Dyson’s Law and the Medical Registrar: A frontline view

This is a follow-up to Dr Aroras’ earlier blog about the recent legislations surrounding Do Not Resuscitate [DNR] orders. Dr Suthahar, who is a final year geriatric registrar, reflects on the immediate impact of the legislation on the wards and the acute general take.

They say change comes slowly to the NHS… Think of the time it takes for the latest NICE guidance, CQUINs, newest drug or quality measures to filter down to the frontlines of clinical work. However in one stroke Lord Dyson in his landmark ruling on DNR orders and the legal necessity to communicate the DNR order to the patient or family members, has effectively changed clinical practice overnight.

Website Review: www.strokeeducation.co.uk

Website Review: www.strokeeducation.co.uk

Website: Informative/E-learning

Target Audience: Hospital Doctors, Jnr Doctors, GPs, Allied health Professionals, Medical Students, General Public

Validity:  Written by and based around a hyper-acute stroke course run by Dr D O’Kane [Clinical Stroke Lead and Honorary Senior Clinical Lecturer]. It is accompanied by relevant references and a thorough literature review.

Review of the iPhone app for Delirium and Dementia

Dr Sutha Yoganathan reviews the new iPhone app: Confusion: Delirium and Dementia

App type: A mix of E-learning/ Clinical Bedside.

Platform and Costs: Apple, Free

Target Audience: Junior Doctors, GPs, Allied health Professionals, Medical Students, Hospital Doctors

Test Drive: The delirium and dementia app is one of the few clinical apps that have been designed with the UK-NHS inspired approach towards managing the confused patient. Based upon the latest NICE guidelines of their respective subject matter, the app makes a decent stab at tackling what many junior doctors find to be a tricky issue.

Geriatric Registrar training – is there too much G(I)M?

With the advent of Modernising Medical Careers, most medical specialities secured their trainees the option to relinquish General (Internal) Medicine – G(I)M.  Cardiology, gastroenterology, endocrinology, respiratory and rheumatology registrars can opt out to undergo speciality-only training, or specify that only 2 out of the 5 years will include acute G(I)M take.

Geriatrics is now the odd one out. Most geriatric trainees undergo 5 year rotations with very few having speciality-only periods of training.

Is there too much G(I)M?

Debate:- Funding social care for older people- The Gathering Storm

The question of how to best fund care of frailer older people in their latter years remains unresolved. Current rules require all older people with assets above £23,250 to personally fund all care requirements and all assets [including property] are included in financial assessments. The arrangements have been criticised by many for forcing those who have worked hard to build assets through their life to

In the past 13 years there had been two independent commissions, three public consultations and now three white papers. The latest of these, the Dilnot report, called for a system for the elderly whereby there was universal coverage: the total cost of care would be capped at £35,000 with social support for old people extended to those with assets of £100,000, incurring a total estimated cost of £4.2 billion in 2025.

The social care issue is thorny and has multiple facets:-

• Can we afford it? – the present economic climate brings to harsh reality the ability of the welfare state model to provide for all aspects of life on limited resources
• Who should fund it? – the government, families or the third sector
• Universal coverage? – Should any legislation cover all people without any exclusions or prejudice? What happens to those, with financial means, who do not wish to contribute to their own care?
• Financial fairness? – What is “fair”?  Who should pay? How much should they pay?
• Equity of provision across the UK? – How do we minimise variability in how legislation and policies are exercised between regions?

What are your views on funding for long term care? Join the debate.

Phone App Review: Qx Calculate

Qx Calculate

Costs: Free

Devices: iPhone, iPad, BlackBerry and Android

Target Audience: All levels of doctors

Review: Ever needed to calculate a GRACE score in a chest pain patient? Or an eGFR in an elderly patient about to initiate bi-phosphonates?  RANSON score in pancreatitis? This excellent medical app for your phone provides ‘at your fingertips’ access to wide variety of medical risk scores.

The app can be customised to UK laboratory units. All manner of scores from Cardiology to Gastroenterology to Neurology to Cardiac surgery are covered and updated free of charge. This would be an invaluable tool on ward rounds or on an on-call shift in the emergency department. Highly Recommended.

For more details and to download, visit the website.

