service to the corresponding adult service1; and the transition of the child with disability or continuing disease to adulthood2. The latter is a much more complex task3; whether it can or should be done solely in a hospital specialist clinic is doubtful. Specialist clinics need to be linked with generic services that have a brief to respond. Designated specialist community teams with this brief have been in existence for over a decade. They are usually led by rehabilitation medicine physicians whose main focus is the disabled adult of working years. These interdisciplinary teams are expert at dealing with the numerous problems of these young people and they work to the young persons' goals. Often the aims include not only educating young persons to manage their own disease and medication but also wider issues such as gaining independence in day-to-day activities (it is not realistic to expect that all, particularly those with neurological disease, can do this on leaving paediatric services) and enabling young persons to structure their own lives and manage their time appropriately. These interdisciplinary teams may be involved with the young person and his or her family over an extended period (often several years). The latter is important as often the young person with chronic disease may use disengagement from the health system as a mechanism for protest if unable to achieve this by other means. In addition, particularly for those with cognitive and physical problems, acquisition of essential skills may take a long time. This is usually not possible in primary care where focus is often episodic. These teams work ¯exibly so that therapeutic intervention can be provided in a variety of settings (at home, at work or in education). This is important in preventing the individual
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from becoming overdependent on health-based services. The teams establish an extensive network of communication with schools and paediatric services to establish protocols for transfer. They often have open access to their services and cross many interagency boundaries (further education, employers, transport, social services, charitable organizations and so on). Do they work? Informal evidence suggests that the young people engage more in areas such as higher education and employment when such teams are involved. This observation is con®rmed by our recent NHS R&D centrally funded controlled study showing that intervention by interdisciplinary teams with a speci®c remit for the disabled school leaver increase societal participation. In summary, the rehabilitation medicine physician and specialist young adult services can complement diseasespeci®c transitional services set up through paediatrics to help adolescents and young people with disabling chronic diseases ful®l their ambitions. Bipin B Bhakta M Anne Chamberlain Rehabilitation Division, School of Medicine, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, UK E-mail:
[email protected]
REFERENCES
1 Viner R. Transition from paediatric to adult care. Bridging the gaps or passing the buck? Arch Dis Child 1999;81:271±5 2 Chamberlain MA. Physicially handicapped school leavers. Arch Dis Child 1993;69:399±402 3 Bent N, Jones A, Molloy I, Chamberlain MA, Tennant A. Factors determining participation in young adults with a physical disability: a pilot study. Clin Rehab 2001;15:552±61
Where shall we send our paper?
I applaud Dr Herxheimer's attempt to encourage authors to make a rational decision about where to send their scienti®c papers (October 2001, JRSM, p. 515). It will certainly be an improvement on the present method which (according to accounts given on our courses) is based on the principle of starting with the journal with the highest impact factor, and then working down. However, I am not sure that Herxheimer's model is the answer. He encourages authors to decide on the basis of where they want to publish; surely a more sensible solution is to decide, using all the available evidence, which journal is most likely to accept the article. Getting a paper published is essentially a sales activity, and the most effective sales people are those who consider the needs of the market rather than their own. Tim Albert Tim Albert Training, Paper Mews Court, 284 High Street, Dorking, Surrey RH4 1QT, UK E-mail:
[email protected]
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Pickles of Wensleydale
Dr Moorhead's article (October 2001, JRSM, pp. 536±540) reminded me of an episode in the mid 1950s. The Department of Medicine in (I think) Shef®eld were conducting a survey to correlate bronchial disease and air pollution, and chose Aysgarth as the control site because of the detailed morbidity records available from Will Pickles' practice. They had no doubt that the beautiful high Pennine village of Aysgarth would provide an excellent pollutionfree comparison to the environment of industrial Yorkshire. They were extremely discom®ted to ®nd that every second person in Aysgarth was coughing his or her lungs out. Was there really air pollution in Aysgarth, or were their standard assumptions wrong? In those far-off days the most sensitive measure of clean air was not chemical but the proportion of melanic trunksitting moths. Typical cryptic moths become visible to their bird predators when the lichens disappear from the treetrunk resting-places, while melanics remain hiddenÐhence their spread into all polluted areas after the Industrial Revolution. The details of the spread and distribution of the industrial melanics were chronicled and experimentally studied by Bernard Kettlewell, a Surrey general practitioner who in partnership with the pioneer medical geneticist E A Cockayne, developed and published the results of his amateur lepidopterology in the 1930s and moved to
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E B Ford's group in Oxford after the Second World War. Kettlewell was asked to catch moths in Aysgarth. I went with him as a newly ¯edged ecological geneticist, and met the venerable Will Pickles. Over 94% of the species we studied (the peppered moth, Biston betularia) were the melanic form. Aysgarth was in fact highly polluted by air swept up into the hills on the prevailing south-west wind, carrying the atmospheric output from the Lancashire manufacturing towns. The clinical symptoms were not anachronistic; Aysgarth was not a proper control. Since those days, Kettlewell's research has become a standard example of evolution in action, described in elementary biology textbooks. And a sequel to it was the two-decade-long study conducted by the late Cyril Clarke in his back garden in the Wirral near Liverpool, and barely mentioned in his obituaries, in which he monitored the decline of the black form of the peppered moth as air quality improved following the implementation of the Clean Air Act. Clarke recorded the fall in frequency of the melanics in his locality from over 90% to below 10%. I routinely used this saga to point out to medical students that a little biological knowledge can, on occasion, be very helpful. R J Berry Department of Biology, Medawar Building, University College London, London WC1E 6BT, UK
