38 e-Letters

published between 2017 and 2020

  • Burnout in the age of COVID-19 - Navigating medical school during a pandemic

    Dear Editor,

    We thank Dr Launer[1] for his reflection on burnout in the age of COVID-19. We would like to share our views on burnout as senior medical students. We believe that medical students are not immune to the pressures that have come from this pandemic and that there are important lessons for students about how to manage burnout before commencing their careers.

    As students, we look to our senior colleagues as examples of how to manage stress and maintain a healthy work life balance. We have seen the passion that most doctors carry with them despite the circumstances and hope to apply what we have observed in our future careers. In Dr Launer’s intriguing reflection, he mentions that junior doctors should be protected from the illusion that clinicians will remain consistently fired with enthusiasm from foundation training through to retirement. We believe this is a concept that should be taught from the very beginning of one’s career, namely in medical school.

    We remember as prospective medical students in secondary education, the discussions that surrounded pursuing a career in medicine being altogether the same - a rhetoric of saving lives and having a job that would be forever fulfilling. Although much of this is true, it seems throughout our education and inevitably as foundation doctors, the sugar-coating is removed and we are able to see what we were never told – that being a doctor can be hard, exhausting and frankly disappointing at ti...

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  • Medical Education during COVID Pandemic-Are we missing Bull's Eye

    We were pleased to read the very timely article in your esteemed journal titled “Continuing medical education during a pandemic: an academic institution’s experience”by Kanneganti et al 1 , The authors have given an in-depth description of various tools being used to impart medical education to postgraduate trainees in prevailing COVID crisis. We would like to commend the authors for the detailed analysis of impact of COVID pandemic on medical education and comment on evolving situation with current evidence so as to complement the issues raised by this thought provoking article.

    The unimaginable power of microcosmic CORONA virus has razed down human capability to master the universe and shown the vulnerability of Man’s vaunted display of power and arrogance.2 Medical education has not remained untouched by its impact. The Corona Virus has not only attacked our corporeal existence, it has affected us mentally, psychologically and institutionally. It has called for physical and social distancing that will make it difficult to hold classes for sizeable number of students to learn together. Although the benefits of direct student teacher interaction and real time two way feedback will be difficult to replicate at online forums 3 , still online classes seem to be the only preferred alternative to face to face education in current scenerio.2

    We at our institute are using WebX platform for online teaching activities. Teachers and students both can use th...

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  • Medical Education and Training during COVID-19 had a severe negative impact

    In a recently published paper entitled ‘Status and situation of postgraduate medical students in China under the influence of COVID-19” (1) is inappropriate, as the authors have hardly described the plights of the postgraduate (PG) students during this pandemic. They have broadly discussed the impact of it on the medical students in general (including both under and postgraduate students). The PG has much different education and training than the undergraduate (UG) students. And, also the responsibilities of these two groups of students are quite different. The PG courses are designed to create experts, who would be able to deliver specialized healthcare to the community. Hence, generalizing the impact of the pandemic on these two dissimilar groups is unfair.

    COVID-19 pandemic has indeed disrupted the medical PG education and training globally, mainly in the following ways:

    1. Due to a substantial decrease in the number of patients attending the hospitals, the requisite clinical experience of history taking, clinical examination, and attending their surgical interventions have been cut down significantly, leading to inadequate specialist training.

    2. The PG teaching is also badly affected by the pandemic, with the abolition of conventional teaching like lectures, ward rounds, inter-departmental meetings, seminars, case presentations, and other academic activities (2).

