M I D L A N D S M E D I C I N E - nsmedicalinstitute.co.uknsmedicalinstitute.co.uk/nsmedical/wp-content/... · Drawing of a louse from observations by Robert Hooke (1635-1703) taken

APRIL 2013 VOLUME 27 - ISSUE NO 1

sh4

6

9

13

15

18

21

27

29

33

36

38

40

42

44

48

EdItOR’S NOtES

SEcUNdUM cLAMO! fRANcIS REPORt 2013: A chARtER fOR cANdOUR

MOVINg ONwARdS: thE MUScULOSkELEtAL INtERfAcE SERVIcE: ItS dEVELOPMENt ANd fUtURE

cLINIcAL EdUcAtION:LESSONS fOR PRActIcE

tEAchINg UNdERgRAdUAtESIN thE cLINIcAL SEttINg

AN APPROAch tO INVEStIgAtINg thE cERVIcAL ScREENINg hIStORY REVIEw MEEtINg

thE AdULt AttItUdE tO gRIEf StAtE - A MEASURE fOR IdENtIfYINg VULNERABILItY IN BEREAVEMENt

gEttINg tO kNOw:tRAcY hALL

ELEctIVE tALE fROM NEPAL

MY JOURNEY tO A kIdNEY tRANSPLANt ANd BEYONd

thE 43Rd wAdE LEctURE: AN EVENINg wIth LEE PEARSON

AwARd wINNERS ANd OthER NEwS

JUNIOR dOctOR dIARIES

BOOk REVIEw: fALLINg & LAUghINg, thE REStORAtION Of EdwYN cOLLINS

tENtAtIVE wORdPLAY

INdEx tO VOLUME 26

M I D L A N D SM I D L A N D SM E D I C I N EM E D I C I N E

47 INtEREStINg IMAgES

2 Midlands Medicine

MR. J. dUNcAN gOUgh, chAIRMAN, NORth StAffORdShIRE MEdIcAL INStItUtE

Changes are occurring at the Medical Institute. You will have already noticed that with the latest edition of Midlands Medicine, the front cover has been refreshed. This is not the only difference – the Journal will now be available to those who want to read it on-line through our Member section of our new web-site www.nsmedicalinstitute.co.uk

This web-site has been developed for existing, and hopefully new, members to keep up to date with news of the Institute and to enable us to communicate with you, and help researchers submit their grant applications on-line. We are also encouraging our ever increasing number of Medical Students to become involved with the Institute by circulating copies of the Journal to which many have already contributed.

Our sister conference centre web-site www.nsconferencecentre.co.uk which was launched after the last edition has already brought new business through the door and we are hopeful for further increased use of our facilities in the future, so that we may continue to support further local Medical Research – Please take a look at both websites – comments would be greatly appreciated.

With the winter behind us, let’s welcome summer, a new Edition of Midlands Medicine and a prosperous Institute.

Midlands Medicine is the journal of the North Staffordshire Medical Institute, whose purpose is to promote postgraduate medical education and research. The journal was first published in 1969 as the North Staffordshire Medical Institute Journal.

cOVER IMAgE

Drawing of a louse from observations by Robert Hooke (1635-1703) taken from Micrographia: or some physiological descriptions of minute bodies made by magnifying glasses : with observations and inquiries thereupon made available for use by Wikimedia Commons. A brief further mention for Robert Hooke occurs in Tentative Wordplay.

Volume 27, No. 1, April 2013 3

M I d L A N d SM E d I c I N EEdItORDr D de Takats

ASSIStANt EdItORMr C Bolger

EdItORIAL BOARdMr D GoughDr I SmithK StevensonMr D GriffithsHelen InwoodDr B DaviesProfessor R ChambersClive GibsonProfessor Bob McKinleyTracy Hall

EdItORIAL ASSIStANtSpencer Smith

thE NORth StAffORdShIRE MEdIcAL INStItUtEPresident: Mr E M TurnerChairman: Mr D GoughHonorary Secretary: Professor S O’BrienHonorary Treasurer: Mr Trevor Cooper

Please forward any contributions for consideration by the Midlands Medicine Editorial Board to the Editorc/o Spencer Smith, Editorial assistant.

By email: [email protected]

Or by post:North Staffs Medical Institute, Hartshill Road, Hartshill,Stoke-on-Trent ST4 7NY

Views expressed are solely those of the author(s) and do not reflect the views of the Midlands Medical Journal.

All material herein copyright reserved,Midlands Medicine ©2013.

cONtENtSEdItORIAL Editor’s notes

Secundum clamo! Francis Report 2013: A Charter for Candour Dominic de Takats

Moving Onwards: The Musculoskeletal Interface Service: Its development and Future Kay Stevenson & Ajit Menon

Clinical Education: Lessons for Practice Clive Gibson

ORIgINALS

Teaching Undergraduates in the Clinical Setting Clive Gibson

An Approach to Investigating the Cervical Screening History Review Meeting Susan Sherman & Emma Nailer

The Adult Attitude to Grief Scale – a Measure for Identifying Vulnerability in Bereavement Linda Machin, Julius Sim & Bernadette Bartlam

REPORtAgE

Getting to Know Tracy Hall

Elective Tale from Nepal John Storrow

My Journey to a Kidney Transplant and Beyond Kirsty Mitchell

The 43rd Wade Lecture: An Evening with Lee Pearson Spencer Smith

Award Winners and Other News

Junior Doctor Diaries Rebekah Mason

ENdPIEcES

Book Review: Falling & Laughing, The Restoration of Edwyn Collins by Grace Maxwell Helen Alcock

Tentative Wordplay Dominic de Takats

Interesting Images

Index to Volume 26

4 Midlands Medicine

“May you live in interesting times.” Goes the old Chinese saying which may be taken as a blessing by the optimistic but which many feel weighs heavily as a curse. Well these are most definitely interesting times with much change afoot. Certainly it is harder now to entertain the notion of the ‘End of History’1 than it may have been in the 1990s. On the national scale we have the coming into force of the Health and Social Care Act this month, at the local level we have seen the last inpatient leave the NSRI so all UHNS inpatient care is now provided on the City General Hospital site, which remains unfinished as rounds of demolition and new building continue in (hopefully) ever decreasing circles. Between those two we have the second Francis Report: in our locale but of national significance, too important to ignore, too substantial to cover in these notes, so please see the editorial which follows.

Fundamental to the delivery of healthcare in the community, in the clinic or at the bedside is the behaviour of the health professional dealing with them there. Clearly we all bring innate qualities to our roles, but on top of that much is taught, didactically or by example. Midlands Medicine has a keen interest in Clinical Education as one of its strands. I am pleased to see we have a stack of relevant contributions, from medical educators, to medical students and recent graduates. And NSMI, by way of more direct support annually gives prizes to top performing medical students. You can see who they were in 2012 in our awards feature.

We have also done particularly well for contributions from members of our Editorial Board in this issue with an Editorial from Kay Stevenson which starts from a community musculoskeletal perspective but then moves on to consider so much more! Clive Gibson starts off a journey into Clinical Education, on which I hope you’ll join him. The scope is introduced in

an editorial piece which he follows with his own first contribution to the series that I’ve asked him to curate. Later we Get to Know Tracy Hall a broadly experienced nurse, our latest recruit to the Editorial Board. Just dipping her toes in the water this time, but I’ve had sight of some of the material she hopes to publish through this organ in the future, and I think it could prove of very great interest to many.

One key purpose of the North Staffordshire Medical Institute is to support medical research locally. You can read which projects were awarded money to support their research in the Award Winners section but two of the recipient teams have kindly written of their work in rather more detail. The topics covered by the two teams, cancer diagnosis and grief in bereavement are both difficult areas. I’m pleased that the NSMI has chosen to support their work rather than shy away and I’m pleased that insights into these projects are available to you through this journal. Both articles are definitely worth a look, even if these matters do not affect you directly, definitely if they do.

A patient, Kirsty Mitchell, has written for us before. Her journey has moved on in exciting and life-changing ways in the intervening years. Something of a roller coaster ride, I found this patient’s perspective highly instructive. A longer term perspective of a life lived with disability comes courtesy of our Editorial Assistant, Spencer Smith, who gives an account both of Lee Pearson and of the Wade Lecture he kindly delivered at the North Staffs Conference Centre last autumn. (I’m not going to tell you more details here: read the article for yourself to find out more!)

We’re interested in following the progress of our two local graduates as they tread the first rung of their career ladders. Alas that’s not going to be easy. You can tell just how busy junior

EdItOR’S NOtES


doctors are from the tone of Rebekah’s piece and the absence of Gemma’s.

Now, we’ve heard one or two patients journeys to this point, but one of the harder roads travelled must be that by Edwyn Collins and others like him. The book review by Helen Alcock ends thus “If you remember 80s indie pop, if you are interested in brain injury, if you are interested in Rehabilitation Medicine then this book should be of interest to you. Or if you can’t face reading the Francis reports from cover-to-cover but feel you ought to have a sense of what they’re about, you could do worse than read this book.” I think you would do well to read the review.

Finally, on a parochial level, we may look at making some changes to this journal. Nothing is decided yet but there are opportunities for change, including more of a web presence than hitherto. One of my disappointments as editor of this journal is the substantial lack of

feedback. Though I grew in an era when it was reasonably safe and widely expected that a lack of complaint was to be seen as all the praise and encouragement one needed or deserved to plough steadily on in the same furrow, for a good job was to be assumed to be being done in the absence of a contrary call, that is not today’s way: feedback should be solicited, sorted, considered and responded to. So, if you have any thoughts how Midlands Medicine should or should not change, please do let me know; I shall take the absence of suggestions as carte blanche for the editorial board to proceed as it sees fit.

REfERENcE

1 The End of History? Fukuyama F The National Interest (1989)

cALL fOR cONtRIBUtIONS

Midlands Medicine aims to fulfil a wide brief spanning from the role of a traditional medical journal to a forum for the dissemination of news and developments in local healthcare in the Midlands. We seek to provide a voice to all interested parties from patients to practitioners in primary, secondary and tertiary care, from medical students to nurse consultants and those in professions allied to medicine.

We wish to range from the history of medicine to ground-breaking research, from audit to audacity. Additionally we aim to be an educational resource for students and practitioners in all healthcare disciplines.

To do this we will publish a variety of types of original articles, including those based on strong opinion, reminiscence, audit projects, case reports, scientific research, dissemination of clinical best practice and lessons learned. Reviews of relevant books an other media will be considered, as will letters in response to previous articles.

There must be many of you out there with something to contribute for the interest of the wider healthcare, medical and surgical community. Projects or audits which were particularly interesting or telling; books you’ve read that have changed the way you look at things, or matters you would like to sound off about. If so, why not get writing? This journal can only thrive on your contributions.

Whether you’re not sure where to start or just wish to polish up on your already written article prior to submission, please request the ‘Guidance for Authors’. If you are thinking about writing an article but wish to discuss it first, please contact the office.

All articles are peer reviewed and subject to editorial approval and to editing.

6 Midlands Medicine

It is three years since we were exposed to Robert Francis QC’s first report on unacceptably poorly delivered healthcare at Mid-Staffordshire NHS Foundation Trust.1 This outsider’s perspective on a district general hospital in our patch was disturbing and painful. But it was only an initial report. He has now spent the intervening years painstakingly listening to testimony and sifting through documentary evidence to come up with a second, comprehensive, report which runs to approaching 2000 pages over three volumes, the executive summary of which runs to 119 pages.2 “Building on the report of the first inquiry, the story [this second report] tells is first and foremost of appalling suffering of many patients. This was primarily caused by a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities.”

Perhaps it is not surprising that it would be no mean feat to summarise succinctly a work on this scale. Fortunately that job has been done by Robert Francis himself, perhaps as best it can be:

thE PROBLEMS

• A culture focused on doing the system’s business – not that of the patients

• An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern

• Standards and methods of measuring compliance which did not focus on the effect of a service on patients

• Too great a degree of tolerance of poor standards and of risk to patient

• A failure of communication between the many agencies to share their knowledge of concerns

• Assumptions that monitoring, performance management or intervention was the responsibility of someone else

• A failure to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession

• A failure to appreciate until recently the risk of disruptive loss of corporate memory

• Focus resulting from repeated, multi-level reorganisation

thE cORREctIVE ActIONS NEEdEd

1. Foster a common culture shared by all in the service of putting the patient first

2. Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated

3. Provide professionally endorsed and evidence-based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service

SEcUNdUM cLAMO!fRANcIS REPORt 2013: A chARtER fOR cANdOURDominic de Takats, Editor, Midlands Medicine


4. Ensure openness, transparency and candour throughout the system about matters of concern

5. Ensure that the relentless focus of the healthcare regulator is on policing compliance with these standards

6. Make all those who provide care for patients individuals and organisations properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service

7. Provide for a proper degree of accountability for senior managers and leaders to place all with responsibility for protecting the interests of patients on a level playing field

8. Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do

9. Develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system

thE gOVERNMENt’S INItIAL RESPONSE

The official response, to date, to the Francis Inquiry’s report was given by The Right Honourable Jeremy Hunt MP, Secretary of State for Health, in a statement to parliament, on 26th March.3 He said the following: “The Government accepts the essence of the Inquiry’s recommendations and we will respond to them in full in due course. But given the urgency of the need for change, I am today announcing the key elements of our response so we can proceed to implementation as quickly as possible.

“I have divided our response into 5 areas:

• Preventing problems arising by putting the needs of patients first;

• Detecting problems early;• Taking action promptly;• Ensuring robust accountability; and• Leadership.”

After expanding in each of these areas, he concludes as follows:

“The events at Stafford Hospital were a betrayal of the worst kind. A betrayal of the patients, of the families, and of the vast majority of NHS staff who do everything in their power to give their patients the high-quality, compassionate care they deserve.

“But I want Mid Staffs not to be a byword for failure, but a catalyst for change.

“To create an NHS where everyone can be confident of safe, high quality, compassionate care.

“Where best practice becomes common practice.

“And where the way a person is made to feel as a human being is every bit as important as the treatment they receive.”

A much fuller initial response is to be found in the publication Patients First and Foremost4

which is a model of earnest contrition and an undertaking to do all possible to get things right in the future.

cOMMENtARY

It is difficult to argue with any of Robert Francis’ recommendations above. Indeed, the government have accepted either in principle or in entirety most of his 290 full recommendations. Midlands Medicine would declare particular sympathy with numbers 1 and 8 above, and wish to play its part in debating, understanding, fostering and disseminating appropriate essential values to be shared by all health workers, particularly with our interests in Clinical Education, training and research.

