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Dear authors,
I was really glad to see an article about this important and hot topic. As
the problem of medicinal irradiation is realized and discussed frequently
the appropriate use of non-radiating technics is becoming more important.
The most important indications of TUS are listed in the article. I agree
with the authors on the main areas of use and would like to add some
comments based on 12 years experience in this f...
Dear authors,
I was really glad to see an article about this important and hot topic. As
the problem of medicinal irradiation is realized and discussed frequently
the appropriate use of non-radiating technics is becoming more important.
The most important indications of TUS are listed in the article. I agree
with the authors on the main areas of use and would like to add some
comments based on 12 years experience in this field with more than 700
patients.
The assessment of the chest is an integral part of the prenatal US which
can help to plan and guide intrauterin intervention and can determine
perinatal treatment.
The pulmonary embolism during pregnancy can be diagnosed without further
imaging and can initiate adequate treatment.
Ultrasonography can detect complications of severe pneumonia (abscess,
pleural component) in new-born and infants earlier than X-ray and is able
to guide intervention. Mediastinal pathologies (thymus, developmental
anomalies and variations of vessels) are in many cases quickly and
properly diagnosed.
TUS has a special role to play in emergency radiology especially when
CT/MRI is not immediately possible. Trauma, vascular pathologies, image
guided interventions are just a few to mention. Catastrophe medicine is an
other important field for TUS.
I hope that many colleagues will realize the true potential of TUS
and it will be more frequently and appropriately utilized in the future.
In his ambitious review article of the management of thyroid
disorders in primary care, Todd appears to have overlooked postpartum
thyroiditis, apart from a brief reference to it in the abstract as a cause
of hyperthyroidism. As there is a prevalence of postpartum thyroiditis of
about 7.5% of all pregnancies and the management of its various
manifestations depends critically on the correct diagnosis being made (1).
This d...
In his ambitious review article of the management of thyroid
disorders in primary care, Todd appears to have overlooked postpartum
thyroiditis, apart from a brief reference to it in the abstract as a cause
of hyperthyroidism. As there is a prevalence of postpartum thyroiditis of
about 7.5% of all pregnancies and the management of its various
manifestations depends critically on the correct diagnosis being made (1).
This detracts from an otherwise useful article. A section devoted to the
problems of managing thyroid disease in pregnancy would also have been
appropriate. Probably the first published cases of postpartum thyroiditis
in the UK were reported in the Postgraduate Medical Journal (2.
(1) Stagnaro-Green A. Postpartum thyroiditis. Best Pract Res Clin
Endocrinol Metab 2004;18:303-316
(2) Hoffbrand B I, Webb S C Postpartum thyroiditis
Postgrad Med J 1978;54:793-795
Sir,
I find it very disheartening to read such research. I do not find the
conclusions of any great shock. I do find it unacceptable to simply ask
questions of medical schools. I find far greater questions need to be
asked of the 'teachers' in hospitals around the country. I have rarely
encountered a consultant that would, or indeed is capable of, teaching. I
recall that during many ward rounds and clinics consultants d...
Sir,
I find it very disheartening to read such research. I do not find the
conclusions of any great shock. I do find it unacceptable to simply ask
questions of medical schools. I find far greater questions need to be
asked of the 'teachers' in hospitals around the country. I have rarely
encountered a consultant that would, or indeed is capable of, teaching. I
recall that during many ward rounds and clinics consultants did not teach
or even acknowledge my presence.They provided no bedside or formal
teaching. I would sit at the back of a clinic, nothing more than an
observer and learn little, if anything. On one such occasion, I remember
attending a clinic where the consultant was reading a copy of The Sun
newspaper. He hastily tried to put this away on my arrival, erroneously
assuming I was a hospital manager. Realisng that I was a student the
consultant returned to his selected reading. Over the course of the next 3
hours I was completely ignored as patients came and went, until there was
a grunt from the consultant which seemingly indicated the end of the
clinic. A complete waste of effort and a bigger waste of taxpayers money.
