Virgin Care Wins Bath and North East Somerset Adult Services Contract

On the 10th of November, after a long process of meetings between local council members, healthcare union staff and members of the public, Bath and North East Somerset council voted in favour of Virgin Care for its delivery of adult services in the area, rejecting the rival bid from ousted former controllers, Sirona CIC.

B&NES council have given their reasons for preferring Virgin Care for this role, citing their transforming services across the country and positive collaboration with GPs, care centres and charities as two of those at the forefront of the decision.

It is important to note that B&NES has made this decision with deep input from the local Clinical Commissioning Group and community champions over two years, so it is the culmination of a number of differing viewing perspectives and backgrounds.

The vote, which was 35/22 in favour of the Richard Branson-owned healthcare firm, marks the first time a for-profit organisation has been in charge of NHS contracts in the B&NES area. It has been met with vehement opposition from numerous individuals and local organisations since the bid was announced, and the company itself has previously been under scrutiny for its use of tax havens, quality of care, and alleged mistreatment of staff.

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National outlets have lambasted VC in the not too distant past

In 2012, a Dispatches documentary revealed how under-target a Virgin Care centre was regarding Chlamydia screening, exposed a memo asking staff to take test kits home with them, in order to increase the number of screens executed and keep them in line with national targets.

A year later, emergency department medics and the CQC expressed deep concern with practice policy, after a VC-run centre triaged a patient using a receptionist as oppose to a healthcare professional. This proved fatal, but Virgin still defended their actions at a hearing, saying that the patient was appropriately treated.

Despite only being in the market since 2010, Virgin Care currently has NHS contracts worth a reported £1bn, and provides services across the country. It being a Virgin subsidiary and having its head offices in the British Virgin Islands, means it is exempt from corporation tax, but, tax aside, the company has said that all profits made by its B&NES services are to be re-invested into local healthcare delivery. At the same time, however, it has been made clear by the company itself and from other sources that Virgin Care are not looking to make profit from this deal.

Confused yet? I am.

With this deal citing a new precedent in the volume of healthcare services of which Virgin Care have control in the UK, confusion isn’t something that benefits patients, and the majority of middling to major news networks have sensationalised this to the point of farce;

The Canary used the headline “While We’re Still Recoiling from Trump, Branson Quietly Buys up the Biggest Chunk of our NHS…”

Given that this deal has been featured in local and national news for well over a year, spawned public and political backlash (acclaim too, in fairness), and has only now reached a conclusion, the word “quiet” isn’t even slightly appropriate in this case. Headlines such as these only serve to stoke the fire.

In order to try to cut through media Chinese whispers and rhetoric, I spoke to Liberal Democrat Councillor for Oldfield Park, Bath, Will Sandry. Will attended, and was an active part of the B&NES meeting, so I asked him for his thoughts on the deal itself, and what he thinks this means for service users in the Northeast Somerset area.

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Cllr Will Sandry (Lib Dem)

Virgin Care have never had charge of a number of the services, such as social work, which are contained under this Adult Services umbrella. As I see it, this makes service users guinea pigs in this case. Would it be fair to say that this is something of a risky move on B&NES’ part?

It’s fair to describe service users as “guinea pigs” because some of the services have not been provided by a private company before, and a key element of Your Care Your Way is a redesign of services so the services themselves will change during the contact. I don’t think this is “risky” because I have faith that the wellbeing of service users will remain paramount.

During the meeting you were, along with one of your Labour counterparts, in favour of moving for a deferral of the vote so as to further scrutinise numbers you felt didn’t “stack up”, appearing to cite distraction techniques and I quote, “Jedi mind tricks”. What about the numbers and overall proposal sounded alarm bells for you?

In our meeting papers the costs of the services were listed as remaining static for 7 years. I did not have confidence that was achievable. The papers were glossy but had scant financial detail. I had also asked for details of the Virgin Care management team that would deliver the contact, but I could not get a clear answer as to how much of their time would be allocated to delivering the B&NES contact. These are the main reasons I wanted more time for scrutiny.

The most vocal reactions from the public have been almost unanimously negative; a petition, anti-privatisation websites and protest marching, as well as cries of “shame” from those who attended the meeting. We know from recent referenda and elections that small samples of public opinion may not represent the view of the community, so with that in mind, what have you and your colleagues heard from service users on the street?

Apart from the vocal reactions you describe I’ve not had any direct concerns raised by service users. I suspect that the vast majority of people don’t know or mind who delivers their care as long as it remains available to them and free at the point of use.

Conservative councillor Anthony Clarke assured the meeting that Virgin Care were not looking to make profit from this deal. I personally find it strange, and indeed improbable that a for-profit organisation isn’t looking to make a profit from a £700m deal. How is the proposed budget going to monitored and how will it be enforced by the council?

I don’t know, but would presume it will be by the Council’s Health Scrutiny Panel or the B&NES Heath and Wellbeing Board. Profit is an interesting thing. An organisation can have legitimate costs (for example the cost of using the “Virgin” brand) but not record any profits for accounting purposes. I don’t know what (if anything) Virgin Group will be charging Virgin Care for the use of the Virgin brand.