However, wider debate seems to centre around number 4, an entreaty to be frankly honest (to

8 Midlands Medicine

AddRESS fOR cORRESPONdENcE

The EditorMidlands MedicineNorth Staffordshire Medical InstituteHartshill RoadHartshillStoke -on-TrentST4 7NY

REfERENcES

1 The Mid Staffordshire NHS Foundation Trust Inquiry:Independent Inquiry into care provided by Mid Staffordshire NHS Foundation TrustJanuary 2005 – March 2009 Volume IChaired by Robert Francis QC

2 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Chaired by Robert Francis QC h t t p : / / w w w .midstaffspublicinquiry.com/report

3 https://www.gov.uk/government/speeches/the-government-s-response-to-the-francis-report

4 Patients First and Foremost: the Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry https://www.gov.uk/government/publications/government-initial-response-to-the-mid-staffs-report

5 Public arena e.g.: http://www.dailymail.co.uk/news/article-2306634/Pressure-growing-NHS-boss-Sir-Bruce-Keogh-heart-unit-U-turn-Leeds-General-Infirmary.html?ITO=1490&ns_mchannel=rss&ns_campaign=1490

6 de Takats D Primum non nocere Midlands Medicine (2010) Vol 26 pp5-6

display candour). But we can already see that the new spirits of openness and swift response to shrill concerns has got off to an awkward start. Concerns voiced over the mortality rates for paediatric cardiothoracic surgery in Leeds at the General Infirmary reached the ears of the medical director of NHS England, Sir Bruce Keogh. On the data available to him on 28th March he felt there was little choice other than to suspend children’s heart surgery at LGI, within two weeks, after more detailed data and analysis thereof, the picture changed and some limited re-opening of the unit permitted.4 A fiasco, perhaps. But I think the openness may have partly mitigated what might otherwise have looked like total confusion and indecisiveness. Many more people now know how difficult these decisions are, and how difficult clinical audit information can be to handle with care, and the possible consequences if it isn’t. Nevertheless, it wasn’t a shining inauguration for the new candour.

Robert Francis’ fear appears to be that we wont whistle blow because whistle blowing is so consequential for the person who does it (think of Steven Bolsin, still in exile in Australia) so he wants to attach to us a duty of candour. Health workers labour under a strong sense of duty so I’m sure there would be something of a change in behaviour.

My fears are that a new spirit of finger-pointing candour will either unleash such a pack of false alarm bells that we’ll become deaf to them, or there’ll be so many true causes for concern that we’ll become inured to them. My hope is that Robert Francis’ recommendation will be implemented in a functional way such that it will re-energise the ancient sport of shroud waving, in a good way, so we really can ‘take complaints seriously’, investigate them thoroughly and then respond responsibly, implementing those fixes of resourcing, cultural change and practice that are necessary to avert preventable harm to patients.

The conclusion offered in this journal three years ago remains apposite: “When we run out of smart things to do, when we’re as lean as can be, we then come face-to-face with having to lower basic standards in many areas as the next

step. Those delivering a service have a duty and a responsibility, before that happens, to blow a shrill whistle and wave the Stafford shroud.”6


Musculoskeletal pain is very common in the general population. In Stoke-on-Trent, at least a third of people over the age of 50 years report having difficulties with normal work (including housework) because of musculoskeletal pain1

and it is the second most common reason for visiting the GP.2 Nationally, it is recognized that arthritis is responsible for 18% of the burden of disability.3 As our population ages, the incidence of musculoskeletal problems will continue to rise and the demands on healthcare services will increase. How will we face this challenge? Does an answer lie in the way we configure our services to move away from silo management of conditions towards managing multiple co-morbidities in one consultation, using the spectrum of healthcare professionals to best effect?

In the late 1990s, forward thinking clinicians started to ask the question, ‘Do all patients with musculoskeletal disease referred to secondary care need to be seen by a secondary care medical practitioner?’ Could these patients be assessed by a range of experienced clinicians including physiotherapists and GPs with Special Interests (GPSIs)? At that time, this was revolutionary thinking, although today we are all very used to having clinical specialists in nursing, physiotherapy and many other allied health professions. However, at that time these professional groups were not employed extended clinical capacities. Underpinning this debate was the knowledge that empirical

research and local audits had revealed that a high percentage of patients waiting to see orthopaedic physicians and rheumatologists often had non-inflammatory conditions and did not require surgery.

Locally, the first service to make use of physiotherapists in an extended clinical role was the Staffordshire Acute Back Pain Service (STABS). A pathway for patients with low back pain was agreed through facilitated meetings led by Professor Elaine Hay (Consultant Community Rheumatologist) and Mr John Dove (Consultant Orthopaedic Surgeon). If initial GP advice and reassurance, plus community physiotherapy, did not improve patients’ symptoms, patients with non-specific low back pain were referred into a specialist physiotherapy-led service, based at the Haywood Hospital. The physiotherapists, supported by the Community Rheumatologist provided rapid assessment and were able to request additional investigations including MRI, X-ray and blood tests as appropriate. Strong links with spinal surgeons, including combined clinics, facilitated appropriate management for the small number of patients thought to be in need of a possible surgical intervention. As this model worked well4, it was followed closely by the SMASHERS service (Stoke musculoskeletal acute hospital early referral system). This service worked on a similar principle and provided rapid assessment for patients with general musculoskeletal disease (except back pain). Dr Peter Dawes, Consultant Rheumatologist,

MOVINg ONwARdS: thE MUScULOSkELEtAL INtERfAcE SERVIcE:ItS dEVELOPMENt ANd fUtUREKay Stevenson, Consultant Physiotherapist, UHNS; Arthritis UK Primary Care Sciences, Keele University; seconded to Staffordshire and Stoke-on-Trent Partnership TrustAjit Menon, Consultant Rheumatologist, Hayward Hospital

10 Midlands Medicine

championed this model and facilitated the debate with orthopaedic colleagues to agree upon appropriate pathways for such patients.

Today, these two services form the Musculoskeletal Interface Service (MIS), which was re-commissioned in 2010 and is hosted in Staffordshire and Stoke-on-Trent Partnership Trust (SSOTP). It assesses 10,000 patients per year across the North Staffordshire and Stoke-on-Trent area. Clinical leadership is provided by Rheumatology (Dr Menon and Dr Hider) and physiotherapy (Kay Stevenson and Dr Kika Konstantinou) with service management (Vicki Taylor) ensuring that the service remains fit for purpose, is sustainable and ensures best value for patients. We provide rapid access to clinics around the Stoke-on-Trent and North Staffordshire area and quick access to diagnostic investigations. Seventy per cent of the patients are seen by specialist physiotherapists and GPs with a clinical interest in musculoskeletal disease. We understand our patient population, as an observational study (SAMBA) housed within the MIS highlighted that a significant number of patients have pain for more than one year (75%), and 20% have anxiety and depression (Roddy et al, 2013). Patients are highly satisfied with their care (98%) and our ‘did not attend’ rates in community clinics are very low (4%).

The strengths of the model can be attributed to:

• Collaborative leadership• Joint appointments• Patient involvement

The MIS has very strong clinical and managerial leadership which is essential as we have many different professional groups offering sessions to our service. These groups include general practitioners, physiotherapists, rehabilitation specialists and rheumatologists. In this context, clinical leadership means providing clinical support, mentorship, training, having clear competency frameworks and clinical algorithms, ensuring opportunities for staff development, promoting educational and research opportunities and integrating research findings into practice.

We have several joint appointments within the service, between the Haywood Hospital and Arthritis Research UK Primary Care Centre at Keele University. They include a consultant physiotherapist, research facilitators, physiotherapists and consultant rheumatologists. Linking clinical practice with academia in this way helps to ensure that research questions are pertinent and that the research findings are integrated into clinical care in a timely way. The Consultant Physiotherapist (KS) has recently been awarded a National Institute Health Research Knowledge Mobilisation Fellowship, which is focusing on translating knowledge and research into practice.

Our patient partners are of huge value to our service. We have a very active and dynamic Arthritis and Musculoskeletal Alliance (ARMA) group that meets every three months. This group is currently working with a local charity, The Haywood Foundation, and with the Partnership Trust (SSOTP) to open a patient information and resource room which will be staffed and run by volunteers. This dedicated space will contain computers, literature, patient information and a meeting space for small patient groups. The volunteers will be trained to act as ‘signposters’ and will be able to guide patients to appropriate information. Patient representatives have also participated in facilitated sessions to help us continually develop our service. Several patients are also part of the Research User Group that oversees the applicability of research from a patient’s perspective at Arthritis Research UK Primary Care Centre at Keele University.

Our model makes use of the differing skills of medical and physiotherapy staff. It is supported by patient representatives, and is effective, efficient and produces high levels of patient satisfaction. We continually ask could this model be used to better effect? Can we configure the service to continue to develop and maximise the skills of the existing team? Currently, our primary focus is the management of patients’ musculoskeletal disease. However, we know from our data that significant numbers of our patients are complex and have a range of health issues as well as their musculoskeletal pain such as anxiety, depression, and obesity.5


A recent publication in the Lancet6 identified that the UK consistently falls below the European average for premature mortality and further action is required in the major causes such as cardiovascular disease and cancers. The report also highlights the growing burden in mental disorders, substance use, musculoskeletal disorders and falls. The musculoskeletal team would be perfectly placed to address one significant issue that could improve the burden of disease, this being physical inactivity. It has been suggested that Physical inactivity can be considered the fourth commonest cause of death after hypertension, tobacco use and diabetes mellitus.7

Our challenge now is how the skills of the Musculoskeletal Interface team, underpinned by research evidence from ARUK Primary Care Centre, can enable us to address the issue of improving physical activity and managing co-morbidity in order to reduce the health burden for patients and local economies. Currently this is an unmet need, and is perhaps a limitation of MIS’s “one-stop-shop” philosophy. Key messages about the importance of activity should be discussed and given priority during consultations, and here medical practitioners

can learn from their Physiotherapist colleagues who are skilled in motivating and supporting individuals and groups to improve their activity levels. The MIS team needs to develop strategies to identify individuals who might benefit from additional interventions aimed at general health improvement and secondary prevention of future disability in order to reduce the impact of musculoskeletal disease and associated comorbidity.8

In summary many patients presenting with musculoskeletal disease, are complex, with a significant proportion having co-morbid problems such as chronic pain, anxiety, depression, and obesity. Future service design needs to move away from silo management of musculoskeletal pain, to the holistic management of co-morbidity. One aspect, advice about how to increase physical activity, is ripe for early integration into such services, to improve not only musculoskeletal pain, but other health issues as well.

The difference between stupidity and genius is that genius has its limits

Albert Einstein

“ “



Kay StevensonConsultant PhysiotherapistNIHR Knowledge Mobilisation FellowPhysiotherapy DepartmentLyme BuildingUniversity Hospital of North StaffordshireNewcastle RoadST4 6QG

[email protected]

REfERENcES

1 Thomas E, Peat G, Harris L, Wilkie R and Croft PR The prevalence of pain and pain interference in a general population of older adults: cross-sectional findings from the North Staffordshire Osteoarthritis Project (NorStOP). Pain (2004) Vol 110 pp361-8

2 Musculoskeletal Matters - “What do General Practitioners See? - Different ages, different problems” October 2009 -http://www.keele.ac.uk/media/keeleuniversity/ri/primarycare/bulletins/MusculoskeletalMatters1.pdf

3 Department for work and pensions Disability Living Allowance - cases in payment Caseload (Thousands): Main Disabling Condition by Gender of claimant http://83.244.183.180/100pc/dla/disabled/ccsex/a_carate_r_disabled_c_ccsex_nov07.html [Date accessed: 1-5-2008]

4 Stevenson K Hay EM An integrated care pathway for the management of low back pain Physiotherapy (2004) Vol 90 pp91-96, DOI: 10.1016/S0031-9406(03)00009-9)

5 Roddy E, Zwierska I, Jordan K, Dawes P, Hider S, Packham J, Stevenson K and Hay E M Musculoskeletal clinical assessment and treatment services at the primary-secondary care interface: an observational study B r i t i s h Journal of General Practice (2013) Vol 63 February pp e141-e148(8)

6 Murray CJL, Richars MA, Newton JN, Fenton KA, Anderson JR et al UK health performance: findings of the Global Burden of Disease Study 2010The Lancet, Early Online Publication, 5 March 2013doi:10.1016/S0140-6736(13)60355-4

7 Matheson GO, Klüg Dvorak J, Engebretsen L, Meeuwisse WH, Schwellnus M et al Responsibility of sport and exercise medicine in preventing and managing chronic disease: applying our knowledge and skill is overdue Br J Sports Med (2011) Vol 45 pp1272-1282 d o i : 1 0 . 1 1 3 6 /bjsports-2011-090328

8 Hill JC, Whitehurst DGT, Lewis M, Bryan S, Dunn K et al Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial The Lancet (2011) Vol 378 pp1560-71


It is hard to imagine any experienced health professional who does not spend part of their time teaching whether in a classic pedagogical educational role passing clinical knowledge and skills to students or trainees, or as a clinician educating patients and allowing informed choices to be made. The General Medical Council recognises this within the teaching and training, appraising and assessing section of Good Medical Practice1, where it states: ‘Teaching, training, appraising and assessing doctors and students are important for the care of patients now and in the future. You should be willing to contribute to these activities.’’And then carries on unequivocally: ‘If you are involved in teaching you must develop the skills, attitudes and practices of a competent teacher’.

It is difficult to define clinical education succinctly, certainly difficult to find a definition that everyone will accept, and even harder to reach a consensus about its aims and purposes. There are many reasons for this but one of the most fundamental is epistemological, that is to do with how knowledge and learning are conceptualised. Essentially clinical education is concerned with questions such as ‘What is the nature of Clinical Knowledge? How does an individual come to possess it? How can they be helped in this process? How do we know that a professional does possess the requisite knowledge?’ Definitions of clinical education contain explicit answers (or assumptions) about these questions.

A broad view of clinical education would be to define it as a teaching and learning process which is student focussed and may be student led, which occurs in the context of patient care. It involves the translation of theory into the development of clinical knowledge and practical skills alongside humanistic and ethical

patient care. It takes part in an environment that is supportive of professional socialisation and lifelong learning2: However, clinical settings are dynamic educational spaces that present both opportunities and barriers to learning and teaching.