Is it not about time we started publishing research on the abilities and
interest of these same senior doctors when it comes to teaching students?
Should we not have doctors competing against each other to bring in money
from students who control their own clinical education budget?
The study highlights the basic principle that you can never beat
experience and by doing tasks timer and time again you improve - i.e
seeing more x-rays. I would advocate the use of BMJ learning modules that
are excellent and case related to make them more realistic.
Something that is used regularly at our hospital is that a team will
request an oral report from a consultant radiologist on-call, either in
perso...
The study highlights the basic principle that you can never beat
experience and by doing tasks timer and time again you improve - i.e
seeing more x-rays. I would advocate the use of BMJ learning modules that
are excellent and case related to make them more realistic.
Something that is used regularly at our hospital is that a team will
request an oral report from a consultant radiologist on-call, either in
person or over the phone out of hours, as our consultants have access to
images at home. In addition, I feel that dedicated teaching sessions on
paediatric x-rays is also needed as working in paediatrics CXR look very
different and often more pathological than they are!
It is surprising that these results are so bad for F1's as I feel
that the majority of undergraduate teaching focuses on CXR and overlooks
other images. What would the difference in AXR be like - an absolute
necessity as a surgical trainee or F1!
Making x-rays a mandatory part of finals as well as looking at an x-
ray during every foundation teaching session could help improve standards,
as could having more department based x-rays review groups to discuss
interesting x-rays or more radiology base grand rounds?
Editors,
In my opinion, this is one among a lot fascinating papers on diabetes, but
not useful at all in GPs day-to- day practice, since primary prevention ON
VERY LARGE SCALE is far better than therapy, also in diabetic field, and
GP role is central in such as enterprise!
Primary Prevention must be performed exclusively in individuals correctly
recognized in a quantitative way at inherited real risk with the aid of a
st...
Editors,
In my opinion, this is one among a lot fascinating papers on diabetes, but
not useful at all in GPs day-to- day practice, since primary prevention ON
VERY LARGE SCALE is far better than therapy, also in diabetic field, and
GP role is central in such as enterprise!
Primary Prevention must be performed exclusively in individuals correctly
recognized in a quantitative way at inherited real risk with the aid of a
stethoscope; in our case, at diabetes real risk since birth.
In fact, it is generally admitted by the Authors that diabetes is a
growing epidemics. However, I state that with the aid of Quantum
Biophysical Semeiotics, the until now either unknown or overlooked newborn
-pathological, subtype a) oncological , and b), aspecific, type I,
Endoarteriolar Blocking Devices in the tissues, wherein does really exist
the real risk of human common and severe diseases, as diabetes.
Obviously that happens in individuals with well-defined Quantum-
Biophysical-Semeiotic Constitutions, in our case, Diabetic “andâ€
Dislipidaemic (See Practical Applications, 6 article on Diabetes, in my
website http://www.semeioticabiofisica.it) (1-6).
Interestingly, e.g., in Diabetes Primary Prevention (PP), we need new
clinical tools, aiming to lower the increasing number of patients,
although the present, expensive screening: in above-cited website
Practical Applications: Diabetes, and Quantum-Biophysical-Semeiotic
Constitutions (1-7).
For instance, in the normal Langheran’s islets microcirculatory bed, there
are exclusively “normal†type II (= in arterioles, according to
Hammersen), but not type I (= in small arterioles) endoarteriolar blocking
devices, i.e. EBD, of first and second classes, according to S.B.Curri
(See http://www.semeioticabiofisica.it/microangiologia). In health, i.e.,
not involved by Diabetic Constitution, we cannot observe type I, newborn-
pathological, EBD in above-mentioned biological system. On the contrary,
in individuals involved by diabetic constitution as well as diabetic
"Inherited Real Risk" and overt diabetes, of course, we observe with the
aid of Quantum Biophysical Semeiotics also type I, newborn-pathological,
subtype b) aspecific , EBD, facilitating the diagnosis and consequently
diabetes primary prevention. In addition, the evaluation of Insulin
Secretion Acute Pick Renal Test is significantly impaired, corroborating
the clinical diagnosis (1-3).