    3. The PGs are finding it challenging to complete their required d...

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  • Predicated improvement on steroids

    Predicated improvement on steroids
    Philip D Welsby
    Assistant Editor, Postgraduate Medical Journal
    1, Burnbrae,
    Edinburgh EH12 8UB
    0131 339 8141

    John Launer’s recent On Reflexion details his heart block and lessons therefrom1. Might I be permitted to offer a similar lesson?
    Ten months ago I was asked “How are you today” Mostly this is a meaningless question, almost rhetorical, used by people to acknowledge your existence in a caring way. I was able to give a quantitative rather than vague qualitative response. “I am now well thank you, on 15 (of prednisolone) having had an ESR in the 80s and a CRP similarly raised.
    I was very fit (at age of 72) with a resting pulse of 60 attributed to daily gym attendance, but then developed a less that definite pain and a less than definite stiffness in my shoulder and pelvic girdle. I correctly suspected Polymyalgia rheumatic and was put on 15mg of prednisolone. Having read the books my girdle symptoms responded within 24 hours (and thank you for your interest). I tapered down to 3mg when I developed a headache, mostly occipital, and less than definite masseter claudication (I became aware that I had such muscles and noted discomfort when playing the clarinet) along with less than well localised temporal tenderness. You all know that this was Temporal Arteritis, another manifestation of Giant Cell Arteritis, and s...

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  • Cancelled Medical School Placements: The COVID-19 Effect

    We thank Dr Ding and Dr Zhang for their article on the impact of cancelling foundation year rotations as a result of the COVID-19 pandemic (1). As two members of the future generation of doctors, we would like to present our thoughts on the difficulties and opportunities that medical students face.
    There are 35 medical schools in the UK that can award a UK medical degree with another six new schools and programmes currently under review by the GMC for approval (2). The UK medical degree is typically 5 years long with the first two years consisting of lecture-based study and the final three years being placement-based clinical teaching. Under normal circumstances in the placement years, medical students, like in the foundation programme, rotate around different medical and surgical specialties.
    Medical schools have responded to the COVID-19 pandemic as they deemed appropriate – this has largely been the suspension of clinical placement, face-to-face teaching, and examinations. In making these difficult decisions medical schools will have had to take into account a number of factors: not only considering student, staff, and patient safety but also the repercussions this will have for the future generation of doctors. The enormity of these decisions is not lost on medical students, as many are left wondering what the implications will be for them.
    One of the decisions of most concern is the cancellation of placements. Similar to the foundation doctors, the r...

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  • Non-communicable diseases at the time of COVID-19 pandemic

    The communication from Pal and colleagues is timely. (1) However, a few more points might have been included.
    At present, Non-communicable diseases (NCDs) are responsible for 55.4% Disability Adjusted Life Years (DALY) in India. (2) The major risk factors for NCDs are tobacco, alcohol abuse, physical inactivity, and unhealthy diet. Therefore, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) focuses on the prevention of risk factors and awareness generation. (3)
    As the ongoing pandemic of Coronavirus disease (COVID 19) is ravaging most of the countries, India has imposed a lockdown for 21 days since 25 March 2020, in an attempt to avoid the catastrophe. While it is being considered as a masterstroke for putting the spread of the epidemic on hold, it would also restrict access to tobacco or alcohol for many, in favor of NCD prevention. However, some routine activities like physical activity would need to be re-planned for this duration, as parks and gyms are not accessible. As public transport is being operated at the minimal frequency, many patients of NCD might find it difficult to reach the nearest hospital for collecting their medicines. For NCD patients purchasing medicines (out-of-pocket expenditure) from a pharmacy, access to medicine may be restricted. Migrants working as daily wager may be the worst hit as the possibility of being laid off looms large, even if the government is asking the...

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  • FMTVDM – Evidence-based outcomes are defined quantitatively.

    Malhotra, et al [1] correctly defines a concern regarding the treatment of patients and the selection of appropriate interventions. However, to provide this “right care and high-value” cardiac care requires the shedding of incorrect beliefs and opinions – including diagnostic, etiologic and treatment - and the quantification of CAD itself.
    Quantification [2] makes it possible to diagnostically define the true extent and severity of CAD present in an individual and to accurately measure CAD treatment outcomes. Only by using true quantification can we remove the errors (sensitivity and specificity) in imaging [2] and treatment studies [3] and provide patients with “right care and high-value cardiology” free of physician bias and misperceptions. To provide this type of care we must focus our full attention on evidence-based medicine; avoiding the errors of the past.
    The very foundation of evidence-based medicine is the ability to accurately, consistently and reproducibley measure quantifiable outcomes [2] as shown in Figure 1, and to avoid the use of qualitative or semi-quantitative methods, which misdiagnose the presence (sensitivity) or absence (specificity) of disease [2]. This is now possible using “The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) Using Same State Single or Sequential Quantification Comparisons” [2].
    FMTVDM is able to accurately, consistently and reproducibly define the extent and severity of CAD by fir...