Teaching Undergraduates in the Clinical Setting is the first of a series of Clinical Education articles in Midlands Medicine which are designed to inform, challenge and educate health professionals about the evidence underpinning clinical education practices and outcomes. This multi-disciplinary series brings together important concepts in healthcare education and is intended to address the context and processes of learning, professional identity and socialisation, feedback and assessment, ethics, and inter-professional education. The authors, who are all experienced clinical teachers, will encourage teaching and learning practices based on research findings, expertise and innovation, and the development of individual teaching methods and styles from a theoretical base that provides relevant principles, direction and support.

With clear links between theory, research and practice, collaboration from a broad range of clinical disciplines, and sharing models for learning and teaching grounded in theory and research, it is hoped that this Clinical Education Series will become a source of reference for health professionals and others who are involved in, or wish to develop an interest in, clinical education. The series provides an opportunity to evaluate and develop teaching skills and to adopt a scholarly approach to clinical education. Such an approach enables health professionals to acquire the necessary expertise for effective clinical teaching in the context of their own educational roles, responsibilities and interests.

cLINIcAL EdUcAtION: LESSONS fOR PRActIcEClive Gibson, Senior Lecturer, Director of Academic Staff Development, KUMS


REfERENcES

1 General Medical Council. Good Medical Practice. http://www.gmc-uk.org/guidance/good_medical_practice/teaching_training.asp

2 Clinical Education in the Health Professions by Sue Kilminster (2009) pp39-40


Without Clinical Teaching, students would be unable to place their theoretical learning into a practical context. Whether it takes place in Primary or Secondary Care, these exchanges will frequently occur within the clinical setting along with patients present. This can present additional challenges to both the teacher and the student with regard to professionalism and clinical and educational governance. Consultants and others are seen as effective role models who demonstrate professionalism, but the literature implies that there is wide variation in the quality and reliability of teaching in respect to venue, setting and speciality. With adequate preparation, junior students are able to reflect upon both social and healthcare experiences and the actions of healthcare professionals using the GMC Duties of a Doctor as a framework1 but if learners are removed from the clinical environment, isolation from patients can lead to a dislocation of theory from practice.

Teaching and learning in any clinical setting is difficult to plan, highly dependant upon context, and is under ever increasing pressure from service provision. However, it can provide unique opportunities for educational contact when used appropriately. Advance planning, by learners and teachers, as described later in this article should facilitate teaching within the clinical surrounding. It is imperative that students are given time to reflect upon learning events. If unplanned teaching occurs that is not scoped to the explicit curricular and assessment programme, then perverse outcomes may arise.2

At a 1999 Conference held in Cambridge on the theme of ‘Clinical Teaching and Learning’ academic medical educators identified four major factors which could improve learning in the clinical environment: 3

1. Integration of the learner into authentic clinical settings

2. Equipping learners with survival skills3. Better use of the clinical environment

and resources for learning4. Expertise in using information

technology

Senior doctors often bemoan the fact that students seem unable to recall facts and apply knowledge to patients’ problems. Research suggests that separation of the basic sciences from clinical care compounds this problem, and that integrating the curriculum and bringing students into contact with patients early will engage them as active learners. A problem based learning course attempts to link the basic and clinical sciences weaving them around patient scenarios: a patient-centred curriculum. These approaches are key to the Keele University Medical School programme. There is further evidence that by placing students into Primary Care environments within General Practice or Community attachments, greater opportunities are available for quality educational events compared to within hospitals where clinical problems may be too complex for junior students and short admissions may leave very little time for reflection.

Learners need proper briefing before moving into new environments, they also need adequate time to reflect upon the experience. Ideally previous students and faculty should mentor new learners and there should be some continuity and point of contact over an extended period. Challenges for students and teachers can be grouped into:

tEAchINg UNdERgRAdUAtES IN thE cLINIcAL SEttINgClive Gibson, Senior Lecturer, Director of Academic Staff Development, KUMS


• Interpersonal skills such as giving and receiving feedback, dealing with abuse

• Coming to terms with illness and dying and dealing with other ethical problems

• Identifying positive coping strategies (and avoiding negative ones)

• Making effective use of time and resources• Obtaining and managing information

Although it is recognised that workplace learning in Primary Care may represent the ideal clinical environment, there is a historic reliance upon Secondary Care where procedures may be narrower and less diversified. Moving the emphasis of teaching into General Practice will require funds to be moved into the community (the money should follow the student). Though direct observation and immediate personal debriefing may be the ideal, time and financial constraints may compel other strategies such as using Simulated Patients trained to give feedback, or using video. Sometimes simple measures such as ensuring access to computers during ‘down time’ will enable literature searches or completion of ePortfolios to be carried out during time that would otherwise be wasted if patients fail to attend clinics. Advanced Organisers may add context or take the form of mini-assignments serving to better structure clinical time.

In many areas of the world, information technology can provide enhanced communication, and provide rapid access to knowledge data bases. It is essential that teachers integrate information technology (IT) systems into the curriculum and align the educational design and final assessment to the medium. Systems can be developed to allow remote access to improve time management and effectiveness. Monitoring and evaluation are key aspects of the educational process; electronic feedback can be used to provide rapid feedback to faculty. The use of IT in clinical teaching can facilitate:

• Self-directed learning• Remote delivery of teaching materials• Electronic communication between

teachers and students• Self-assessment• Accessing databases on the internet• Logging progress on ePortfolios• Quality Assurance and evaluation of

educational events

Parsell and Bligh found, in 2001, in a thematic review of the literature on teaching and learning in clinical settings, that clinical teaching is “variable, unpredictable, immediate and lacks continuity”. Staff and faculty development are key elements to ensure that medical teachers deliver effectively. It is imperative to ensure that everyone is well prepared, that the intended learning outcomes are identified and known by students and teachers alike and that the teaching and assessment methods chosen are appropriate. They describe a three stage process for Clinical Teaching, which must engage both learners and teachers:

• Prior planning and preparation• Teaching with patients• Reviewing: Charting, giving feedback

and reflection

Prior planning and preparation should include assessing the learners’ knowledge and educational needs, along with their clinical skills at that point in training. The environment should be prepared to allow both appropriate privacy and confidentiality to patient and learner during the clinical examination and subsequently during feedback. Students may be given increasing roles in patient management as they develop.


Patients should be chosen carefully in order that more common illnesses are understood before exposing them to more complex clinical problems. This can be difficult to achieve in Secondary Care because patients with simpler forms of illness will predominate in Primary Care whereas more complex and more advanced cases which might form a small part of Primary Care practice are funnelled into, and thus concentrated within, Secondary Care.

It is helpful if patients are articulate and can communicate well whilst students are developing their own communication skills and developing their individual strategies for conceptualising problems.

Reflection is a key aspect of adult learning, and giving good feedback is seminal to this process. Evaluation and feedback to the learners should be given immediately after the learning event, outside of the examination room, but in a safe and private area for the student.

Custers et al in 2000 identified six common errors in student clinical thinking:

• Not generating plausible hypotheses• Collecting too much information• Incorrect interpretation of cues• Over-emphasis on positive findings• Premature closure• Ordering too many investigations

They argue that students should be given defined models to analyse problems and to apply to patient cases. These models can be applied to monitor case progress and form the basis of communication with other health care professionals.

Finally, faculty development is essential in order to optimise the effectiveness of clinical teaching. Teachers should be well prepared for each teaching exchange. They should be able to assess the learning needs of students, and subsequently set (and deliver) optimum learning outcomes for their students. Teaching should be aligned when appropriate to the assessment methods which are to be applied.


Clive GibsonDirector of Academic Staff Development,Keele University Medical SchoolDavid Weatherall BuildingKeele CampusST5 5BG

[email protected]

REfERENcES

1 Stark P, Roberts C, Newble D, and Bax N Discovering professionalism through guided reflection Medical Teacher (2006) Vol 28 pp5-31

2 Hays R Teaching and Learning in Clinical Settings Radcliffe Publishing (2005) Oxford

3 Gordon J, Hazlett C, Cate O, Mann K, Kilminster S et al Strategic planning in medical education: enhancing the learning environment for students in clinical settings Medical Education (2000) 34 pp841-50

4 Parsell G and Bligh J Recent perspectives on clinical teaching Medical Education (2001) Vol 35 pp409-14

5 Custers E, Stuyt P and de Vries Robbé PFClinical problem analysis: a systematic approach to teaching complex medical problem solving Academic Medicine (2000) Vol 75 pp291-7


In 2009, there were 3,378 new cases of cervical cancer in the UK.1 Many of these women will previously have had some interaction with the National Health Service cervical screening programme (NHSCSP). National guidance requires that all cases of cervical cancer are subject to an audit, and advises that women diagnosed with cervical cancer should be invited to discuss the findings of the review of their personal cervical screening history.2-3

It is believed that such history review meetings may be beneficial to women who want to gain a better understanding of why they developed cancer despite participating in the screening programme. However, to date, there have been no studies to evaluate the psychological impact of cervical screening history review meetings on women who have been diagnosed with cervical cancer.

It is likely that some women may experience confusion or distress as a result of the history review meeting, particularly if a screening programme problem is disclosed that may have prevented the earlier detection and treatment of their cancer. For example, using the audit process to investigate the development of cervical cancer, a study of all cases diagnosed at the University Hospital of North Staffordshire between 2003 and 2006 identified several contributing factors.4 Although patient compliance was deemed to be the principal contributing factor in almost half of cases, 20% of cases were associated with cytological undercall or colposcopic mismanagement.

Anecdotal evidence suggests that invitations to attend history review meetings are not offered by all clinicians. One potential explanation is

that the fear of causing patients distress may discourage clinicians from offering women the findings of a review of their cervical screening history. Furthermore, concerns about how to conduct the meetings appropriately may also stand in the way. Current best practice guidelines advise that history review information should be passed on by the clinician responsible for the patient’s treatment after this treatment has concluded. Where a possible or probable false negative screening result has been identified, it is advised that history review meetings should be delivered in accordance with breaking bad news protocols so that women are provided with information, their concerns are elicited and reassurance is given.

Along with literature on ‘breaking bad news’, more appropriate insights into the potential psychological impact of the review meetings may also be gained from the literature about discussing a cancer diagnosis and the disclosure of medical errors. For example, in 2011, a study examining UK patients’ preferences for the delivery of a cancer diagnosis, found that 40% of patients were dissatisfied with how their diagnosis was delivered.5 The reasons given for this included a lack of sympathy shown by the clinician, pessimism, the use of technical jargon and a lack of privacy and support. It is likely that the manner in which information is communicated during history review meetings will similarly affect the impact of that information on the women involved.

It has also been suggested that the manner in which a disclosure about medical errors is made has an impact on how well patients cope, with evidence indicating that patients suing their clinicians in the US are often more

AN APPROAch tO INVEStIgAtINg thE cERVIcAL ScREENINg hIStORY REVIEw MEEtINgSusan Sherman and Emma Nailer, School of Psychology, Keele University


angry about the way they had been treated than they are about the event itself.6 A study in 2009 explored how disclosure of adverse events affected hospital patients’ perception of their quality of care.7 One finding which is of particular relevance to the current study is that patients who reported adverse events which had been disclosed to them were twice as likely to rank their care as good or excellent compared to those who reported an adverse event that was not disclosed. It is conceivable that women attending screening history reviews may be more satisfied with their care following the disclosure of a screening problem, possibly as a result of a heightened sense of trust in the clinical team due to the openness and transparency of the procedure. However, a second finding of interest from the study is that lower quality ratings were associated with events that still adversely affected the patient at the time of the survey. Therefore, women who are still living with a cancer diagnosis or are suffering from on-going side effects from cervical cancer treatment, may have a diminished perception of quality of care.8

Research suggests that communication between clinicians and their patients could be improved by attempting to meet the information needs of patients.9 One factor that will have an impact on how much information patients want and can deal with is individual coping style. Two main coping styles have been identified: monitoring and blunting.10 Monitors typically want more information and indeed seek it out, whilst blunters prefer less information and are often information-avoidant. It is likely that blunters would, therefore, be less likely to accept an invitation to a review meeting. For those patients who do attend, there is evidence that patients do better psychologically and physiologically, when information they receive about their medical condition is tailored to their particular coping style.10 One caveat to this that is especially pertinent to the screening review is that in a study exploring coping styles in low-income minority women who had to undergo diagnostic colposcopy, a significant proportion of high monitors (44%) blamed themselves for the onset of their abnormal Pap smear results.11 In the event of a woman who was both a high monitor and a lapsed attender being invited for

a screening history review meeting, great care would need to be taken not to cause unnecessary distress.

Evidence shows that women attending screening history review meetings are already likely to be experiencing elevated levels of anxiety and depression as a result of having cervical cancer.12 A study in 2005 found that survivors of cervical cancer (5-20 years post treatment) reported significantly more anxiety than survivors of a comparable (endometrial) cancer, and more dysphoria, anger, and confusion than either endometrial cancer survivors or healthy controls.13 Therefore, it is especially important to determine any additional psychological burden that disclosure places on women.

The aim of this study will be to examine the patients’ experience of the cervical screening history review meeting using a mixed methods approach; using qualitative and quantitative methods in order to identify both the scale of concerns and their nature. We are currently sending a questionnaire out to patients from several NHS Trusts in the Midlands who have had a diagnosis of cervical cancer and subsequently attended a screening review meeting. The questionnaire asks about their experiences of the review from the point of invitation to their feelings after the event. For those respondents who are happy to discuss the matter further, we are conducting follow-up interviews to explore the issues in greater depth. In particular, we hope to identify any benefits that patients might report from the process and to understand the nature, extent and duration of any distress reported as well as potential solutions or methods by which that distress can be minimised.

The findings of this study will be used to develop research based recommendations for best practice in the disclosure of audit results to patients. Clearer guidance and a better understanding of the psychological impact of screening history review meetings on women who have been diagnosed with cervical cancer may encourage more NHS Trusts and clinicians to offer women invitations to attend history review meetings.