Finally, an interesting clinical tool in recognizing diabetic
constitution -dependent inherited real risk, as well as in diagnosing
diabetes since early stages and diabetic monitoring proved to be bedside
Quantum-Biophysical- Semeiotic Osteocalcin Test (10) As a matter of fact,
Pre-hypertension during Young Adulthood may be involved by Coronary
Calcium Later in Life exclusively in presence of Inherited Real Risk of
CAD, typical for individuals with lithyasic Constitution, present in about
50% OF ALL CASES OF Pre-Metabolic and Metabolic Syndrome (13-15).
Considering the frequent association between hypertension and diabetes,
with or without CAD INHERITED REAL RISK (14, 15) more important proved to
be, in my 53-year-long clinical experience, bedside recognizing diabetic
predisposition, now-a-days possible since birth, utilising a lot of
methods, different in difficulty, but all reliable.
For the first time, from the clinical view-point, I have recently
illustrated an original manoeuvre, based on a singular activity of
osteocalcin, and reliable in bedside detecting diabetes in one minute,
with the aid of a stethoscope (10). In fact, osteocalcin, a product of
osteoblasts, among other action mechanisms, stimulates both insulin
secretion and insulin receptor sensitivity. As a consequence, osteocalcin,
secreted by above-mentioned bone cells during mean-intense lasting digital
pressure – for instance – applied upon lumbar vertebrae, brings about
increasing pancreatic diameters, i.e., technically speaking, type I,
associated, Langherans’s islet microcirculatory activation, so that
doctors assess pancreas size augmentation, which in health, lasts 10
seconds exactly (1-11). After that, pancreas diameters return to basal
value for 3 sec. The second pancreas size increasing lasts 20 sec., and
finally the third show the highest value: 30 sec. I terme such as clinical
investigation. On the contrary, in case of diabetic constitution (3, 4,
11, 13) the first pancreas increasing persists normally (10 sec.), but
both the second and the third are less than physiological ones (i.e., less
than 20 sec. and respectively 30 sec.). In presence of intense inherited
real risk of diabetes (6), such as impairment is greater. Finally, in case
of diabetes the alteration is present already in the first evaluation,
wherein duration appears less than 10 sec., inversely related with
disorder seriousness. Subsequently, I have ascertained that Ronald’s
Manoeuvre result pathological already in individuals involved by both
Diabetic Constitution and Inherited Diabetic Real Risk (1-11).
Interestingly, not only in examining subject, but also in all others, even
if kilometers way from him (her), according to Lory’s experiment, based of
no local realm in biological systems (12), pancreas show identical
modifications, allowing doctors to made clinical diagnosis until now
impossible (1-13).
1)Stagnaro S., Stagnaro-Neri M. Valutazione percusso-ascoltatoria del
Diabete Mellito. Aspetti teorici e pratici. Epat. 32, 131, 1986
2) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica.
Il Terreno Oncologico. Travel Factory, Roma, 2004.
http://www.travelfactory.it/semeiotica_biofisica.htm
3) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-
Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la
definizione della Single Patient Based Medicine. Travel Factory, Roma,
2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
4) Stagnaro S., Stagnaro-Neri M. Single Patient Based Medicine.La
Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina.
Travel Factory, Roma, 2005.
http://www.travelfactory.it/libro_singlepatientbased.htm
5) Stagnaro S. Pivotal role of Biophysical Semeiotic Constitutions in
Primary Prevention. Cardiovascular Diabetology, 2:1, 2003
http://www.cardiab.com/content/2/1/13/comments#5753
6) Stagnaro S. Stagnaro Sergio. Newborn-pathological Endoarteriolar
Blocking Devices in Diabetic and Dislipidaemic Constitution and Diabetes
Primary Prevention. The Lancet. March 06 2007.
http://www.thelancet.com/journals/lancet/article/PIIS0140673607603316/comments?totalcomments=1.