What happens if this figure is exceeded? Comparing news reports from this year, it already appears to have increased by £200m, so how does the council aim to allay concerns and potential indignation that a for-profit organisation (who controversially escape corporation tax) may possibly have a future need to utilise tax payers’ money in order to do its job? 

Savings can also be made by redesigning a service to deliver the same outcomes – this was always the aim of Your Care Your Way. Ultimately if that doesn’t work I imagine that the tax payer (local or national) will pay or there will be a reduction in the levels of service available.

Has anyone shed any light on how Virgin Care plan to reinvest profits that they have assured us they aren’t trying to make?

No

We in healthcare treat patients using a risk:benefit ratio, wherein the potential risks of a treatment should be less than the benefits they could provide in order to make them viable. Given that the issues surrounding Virgin Care’s practices have been documented nationally, were these problems taken into account and considered to be outweighed by the benefits a VC-driven service could provide?

As an opposition Councillor who voted against the deal, this is a question for those who voted in favour of it. In B&NES we have good Heath and Social Care, in part because we don’t play a political game over it. Nobody would thank us for that. If it could have been proven to me that the deal was the best for our residents I would have supported it despite any personal political concerns about privatisation. Let’s hope it is a good deal for service users, but I could not be convinced about the finances of it.

Finally, Will, our whole healthcare system hinges on its patient-centred approach. Given the vote for Virgin Care, despite the vocal opposition to it, it can be logically assumed that the majority of the council feel it will bring about positive changes. What sort of changes can service users expect to see under Virgin Care? What has been proposed that betters the existing system?

I can’t speak for those who voted for the deal, but it is logical to assume they did feel it would bring about positive changes. The contact is too big to list what specific changes might be made, but I imagine any changes will attempt to keep the same beneficial outcome for service users while reducing costs.

These represent the thoughts and opinions of Cllr Sandry himself, and are not necessarily indicative of those held by his associates, or by Bath and North East Somerset Council

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Fitbit’s Familiarity with Class Action Lawsuits

Fitbit, the wearable fitness tracker, has gone from strength to strength since its launch. The company recorded a record $1.858 billion (!) in revenue at the close of the 2015 financial year, and, due to its affordable price tag, everyone from we regular folk, to soon-to-be ex-P.O.T.U.S. Barak Obama can be seen wearing one. That said, Fitbit are known to court controversy; in 2015, it was suggested that the advertised “sleep-tracker” in the company’s Flex model was inaccurate, and over-logged sleep. This case is still ongoing, but it is important to note that it is not suggesting negligence with regards to health; rather that the product itself was falsely advertised. It remains to be seen how this case will play out, but as if that wasn’t enough, at the beginning of the year, a multiple-plaintiff class action lawsuit was filed, with a study showing evidence that Fitbit’s PurePulse technology was woefully inaccurate during exertion.

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The study, performed by a team at California State Polytechnic, compared exertional heart rates acquired via the wearable device and from an ECG. After exercising 43 individuals for 65 minutes, it was noted that the various Fitbit models displayed a heart rate that differed by up to 22bpm compared to that on the ECG, and that some didn’t display a heart rate at all.

According to the study’s team, there exists a distinct lack of rigorous, scientific testing in the wearables market (this is further suggested by lawsuits filed against other, similar product developers), but Fitbit have dismissed both this statement and the study itself, citing bias and, perhaps humorously for reasons I shall soon disclose, a lack of scientific methodology. Fitbit have stated that they perform extensive testing during development, and have pointed towards another study which purports to have found PurePulse products to be highly accurate, although it is important to note that this particular study tested a sample size of two (yes… two).

Wearable devices aren’t anything new, but with technological advances, they are no longer being seen as simply fitness trackers and companies are exploring their application in healthcare. As this gains further traction, accuracy will be incredibly important. In fact, one of the plaintiffs in this case, an 82 year old woman, has alleged that her device underestimated her heart rate by such a margin, that were she to have tried to reach her supposed target heart rate, she would have likely done serious damage to her health, so it is already having a potential impact.

The company’s financial growth since the launch of this generation of devices is thought to be largely due to PurePulse, what with it being the most heavily marketed new feature, so Fitbit’s request that the case be dismissed has last week been denied. Judge Susan Illston has decided that the plaintiffs case has sufficient merit, with regard to fraudulent claims about Fitbit’s accuracy, so it will be considered in court. This does not necessarily give an indication as to the outcome, however.

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The Royal National Hospital for Rheumatic Diseases: History and Bath Medical Museum

I must have walked past this building thousands of times over the years. I’d always admired its exterior, whose 18th century aesthetic still fits perfectly with the rest of Bath’s modernised Georgian motif. The stonework might be slightly mottled and tarnished by years of pollution, and its being surrounded by coffee shops and high-end clothing outlets *almost* detracts from the majesty the building exudes, but the Royal National Hospital for Rheumatic Diseases, nestled right in the North Somerset city’s centre still looks beautiful. I remember the public outcry when it was announced that a large chunk of the building had been sold, and subsequently leased to a novelty Mexican food chain; this building is a part of this city, not just for the patients treated within it, but for all of the residents of Bath.