AddRESS fOR cORRESPONdENcE:

Dr Sue ShermanSchool of PsychologyKeele UniversityST5 5BG

[email protected]

REfERENcES

1 Office for National Statistics (2011)

2 Department of Health. Audit of invasive cervical cancer. NHS cervical screening programmes NHSCSP Publication No 28. (2006)

3 Patnick J (Ed.) Disclosure of audit results in cancer screening: Advice on best practice NHS Cancer Screening Programmes (2006) Cancer Screening Series 3

4 Moss EL, Pearmain P, Askew S, Owen G et al Implementing the national invasive cancer audit: a local perspective BJOG (2010) Vol 117 pp1411-6

5 Brown VA, Parker PA, Furber L and Thomas AL Patient preferences for the delivery of bad news– the experience of a UK Cancer Centre Eur J Cancer Care (2011)Vol 20 pp56-61

6 Lamb R Open disclosure: The only approach to medical error Quality and Safety in Health Care(2004) Vol13 pp3-5

7 Lopez L, Weissman JS, Schneider EC, Weingart SN, Cohen AP and Epstein AM Disclosure of hospital adverse events and its association with patients’ ratings of the quality of care Arch Intern Med (2009) Vol 169 pp1888-94

8 Moss EL, Sherman SM, Pearmain P and Redman CWE The NHS cervical screening programme audit of invasive cervical cancers: who benefits? BJOG (2011) Vol 119 pp1-4

9 Fallowfield L and Jenkins V Effective communication skills are the key to good cancer care Eur J Cancer (1999) Vol 35 pp1592-7

10 Miller SM Monitoring versus blunting styles of coping with cancer influence the information patients want and need about their disease, Implications for cancer screening and monitoring Cancer (1995) Vol 76 pp167-77

11 Miller SM, Roussi P, Altman D, Helm W and Steinberg A Effects of coping style on psychological reactions of low-income, minority women to colposcopy J Reprod Med (1994) Vol 39 pp711-8

12 Andersen, B. L, Anderson, B, and de Prosse C (1989) Controlled Prospective Longitudinal Study of Women With Cancer: II. Psychological Outcome Journal of Consulting and Clinical Psychology (1989) Vol 57 pp692-7

13 Bradley S, Rose S, Lutgendorf S, Costanzo E and Andersen B Quality of life and mental health in cervical and endometrial cancer survivors GynecolOncol (2006) Vol 100 pp479-86


INtROdUctION

Practitioners and service providers in the field of bereavement care face two significant challenges. The first comes from contemporary research which estimates that only 10-15% of the bereaved population is in need of therapeutic support. The effectiveness and appropriateness of intervention is questioned.1 unless there is a significant level of distress or complicated grief is used as a criterion for treatment.2 It is crucial, therefore, that practitioners across all sectors of health and social care are able to identify this vulnerable group of people and distinguish the response to their needs from the needs of the wider population of bereaved people. The second challenge comes from funders whose financial support is increasingly dependent upon evidence that services are being offered to those who most need it and that efficacy can be demonstrated in addressing grief needs. This research asks whether the Adult Attitude to Grief scale3 (AAG) can be used as a valid and clinically useful measure of grief which can reliably identify vulnerability. The AAG is already used in practice to profile the grief of those presenting for support in their bereavement. The anticipated consequence of the development of a vulnerability indicator would be more effectively targeted resources and interventions to those most at risk of negative outcomes in their grief.

Reports by practitioners engaged in this research report good face validity and preliminary statistical analysis is also encouraging.

BAckgROUNd

Grief is a reaction to a significant loss such as bereavement, which can profoundly affect all aspects of life and capacity to function well. The consequences for those rendered most vulnerable by grief can vary from severe psychosocial distress4,5 through to physical disturbances as extreme as suppression of the immune system and neuro-endocrine dysfunction.6 Complicated grief reactions are characterised by difficulty in functioning in work and in social relationships, a sense of meaninglessness, prolonged yearning for the deceased, disruption in personal beliefs, potential misuse of drugs and alcohol, and antisocial behaviour.7-9 These maladaptive responses to loss will be represented significantly in the case-loads of doctors, and other health and social care professionals. Mitigating the negative outcomes of loss and bereavement is, therefore, a significant issue for public and personal health.

What is clear is that there is an enormous range of individual responses to loss10,11 yet public and voluntary services, which have been increasingly involved in the provision of bereavement care in the last three decades12,13 are largely offered on the basis of ‘one-size-fits-all’. New understanding about the human capacity for resilience suggests that for many people characteristics of personal resourcefulness, a positive life perspective and social embededness are key factors in competent emergence from traumatic or disturbing life events,11,14-16 leaving just an estimated 10–20% of the general bereaved population potentially susceptible to complicated grief.4

thE AdULt AttItUdE tO gRIEf ScALE – A MEASURE fOR IdENtIfYINg VULNERABILItY IN BEREAVEMENtLinda Machin, Julius Sim & Bernadette Bartlam.Research Institute for the Social Sciences, Keele University.


Complications in grief need to be understood in terms of complex interconnecting circumstantial and coping factors.10 Circumstances that have been shown to increase the risk of a problem outcome in bereavement include: sudden unexpected deaths, including suicide and murder; the death of a child; concurrent crises, such as divorce, unemployment, financial problems, health problems; and perceived lack of social support.17 Personal strengths/weaknesses associated with personality and acquired life-experience influence whether or not an individual has an effective capacity for coping with loss and bereavement. When a loss experience and the stress of coping with it are juxtaposed, a person’s psychological and social resource base will be tested.18,19

The scope of the work in the sphere of bereavement is enormous. There were 484,367 deaths registered for England and Wales in 201120 and Cruse Bereavement Care (the largest voluntary organisation in the UK offering bereavement support), reported they had nearly 100,000 requests for help in 2009.21

To bereavement may be added all the other significant life losses which produce grief e.g. loss and relationships, including abuse and the breakdown of relationships; physical/mental illness and disability; economic and political losses including unemployment, homelessness, financial problems, marginalisation for reasons of ethnicity, age and sexual orientation etc.11

However, for the purposes of this study the focus was specifically on bereavement.

thE AdULt AttItUdE tO gRIEf ScALE (AAg) AS A RESEARch tOOL

The AAG scale is derived from the concepts proposed in the Range of Response to Loss (RRL) model3 which identifies the immediate spectrum of grief reactions as ranging from an emotional state of being ‘overwhelmed’ to a cognitive/behavioural state of trying to stay in ‘control’. The model suggests that the ability to balance these competing reactions is evidence of ‘resilient’ coping. Although there is a conceptual fit between these notions of grief and those identified in two significant contemporary grief theories - attachment theory22 and the dual

process model of grief,23 the Adult Attitude to Grief scale was devised to test the validity of the three proposed categories in the RRL model.

The AAG scale contains three clusters of items designed to measure the constructs:

Overwhelmed self-report statements:

2. For me, it is difficult to switch off thoughts about the person I have lost.5. I feel that I will always carry the pain of grief with me.7. Life has less meaning for me after this loss.

Controlled self-report statements:

4. I believe that I must be brave in the face of loss.6. For me, it is important to keep my grief under control.8. I think its best just to get on with life after a loss.

Resilient self-report statements:

1. I feel able to face the pain which comes with loss.3. I feel very aware of my inner strength when faced with grief.9. It may not always feel like it but I do believe that I will come through this experience of grief.

(N.B. a) the numbers here represent the order in which the scale is used in practice i.e. the categories are mixed b) scoring is on a 5 point Likert scale, in a range from 4 for ‘strongly agree’ through to 0 for ‘strongly disagree’ ).

Categorical validity was confirmed in the study by Machin3. Since then, the 9 item scale has increasingly been used in practice as a measure used to profile individual grief.24,25

The RRL model has evolved to include a fourth element, that of vulnerability, as an opposite coping response to resilience in which incapacity to cope with the spectrum of grief reactions (overwhelmed/controlled), is characteristic.11 (See Figure 1.)


cORE gRIEf REActIONS The question raised by this development has been whether the profiling capacity of the AAG scale could be extended to identify vulnerability. The proposed formula for this, and the key hypothesis in the research, was to combine the scores of the overwhelmed and controlled reactions and deduct the resilient responses to calculate vulnerability:O + C – R = V I (vulnerability indicator)

MEthOdS

The key objectives of this research were to test the psychometric properties of the Adult Attitude to Grief scale (AAG) and to test its validity as a tool to calculate the degree of vulnerability in people presenting for support in their loss.

Identifying the psychological components of complicated grief still remains a challenge for both researchers and practitioners. Foremost in this field of research have been Prigerson and Maciejewski, who have produced a measure of Prolonged Grief Disorder (PGD), which is now being proposed as an officially recognised psychiatric disorder.26 It is worth noting that while other psychiatric conditions such as depression27, and/or anxiety28 have been regarded as components of complicated grief, they do not provide a complete definition of the complex spectrum of grief responses which might make individuals vulnerable in their bereavement.

Against this theoretical background this research calculated a vulnerability indicator based on the responses to the AAG scale and tested for validity and reliability, by correlating against client responses to other validated tools identifying prolonged grief (PG-13), depression (PHQ 9) and anxiety (GAD -7). Additionally, clients’ details including, demographic information e.g. gender, age, relationship to the deceased etc. and clinical data e.g. nature of the grief and coping responses to it, complicating personal/ circumstantial/ social factors etc. were analysed.

Three bereavement services already routinely using the AAG were partners in the research. Clients who gave consent for their anonymous data to be released to the research team were included in the study. Data collection began in March 2011 and concluded in September 2012.The study received approval from the University’s ethics review panel.

fINdINgS

Study sample: 168 clients participated (128 female and 40 male). Ages ranged from 18 to 85 with 64% falling within the 36 to 65 age span. 96% of the sample was British and 76% self-referred to services for support. Spousal bereavement constituted the largest category of loss (35.7%) followed by adult daughters and sons grieving the loss of a parent (35%). 41.6%


were bereaved following a long illness in their relative and 27.4% following a short illness. Characteristics of grief reactions were: grief dominated by distress and despair 57.7%; an inability to accept the death 48%; disturbed and intrusive thoughts about the loss 47.6%; strong feelings of anger, guilt and blame 45.8%. 82.7% had difficulty coping with their feelings and 65.5% had difficulty coping with the meaning of their experience. One or Two personal, circumstantial or social factors complicated grief for 78.5% of clients.

Practitioners reported that the vulnerability indicator calculated from the AAG scores provided a measure of vulnerability which equated with their professional judgement of the client’s clinical state.

Preliminary analysis of the quantitative data suggests a significant degree of reliability for the proposed identification of vulnerability. Full analysis is nearing its final stage.

dIScUSSION

This is an innovative study building on international research into complicated grief, using a model (the Adult Attitude to Grief scale,3) which has already become a widely used practice tool for identifying the way in which individuals grieve. The research proposed exploring, through the attitudes people bring to their loss experience, an immediate self-report insight into the complex variations in grief, which allow for the range of conventional psychological components to be incorporated into a simple 9-item measure of grief. It investigated whether an indication of vulnerability could be derived by summating those items on the scale that are indicative of vulnerability, i.e. the overwhelmed and controlled items, and discounting the mediating resilient items. The early indications are positive and suggest that the AAG provides an important validated approach to assessment.

Schut asserts that ‘A robust set of risk factors is likely to contribute to sound outcomes from interventions for bereaved people’.29 A model of intervention is being developed to address varied ways in which vulnerability is manifest.11

For those overwhelmed by grief the approach is to counter the sense of powerlessness generated by their emotional state of distress and focus on the development of cognitive / behavioural / social strategies for re-engaging with those areas of life where control is possible. Conversely, for those who aspire to be in control but who are undermined in their usual functioning style by the powerlessness of their loss, focus is on the safe exploration of emotion and thinking as a way of re-establishing a sense of agency. In every situation of addressing personal grief reactions, facilitating resilience is a parallel goal achieved by helping to identify the bereaved person’s strengths, their capacity for hopefulness and effective use of social support systems.

Whilst grief is usually associated with death, dying and bereavement, it is also a characteristic response to many other life losses. Consequently, the focus of this research has potential application across many areas of health and social welfare. These cross-disciplinary implications are reflected in the make-up of the research team representing as they do the fields of health and rehabilitation, gerontology, and bereavement care.

cONcLUSIONS

The effective identification of people who are vulnerable and the appropriate targeting of interventions and resources are crucial to both high quality care and cost efficient services.

AckNOwLEdgEMENtS

The authors acknowledge financial support for this research through a grant given by the North Staffs Medical Institute. The authors also wish to thank the Dove Service (North Staffordshire ), St Giles hospice (Lichfield) and the Marie Curie hospices (Belfast and Hampstead) for their help with data collection and Aisling Bartlam for help with data entry.