Hidden!!!. Therefore See either reference 13) or www.fce.it,
http://www.fceonline.it/index.php?option=com_content&task=view&id=3736&Itemid=47
7) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of
Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
8) Stagnaro Sergio. New bedside way in Reducing mortality in diabetic men
and women. Ann. Int. Med.2007. http://www.annals.org/cgi/eletters/0000605-
200708070-00167v1
9) Stagnaro Sergio. Single Patient Based Medicine: its paramount role in
Future Medicine. Public Library of Science.
http://medicine.plosjournals.org/perlserv/?request=read-response 2005
10) Stagnaro Sergio. Bedside Biophysical-Semeiotic Osteocalcin Test in
Diagnosing and Monitoring Diabetes. The Lancet, January 28, 2008.
http://www.thelancet.com/journals/lancet/article/PIIS0140673608601014/comments?action=view&totalComments=2,
HIDDEN !!!! See www.fce.it,
http://www.fceonline.it/index.php?option=com_content&task=view&id=3736&Itemid=47
11) Stagnaro Sergio. Il test Semeiotico-Biofisico della Osteocalcina nella
prevenzione primaria del diabete mellito. www.fce.it,
http://www.fcenews.it/index.php?option=com_content&task=view&id=909&Itemid=47
12) Stagnaro Sergio e Paolo Manzelli. L’Esperimento di Lory. Scienza e
Conoscenza, N° 23, 13 Marzo 2008.
http://www.scienzaeconoscenza.it//articolo.php?id=17775
13) Stagnaro Sergio. Pre-Metabolic Syndrome and Metabolic Syndrome:
Biophysical-Semeiotic Viewpoint. www.athero.org, 29 April, 2009.
http://www.athero.org/commentaries/comm904.asp
14) Stagnaro Sergio. Without CAD Inherited Real Risk no diabetic is
involved by coronary disorder. CMAJ, 6 May 2009.
http://www.cmaj.ca/cgi/eletters/180/9/919#127646
15) Stagnaro Sergio. Reale Rischio Semeiotico Biofisico. I Dispositivi
Endoarteriolari di Blocco neoformati, patologici, tipo I, sottotipo a)
oncologico, e b) aspecifico. Ediz. Travel Factory, www.travelfactory.it,
Roma, Luglio 2009.
Generating scientific evidence is but one aspect of the equation,
which possibly influences policy makers, and on which the politicians
ultimately takes decisions.
The authors highlight initiatives, such as the Movement for Global
Mental Health, which is a step in the right direction .The other aspects
are generating public opinion, by creating awareness amongst lay people
through dissemination of scientific ev...
Generating scientific evidence is but one aspect of the equation,
which possibly influences policy makers, and on which the politicians
ultimately takes decisions.
The authors highlight initiatives, such as the Movement for Global
Mental Health, which is a step in the right direction .The other aspects
are generating public opinion, by creating awareness amongst lay people
through dissemination of scientific evidence say through initiatives such
as the WHO-led Health Inter Network Access to Research Initiative (HINARI)
that offer institutions in LAMI countries electronic access to thousands
of journals at no or very low cost [1], having meaningful debates,
lobbying by both the guardians of Public Offices and Non-Governmental
Offices i.e. various stakeholders, in response to the generated evidence
base. The generated opinion should be strong enough to influence policy
makers and politicians.
If there is a perfect match, the policy makers acknowledge the
evidence and appropriate actions are then taken by the politicians in
implementing the scientific evidence.
If there is a mismatch, then it leads to policy makers and
politicians taking unscientific decisions, which then has a marked impact
on the morale of the scientific community [2] and the public in general
suffer.
If these mismatches happen in high income countries, what are the
odds of this happening in low and middle income countries (LAMI)?