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Despite admiring it from the outside, I’d never consciously considered its interior. I’m not sure how many people actually have, to be honest; those I questioned had either never looked past the front doors, or had simply “heard it was quite nice” through the grapevine. I recently had the opportunity to begin to learn echocardiography at the RNHRD in Bath, and whilst I was waiting for my superiors to arrive I decided to have a look around, as it was clear from stepping through the front doors that it was a building steeped in history.

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The main foyer is rather breathtaking: the original marble floors are still a prominent feature just past the reception area, paintings, such as that which is the header on this article adorn the walls and connecting the ground and first floors are beautiful, finished wood staircases that look like something out of Disney castle. I had to stop for a moment just to take it all in. Having spent a fair amount of time in hospitals, I had assumed that they (for all intents and purposes) look pretty similar; white walls, long corridors with small, commissioned pieces of generic mixed media/ abstract work hung at eye level along them, and that style of lino flooring that evokes memories of the school gymnasium, squeaking underfoot at the slightest hint of moisture on one’s shoes. Now, I’m not saying this is a bad thing (far from it), but the RNHRD has a unique character. It has charm and detail that I’ve only found in stately homes and upscale galleries. It also has history to rival these places.

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Frances MacDonald, 1949

The funding for the hospital was procured predominantly via a public subscription set up by Richard (Beau) Nash in 1732. Names such as Lord Palmerston, Mr Jeremiah Pierce, and Dr William Oliver are listed as donors, as well as other local and national figures, and as a result of their capital, the building, constructed as a hospital for the sick poor opened in 1742. Built using stone gifted by local legend Ralph Allen, the then Bath General Infirmary was the first hospital to offer treatment to the entire UK, leading many to view it as a foundation of the National Health Service devised in 1948.

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Locals, or those fond of UK trivia will likely already be aware of the hot springs on which Bath sits, and these were utilised in the hospital for therapeutic purposes (interestingly, Bathonians were, for a time at least, not permitted to become patients of the Infirmary, presumably because they as residents, already had a right of access to the spring waters), and these were made available to patients on condition that a fee be paid upon admission. For English patients, this was around £1.50, which later became £3, and for those from Scotland and Ireland, £3, which became £5. These sums were either paid for by the patients themselves, or on their behalf by wealthy benefactors, and covered the cost of treatment and the return home, or, in the worst case, mortality and the subsequent burial arrangements.

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Patient sedan chair

 

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A brass badge, worn by a patient whilst under hospital care

Patients were taken to the bath sites via hospital sedan chairs (designed by surgeon Archibald Cleland, subsequently dismissed for improper conduct in 1743), and impelled to wear brass badges that both identified the patient number and their ward, and to prevent drunkenness whilst out of the hospital grounds. Local landlords were forbidden from serving alcohol to patients, as it was detrimental to their recovery. Failure to adhere to this rule would have risked their licence, so it was likely seldom flouted.

The hospital was initially far smaller than its current size, with new wings and blocks being added throughout the years, including the top floor in 1793 (costing £900), renovation efforts and the implementation of additional units continuing well into the tail-end of the last century.

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The Roman pavement, discovered in 1859

When the building was being extended in the late 1850’s, a Roman pavement was discovered during the foundation digging. It is dated as hailing from between AD60 and AD410 and is still in place at the bottom of the stairs to the basement level. The mosaic is still part of a larger floor and runs underneath much of the building itself.

Given the tenure of the building within the city, it has seen its fair share of conflict; as well as being used to treat the wounded during the Jacobite Rebellion, the Crimean War, South African War and both World Wars I and II, it suffered damage due to ordinance during the latter conflict in 1942 wherein it received a direct hit. Despite this, however, the roughly 200 patients still within the confines of the hospital were uninjured.

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Damage to the RNHRD in 1942

As far as treatment goes, the hospital has been a specialist rheumatology centre since it opened, and continues to operate as such. It offers treatments for pain management, chronic fatigue and utilises hydrotherapy as it did when it was concieved. It also functions as a research centre in these areas, encompassing both in-house studies and those of a more national variety. In addition, and I feel rather interestingly given its history with servicepersons, the centre offers specialist support to ex-military personnel, regardless of the time of onset of condition, and provides pain-management and post amputation complication therapy amongst other things.

Royal Patrons have presided over the RNHRD since its foundation, with the current President being Camilla, Duchess of Cornwall, who has been in the position since 2006. The first, in 1745, was Frederick, Prince of Wales. In 1991, the RNHRD became an NHS Trust, and was upgraded to an NHS Foundation Trust in 2005. In February 2015, the hospital was acquired by the Royal United Hospital (RUH), Bath, which now manage the centre.

The Royal National Hospital for Rheumatic Diseases truly is a wonderful hospital, and the patients who use its services do so over a number of years,  crediting it with a “family feel”. Whilst researching this article, I spoke to a volunteer at the hospital, who told me of her time as a patient, both in and out, and her desire to provide a friendly ear to current service users. She told me that volunteers had relaxed her when she herself needed the hospital’s facilities, and it was that, combined with the care she was provided that inspired her to give back to the trust.

The family feel of the RNHRD was in jeopardy whilst the hospital was under considerable financial strain, but its acquisition by the RUH allowed it to continue to function with only minimal service absorption by the Royal United. This continued service will surely help the current patient base, and will enable the hospital to remain the part of the city that it has been since its conception.