Dr Linda MachinResearch Institute for the Social Sciences,Keele University.ST5 5BG

Email: [email protected]

REfERENcES

1 Neimeyer RA Searching for the meaning of meaning: grief therapy and the process of reconstruction Death Studies (2000) Vol 24 pp541-58

2 Neimeyer RA Grief counselling and therapy – the case for humility Bereavement Care (2010) Vol 29 pp4-7

3 Machin L (2001) Exploring a framework for understanding the range of response to loss; a study of clients receiving bereavement counselling Unpublished PhD thesis: Keele University UK

4 Prigerson HG and Jacobs SC (2001) Traumatic Grief as a Distinct Disorder: A rationale Consensus Criteria and a Preliminary Empirical Test in MS Stroebe RO Hansson W Stroebe and H Schut (eds) Handbook of Bereavement Research (p613-645) Washington: American Psychological Association

5 Stroebe W (2000) Social Psychology and Health (second edition) Buckingham: Open University Press

6 Hall M and Irwin M (2001) Physiological Indices of Functioning in Bereavement in MS Stroebe RO Hansson W Stroebe and H Schut (eds) Handbook of Bereavement Research pp613-45 Washington: American Psychological Association

7 Parkes CM and Weiss RS (1983) Recovery from Bereavement New York: Basic Books

8 Stroebe W and Stroebe MS (1987) Bereavement and Health C a m b r i d g e University Press

9 Thompson N (2012) Grief and its Challenges Basingstoke: Palgrave Macmillan

10 Stroebe MS Folkman S Hansson RO and Schut H (2006) The prediction of bereavement outcome: Development of an integrative risk factor framework Social Science and Medicine 63: 2440–2451

11 Machin L (2009) Working with Loss and Grief: A New Model for Practitioners London: Sage

12 Parkes CM Relf M and Couldrick A (1996) Counselling in Terminal Care and Bereavement Leicester: British Psychological Society

13 Worden W (2003) Grief Counselling and Grief Therapy London: Tavistock/Routledge

14 Frankl V (1959) Man’s Search for Meaning Boston: Beacon Press

15 Seligman M and Csikszentmihalyi M Positive psychology: an introduction American Psychologist (2000) Vol 55 pp5-14

16 Greene R Holocaust survivors: a study in resilience Journal of Gerontological Social Work (2002) Vol 37 pp3-18

17 Sanders C M (1993) Risk Factors in Bereavement Outcome in MS Stroebe W Stroebe and RO Hansson (eds) Handbook of Bereavement: Theory Research and Intervention Cambridge: Cambridge University Press pp255-67

18 Folkman S (2001) Revised coping theory and the process of bereavement in MS Stroebe RO Hansson W Stroebe and H Schut (eds) Handbook of Bereavement Research pp563-84 Washington: American Psychological Association

19 Lazarus R S and Folkman S (1984) Stress Appraisal and Coping New York: Springer


20 Office for National Statistics (2012) Births and deaths in England and Wales2011: wwwstatisticsgovuk/statbase/Productasp?vlnk=14409

21 Kerslake D (2010) Leading the Way in Bereavement Care Report of the CEO Cruse Bereavement Care PO Box 800 Richmond Surrey TW9 1RG

22 Ainsworth MDS Blehar MC Waters E and Wall S (1978) Patterns of Attachment: A Psychological Study of the Strange Situation Hillsdale NJ: Erlbaum

23 Stroebe M and Schut H The Dual Process Model of coping with bereavement: rationale and description Death Studies (1999) Vol 23 pp197–224

24 Machin L and Spall R Mapping grief: a study in practice using a quantitative and qualitative approach to exploring and addressing the range of response to loss Counselling and Psychotherapy Research (2004) Vol 4 pp9–17

25 Machin L (2007) The Adult Attitude to Grief Scale as a tool of practice for counsellors working with bereaved people A study report sponsored by Age Concern Tameside and Keele University

26 Prigerson HG and Maciejewski PK A call for sound empirical testing and evaluation of criteria for complicated grief proposed by the DSM V Omega (2006) 52 9-19

27 Kroenke K and Spitzer RL The PHQ-9: A new depression and diagnostic severity measure Psychiatric Annals (2002) Vol 32 pp509–521

28 Spitzer RL Kroenka K and Williams J A Brief Measure for Assessing Generalised Anxiety DisorderThe GAD –7 Archives of Internal Medicine (2006) Vol 166 pp1092-7

29 Schut H Grief counselling efficacy – have we learned enough? Bereavement Care (2010) Vol 29 pp8–9

Intelligence is the ability to adapt to change

Stephen Hawking

“

“


As a new member of the editorial board of Midlands Medicine, I would like to take the opportunity to introduce myself. I trained as a Registered General Nurse (RGN) at what is now the University Hospital of North Staffordshire (UHNS). On qualifying in 1987 I took a post as a Staff Nurse on various medical wards at the North Staffordshire Royal Infirmary (NSRI), including a six-month stint when the Medical Assessment Unit (MAU) first opened at the City General Hospital (CGH). At the time, April 1989, it was seen as revolutionary, whereby ambulance crews were allowed to directly attend the unit rather than go first to A&E at the NSRI, today, its normal practice. In 1994 I moved to acute surgery and in 1996 I joined the community nursing team. I have had the opportunity to work in various areas, I have met some wonderful characters and it is a privilege to be able to nurse people in their own homes. The concept of nursing in the home is very different to that of hospital nursing.

The nature of community nursing, though, seems to remain rather elusive to many of the colleagues I come across who do not appear to have a true understanding of the various roles and services available within primary care. At present I work as the Non-Medical Prescribing (NMP) Lead for Staffordshire and Stoke-on-Trent NHS Partnership Trust. This role carries responsibility for over 700 NMPs working across the organisation within a variety of different settings and staff includes nurses and a variety of Allied Health Professionals. I am a member of the Nurse Advisory Group for the British National Formulary.

Until recently I was also an Advanced Nurse Practitioner within Community Nursing working in an Admission Avoidance Service for Adults. Single Point of Care was established in 2010, where the emphasis is to try to reduce inappropriate admissions to UHNS. However I’m very much a clinician, so whilst enjoying my strategic and leadership roles, I feel the need to remain clinically active; therefore I work on a bank basis for PrimeCare Forensic as a Custody Nurse. This new speciality of nursing is a challenging role and uses all my skills. In my spare time, I am a member of the conference organising committee of Primary Care Respiratory Society UK (PCRS-UK), a committee member of the Haywood Back Welfare Trust and co-chair of the Staffordshire North Respiratory Alliance (SNRA).

My passion is respiratory disease, and my Masters is in Advanced Respiratory Management. As a result of the work I have undertaken within community nursing and the management of people who have COPD, I received the Queens Nurse Award.

gEttINg tO kNOw tRAcY hALLTracy Hall, Non-Medical Prescribing Lead Staffordshire & Stoke-on-Trent NHS Partnership Trust, New member of the Midlands Medicine Editorial Board


I was the first community matron locally and set up the service which has evolved across the health economy. My philosophy is to treat people as I would want to be treated myself, with respect, dignity, and where appropriate with humour.

As mentioned previously, my passion concerns the management of respiratory disease and ultimately making a difference to the people in my care. In forthcoming issues of Midlands Medicine I hope to be able to present articles about respiratory pathophysiology, patients with interstitial lung disease and palliative care for patients with end-stage respiratory illness, including how such patients might be managed in the community more often than in hospital, wherever happens to be their preference.


Tracy HallNon-Medical Prescribing Lead Staffordshire & Stoke-on-Trent NHS Partnership TrustMedicines Management DepartmentEdric HouseWolseley CourtTowers PlazaWheelhouse RoadRugeleyStaffsWS15 1UW

There are seven [virtues] ... to lighten your work and they are tact, tidiness, taciturnity,

sympathy, gentleness, cheerfulness, all linked together by charity

“ “William Osler


My elective was in the remote Eastern district of Nepal in a town called Taplejung. Taplejung was a 2 day journey from the capital Kathmandu, in total 25 hours by local bus and jeep.

The district hospital served a population of 500,000 local Nepalis, mainly residents living in the rugged foothills and mountains of the Himalayas. The hospital itself had 20 inpatient beds and ran an outpatient clinic (OPD) every day, excluding Saturday (as this is holy day in the Hindu week, like the Sabbath in Christianity). The hospital had three doctors, six paramedics (a role similar to Advanced Nurse Practitioner), eight paramedic students, 10 sisters and six helper/porter/cleaners.

Our tutor, Dr Deepak – at the equivalent stage of FY2, for one year previously had run the hospital by himself. One doctor for 500,000 patients. His ‘claim to fame’ as such was that he had once seen 400 patients in OPD in one day. Having seen OPD, I do not doubt this!

Healthcare in Nepal can be split into public and private. The minority that can afford to pay for private healthcare do. There is not an emergency number that can be called for assistance at home. In Taplejung, if someone was ill, they would have to make their own way to the hospital. Failing this, they would have to be carried by their family or members of the community. The hospital had distributed stretchers to every large village it supported.

Countless times I would see elderly ladies on a stretcher, carried by four young, topless Nepali boys into the hospital. Here, they would rest on the floor and be seen by one of the paramedics, who were always first on-call. If they could not cope with the situation, they would call the doctors, second on-call. 24 hours a day, seven days a week, the doctors were on-call. A fact I was very aware of when the weekly

Friday evening session of drinking whiskey and thomba (a local millet wine) took place! We saw one extreme example of a ‘Himalayan ambulance’ on a health camp trek to the Tibetan border. A man was carrying his sick wife on his back. He had walked for a number of days and was now only seven miles from the hospital. Deepak told us that when such examples came through the door, even if it was a minor illness he would keep the patient in a couple of days to allow the stretcher bearers time to rest!

The government of Nepal has agreed to provide 40 different medicines free to the public. It is these that the doctors try to prescribe most regularly, to help the patient save money. All medications however, are prescribed by brand rather than generically. I found it very difficult to assist in prescribing, or indeed decipher what had been prescribed as I did not recognise any of the Indian/Nepali brand names. I also found the prescribing of antibiotics very lax, perhaps by necessity. As we were so remote, laboratory tests were of an extremely basic nature, indeed, someone viewed bloods through a microscope. Because of this, sputum tests were very expensive and rarely ordered, so antibiotics were prescribed in enormous amounts.

If someone had diarrhoea, or a chest infection, at least three different antibiotics were used to combat the organism. This of course, introduces resistance and, accompanied with the fact almost 70% had active tuberculosis infection (TB) or latent TB. Recovery from infections was very laboured. Regarding TB – I was very aware of just how prevalent it was in the country. I saw tuberculosis affect many different systems and organs in my time in Nepal. One of the most irritating things about attempting to treat the disease was poor patient education. The hacking and spitting that seems a cultural norm in this part of the world, was not only disgusting and revolting, it also acted

ELEctIVE tALES fROM NEPALJohn Storrow, formerly 5th Year Medical Student, KUMS


as a perfect transmitter of the disease. It seemed futile attempting to treat it!

Taplejung is a very remote place. Kanchenjunga, the world’s third highest mountain, is a five day walk. Tourists only come to this part of the country for the base camp trek and to summit the mountain itself. We were very much seen as outsiders, but were welcomed by the community. The leading causes of morbidity in the area included skin disease, worm infestation,

lower and upper respiratory infections, dental and eye problems, alcoholic liver disease, COPD and hypertension. As many patients had walked many hours/days to get to the hospital, chronic disease management was very difficult to achieve. Hypertension, for example, would be treated off just one high reading. The patient would then be given a one month’s supply of medication and told to return when it was up. The small number that did would then take back enough medication until their next trip. If there was no hypertension on their return, then no check ups would be arranged. It seemed odd to me that everybody wanted to know their blood pressure, even, young people. Everyone was also very curious about their weight; nearly everybody checked their weight on the old scales at the back of the room.

We attempted to learn about the lesser seen diseases in the UK such as worm infestation. We also saw a lot of skin diseases – chickenpox, vitiligo, burns, abscesses, wound infections, etc. Health problems in Nepal seem to be similar to those of the UK though. They have a problem with hypertension and a big problem with alcoholic liver disease (a lot of elderly patients turned up drunk to the outpatient clinics). Indeed the thomba (as mentioned earlier) is seen as a staple diet in this part of the country

and it not uncommonly makes up the majority of a Nepali person’s daily calorific intake.

The emergencies we encountered were mainly involving trauma cases. A lot of people had been involved in motorbike accidents (the road to Taplejung had only been completed a year earlier, and cars were a novelty). One case was a 4-year-old girl who had been knocked down in the road by a motorbike whilst playing. It was a case of hit-and-run, the girl, fortunately did not have any serious injuries. However, the family knew who the driver was and was forming a mob to go to his house and beat him. If a case could not be handled at the hospital then they would be referred to the nearest city – a 10 hour drive away through the dirt roads of the mountains. This also cost 1800 rupees (about a week’s wage).


We were privileged enough to be invited upon a nine day trek to outlying villages to set up free health camps for the more remote parts of the district. We trekked towards Kanchenjunga and over a high mountain pass at 4700m. This allowed me to practise some high altitude medicine and discuss with Deepak, who had undertaken a diploma in mountain medicine, the basics of acute mountain sickness and the principles of treatment. The health camps themselves were a huge success, providing outpatient clinics, dental check up and tooth extraction, eye tests and glasses. I got to see an even more remote area of Nepal, on the Tibetan border and was very honoured to be staying in Sherpa’s houses and was treated with much respect.

Typically, a day would start at 10am with a ward round. They make even the fastest surgical ward rounds in the UK look slow! A lot of it was telling the patients they were treated and discharging them, or asking the patient if they still felt ill – if yes, they stayed in. Hospital treatment was often just an IV infusion of saline of course (the Nepali public believed this was a cure to everything – indeed some members of public would attend once every three months for an infusion as they believed it would improve their health). Then outpatient clinic would start at 11:00 am for three hours, it is a cross between GP and A&E. This was an experience.

A case of 8-10 different patients in a single room crowding around the doctor thrusting their form at him. He would then see one of the patients, whilst the others listened and looked in. Privacy is not really understood in Nepal. If something was even remotely interesting, everybody would come just to look! It was like a conveyor belt, seeing as many as 500 patients in a day between 2 doctors and 3 paramedics. Each patient would be seen in 2-3 minutes. The doctor would ask what was wrong and then either listen to the chest, look at the limb, look at a plain radiographic film (very poor technical quality) and then prescribe as many medications as possible to combat the illness. The day would then effectively be finished, yet the doctors were always on call. There would be a lot of tea consumed (as in the UK). There were no jobs as such to do as there were no

labs, scanners, etc. Discharge summaries took all of a minute to complete. There was a lot of sitting around talking, reading, reflecting and discussing various methods of treating diseases in the UK and Nepal.

As well as the 3-monthly IV infusions, some other beliefs of the remote villagers bemused me. The Sherpa people believed that systemic medications would have no effect upon ailments confined to the limbs. For example, they would refuse diclofenac tablets for osteoarthritis of the knees, insisting instead that they had diclofenac gel, as only that would work. Indeed the strangest thing I saw was a Sherpa refusing to leave the room until the doctor had placed his stethoscope on the Sherpas knee in order to assess just how bad his OA was. The doctor obliged, grinning, just to humour the patient!

In terms of my learning, I learnt a lot. The role nurses play in the healthcare of patients in the UK is vital. There is no such care in Nepal. The families are responsible for feeding the patients, bringing in the customary Dahl baat (rice and vegetable curry that Nepali’s have twice a day) and providing water. The families were also responsible for paying for radiographs (180 rupees – about £1.20) and laboratory tests. The sisters in Taplejung did 6 hourly observations and were there to give medications and alert the paramedics to any rapid deterioration. A role similar to the UK, yet they never seemed as busy! I learnt different methods of treating diseases, also that our treatments of the common chronic disease were very similar.

The Nepali actually use NICE guidance to treat hypertension and COPD as they do not have any guidance of their own! Using the government’s 40 free drugs of course! I also began to appreciate just how hardy the Nepali people are. They put off seeking medical attention until, on many occasions it is too late to treat. Osteoarthritis is a prime example, years of carrying huge loads on their backs has caused advanced OA crippling their knees, yet nothing can be done except for painkillers. This made me appreciate just how easy the public has it in the UK. People complain about a couple of hours waiting time, yet here, people have to walk 5 days just to get to a hospital. I felt very sympathetic towards them,


but they did not need my sympathy, they just got on with life, always with a big smile. There is no patient autonomy in Nepal, it is compliance. The doctor’s word is final and doctors still hold a high social place in the extremely hierarchical Nepali structure.