Opinion:- Manning the barricades

Mass uprisings and a call to arms in the name of democracy and freedom are usually confined to overthrowing unjust dictatorships. Across the globe there have been a series of ‘revolutionary Springs’ and this zeal seems to have spread to an unlikely group :– academic researchers and scientists. As of April 2012, 10,700 researchers have joined a boycott of Elsevier (the biggest publisher of online and academic journals).  Is there accusations of slave labour? A whiff of unethical  animal experiments? Lack of an appropriate Olympic compensation bonus?

The main issue seems to be regarding Open access ie the right to have free access to published research. At first glance, the issue seems trivial. How else would publishing companies re-coup the cost of printing, ink and distribution. Delving deeper, Elsevier made a profit of £768 million on an annual turn-over of £2.1 billion in 2011. So clearly they have not been affected by the global economic downturn.

Geriatricians’ Corner:- Ortho-geriatrics…..A tale of two specialities

Much akin to Charles Dickens’ famous tale of two cities, the orthopaedic bastille has been stormed with the publications of the Blue book and BOAST 1 guidelines. Supported by heavy artillery in the form of the new HRG tariff for hip fractures, the revolution has well and truly begun. Ortho-geriatric services across UK have been transformed and this has catapulted this emerging sub-speciality onto the map. As a trainee, the changes have been marked, radical and at times near miraculous. Orthopaedic junior doctors are actually taking time to document AMTS scores (Abbreviated Mini-Mental Test Score) in the admission clerk-in whilst Ortho-geriatricians are culturing a knack of looking at post-op wounds and prescribing post-op venous thrombo-prophylaxis.

The Regs’ Review:- POPS Course- Guys and St Thomas’ Hospital- March 2012

Overview
A 2 day course covering all aspects of pre-operative issues concerning the older surgical patient. Organised intermittently throughout the year in London(with proper planning can make for a productive long weekend in the capital).

Target Audience
Consultants, Registrars (excellent for the pre-operative bits on the curriculum) , Specialist Nurses and other health professionals involved with surgery and the older patient

Review
An excellent and thought-provoking course which features a diversity of speakers and covers a broad remit of pre-operative issues specific to older patients. From hypertension to cardiac status; high blood sugars to low HB the course tries to answer majority of plausible clinical scenarios that may be encountered in day-to-day clinical practice. Ortho-geriatrics is also featured during the 2 days and as a bonus there are also excellent talks and insights regarding the highs and lows of setting up a new service.

The local Pre-operative service [set-up and championed by Guys and St.Thomas hospital] is also introduced to the audience. The service is highly comprehensive covering both the Pre-operative and Post-operative journey of the older patient. Patients do seem to be managed better and there is greater integration between surgeons and geriatricians.

Overall, this is an excellent course which will leave you better off for having attended.

Value for money:
Priceless as it is the only one of its kind so far.

The Regs’ Review:- Kings’ College Gerontology MSc

http://www.kcl.ac.uk/prospectus/graduate/gerontology

Overview:-  One or two year (part-time) post-graduate programme at Kings College London

Review:- I can’t say how much this course has transformed my approach to geriatrics. It not only built up my knowledge around the biology of Aging, but also about the impending population ageing dilemma and its policy implications with regards to health, social and pension policy. Everything now makes sense(why older patients have to sell their house to fund their care?) and falls into place. The dissertation is tough (I had to touch up mine) but it instils in you a drive and appreciation for good research.  The lecturers and the course programme are well structured. The course is challenging and requires a lot of hard work. Not everyone gets through.  However, it is well worth the time and effort. You won’t regret it.

Value for money:-  Funding options in the forms of Grants are available from various sources (BGS, RSM, Deanery and Kings College itself). Use of study budget may also be feasible in certain deaneries. The course imparts a lot of value-added skills as part of the programme. The essay writing and dissertation are invaluable towards building analytical, critical appraisal and research method skills.  Option available to go on to pursue a Phd or MD. In terms of knowledge and core skills gained this course is priceless.

Insider Tip:- Take a year out of the programme  and do the course full-time. The part-time option is seductive but near impossible once you factor in work commitments. You can easily balance the course-work with the odd day of locum work to pay the mortgage. Doing the course full-time really enables you to work on your dissertation and no distractions from on-calls or nites.