 

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This flag hangs over the museum, and was made to celebrate the 250th anniversary of the RNHRD.

 

Rather wonderfully, the hospital contains a museum, situated in the chapel, which outlines the history of the building and the staff and patients who have used it throughout the years. Many of the photographs found in this article were taken in the museum, and it’s full of information about the building and its history; well worth a visit if you’re in the area!

Thanks to the museum staff at the RNHRD for taking the time to talk to me and allow me to take photographs. Without them, I wouldn’t have been able to write this article.

If you’re eager to explore more, head over to Medical Heritage or visit the RNHRD homepage, and if you’re local to Bath, then be sure to drop into the Bath Medical Museum, situated within the RNHRD.


 

SCST Diploma Day: A Reflection

Myself and OliGS recently sat the SCST Electrocardiography Diploma and Practical Examination, so I thought I’d jot down some of my experiences in the run up, and my retrospective thoughts on the day itself.

If you’re thinking of doing it, or have your PTP finals looming, then read on, as this will give you an idea of what to expect.

I’ll start by saying this: Oli and I have NEVER been so stressed in our entire lives.

This exam was a nightmare for which to prepare; I have extensive experience in taking exams, and it is my view that they’re 50% what you know, and 50% what the examiners want you to tell them. Without having met these examiners or seen a previous paper, it was very difficult to know what to really nail, in the revision stage. The syllabus was long, detailed, and contained what seemed like an entire career’s-worth of things to learn, so we already knew it was going to be a slog, but nothing prepared us for the written paper…

Read these. Lots.

We studied, sometimes sleeplessly, for weeks. Tested each other on rare arrhythmias, read textbooks cover-to-cover (repeatedly), and watched each other’s once sunny outlooks and youthful (ahem) features rapidly wither as the examination date draw closer. It consisted of 20 multiple choice questions, 10 arrhythmia analysis and knowledge questions, and 4 full ECG analysis recordings. Some of these were almost instantly recognisable, but others were brutally difficult to analyse. The MCQs (often the most looked-forward to section of any exam) were equally tough. Those 3 hours lasted a lifetime…

We left the exam battered and bruised, but glad it was over.

But it wasn’t over. It was far from over. As well as the written paper that had almost ruined us, we had the practical exam to do as well.

We had made sure that during our post-ECG placements we still got ourselves in the clinic so as to keep everything fresh, as performing a perfect ECG is not like riding a bicycle.

 

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The last attempt before test day

It turns out that this was the correct call, as was practicing on one another in the hotel the evening before the exam; the margin for error in the exam is 2mm(!) Anyone who’s had an informal assessment, or had their Direct Observed Practice scrutinised whilst training knows that it’s very easy to second-guess when it comes to electrode placement, and despite having 20 minutes to complete the whole thing, this timeframe becomes devastatingly short once you’re in there. It’s a clinical assessment, so one needs to complete the necessary ID checks, explain the procedure to the patient AND to the examiners (i.e. in two different ways), perform it whist answering questions, and then complete a verbal examination.

Three hours after we had finished the written paper, we were called to attempt our practical exam. There were ashen faces all around. Some were on those still waiting for their number to be called as ours had just been, others had been told that their 2 attempts had been unsuccessful. Neither of us were looking forward to this. Now, given that I’ve already stated that each electrode is allowed to deviate only 2mm from the precise, gold standard location, the internet-purchased electrodes pictured in the above image would be somewhat unfair, right? It seems that the examination board concur, as they provide some rather cool, transparent electrodes complete with crosshairs. They doesn’t make it easier, per se, but they certainly go some way eliminate that lingering trepidation when it comes to deciding you’re happy with your placement and ready for judgement.

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Crosshair emblazoned electrodes(!)

I opted for the “all at once” technique: I explained everything to the patient before I started, gained consent, then explained everything I was doing as I went along. Once was put simply to the patient, then once to the examiners, using correct terminology. I paid extra special attention to V1, V2 and V4, as my patient had a particularly wide sternum, so I wanted to be totally sure that I had the sternal border, especially given the electrodes were rather far apart when placed and looked slightly odd to me. After I took a step back and looked at my work, I was incredibly tempted to move the aforementioned electrodes, but either due to fear, fatigue, or a combination of the two, I decided to leave them as they were, opting to go with my initial judgement. After that, I waited.

I’m not entirely sure how the placements are measured, as candidates are asked to leave the room whilst they are checked by two examiners. I heard someone mentioning special rulers, but I didn’t get a look at them (it’s all very cloak and dagger), in any event, you’re called back into the room and, in my case at least, informed of your passing or failing grade. I’m pleased to report that I passed on the first attempt, which as I’m sure you can imagine, was a tremendous relief; I lost my cool somewhat, and expressed my joy rather loudly, as I was informed I wouldn’t have to do it again. Oli soon found me in the waiting area and, grinning wildly, slapped me on the back and hissed “YESSSSS!” before promptly throwing himself into a chair. It was over, and we were victorious.