One thing I was surprised at was the police bringing in prisoners to the hospital daily. Because there are army/police posts in every town, even villages in Nepal, a lot of Nepali people spend an evening in jail as they get in to drunken brawls. Those that do, end up being brought to the outpatient department in the morning for a check up. The doctor records the patient’s ailments and bruises, so that if any brutality goes on in the jail, it can then be used as evidence. We heard stories, however, that because of this, the police generally roughed up the prisoners just after they had arrested them so that the prisoner already had the marks when going to see the doctor and it could not be proven how they had got there.

In conclusion, I had a fantastic elective, from the extremely long journey to Taplejung – being able to see real Nepal and a huge majority of the country, to the time spent with the local community, to the health camp trek and through to being thoroughly immersed in the hospital life. I have no regrets and believe I have learnt a lot and gained a very valuable experience from my time spent in Nepal. It is a simply astonishing country.

Editors note: Apologies to JS for inadvertently missing his article out of the last issue despite having used one of his pictures on the front cover!

The liar’s punishment is not in the least that he is not believed but that he cannot

believe anything else“ “

George Bernard Shaw

[email protected] | 0800 408 3870 | www.netinspire.co.uk


Since I last wrote about the difference that an insulin pump had made to my health and life1 quite a lot has happened. I joined the transplant list, started dialysis and have been lucky enough to have received a kidney transplant. This article describes the effect that these things have had on my life, both positive and negative.

My pump continued to work well and I became more adept at adjusting for different circumstances and foods. With the improved control the patches of necrobiosis, which I’d had for over 20 years, healed completely leaving only scarring. The insertion of a Mirena coil helped to regulate my hormones, reducing the unpredictability in my diabetes even further. All of this helped to prolong the life of my kidneys and delay the start of dialysis by about five years.

dIALYSIS

My kidney function slowly continued to deteriorate meaning that my diet had to become much stricter, making eating out almost impossible. The temptation to cheat was strong but I very quickly realised that it wasn’t worth it as the effect of high potassium made me feel so unwell. The main effect on my life was the fatigue, making everything feel like an effort. This was added to at first by anaemia until I started having erythropoiesis stimulating agent (ESA) treatment and by my Rheumatoid Arthritis (first diagnosed in 2003) which, though controlled by methotrexate, still added to the fatigue. In 2005, I had taken voluntary severance from work and this improved my health for a while as I was able to pace myself more and not become so exhausted.

These effects were all gradual and it is difficult to say when things changed but when my Consultant once more raised the subject of

the operation to insert the Tenkhoff catheter I welcomed it, feeling that I had gone as far as I could without dialysis. The recovery from the operation was very painful and seemed to take a long time. Having a tube coming out of my belly took quite some getting used to. To begin with I couldn’t even look at it but in time it became “normal”.

I didn’t have too much trouble with the training for the APD (automated peritoneal dialysis) machine. Though it seemed daunting at first, the training was excellent and I picked it up quickly. Once at home with the machine I followed the instructions carefully and tried to avoid taking short cuts to minimise the chances if infection. The first night on APD I got no sleep at all, the noise of the machine and the anxiety of the new treatment kept me awake. However, the following night I was so tired that I slept soundly all night and after that had no problem sleeping, with the exception of occasional machine alarms!

Starting dialysis came as a relief as I felt so much better. I still lacked energy but had more than before and so could do more with my life. The dialysis worked very well and before long I was down to only five nights a week on the weakest solution. I have to say that I really looked forward to my nights off! Care was still needed with my diet but it was nowhere near as restrictive and as I avoided things like baked potatoes and other very high potassium foods I could eat relatively normally.

One disadvantage of being on the machine was needing to go to the toilet at night as disconnecting from the machine in middle of night was time consuming, cold and disrupted my sleep. For holidays we took the machine and supplies with us as we stayed in the UK; we simply chose holiday cottages based on size of bedroom and proximity of the bathroom. I

MY JOURNEY tO A kIdNEY tRANSPLANt ANd BEYONdKirsty Mitchell, Patient


needed to buy new clothes to avoid problems with the tube and over time changed almost my whole wardrobe.

I had no major problems with being on dialysis, a slight scare with blood in the line was resolved quickly when it was realised that it was associated with menstruation. The only other problem was with over-granulation after my exit site was caught by a seatbelt.

My remaining kidney function stayed fairly stable, and I just kept pottering along, able to do a little but my energy faded very fast and I would normally be installed in front of the TV by mid afternoon. Having a day out meant a day or two of doing nothing to recover but at least I could now enjoy days out.

tRANSPLANt LISt

I was placed on kidney transplant (waiting) list in early 2009. As I had no potential live donors I knew I was waiting for a cadaveric kidney. Before going on the list I had a number of tests over a period of time, received lots of information and had a visit to Manchester Royal Infirmary to meet the transplant surgical team. Once on the list it was just a matter of monthly blood tests and waiting for the call. My preparations were minimal, I made a note of the numbers of people to contact when I went in to hospital, my husband started saving his annual leave allowance and making sure that his work colleagues were aware of the situation, and I packed a bag – eventually. It didn’t feel completely real for me so I didn’t think about it much, and just got on with life. I was only really reminded of it when other people asked how long I’d been on the list.

The first call came about two and a quarter years after joining the list, and suddenly it was very real and I had to face the fact that it really could happen. I was a back-up and so I stayed at home. Luckily I only had to wait about six hours before being stood down. The second call, about two weeks later, was much the same except it was nearly twelve hours later that I was stood down, by which time I was dehydrated and very hungry. By the third call, which was

seven months later, I had moved up the list and was second in line. This time they needed me to go to the hospital, so off we went and got within a mile of hospital when it was called off. In truth I wasn’t too upset as it had all been a bit of a shock!

When the fourth call came I was much calmer as I was a back-up candidate again and had convinced myself that it wasn’t my turn. We got to the hospital and I had all the blood tests and answered lots of questions and then we were left to wait. I was waiting to be sent home and thinking fondly of a bowl of cereal when suddenly it all changed and it was my turn. Half an hour later I was unconscious and on my way into surgery. For me this was the best way it could have happened as I had no time to worry and so was much calmer than I would otherwise have been.

tRANSPLANt

I woke up after the operation feeling tired but much better than expected and there was little pain. My new kidney had started working immediately and continued to do well from then on. My blood results returned to normal levels very quickly and I was out of hospital after a week. I felt so much better straight away and as soon as I was allowed to get out of bed I was up and about.

The first two months went well as my tablets were adjusted and the doses went gradually down. At the beginning of the third month I developed oral thrush, this got a firm hold despite treatment and I then developed sepsis and was admitted to hospital. I was diagnosed with acute necrotising and ulcerating gingivitis and was on IV antibiotics for two weeks. Whilst in hospital I developed shingles and my white cell count dropped to a very low level. All-in-all it wasn’t a good month. The problem with my white cell count was linked to my immuno-suppressants and I was left on a lower dose, at which level my white cell count remained stable. The main positive in all of this was that my new kidney continued to work well throughout this period of illness.


It is now just over a year since my transplant and things are still going well. I feel so much better, I have lots of energy, I wake up feeling refreshed, and can now walk a few miles. My arthritis is completely suppressed by the immuno-suppressants. I recently graduated with an MSc which I managed to finish off in six months after the previous six and a half years of struggling to do the other half of it. I am now looking to return to work in the near future: having received a kidney transplant I really feel like I’ve got my life back!

REfERENcE

1 Mitchell K My New Life with an Insulin Pump Midlands Medicine (2008) Vol 25 pp136-7

An intellectual is a man who takes more words than necessary to tell more than he knows

Dwight D. Eisenhower

“ “


The North Staffordshire Medical Institute has held an annual Wade Lecture since 1969, the purpose being a lecture for the general public, as an acknowledgement for their support and donations to the Institute. Over the years various speakers from different backgrounds have given an insight into their lives and work. These include such names as Sir Patrick Moore, Lord Lichfield, Stella Rimington, Terry Waite and Frank Gardner to name but a few. Our most recent guest speaker was none other than local Paralympian and ten times Paralympic games gold medallist Lee Pearson.

It seemed fitting, given that Great Britain had hosted both the Olympics and Paralympics, that local lad Lee should be our 2012 speaker. He not only gave an insight to his para-equestrian

discipline (Dressage) but also about the issues and obstacles he has had to overcome with his disability to achieve what he has to this day.For those that are unaware Lee was born with arthrogryposis multiplex congenita a rare non-progressive congenital disorder characterized by multiple joint contractures, muscle weakness, atrophy and fibrosis. Despite this Lee has grown into one of the nation’s most successful sportsmen, not only winning a total of 27 medals at various Paralympics, but also BBC Midlands Sports Personality of the year.

He first came to public attention at the age of six, by which time he had already undergone 15 operations, when Margaret Thatcher carried him up the staircase of 10 Downing Street to receive his 1980 Children of Courage Award.

thE 43Rd wAdE LEctURE: AN EVENINg wIth LEE PEARSONSpencer Smith, Editorial Assistant

Mr D Gough, Chairman of The North Staffs Medical Institute, with Lee Pearson


Since then he has been honoured with an MBE, OBE & CBE.

His recollection of life from his birth at North Staffordshire Hospital, as it was then, to present day sportsman was humorous, heartfelt and inspirational. He spoke about his early days growing up and his parents’ determination to make his life as normal as they possibly could. This included sending him to a mainstream school, not a special needs school. He was very popular at school and became an accomplished horseman back then. His first job was working in a supermarket, sticking prices on jars and tins. However after watching the 1996 Paralympics, held in Atlanta, he discovered the possibilities of a full time career in sport. He won three gold medals in the championship dressage, freestyle dressage and team dressage events at the 2000, 2004 and 2008 summer Paralympics. He won gold in the team dressage event at the 2012 summer Paralympics, silver in the championship dressage and bronze in the freestyle. All the medals that he won at the 2012 Paralympics he brought in to be displayed.

The lecture may have been held on a slightly cold October evening, but the warmth of Lee’s personality and stories certainly entertained the audience and stoked the slowly dying embers of the euphoric afterglow of a very successful Olympic and Paralympic games, both in the way they came together and in terms of the Team GB medal tally, to which Lee made his clear contribution. I, along with the nation, was certainly gripped with Olympic fever! Watching the nail biting 5000m and 10,000m race of Mo Farah, the dramatic Heptathlon win of Jessica Ennis, Andy Murray’s victory, along with the gold medal victory of Greg Rutherford in the long jump, a first for Great Britain since 1964! These along with the other success of our athletes, brought that feel good factor to the nation, that sense of pride which was already in place following the Queens silver jubilee celebrations. It certainly made 2012 a year to remember! And we’re very grateful to Lee for sharing some of that directly with us in the form of the 2012 Wade Lecture.


Congratulations go to the following recipients of 2012 Research Awards from the North Staffordshire Medical Institute:

Dr N Telling and Dr E Cespedes, awarded: £10,000 for:

Magnetic nanodiscs: A new spin on hypothermia

Dr S. Kalra, Prof C. Hawkins and Prof R. Strange, awarded: £9,698 for:

Study of Immuno-genetic Factors Affecting Outcome in Multiple Sclerosis

Dr S Sherman, Mr C Redman, Prof M Murray, Miss P Pearmain, and Mrs P Hadden,awarded £9703 for:

Identifying and promoting best practice in communicating to patients the results of cervical screening history reviews following diagnosis of cervical cancer

L Machin, B Bartlam and Prof J Sim awarded £4,500 for:

Identifying Vulnerability in Grief

The North Staffordshire Medical Institute Medical Student Prizes(Supported by The Bicentenary Fund) were awarded as follows:

The Keele University Medical Student best overall performance in Year 2 – (2011-12) Miss Eleanor Johns The Keele University Medical Student best overall performance in Year 4 OSCE – (2011-12) Miss Laura Davis

Congratulations also to Editorial Board member Kay Stevenson:

Consultant Physiotherapist Kay has been awarded one of only five prestigious Knowledge Mobilisation Fellowships from the National Institute of Health Research (NIHR).

The aim of the fellowship is to ensure that high quality evidence and knowledge are applied in everyday clinical practice to help improve patient care. Kay currently holds an innovative joint post between the NHS and the Institute of Primary Care at Keele, with a focus on supporting evidence-based practice.

AwARd wINNERS


It would be remiss not to record for posterity the end of inpatient services at the North Staffordshire Royal Infirmary.

The last patient moved off site early in the afternoon on 6th December 2012. The last ward to move was Ward 29, the renal ward, which had remained up at the NSRI site in not-so-splendid isolation for over six months together with outpatient haemodialysis units on Wards 31 and 34, and some outpatient facilities for peritoneal dialysis and kidney transplant patients on Ward 26.

The facilities have all relocated to Ward 124, The Haemodialysis Unit and the Kidney Unit which share a purpose-built facility and adjacent refurbished retained estate at the heart of the City General site.

OthER NEwS

Our greatest weakness lies in giving up. The most certain way to succeed is always to

try just one more time

Thomas A. Edison

“ “


The time has come for another entry in my FY1 diary and boy, has this year gone fast! As I write this entry I am in between ranking jobs for my FY2 application and I can’t believe the time has come for this already. It’s difficult to believe that the next time I write I will be an FY2. You know what they say, time flies when you’re having fun!

April signals the changeover of FY1s for the final time. I am currently coming to the end of my four month placement on Obs and Gynae and I can honestly say I’ll be really sad to leave. I’ve thoroughly enjoyed my time there and I’ve got to see and do lots of exciting things. A typical week on O&G is very varied as our days are split in half on the rota meaning we can be on labour ward in the morning and in gynaecology clinic in the afternoon. I have had the privilege of being part of the gynae-oncology team which meant I was fortunate enough to attend the gynae-oncology clinic every week and I also got to spend a lot of time in theatre which I have enjoyed more than I ever thought I would. I will definitely miss O&G but I’m also looking forward to my next job in cardiology.

For me, one of the most difficult parts of being an FY1 is moving onto a new job just as I am settling into a previous job. Four months really isn’t a long time! As is usual for me, I was apprehensive when I started my four month rotation on O&G as I was worried about filling the shoes of my predecessor and I was keen to make a good impression. As I gradually got used to the different elements of the job and learned what was expected of me, my confidence grew and I started to enjoy the job without worrying. I am starting to recognise the same feelings of nervousness now I am due to change onto cardiology but am hoping that once I settle in and learn what is expected of me I will start to feel more comfortable in my job. I think fear of the unknown is the biggest plague for an FY1 doctor!