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  • The truth is more complicated

    The medical myths, using anti-MMR as an example, follow a formula of being easy to understand and not difficult to retell. Similar to urban myths, the knowledge of a medical myth is not reduced by distance from the case. For example, as told to me in my paediatric emergency department, a patient's cousin's friend whose child became autistic following vaccination is viewed as an absolute truth.

    Compare this with medical rebuttal. Frequently the caveats of more research is needed or the results from a small study litter the conclusion sections. Typically the writing is dense and heavy on jargon. It's also common for there not to be an absolute answer.

    Perhaps we should sharpen our writing and be more definitive. ‘Tweetorials’ are useful but they need to be short and snappy.
    Conflict of Interest
    None declared

  • The differential diagnosis should include dissecting aneurysm of the aorta

    The differential diagnosis of pneumothorax with haemodynamic compromise(1) ought to include the two subtypes of tension pneumothorax associated with dissecting aneurysm of the aorta(DAA), namely, tension pneumothorax with concurrent haemothorax(2), and tension pneumothorax without concurrent haemothorax(3)(4).
    In the report of DAA-related haemopneumothorax(2), antemortem chest radiography clearly documented the presence of tension pneumothorax without concurrent fluid collection in the pleural space. The patient collapsed and died soon after insertion of a chest drain intended to relieve the pneumothorax. Autopsy revealed an adhesion between the visceral lung pleura and the aortic aneurysm through which the dissection had penetrated the lung parenchyma. The parenchymal haematoma had subsequently “spouted out” from a 20 mm tear on the pleura, giving rise to haemothorax(2). The sequence of events might have been similar, in some respects, to the sequence of events in a 79 year old man who experienced a haemopneumothorax which was, however, much less striking in its severity(5). In the latter case there was no haemodynamic compromise. The patient had initially complained of “spitting” blood, without concurrent chest pain, back pain or breathlessness. Chest radiography revealed an abnormal air-fluid level in middle lung field on the right side. Subsequent contrast-enhanced tomography revealed Type B aortic dissection, a pneumothorax adjacent to the dissection(pre...

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  • coexistence of tuberculosis and sarcoidosis needs to be ruled out

    Given the fact that tuberculosis and sarcoidosis have many stigmata in common (including the occurrence of noncaseating granulomas), a diagnosis of multiorgan sarcoidosis (1) can only be established beyond doubt if care has been taken to rule out the coexistence of sarcoidosis and tuberculosis using the strictest criteria for ruling in or for ruling out tuberculosis. Evaluating tissue samples for M tuberculosis through the use of the polymerase chain reaction (PCR) is one such strategy, given the fact that sensitivity for M tuberculosis infection is significantly higher for PCR than for BACTEC radiometric culture (74.4% vs 55.8%), although the two modalities have comparable specificity, namely, 97.2% vs 100% (no significant difference) (2). Accordingly, when the authors state "All biopsy specimens and bronchial washings were negative for TB (1), we need to know whether those samples were subjected either to mycobacterial culture or to evaluation by PCR.
    The coexistence of sarcoidosis and tuberculosis was documented unequivocally in a 35 year old woman who initially presented with histologically and bacteriologically confirmed tuberculous lymphadenitis. She subsequently developed bilateral lung infiltrates. Histological specimens obtained via transbronchial biopsy and open lung biopsy showed features consistent with sarcoidosis. In addition, however, the presence of mycobacterial DNA in those tissue specimens was documented by PCR (3).
    In another report, a...

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