We didn’t speak too much about it, on the way home, but in the couple of days that have passed since the exam, we both feel a tremendous sense of pride that we actually did it, and did it successfully. If I were to give you all some advice, it would be the following:

  1. Be prepared for anything and everything, including waiting around for a long while
  2. Practice analysing ECGs until you hate them
  3. Practice performing ECGs until you hate them
  4. Go with your gut as much as you can during the practical exam
  5. Bring lunch
  6. Don’t under ANY circumstances, stay at the Ibis Hotel in Birmingham’s Chinatown district (I can’t stress this enough because it backs onto a nightclub that doesn’t stop playing the most bass-heavy music until the wee hours of the morning)

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7 Epic Fails to Avoid During Your Medical Fellowship

by Robin Dale

A cardiology fellowship will give you the opportunity to be fully prepared for the field and can go as long as four years. It will help you to hone your clinical skills and have cutting edge skills in surgery. A mix of research, public lectures, clinical experience, and classroom-based learning all combined enable one to be very well versed in the field at hand. Fellowships in Cardiology range from Cardiac Surgery Training, Cardiac Critical Care and Paediatric Cardiology, Vascular and Interventional Radiology, and Vascular Surgery and Endovascular Therapy Fellowships.

Several institutions offer what are considered the best Cardiology Fellowship Programs. To choose and get accepted into the best cardiology fellowships programs successfully, requires much more than an exceptional personal statement; applying to a residency, especially a cardiology one, is challenging and requires a lot of work. The existing places for such mentorships are extremely limited and contested, so you have an obligation to be unique and to stand out in order to be accepted.

Your cardiology fellowship personal statement is an opportunity whereby you can say why you feel you are the most deserving of being enrolled in the program. Elevating yourself above the bar will determine whether you are accepted or rejected. Here you will find the help to writing a personal statement for fellowship in cardiology, as well as some dos and don’ts.

Fellowship goes above and beyond a good resume. A good resume can only go a long way. You can be the most qualified and have the best CV, but this will not guarantee you a spot in the fellowship program. As a candidate, do research on your options, enhance your exposure on volunteer work, conduct clinical research projects, and get publications.  Ensure that you have filled the gaps in your resume and took the time to address all of them practically. Most candidates limit their options depending on where the hospitals are situated. This approach is detrimental, however, and prevents them from having a varied list and therefore options pertaining to the top-notch institutions. As a candidate, you can polish up your resume with a clearly defined and well put together personal statement.

The AMA or the American College of Physicians. Most candidates are not part of any corporate entity that advocates for their medical practice. With the continuous cutting of funds in the national budget, it is getting harder and harder to provide any services. This, in turn, has reduced the number of applicants able to be accepted and therefore numerous candidates find themselves being turned down. Joining the AMA will help you get a fair trial and increase your chances of getting approved.

Application to highly competent residency. Programs in radiology, dermatology and cardiology are highly competitive, and the stakes are high. Some of these students’ performances in their former medical school are usually not up to standard and sometimes place few schools on their ranking list.

Expansion of classification list. Students tend to limit their options and apply to a few residency programs. However, it is encouraged that a student lists down at least five hospitals to increase their chances of getting accepted. These choices can either be within their chosen specialty or even selecting a different specialty.

Transitional slot. A student can contact their medical school and ask for an interim slot or see a research fellowship. With this, the candidate will be able to become more competitive in the field and increase their chances of approval. An additional degree is also a supplement to a candidate’s resume and consideration.

Ill-preparedness. Two or more years of postdoctoral training whereby there is formal coursework in the fundamental sciences pertinent to the investigator’s area of expertise; this increased chances of attaining a fellowship.

Medical residency interview. It’s like a pass mark for all residents. Most programs won’t absorb candidates they have not interviewed. It is crucial that you take this interview seriously as it will not only determine if you will get accepted but also where you will get accepted.


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Robin Dale is a junior doctor and her passion is guest post writing. She is fond of writing useful posts for students to make their learning lives easier and more effective. Her own life credo is “Keep calm, study hard, and become a doctor”.

 

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TSP Mobile: ECG

EDIT: The Android version of TSP Mobile: ECG is available for download, but due to the way in which Google Play operates, I have been unable to offer it for free. The iOS version, when available, will be gratis for the promised 14 days however. Still no word from Apple when that will be, but I have been assured that it is being vetted as I type this, so fingers crossed!

Original article follows:

Well, that TSP mobile app I promised…

I’ve been saying I’d do it for months and, despite remaining fairly quiet with information about starting, I actually have been working on it. So much so, in fact, that the bulk of the development is finished! It’s in final stages of testing, after which it will be available on the Google Play and iOS app stores, where it will be free for the first two weeks of release, so please download it and leave some constructive feedback and a review.

The app features tutorials on ECG analysis, exercise and ambulatory ECG, cardiac flow and cycles, action potentials and useful formulae for trace analysis. Each section is laid out in an easy to follow format, with colourful diagrams and both real and illustrated ECG traces.

Heart rate and QTc calculators are included to aid analysis without leaving the app, and also access to the website blog, so you need never miss an update.

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I hate advertisements in apps, so in order to keep TSP mobile ad-free, I will charge £1 to download it after these introductory 14 days are over. In an ideal scenario, I would keep it completely free, but it has been, and continues to be, a rather expensive endeavour from both a chronological and economical standpoint especially for my shallow, student pockets, so I hope you understand why I have decided to charge.