One of the best parts of being an FY1 doctor at Stoke is being able to see Keele medical students on the wards and help them out where I can. And more importantly it’s great being able to sign their books! I still find it strange that I am allowed to sign off students’ clinical skills and attendance when just one year ago I was in their shoes, begging someone to sign my book for me! I really enjoy being able to interact with students, teaching them and giving advice where I can. As the first Keele cohort we never had the opportunity to speak to anyone who had gone through the Keele course but now it is different for the years below us. It’s really nice to be able to understand what the students are going through and impart advice about how we coped and what kind of things we did to pass the exams. I enjoy having the students around on the ward as I find that most of them are very eager and keen to learn from us. After all they will be the FY1s in no time.

An important lesson I have learnt this year is how to balance my work life with my social life.

JUNIOR dOctOR dIARIESRebekah Mason, FY1 doctor, UHNS


It’s not all work and no play as an FY1 and I was lucky enough to have a week off in January where I went to play on the ski slopes of Bansko in Bulgaria. I had never skied in my life so went to Bulgaria as a complete beginner but I can definitely say it was a very fun and exciting holiday. As part of the package we had six days of ski lessons and were skiing down red runs by the end of the week. It wasn’t the most relaxing holiday I’ve ever been on as we were up at half past seven every day and my muscles have never ached so much in my life! I could barely walk on the third day but what a great work out. I’d definitely recommend Bansko as the skiing there was great.

It’s hard to believe how much has happened in the last year. This time last year I was getting ready to go away on my elective and was anxiously anticipating my birthday as that was the day I found out my exam results. In the last year I have spent two months in Nepal, graduated from medical school, said goodbye to friends, made new friends and begun my career

as a doctor. This just goes to show how quickly time goes and I am expecting the next year to fly by in a blur as well! I’m still thoroughly enjoying my FY1 year at Stoke but the time has come for me to start thinking about what I want to do as a career and where I want to complete my training. There is so much to take into account and I feel I have a very big decision coming my way. First of all I have to choose what I am going to specialise in, as I am currently undecided, and then I have to decide whether I want to stay in the West Midlands or move closer to home and return to the North. This time next year I will have applied for my speciality training and I will already know what job I will be going into in August 2014 and where that will be. But just now that’s all an open road…

Baby: a loud noise at one end and no sense of responsibility at the other “

“Ronald Knox


Yes it is the Edwyn Collins of the early 80s indie band Orange Juice who with that band, and as a solo artist, has released nine albums including Gorgeous George containing the world wide hit ‘A Girl Like You’. Grace Maxwell has been his manager and partner since 1984 and they have a son, Will.

In February 2005 Grace walked through the door expecting that Edwyn would have had dinner ready with The Antiques Roadshow on the television. Instead she smelt burning. She found Edwyn on the floor in front of the sofa semi-conscious, trying, but unable, to speak.

Edwyn suffered two significant intra-cranial haemorrhages. Neurosurgery was undertaken which helped but he subsequently contracted MRSA infection after an operation to replace a piece of skull. He couldn’t read, speak, write, walk, sit up or feed himself. He lost all movement in his right side. He was completely dependent on others for all aspects of daily living and, most devastating, was suffering from aphasia. This book is Grace’s account of Edwyn’s struggle to re-learn what he had lost, from those first days when medical staff were very pessimistic about any chance of his recovery through six agonising months of rehabilitation in hospital, his return home and beyond.

It is an honest as-it-happened account of an experience of healthcare ranging from excellent:“I knew I could leave him ……..This is a measure of how much confidence you can have in the ICU; at least in our experience of it. The NHS at its brilliant best. No slacking, no lapses, the cutting edge. Everything here happened at such a level as to render my interference ludicrous”to poor:

“ But Edwyn is certainly not so safe away from this place [ICU]. And from here on in, I’m back on duty, to keep my eyes and ears open for the inevitable failings and omissions….I would have to watch the staff like a hawk if Edwyn wasn’t to experience unnecessary setbacks. I couldn’t assume they had it under control. On some wards they did, sometimes, on some shifts, but it was scarily inconsistent care”

To the absurd:“….the neurosurgeon came for a look at Edwyn and, looking at the space in his skull, under the skin, where the bone used to be, asked me if I could remember where they had kept the bone flap.”

There is a vivid description of receiving bad news:“The neurologist takes me alone into a side room. What he tells me I absorb silently. And this is what I feel. An explosion. My blood, surging. My skin tingling, pins and needles. My eyes feel like they don’t fit… There is absolutely nothing nasty about this man whom I will never see again. But I still feel a kind of hatred towards him.”

There is poignant brushing up against other people’s stories, brief glimpses of other people’s nightmares, the not being able to say goodbye to the husband of a patient who died after she was moved to a side room, the brief exchanges with room mates who were left behind when Edwyn was moved on, the harrowing description of those elderly people who didn’t have relatives to feed them not being fed by busy staff.

BOOk REVIEw: fALLINg & LAUghINg, thE REStORAtION Of EdwYN cOLLINS BY gRAcE MAxwELLHelen Alcock, Junior Doctor


This is an account of one person’s recovery just as much in spite of the healthcare system as because of it. It is the account of a person with a full time articulate, able-bodied partner with enough financial and personal resources to get the best care from a health service at best stretched and at times completely dysfunctional. This is a recovery facilitated by the best nutrition as all hospital food was refused in favour of deli-bought morsels tailored to Edwyn’s individual needs and later, as mobility allowed, meals at local restaurants. This is the story of a man who was unable to speak but whose partner was able to quickly and accurately assess the relevant chain of command responsible for a delay in his treatment and by threatening the right person in that chain was able to secure treatment for him, even on a Friday afternoon. This is Grace’s story too, of her journey and of the value of well expressed, intelligent, concerned belligerence, and its place in getting the best out of the NHS when it comes to ward care outside the ICU setting.

“I will fight for him, I will protect him. He’s at the mercy of bastards like this for the time being, but they won’t have the final say on his destiny.”

Edwyn went on to make a good recovery regaining much speech and he has taught himself to play the guitar again, to the extent that he can do manage some performance work in addition to song writing. But, understandably, gruelling world tours remain in the past for him.

The terrifying truth that runs through this narrative seems not to be that recovery from a serious brain injury is possible but that it is largely dependent on the ability of your relatives to identify and secure the services and resources that you will need. This book was written before there was any hint of the troubles at Mid-Staffordshire Foundation Trust. In the light of what the Francis reports have brought to our attention, some of the accounts will make for quite disturbing reading, as we realise what has happened to the many who didn’t happen to have a Grace Maxwell on their team. If you remember 80s indie pop, if you are interested in brain injury, if you are interested in Rehabilitation Medicine then this book should be of interest to you. Or if you can’t face reading the Francis reports from cover-to-cover but feel you ought to have a sense of what they’re about, you could do worse than read this book.

Everyone is a genius at least once a year. The real geniuses simply have their bright

ideas closer together

Georg C. Lichtenberg

“ “


Let us set out on this tenth outing with decent intent. Okay, I yield, it’s…

fAt USE

We dealt previously with the grave matter of death1 learning that gravitas [Latin] carried with it the senses of weight/heaviness/pressure. Perhaps it is not a surprise that there are equivalent words in Greek: baros=weight, barys=heavy. The medicalisation of obesity has spawned the surgical discipline of bariatric surgery, the term bariatric being derived from the Greek barys + iatros [physician or healer]. (I guess the term could transliterate as ‘heavy doctor’, but of course it refers to healers of the weighty, who are clearly surgeons.)

We use the other sense of baros, that meaning pressure, when we listen to the weather forecast and hear mention of the atmospheric pressure in millibars. A bar is a unit of pressure equivalent to 100 kPa and is similar to the average atmospheric pressure at sea level (one atmosphere). (Doctors may well be more used to mini bars, but that’s another story.)

Hyperbaric could transliterate as ‘very heavy’ and that would be very close to a translation. Hyperbaric (oxygen) therapy may now refer to therapeutic attempts in difficult-to-treat situations such as multiple sclerosis, necrotising fasciitis, stroke and carbon monoxide poisoning but such uses remain rather contraversial2.

It previously more immediately conjured up the image of decompression chambers for the treatment of the bends (decompression sickness, not the album by Radiohead) a condition of deep sea divers who, from great depth, ascend too rapidly and develop symptoms as the result of nitrogen coming out of solution in the circulation as a series of nitrogen bubble emboli. These divers are literally becoming

internally overblown, inflated. The treatment is recompression in a hyperbaric chamber followed by slow controlled decompression.

The word fat has, unfortunately gained undertones, overtones, associations and connotations of prejudicial insult (“fat and lazy and good for nothing”, possibly particularly resonant in the current political climate). Doctors and other healthcare professionals never wish to come across as insulting but do need to refer to patients who are fat for reasons of illness risks and practical considerations associated with being so. One defence is to calculate a body mass index (BMI) and to point at the number on the chart and then blame the chart for raising the categorisation as:

≥25-29.9 kg/m2 Overweight≥30-35.9 kg/m2 Obese≥35-39.9 kg/m2 Very obese≥40 kg/m2 Morbidly obese

But most practitioners are too concerned to do that and so retreat into the jargon of quoting the BMI itself, allowing the receiver of the information to back translate into the English. I must hand a compliment to a nursing colleague who, with admirable linguistic inventiveness and positive spin worthy of Alistair Campbell, referred to a large patient as a ‘nutritional over-achiever’.

NAME chANgERS

Names have changed names over the years, so although first names used to be Christian names, this is a clear misnomer in our ever multicultural, and not forgetting secular, society. Interestingly bureaucracy sometimes prefers first names to be forenames which has a formal

tENtAtIVE wORdPLAYDominic de Takats, Consultant Nephrologist, UHNS


and perhaps arcane ring to it so helping us to imagine that it’s the name we’ve always used for the first given name, so blinding us to the socially necessary and logically demanded term of first name. Family names may be mistakenly called second names, a term making no distinction between surnames and second given names. Second given names may be erroneously called middle name [as foolish, awkward and familiar as social classes quaintly and wrongly running: upper, middle and working (instead of lower) when possibly those least likely to be employed are those who might consider themselves working class on the scale: natural irony] as it only works out as a middle name if there are three single element names, two given and one surname. This is easily gotten round by allowing middle names to be asked for, rather than just a middle name. So on official forms should we now alliterate first and family name? Or ask for given name and surname? Some blood forms are very direct and ask simply for first name and last name. If they asked for First name and LAST name that would please me more. I’m bemused by the failure of national adoption of the simple expedient of capitalising the surname, particularly given the complete inconsistency of whether the first name is written first and the last name last or the first name written last and the last name written first. You don’t see the problem? Consider the following:

Owen Thomas Howard Micheal Jenny Andrew Charlotte James Livingston Jonathan (Seagull)

Michael GEORGE Jonathan MICHAEL3

Of course the Icelandic system is completely different, yet we have managed to constrain Magnus Magnussen and Björk Guðmundsdóttir to fit our view of how these things should be done, blithely disregarding their largely patronymic system in which girls are ascribed as their father’s daughters using their father’s first name in the designation whilst he, in turn will be designated as his father’s son, first name with first name so we get names the equivalent of Mark John’s son, then Cynthia Mark’s

daughter. Occasionally children are named after their mother’s first name (by permission of the state). What such a system means is that it is more difficult to trace family lines, an exaggerated form of the confusion that women changing their surname on marriage (or not) can sometimes cause for us.

I have disingenuously disregarded the fact that Björk (like Plato, Cher and Sting) is generally known monomously. In case you think this a modern conceit, I should point out that many come from Ancient Greece: Aristotle, Archimedes, Pythagoras and Socrates. The latter is perhaps best known to medical students not so much as an historical figure as a mnemonic for eliciting the further characteristics of pain when taking a history:

S - siteO - onsetC - characterR - radiationA - associationsT - time courseE - exacerbating/relieving factorsS - severity

The Spanish approach to family surnames could challenge us: They are happy to multi-barrel family names to include the four grand parental surnames for the current generation, dropping off earlier generations as and when things get a little too cumbersome (or repetitive in the case of consanguinity).

Not only have our names for names changed but patients also change their actual names with surprising frequency: a study of paediatric surgical patients spanning five years found about a third of children had either their forenames or surnames changed and both names had been changed in just over one per cent of cases.4

NAME thAt thINg

On a ward round after talking with a stroke patient none of us doctors could find the word to describe his word finding difficulties. Dysnomia would cover it (synonyms: nominal aphasia,


anomia). Interestingly, that word claims also to have a place in Greek mythology (from the Greek word Δυσνομία meaning “lawlessness”) and derivatively, in space as a moon of the dwarf planet Eris, officially designated (136199) Eris I Dysnomia. It was discovered in 2005 by Mike Brown and the laser guide star adaptive optics team at the W. M. Keck Observatory.

BLAck ANd whItE ANd REd ALL OVER

What is black and white and red all over? If spoken, the question invites the answer ‘a newspaper’, as written, some might respond ‘a zebra caught by lions’ but the correct answer may be ‘an erythristic badger’. Many of you will know what an erythristic badger is, but for those who don’t, it is a badger heterozygous for melanin pigment so it’s darker patches are lighter than they might be, and with a slight red tinge. Red is an emotional colour, at least a colour associated with emotions. It may connote anger or (just add ‘d’) danger or excitement. It also is very powerful, particularly in the form of freshly spilt (human) blood as it can cause some people to turn white and keel over (capsize). Eskimos have many words for snow; we have a few for red, but they tend to be longer: crimson, vermilion, or refer to red variants: cerise, puce, heliotrope.

The closest medical word to erythristic is erythrocyte which derives from eruthros [Greek=red, Proto-Indo-European=reudh] and kutos [Greek=cell]’ The compound coinage is, however, more modern since the concept of cells as units of structure only originated after explorations using the first microscopes by Robert Hooke in the 17th Century. He studied the structure of cork and other plant materials and was struck by the order, structure and discretely separate places he could discern. This reminded him of monks’ cells in monasteries: small discrete places with distinct boundaries, serving a purpose in a larger three dimensional structure. Monks live not only in ordered surroundings but live in orders. The word ‘order’ is most often encountered in hospitals these days in the phrase ‘Order Comms’, short for Order Communications. This is a rather robust way of referring to the contents of an

electronic system for the transmittal of requests for tests.