Let’s hope, the equation improves between the scientific communities
and the policy makers/ politicians.
References:
1. Editors and WHO November 2003 Group. Galvanising mental health
research in LAMI countries: Role of the scientific journals. Ann Gen Hosp
Psychiatry. 2004; 3:5
2. news.bbc.co.uk/1/hi/uk_politics/8336509.stm
in my opinion, ascertaining 26 gene mutation as well as one gene-
based risk score for lung cancer susceptibility in smokers and ex-
smokersaiming to recognize individuals ââ¬à possiblyââ¬ï¿½ at risk of lung cancer
are expensive and impossible on vast scale!
Fortunately, Baserga's sign, I described in earlier article (1), proved to
be useful in bed-side recogn...
in my opinion, ascertaining 26 gene mutation as well as one gene-
based risk score for lung cancer susceptibility in smokers and ex-
smokersaiming to recognize individuals â₁“possiblyâ€� at risk of lung cancer
are expensive and impossible on vast scale!
Fortunately, Baserga's sign, I described in earlier article (1), proved to
be useful in bed-side recognizing iron-deficiency syndrome. In fact, due
to iron deficiency, erythropoietin can not stimulate bone-marrow, as it
happens in healthy subject, provoking Baserga's sign. In a few words, in
a individual, lying down in supine position, psycho-physically relaxed
with open eyes to prevent melatonin secretion, mean-intense digital
pressure applied upon middle line of sternal body, brings about gastric
aspecific reflex after a latency time of exact 10 sec., indicating that
bone-marrow activity is normal, according to my Angiopathy theory (1-4).
On the contrary, after stimulation of renal erythropoietin secretion by
pinching lateral abdominal skin for 15-20 sec., the second evaluation
shows a statistically lowered latency time: 6 sec. precisely, due to bone-
marrow increased microcirculatory activity. Notoriously, exclusively in
presence of normal iron tissue level, endogenous erythropoietin can act on
bone marrow. In fact, in iron deficiency syndrome, the lowering of sternum
-gastric aspecific reflex, i.e., Retyculo-Endothelial System Hyperfunction
Syndrome (RESH) (2, 3), is clearly compromised, in inverse relation to the
seriousness of underlying iron deficiency
Interestingly, in lung cancer (e.g. adenocarcinoma), I observed a
'variant'� form of the Baserga's sign. Really, I suspected that stimulating
cutaneous trigger-points, related to lung cancer even in the initial stage
of Cancer, i.e., Inherited Oncological Real Risk (1-6) by digital
pressure, could provoke the output of tumour cell products, which in turn
stimulate bone-marrow, at the moment partially suppressed in its function.
According to Max Born, a new theory must be â₁“madâ€� enough to be true.
In health, mean-intense digital pressure, applied on skin projection area
of diverse lung lobes (= stimulation of pulmonary trigger-points), brings
about gastric aspecific reflex after exactly 8 sec. latency time (lt), and
the basal latency time of Rethiculo-Endothelial System Hyperfunction
Syndrome (2-6) persists identical, under the same condition, when the
stimulation of lung trigger-points lasts about 15-20 sec. In fact, the lt
of sternum-aspecific gastric reflex, i.e., RESH (= mean-intense digital
pressure applied upon the middle line of sternal body, and/or iliac
crests) persists identical to the basal one: lt 10 sec., also after
stimulating the trigger-points of healthy lung for about 15-20 sec.,
indicating absence of erytropoietin-like substance secretion from lung (or
every biological system, of course).