Stay tuned to TSP via site, Twitter or email for a release date. It’s very soon!

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Ethical Implications of Switching Off a Pacemaker

On the 24th of September, the BBC reported the story Nina Adamowicz. Nina, a 72 year old lady with an Implantable Pulse Generator (IPG) who, after having the device for almost 20 years, has requested it be switched off.

After suffering a minor infarct, Adamowicz had said that her continued deteriorating health became too much to bear, said she felt like she was waiting in line to be executed, so she requested her device be switched off. She is reported as stating “It isn’t about ‘I want to die’; I’m dying”.

Her case was referred to her local trust’s ethics committee, who, after careful deliberation decided to proceed in line with the wishes of Mrs Adamowicz.

Before passing away on the same night that her device was switched off, Nina Adamowicz stated that she believed she had the right to decide whether or not she wanted the IPG on or off, and stood by her decision.

This case is thought to be the first of its kind in the UK, but Chicago device specialist Dr Westby Fisher professes to doing this exact thing on a dozen separate occasions. Westby considers the ceased action of an implantable device to removing a feeding tube, or switching off a ventilator.

In particular, in a piece for massdevice.com, Fisher tells of a patient who refused dialysis, saying he’d rather let nature take its course. The patient, who also had an IPG, requested that this was switched off, so Westby agreed, and the next day switched off tachyarrhythmia detection on the device. Fisher says that he feels that both he and his patient did the right thing, together.

I for one, am confused as to the ethical pathway involved in coming to both this decision, and that of the ethics committee associated with Nina Adamowicz.. Assisted suicide is complex, but with respect to these scenarios, is defined as the intentional encouragement or assistance to a patient in ending their own life and it is still illegal under the 1961 Suicide Act of UK law . A medic who administers an overdose of muscle relaxants to a patient whose condition is diagnosed as being terminal, even at the behest of that patient, would be punishable by UK law with manslaughter or murder and potentially serve the maximum terms associated with each.

Why then, is hitting the off switch on a pacemaker not considered to be comparable to the example given previously? Patients with implantable devices often have them to combat life-threatening arrhythmias, so in turning them off, this can effectively issue a death sentence to that patient.  I’m not arguing for or against any form of assisted death; I neither understand its intricacies or feel it is my place to denounce or advocate something with which I have had precisely zero experience, I’m simply confused as to why an immediate form of assisted dying is outlawed, and something so similar (on the surface at least), is not. Adamowicz’ clinician has said that other professionals are split in their opinion on his decision, with some feeling it to be “uncomfortably close to euthanasia”.

Is it fair to patients with terminal diagnoses that are forced to travel to countries such as Switzerland, wherein some forms of euthanasia are legal, simply because they do not have an IPG? Does the severity of the condition have any part to play? How similar do individual cases have to be so as to render one illegal and another not so? I have a feeling that this case will spark long debate throughout the medical and legal professions in the UK, and will follow its progress closely.

BBC article

Westby Fisher’s blog

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The Power of Social Media Influence

Like it or loathe it, social media is pretty much inescapable. It’s used by your family, friends, and increasingly by institutions and corporate entities to connect and share ideas, market and promote. Statista puts worldwide social media usage at 2.22 billion people, so it’s no surprise that it has been utilised, and continues to be, to the extent to which we are now accustomed.

It’s been proved that it’s possible to connect with all kinds of people using social platforms, so why should the resource fall solely into the hands of multi-million dollar companies like Coca-Cola and McDonalds, for whom advertising is merely a formality, as oppose to a make-or-break necessity?

Perhaps it needn’t.

Due to the fairly self-regulating nature of some of healthcare’s more specialised areas, the burden falls predominantly on us to showcase innovations and engage with patients, prospective students and fellow professionals. Networking tools like LinkedIn are already being used to connect professionals, even from physiology backgrounds. This platform is relatively self-serving, being a predominantly business to business niche, but according to current statistics it has seen a rise in use to over 60 million views per month in 2016, so is undeniably a great tool to use for quick networking with other like-minded individuals.

Of course, social media can be used to network with everyone, not just our own, so, in the same way that we utilise more than one test to make a diagnosis, we should be using the whole spectrum of tools in this instance, shouldn’t we? Facebook (1.6 billion users worldwide) and Twitter (325 million)  usage polls would suggest that users are logging on for a surprisingly narrow selection of reasons. 68% (Twitter) and 65% (Facebook) of users state that they log on to keep abreast of the latest news relevant to themselves, and 63% and 48% of Twitter and Facebook users respectively, use the platforms to receive information relevant to their personal interests. These present huge, potentially untapped resources for healthcare professionals, that can be used to promote transparency and trust, gain feedback and keep colleagues and patients informed.