So erythrocyte is a conceit of a back translation into a supposed Greek antecedent; the simple English term ‘red cell’ has the advantages of being plain and honest, simple to understand, shorter to say and easier to pronounce.


Dr D de TakatsConsultant NephrologistThe Kidney UnitUniversity Hospital of North StaffordshireNewcastle RoadStoke-on-TrentST4 6QG

REfERENcES

1 de Takats D Word play: free association Midlands Medicine (2009) Vol 25 pp236-8

2 http://drcranton.com/hbo/widelyaccepted.htm

3 Sir Jonathan Michael, first Medical Director of, then, Queen Elizabeth Hospital in Birmingham, now in Oxford: http://shelfordgroup.org/members/sir-jonathan-michael/bio

4 Strong S, Evans K and McNally J The name game BMJ (2012) Vol 345 p45BMJ 2012;344:e3008

OthER SOURcES

Wikipedia

http://www.etymonline.com/abbr.phphttp://www.myetymology.com/


Cross sectional imaging in two middle-aged Caucasian females with ADPCKD are shown. In the upper image, polycystic liver dominates, and the kidneys (outlined) lie relatively more posteriorly, there is little room for other intra-abdominal contents, the anterior abdominal wall is tented and the early satiety this situation causes is strongly reflected in the very small amount of subcutaneous fat. This is more readily appreciated by comparison to the more usual situation seen in the lower image where the kidney cysts predominate, there are only a handful of cysts in the liver and much more room for other intra-abdominal contents and there is a clear reservoir of subcutaneous fat due to normal Western nutrition.

INtEREStINg IMAgES

INdEx tO VOLUME 26

tItLE AUthORS ISSUE PAgE

Primum non nocere de Takats, D Apr-10 5

Audit: Not Just a Simple Cycle Laszlo, P Apr-10 7

Anorexia Nervosa Then and Now Bennett, C Apr-10 9

An Audit of Risk assessment and Risk Management at the Time of Discharge from Acute Mental Health Wards

Bannett, CThorley, H

Apr-10 12

Psychiatry over the Next decade: The Return of Common Sense Gee, M Apr-10 16

The Social Security Appeal tribunal: A brief overview of the role of the Medical Member Thomas, J Apr-10 20

Patient Power in the Potteries Hothersall, T Apr-10 22

Fit for the Future: Modernising Healthcare in North Staffordshire Russell, GAndrews, E

Apr-10 24

Turning Stem Cells into Tendon Forsyth, NR Apr-10 28

The Identification of Genes Contributing to Drug Resistance in Ovarian Cancer Richardson, A Apr-10 30

Medical Student Diaries Mason RHegarty, G

Apr-10 33

Word play Fore! de Takats, D Apr-10 36

CKD Stages Have Their Uses de Takats, D Oct-10 53

Greening Health Services Laszlo, P Oct-10 55

Incorporating Telehealthcare into Everyday Practice Chambers, RO’Connell

Oct-10 57

Map of Medicine in Fit for the Future Davies, JRussell, G

Oct-10 64

Review of Guidelines on Haematuria Walker, S Oct-10 67

Guidelines for non-Visible Haematuria Walker, Sde Takats, D

Oct-10 79

Getting to Know the Clinical Immunology Service Goddard, S Oct-10 82

Getting to Know the CKD Team Reddy, S Oct-10 84


Oct-10 86

My Medical Elective in Stoke Kustermann, A Oct-10 89

Quntiscential Wordplay de Takats, D Oct-10 90

Sharing Resources for Health in England de Takats, D Apr-11 101

Nudge the See-Saw Laszlo, P Apr-11 103

James Bateman and On The Origin of Species Carter, T Apr-11 105

An Illegal Immigrant; a Junior Doctor’s Ethical Dilemma Ahmed, BLR Apr-11 109

Evaluating the anti-Malarial Properties of Synthetic Derivatives of Naturally Occurring Compounds from Traditional Medicinal Plants

Horrocks, PAllin, S

Apr-11 111

Transcriptional Effects of Corticosteroid Therapy on Myelin Genesis and Neuronal Health Chari, DM Apr-11 114

Abstracts from the UHNS Audit and Research Symposium Day Various Apr-11 117

Medical Student Diaries Hegarty, GMason R

Apr-11 122

Six Weeks in Stoke: a Syrian Perspective Haroun, J Apr-11 124

Book Review: So Much for That by Lionel Shriver Alcock, H Apr-11 126

Word play: Sixth up de Takats, D Apr-11 128

Covenants in Healthcare Laszlo, P Oct-11 142

Reflection on Reflection de Takats, DJohn, T Peake, D Farrugia, D

Oct-11 144

How to Pursue a Career in Obstetrics & Gynaecology Clarke, H Oct-11 148

As it happened

Midlands Medicine48


tItLE AUthORS ISSUE PAgE

Making Clinical Commissioning work in North Staffordshire Chambers, R Oct-11 151

WHR Rivers (1864-1922): Conquering the Inner Demons Hands, H Oct-11 157

Review of Serious Incidents Requiring Investigation involving Medicines in 2009-2010 Seal, R Oct-11 163

Case Report: Iatrogenic Overdose of aciclovir with Serious Consequences Chanouzas, DReddy, S

Oct-11 172

Case report and review of literature: Myasthenia Gravis, an Unusual Cause of Abdominal Pain Carter, TSaeed, SAM

Oct-11 174

Medical Student Diaries Mason, RHegarty, G

Oct-11 178

Book Review: Running Free: Breaking Out from Locked-in Syndrome by Kate Allatt and Alison Stokes Khalid, R Oct-11 180

Book Review: The Immortal Life of Henrietta Lacks by Rebecca Skloot Anonymous Oct-11 182

Word play 7: Heptology de Takats, D Oct-11 184

The Autonomy Spectrum Laszlo, P Apr-12 198

Fifty years on: Smoking and Health de Takats, D Apr-12 200

Orthopaedic Stem Cell Therapy at the University Hospital of North Staffordshire: the STEMM project Griffiths, SGupta, S McKinnon,J Carpio, R Griffiths,D Forsyth, N

Apr-12 203

The Potential for use of Breath Analysis in Monitoring Diabetes Mellitus Smith, DSpannel, P Fryer, AA Hanna, F Ferns, GA

Apr-12 208

General or Spinal Anaesthetic in Pelvic Surgery: The GOSIP Study El-Gizawy, Z Apr-12 214

Laboratory Research During Undergraduate Medical Training: A Personal Perspective Devine, O Apr-12 217

Medical Student Diaries Hegarty, GMason, R

Apr-12 219

Book Review: If Wards Could Talk Alcock, H Apr-12 221

Octologos ludus de Takats, D Apr-12 223

Don’t Cry “Wolf!” de Takats, D Oct-12 238

The Place of Clinical Teaching Fellowships in Career Development Cousland, Z Oct-12 241

Green Medicine Is Good Medicine: Practising Sustainable Healthcare Shelton, C Oct-12 243

Evaluation of Green Medicine Teaching Shelton, C Oct-12 248

Mind the Gap: the Art of Replacing Missing Teeth Gibson, C Oct-12 252

Reflection: NHS Health Checks – challenges of delivery and potential solutions for general practice teams in Stoke-on-Trent

Kumar, JChambers, R,Mawby, Y Iqbal, Z Ryder, N

Oct-12 256

The STORM (Staffordshire Trauma Orthopaedic Reduction Machine) Bajgoric, S Oct-12 262

The Development of Major Trauma Services in the North West Midlands Oakley, PNassrally, S

Oct-12 265

How To Get into Specialty Training: A Guide for Medical Students and Foundation Doctors Todiwala, A Oct-12 273

Elective Tales from Peru Williamson, H Oct-12 278

Junior Doctor Diaries Mason, RHegarty, G

Oct-12 281

Book review: Before I go to Sleep by SJ Watson Alcock, H Oct-12 283

Word play 9: Nonentity de Takats, D Oct-12 284


Ordered by first author

tItLE AUthORS dAtE PAgE

An Illegal Immigrant; a Junior Doctor’s Ethical Dilemma Ahmed, BLR Apr-11 109

Book Review: So Much for That by Lionel Shriver Alcock, H Apr-11 126

Book Review: If Wards Could Talk Alcock, H Apr-12 221

Book review: Before I go to Sleep by SJ Watson Alcock, H Oct-12 283

Book Review: The Immortal Life of Henrietta Lacks by Rebecca Skloot Anonymous Oct-11 182

The STORM (Staffordshire Trauma Orthopaedic Reduction Machine) Bajgoric, S Oct-12 262

An Audit of Risk assessment and Risk Management at the Time of Discharge from Acute Mental Health Wards

Bannett, CThorley, H

Apr-10 12

Anorexia Nervosa Then and Now Bennett, C Apr-10 9

James Bateman and On The Origin of Species Carter, T Apr-11 105

Case report and review of literature: Myasthenia Gravis, an Unusual Cause of Abdominal Pain Carter, TSaeed, SAM

Oct-11 174

Incorporating Telehealthcare into Everyday Practice Chambers, RO’Connell

Oct-10 57

Making Clinical Commissioning work in North Staffordshire Chambers, R Oct-11 151

Case Report: Iatrogenic Overdose of aciclovir with Serious Consequences Chanouzas, DReddy, S

Oct-11 172

Transcriptional Effects of Corticosteroid Therapy on Myelin Genesis and Neuronal Health Chari, DM Apr-11 114

How to Pursue a Career in Obstetrics & Gynaecology Clarke, H Oct-11 148

The Place of Clinical Teaching Fellowships in Career Development Cousland, Z Oct-12 241

Map of Medicine in Fit for the Future Davies, JRussell, G

Oct-10 64

Primum non nocere de Takats, D Apr-10 5

Word play Fore! de Takats, D Apr-10 36

CKD Stages Have Their Uses de Takats, D Oct-10 53

Quntiscential Wordplay de Takats, D Oct-10 90

Sharing Resources for Health in England de Takats, D Apr-11 101

Word play: Sixth up de Takats, D Apr-11 128

Reflection on Reflection de Takats, DJohn, T Peake, D Farrugia, D

Oct-11 144

Word play 7: Heptology de Takats, D Oct-11 184

Fifty years on: Smoking and Health de Takats, D Apr-12 200

Octologos ludus de Takats, D Apr-12 223

Don’t Cry “Wolf!” de Takats, D Oct-12 238

Word play 9: Nonentity de Takats, D Oct-12 284

Laboratory Research During Undergraduate Medical Training: A Personal Perspective Devine, O Apr-12 217

General or Spinal Anaesthetic in Pelvic Surgery: The GOSIP Study El-Gizawy, ZCooper, J

Apr-12 214

Turning Stem Cells into Tendon Forsyth, NR Apr-10 28

Psychiatry over the Next decade: The Return of Common Sense Gee, M Apr-10 16

Mind the Gap: the Art of Replacing Missing Teeth Gibson, C Oct-12 252

Getting to Know the Clinical Immunology Service Goddard, S Oct-10 82

Orthopaedic Stem Cell Therapy at the University Hospital of North Staffordshire: the STEMM project Griffiths, SGupta, S McKinnon,J Carpio, R Griffiths,D Forsyth, N

Apr-12 203


tItLE AUthORS dAtE PAgE

WHR Rivers (1864-1922): Conquering the Inner Demons Hands, H Oct-11 157

Six Weeks in Stoke: a Syrian Perspective Haroun, J Apr-11 124

Medical Student Diaries Hegarty, GMason R

Apr-11 122

Medical Student Diaries Hegarty, GMason, R

Apr-12 219

Evaluating the anti-Malarial Properties of Synthetic Derivatives of Naturally Occurring Compounds from Traditional Medicinal Plants

Horrocks, PAllin, S

Apr-11 111

Patient Power in the Potteries Hothersall, T Apr-10 22

Book Review: Running Free: Breaking Out from Locked-in Syndrome by Kate Allatt and Alison Stokes Khalid, R Oct-11 180

Reflection: NHS Health Checks – challenges of delivery and potential solutions for general practice teams in Stoke-on-Trent

Kumar, JChambers,R Mawby, Y Iqbal, Z Ryder, N

Oct-12 256

My Medical Elective in Stoke Kustermann, A Oct-10 89

Audit: Not Just a Simple Cycle Laszlo, P Apr-10 7

Greening Health Services Laszlo, P Oct-10 55

Nudge the See-Saw Laszlo, P Apr-11 103

Covenants in Healthcare Laszlo, P Oct-11 142

The Autonomy Spectrum Laszlo, P Apr-12 198


Apr-10 33


Oct-10 86

Medical Student Diaries Mason, RHegarty, G

Oct-11 178

Junior Doctor Diaries Mason, RHegarty, G

Oct-12 281

The Development of Major Trauma Services in the North West Midlands Oakley, P Oct-12 265

Getting to Know the CKD Team Reddy, S Oct-10 84

The Identification of Genes Contributing to Drug Resistance in Ovarian Cancer Richardson, A Apr-10 30

Fit for the Future: Modernising Healthcare in North Staffordshire Russell, GAndrews, E

Apr-10 24

Review of Serious Incidents Requiring Investigation involving Medicines in 2009-2010 Seal, R Oct-11 163

Green Medicine Is Good Medicine: Practising Sustainable Healthcare Shelton, C Oct-12 243

Evaluation of Green Medicine Teaching Shelton, C Oct-12 248

The Potential for use of Breath Analysis in Monitoring Diabetes Mellitus Smith, DSpannel, P Fryer, AA Hanna, F Ferns, GA

Apr-12 208

The Social Security Appeal tribunal: A brief overview of the role of the Medical Member Thomas, J Apr-10 20

How To Get into Specialty Training: A Guide for Medical Students and Foundation Doctors Todiwala, ANassrally, S

Oct-12 273

Abstracts from the UHNS Audit and Research Symposium Day Various Apr-11 117

Review of Guidelines on Haematuria Walker, S Oct-10 67

Guidelines for non-Visible Haematuria Walker, Sde Takats, D

Oct-10 79

Elective Tales from Peru Williamson, H Oct-12 278

North Staffs Conference Centre

Documents

M I D L A N D S M E D I C I N E - nsmedicalinstitute.co.uknsmedicalinstitute.co.uk/nsmedical/wp-content/... · Drawing of a louse from observations by Robert Hooke (1635-1703) taken