On the contrary, in case of lung cancer 'inherited real risk' (6, 7) and
overt lung cancer, under the same condition (= mean-intense digital
pressure, applied precisely on disorder cutaneous projection area, lasting
15-20 sec.), one observes a significant reduction of RESH lt, lowering
from 10 sec. to 6 sec., in relation to the seriousness of underlying
disorder. In addition, in presence of lung cancer 'inherited real risk'�,
characterized by the presence of newborn-pathological, type I, subtype a),
oncological, Endoarteriolar Blocking Devices (6, 7), interestingly, basal
lt. of lung-aspecific gastric reflex may result normal (i.e., 8 sec.), but
reflex duration is pathologically more than 4 sec. (NN lower than 4 sec.:
parameter value of paramount diagnostic importance, correlated with local
Microcirculatory Functional Reserve), and finally follows the pathological
tonic Gastric Contraction, absent under physiological conditions, and
typical of oncological disease.
In presence of overt lung cancer, even in initial stage, latency time of
lung-gastric aspecific reflex lowers significantly (NN = 8 sec.), reflex
duration is increased (more than 4 sec.), followed, without delay, by
'pathological'� tonic Gastric Contraction (tGC)
I suggest such as biophysical-semeiotic signs as worthy of attention,
although further investigations are necessary. In fact, what referred
represents, so I think, a paramount clinical tool in lung cancer primary
prevention as well as in the war against pulmonary malignancy.
.
References
1) Stagnaro S. Segno di Baserga: diagnosi clinica semeiotico-
biofisica della carenza di ferro mediante valutazione dellâ₉„¢attivitÃÂÂ
midollare dellâ₉„¢eritropoietina endogena. www.semeioticabiofisica.it, URL:
http://www.semeioticabiofisica.it/semeioticabiofisica/Documenti/Eng/Segno%20Baserga%20variant%20engl.doc
2) Stagnaro S., Sindrome percusso-ascoltatoria di Iperfunzione del
Sistema Reticolo-Istiocitario. Min. Med. 74, 479, 1983 (Medline)
3) Stagnaro-Neri M., Stagnaro S., Appendicite. Min. Med. 87, 183,
1996 (Medline)
4) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica del torace,
della circolazione ematica e dellâ₉„¢anticorpopoiesi acuta e cronica. Acta
Med. Medit. 13, 25, 1997.
5) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica
Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004.
http://www.travelfactory.it/semeiotica_biofisica.htm.
6) Stagnaro S. Reale Rischio Semeiotico-Biofisico. Ruolo diagnostico
e patogenetico dei Dispositivi Endoarteriolari di Blocco neoformati-
patologici tipo I, a) e b). Ed. Travel Factory, Rome,
www.travelfactory.it, Luglio 2009.
Clinicians should not take comfort either in the fact that most
narrow complex tachyarrhythmias(including atrial fibrillation) have the
potential to be treated pharmacologically by frontline medical staff(1),
or in the observation that many affected patients do not have overt
stigmata of heart disease(1). Given the fact that even a highly prevalent
disorder such as atrial fibrillation(AF) is liable to misdiagnosis as
su...
Clinicians should not take comfort either in the fact that most
narrow complex tachyarrhythmias(including atrial fibrillation) have the
potential to be treated pharmacologically by frontline medical staff(1),
or in the observation that many affected patients do not have overt
stigmata of heart disease(1). Given the fact that even a highly prevalent
disorder such as atrial fibrillation(AF) is liable to misdiagnosis as
supraventricular tachycardia, with attendant risk of popentially fatal
proarrhythmia if inappropriately treated(2), and also in view of the fact
that recognition of the familial short QT interval variant of AF has the
potential to save lives if appropriate diagnostic clues are pursued(3),
there is huge potential for improvement in the management of narrow
complex tachyarrhythmias even if one only takes AF as an example. The
observation that "atrail fibrillation, at its fastest...will often appear
regular"(1) is exemplified by a study where, among 65 subjects originally
diagnosed as having regular narrow-QRS complex tachycardia, 32 proved, in
retrospect, to have been AF patients misdiagnosed as having
supraventricular tachycardia(2). In one such instance, administration of
adenosine provoked an episode of sustained ventricular fibrillation(VF)
requiring direct-current countershock(2). Exemplifying the presentation of
AF without structural heart disease is the syndrome of familial short QT
interval, in which other manifestations include syncope and sudden death,
the latter potentially preventable through implantation of cardioverter
defibrillator(3). Accordingly, the management of AF should include, not
only "feedback" to frontline clinicians about their performance in
interpreting electrocardiograms, but also routine inquiry into family
history of syncope and sudden death, especially in patients who appear to
have no stigmata of structural heart disease.