I’ve mentioned before, the relatively unknown nature of physiology as a profession, so I think that taking hold of the opportunities available on Twitter, and other forms of social media could be something that could benefit physiological science. One of my favourite online healthcare personalities is Mr Olivier Branford, a plastic surgeon in London. He advocates education as a resource that should be available to all, and public engagement as a high priority. Olivier has over 62.1k followers and uses Twitter to provide news relevant to his specialism, and to wider healthcare in general. I conversed with him about the use of social media as a free platform to provide evidence, studies, inspiration and information to students, prospective students and patients everywhere, and we both agreed that it was the perfect resource to utilise. We aren’t alone, however; Olivier ran a telling informal poll, the results of which I have displayed below, enquiring as to what other users believed was the best way for plastic surgeons to use social media, and I feel that the words “plastic surgeon” can be substituted for any within the health service with a similar outcome. As you can no doubt see; despite the unscientific nature of the evidence, the percentages speak for themselves.

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Whilst it would be incorrect to state that healthcare organisations have no presence on social media, they don’t dominate in the same way that more commercial entities do, at least not in the UK. That doesn’t necessarily mean that it is a lost cause, however. Mr Branford has provided a personal touch that corporate entities cannot emulate; his approach of “evidence not opinion” when dealing with healthcare information, is complimented by his willingness to offer an opinion when it’s relevant, on top of the facts. This transparency is refreshing, and, in conjunction with his professional accolades, is surely something that has aided him in gaining  over 62.1k people who want to listen to what he has to say. The cardiac physiology profession is notoriously under-staffed, and whilst the numbers of applicants is on the increase, a quick visit to various college forums shows that the ins and outs of the career are still lost on many students (if you can find a discussion at all). The general career pathways and the salaries seem to be known to these confused individuals, but the actual job is what nobody has much of an idea about. How are we to persuade these potential cardiac scientists to sign up if they don’t know what they’ll be doing for the rest of their professional lives? Asking someone to commit their future to a career and saddle themselves with increasing debt when they don’t really have a great deal of information readily available to them is a far cry from the informed consent we strive to gain from our patients. Taking responsibility, and putting some research into one’s own future is obviously something everyone has to get used to, but I’m sure most people remember how overwhelming that was, so the shortage of new staff members must be more complicated than students simply not looking hard enough. Besides which, it SHOULDN’T be so difficult to find this career..! I’ve got a year to go until I qualify, and I’ve met some truly inspiring people whom, if I wasn’t already on my way, I know could easily convince me to start. We find what we do fascinating, so surely some of these young minds will be just as invested if they have the chance to see it for themselves.

SocMed by age

The Pew Research Centre provides data that places 16-24 year olds as the most avid users of social media (above), and displays a steady growth of users across all age groups year-on-year since 2005, so with a collective effort, it surely wouldn’t be too difficult to a) entice some of these users who are in the middle of their A-Levels, and unsure of which healthcare profession is for them, and b) come together as a profession in a more open and approachable manner to showcase our science and how much of an impact we have on medical diagnostics.

Olivier Branford is a plastic surgeon and associate editor of PRS Global Open journal, and can be found on Twitter under his eponymous handle @OlivierBranford.

Social media statistics obtained from The Pew Research Centre, Statista & Visually

Heart

Review: Epicardio Simulation v1.5 (Full Version)

Download for Windows/OSX:

  • Trial (Free)
  • Paid (£149-£215)
  • 60% discount for full-time students

Developer: Epicardio.Ltd

After my review of the temporary access trial of Epicardio Simulation (which offered a great deal of praise, I might add) I couldn’t wait to have a look at the full version’s features. I still can’t afford it yet even with the 60% discount offered to full-time students, but thankfully, the good people at Epicardio.Ltd allowed me to access the complete package so that I could review it. As I’ve already covered some of the functions of the program, I won’t re-tread old ground, but you can check out what I thought of the trial version here, and consider this a continuation of those original opinions.

So, what functionality is offered by the full version? Let’s go over it now.

The previously-unavailable tutorial section has some marvellous interactive elements; a view of the electrical action and a live ECG accompany the written tutorial pages, allowing the user to view the very thing they’re reading about in real-time. The procedurally generated ECGs are very accurate (I’ve measured them), but if you want to see a genuine patient-obtained trace recording, then one is included with each arrhythmia, too, which really helps with comparisons to the actual recordings one is likely to find in practice.

Almost everything you can think of is covered in some capacity, both on its own, and linked with other, relevant arrhythmias, so you really get a feel for just how interwoven some conduction and rhythm abnormalities can be.

A marvellous inclusion is the level of interactivity within the tutorials; degradation from VT to VF, for instance, is displayed live on the ECG strip and the defibrillator (that I didn’t really have cause to use in the trial version) can be charged, and a shock administered, altering the rhythm strip as it would a real patient.

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The pacing tutorials are easy to use and easy to follow; they walk you through the physics of single and dual chamber, as well as biventricular pacing. In using them to learn the basics of pacing, I can appreciate how effective the arrhythmia sections are and how useful they would have been during the early days of my studies. The interactivity of the aformentioned tutorials remains, too. Placing a pacing wire in different sites allows the user to view live rhythm changes, and sensitivity, HR and pacing rate can be toyed with so as to identify intrinsic rates and pre-pacemaker abnormalities such as 3rd° AV Block on the real-time trace.