References
(1)Linton NWF., Dubrey SW
Narrow complex(supraventricular) tachycardias
Postgraduate Medical Journal 2009;85:546-51
(2) Knight BP., Zivin A., Souza J et al
Use of adenosine in patients hospitalized in a university medical center
Am J Med 1998;105:275-80
(3)Schimpf R., Wolpert C., Gaita F., Giustetto C., Borggrefe M
Review Short QT syndrome
Cardiovascular Research 2005;67:357-66
In the context of the follow-up consultation, be it in the in-patient
or in the out-patient setting, the first three seconds should include the
catechism "are you better, same, or worse". This open-ended approach gives
the doctor the opportinity to assess whether or not he is "on track" with
the diagnosis and treatment, and it leaves little opportunity for "denial"
on his part. I suspect that, to a large extent, diagnostic...
In the context of the follow-up consultation, be it in the in-patient
or in the out-patient setting, the first three seconds should include the
catechism "are you better, same, or worse". This open-ended approach gives
the doctor the opportinity to assess whether or not he is "on track" with
the diagnosis and treatment, and it leaves little opportunity for "denial"
on his part. I suspect that, to a large extent, diagnostic error in
medicine is attributable, not only to failure to consider other
possibilities once an initial diagnosis has been reached(so-called
premeture closure)(1), but also to the fact that an unsuccesful
therapeutic diagnostic trial is not correctly identified because, on
follow-up, the patient has not been specifically asked whether he is
"better, the same, or worse".
References
(1) Graber ML., Franklin N., Gordeon R
Diagnostic error in internal medicine
Archives of Internal Medicine 2005;165:1493-9
In reporting their impressive study of the preparedness of Foundation Year (F1) doctors for clinical practice, Matheson & Matheson conclude that medical schools may not adequately prepare medical graduates, that more opportunities for experiential learning are needed during the final year of medical school, and that explicit assessment criteria are needed [1]. Where prescribing is concerned, their conclusions have been support...
In reporting their impressive study of the preparedness of Foundation Year (F1) doctors for clinical practice, Matheson & Matheson conclude that medical schools may not adequately prepare medical graduates, that more opportunities for experiential learning are needed during the final year of medical school, and that explicit assessment criteria are needed [1]. Where prescribing is concerned, their conclusions have been supported by previous studies.
Preparedness to prescribe
In 2006, Han & Maxwell surveyed 100 Edinburgh F1 doctors and found that only 32 considered themselves 'competent to prescribe' at the time of graduation [2]. Under 50% felt comfortable in providing information about possible treatments to allow patients to make informed decisions about their care. The majority complained about a lack of practice and formal teaching of basic clinical skills relating to drug therapy.
In the same year, in a study of 193 pre-registration house officers and 212 consultant educational supervisors in the West Midlands, both groups ranked the house officers' communication skills highest (best prepared) and ranked basic doctoring skills (such as prescribing, treatment, decision making, and emergencies) lowest [3].
A later study, funded by the GMC, of preparedness for all aspects of clinical practice, not just prescribing, showed that medical students in three medical schools felt prepared for all the duties that they would be expected to carry out as newly qualified doctors - except prescribing [4]. Indeed, when the graduates of two of the schools were given a rudimentary test of their prescribing abilities, over 80% failed.
Teaching and assessment
There is also evidence of a lack of teaching and assessment, although when clinical pharmacology teaching is provided it is said to be of high quality [5]. In 2007 Tobaiqy et al. asked F1 doctors in the Aberdeen Teaching Hospitals about their knowledge of clinical pharmacology and therapeutics (CPT) relevant to practical prescribing [6]. Of 90 doctors, 30% rated their knowledge of CPT as poor or worse and only 8% rated it as good; 74% reported having witnessed an adverse drug reaction (ADR) and 55% a drug-drug interaction, a number of which had resulted in patient morbidity or mortality; 42% stated that they had not been taught enough during their undergraduate years about avoiding ADRs and 60% about avoiding drug-drug interactions.
In 2008, Heaton et al. reported a survey of 2413 students who graduated in 2006-8 from the 25 UK medical schools with a complete undergraduate curriculum [7]. There were few distinct courses (17%) and assessments in CPT (or equivalent) (13%). The most common mode of learning was opportunistic learning during clinical attachments (41%). Only 38% felt confident about prescription writing and only a minority (35%) had filled in a hospital prescription chart more than three times during their training. Most (74%) felt that the amount of teaching in this area was 'too little' or 'far too little', and most tended to disagree or disagreed completely that their assessment 'thoroughly tested knowledge and skills' (56%). When asked if they were confident that they would be able to achieve the prescribing competencies set out by the GMC, 42% disagreed or tended to disagree, whereas only 29% agreed or tended to agree.
Conclusions
These deficiencies have practical consequences. Medication errors are common and contribute to morbidity and mortality [8]. Adverse drug reactions are responsible for 6.5% of all general medical admissions to hospitals [9] and occur in just under 15% of patients in hospital [10]; many are preventable.
Assessment drives learning, and we strongly agree that more teaching and proper assessment of practical prescribing skills, as underpinned by basic pharmacological knowledge, is needed in the final years of undergraduate medical education.
References
1. Matheson C, Matheson D. How well prepared are medical students for their first year as doctors? The views of consultants and specialist registrars in two teaching hospitals. Postgrad Med J 2009; 85; 582-9.
2. Han WH, Maxwell SR. Are medical students adequately trained to prescribe at the point of graduation? Views of first year foundation doctors. Scott Med J 2006; 51(4): 27-32.
3. Wall D, Bolshaw A, Carolan J. From undergraduate medical education to pre-registration house officer year: how prepared are students? Med Teach 2006; 28(5): 435-9.
4. Illing J, Morrow G, Kergon C, Burford B, Spencer J, Peile E, Davies C, Baldauf B, Allen M, Johnson N, Morrison J, Donaldson M, Whitelaw M, Field M. How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools. Final summary and conclusions for the GMC Education Committee, 2008. http://www.gmc-uk.
org/about/research/REPORT%20-preparedness%20of%20medical%20grads.pdf.
5. Ellis A. Prescribing rights: are medical students properly prepared for them? BMJ 2002; 324(7353): 1591.
6. Tobaiqy M, McLay J, Ross S. Foundation year 1 doctors and clinical pharmacology and therapeutics teaching. A retrospective view in light of experience. Br J Clin Pharmacol 2007; 64(3): 363-72.
7. Heaton A, Webb DJ, Maxwell SR. Undergraduate preparation for prescribing: the views of 2413 UK medical students and recent graduates. Br J Clin Pharmacol 2008; 66(1): 128-34.
9. Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, Farrar K, Park BK, Breckenridge AM. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329(7456): 15-19.
10. Davies EC, Green CF, Taylor S, Williamson PR, Mottram DR, Pirmohamed M. Adverse drug reactions in hospital in-patients: a prospective analysis of 3695 patient-episodes. PLoS ONE 2009; 4(2): e4439.
Conflict of Interest:
JKA is a clinical pharmacologist and President of the British Pharmacological Society, which is co-funding, with the UK Department of Health, the e-Learning for Health programme Prescribe, a UK initiative to develop a national e-Learning resource to support prescribing education. SM is a clinical pharmacologist, Chairman of the British Pharmacological Society's Prescribing Committee and Clinical Lead for Prescribe.
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