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The test area throws generated ECGs at the student, and offers multiple answers from which to choose. Much like any degree-worthy multiple choice test, they range from incredibly easy to downright tricky, but a review section allows you to view the areas that might require further learning before each future run-through. As with the main bulk of the software, measurement calipers are useable during the test, allowing for some precise questions to be given.  Importantly, this software allows and encourages repetition; fundamental to successful learning. It may seem obvious, but I noticed that my understanding of unfamiliar areas increased the more I explored them. What won’t be obvious, is just how quickly this occurred. With the addition of the test function, the user can consolidate what they have learned at their own pace, and not have to exit the program find a different testing app.

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My time with the trial version of Epicardio only threw up a couple of minor issues. Whilst these are still present, they detract from the simulator even less than before, due to the myriad of extra content present in the full release. My only new problem came in the single chamber pacing tutorial, wherein I was instructed to reduce the pacing rate to 45bpm, yet I couldn’t lower it past 50bpm. This made it impossible to view the intrinsic rhythm of the digital patient (the point of the page in question’s existence), but only in this instance. It’s worth pointing out that regular updates exist to iron out glitches such as this, so errors needn’t remain for long.

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If, like me, your learing speed is increased by doing, as oppose to just reading or seeing, then you’ll find this tool invaluable. To be able to safely induce life-threatening ventricular rhythm is, understandably, an uncommon occurrence, so a method to facilitate this, and things like it, is always going to be welcome for students. In Epicardio, however, you get so much more than that. Pacing of all types is covered in depth, real and digitally created ECGs, and an effective test facility really do set this above any of the other programs that I’ve used. It’s also incredibly simple to get the hang of, too. The things it does well far outweigh its minor issues, so I can wholeheartedly recommend this program to everyone who wants learn about cardiac arrhythmia and interventions. Whilst the implementation of a 60% student discount brings the price down to the £59-£89 mark, it is still expensive, but you really do get what you pay for.

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Tetralogy of Fallot

Recently, in a Holter clinic, I dealt with an 8 year old patient who was on the road to recovery after a diagnosis of congenital defect, Tetralogy of Fallot. As a result, I got hold of the most interesting ECG I have recorded to date.

Background

ToF is a rare congential defect affecting the heart, that results in an insufficiency of oxygenated blood leaving the heart through the systemic circulation. Thus, it is considered a cyanotic disorder.

The disorder affects roughly 5 in 10,000 infants, and has an equal gender distribution.

Generally, four pathologies comprise ToF. Whilst all four are not always present, three can consistently be found. ToF is a progressive disorder, in that each pathology gives rise to the others.

The four principal defects are:

RVH

PVSTEN
L-R: Normal and stenotic PV

 

  • Pulmonary Stenosis
VSD
VSD supplying mixed blood via OvA

 

  • Ventricular Septal Defect
    • Hole in septum, due to malformation, causing oxygenated and deoxygenated blood to mix within cardiac structure
  • Overriding Aorta
    • Aorta is placed over VSD, transporting blood with low O2 content to wider systemic circulation

Cyanotic episodes require immediate correction, before surgical intervention.

  • High flow O2 administration
  • Physical positioning
    • Knees to chest
    • Parent cradling the child will illicit this effect naturally
  • NaCl fluid bolus
  • Vasopressor therapy
    • Increases systemic vascular resistance, shunting blood through pulmonary system.
  • Continuous ECG and SpO2 monitoring

Surgical intervention usually repairs the VSD and addresses pulmonary pathology, often at the same time.

Prognosis for ToF patients is generally very good.

  • Overall outcome improved since surgical treatment has improved
    • Survival of surgery is currently 95-99%
  • 36 year post-surgical survival is currently 96%
  • Patients who undergo surgical treatment are at greater lifelong risk of ventricular arrhythmia
  • Complications can arise as a result of a transannular patch repair, specifically;
    • RV dysfunction
    • Heart block (risk of HB has dropped to around 1%, in recent studies)
    • Heart failure
    • Recurrent or residual VSD

Hx:

  • 8 y/o
  • Previous diagnosis of ToF
    • VSD
    • PV Stenosis
    • Mild RVH
  • Treatment:
  • Transannular patch repair
  • PV Replacement

Medication:

  • Daily:
    • Atenolol
    • Aspirin

This patient was having a 24hr Holter recording to assess cardiac recovery after their most recent procedure; the PV replacement. Physical examination showed a RVOT murmur, whilst echocadiography displayed a mild RVH and PV regurgitation. Left heart functionality has been classed as excellent.

Previous ambulatory study has shown no arrhythmic action, save for that considered normal in a child of this age. No previous ECG recordings were available.

Upon monitor removal, a 12-Lead ECG was performed, the resulting trace was as follows:

ToFECG (2).png

  • Sinus rhythm with BBB morphology
  • Sokolow-Lyon value of 36mV for RVH
  • QRS & ST segment abnormalities in all leads

Ambulatory analysis relating to the most recent study did not differ greatly from previous monitoring, showing occasional sinus arrhythmia and bradycardia, five non-conducted P waves were found, and two of these gave rise to periods of sinus bradycardia. All other instances were gradual onset/offset.

Nocturnal bradycardia reached rates as low as 34bpm.

What does everyone think of this ECG and brief ambulatory report? Let us know by leaving a comment below!

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