39 e-Letters

published between 2019 and 2022

  • Response to Interarm BP difference

    Thank you for your valuable comments on our paper. According to the British and Irish Hypertension Society and the American Heart Association, clinicians should measure patients' blood pressure (BP) in both arms to diagnose possible cardiovascular anomalies and select the higher BP arm for subsequent measurement.1 The clinician is recommended to document patients' BP differences in both arms. Cardiovascular risks could be controlled more tightly when there is a persistent discrepancy of more than 15mmHg. Patients should be told which arm to use for future measurements.
    In our study, all participants had BP measured in both arms by the nurses upon recruitment. The arm with higher BP was documented and used in subsequent clinical and home BP measurements. Clinic nurses checked if participants had selected the correct arm at follow-up six weeks later.

  • Catchers and Leadership

    This was a most enjoyable read.

    "The role of wicket keeper is similar to being a catcher in baseball, and not usually associated with charisma or conventional leadership."

    In baseball, until November 2004, one of the longest and most famous droughts (years without winning the World Series) was that of the Boston Red Sox. It was said that they had been cursed for selling Babe Ruth, one of the greatest hitters in history, to their hated rivals, the New York Yankees. This was known as the Curse of the Bambino.

    But the historic curse was ended in 2004, when the Red Sox finally won the Series, under the exceptional leadership of their captain, the catcher Jason Varitek.

    As with the leadership of Mike Brearley in cricket, Jason Varitek in baseball showed that the exception proves the rule for catchers in every field.

  • Interarm difference in blood pressure

    It is axiomatic that , on initial assessment of a patient's blood pressure(BP), measurement should be recorded in both arms, and the higher of the two readings should be used for diagnosis and management(1). I would add that the arm with the higher blood pressure should be the arm from which home blood pressures are measured.

    Was that requirement fulfilled in the study evaluating knowledge and practice of home blood pressure monitoring?

    Awareness of interarm blood pressure informs the technique of blood pressure measurement. It also adds information about prognosis given the observation that "Every 10 mm Hg difference in systolic BP between arms conferred a mortality hazard of 1.24(95% Confidence Interval 1.01 to 1.52 after adjusting for average systolic BP and chronic kidney disease"(2). Arguably, the rationale for this observation comes from the meta analysis which showed that a difference of 15 mm Hg or more in systolic BP is associated with cerebrovascular disease and with peripheral vascular disease, and increased cardiovascular mortality, respectively(3).


    (1) Giles TG., Egan P
    Inter-arm difference in blood pressure may have serious research and clinical implications
    The Journal of Clinical Hypertension 2012;14:491-492
    (2) Agarwal R., Bunaye Z., Bekele DM
    Prognostic significance of bwteen-arm blood pressure differences
    (3)Clark CE., taylor R., Shore...

    Show More
  • Language Matters

    The article by Launer [1] raises the issue as to whether diagnostic labels are to be avoided as they can be stigmatising and judgemental. Within the article, the term ‘patient’ was used to convey the individual in receipt of the diagnosis. In recent years it has been suggested that ‘patient’ itself be avoided - as it can imply passivity in the face of the medical profession [2]. The word derives from the latin patiens, which means suffering; but also acquiescing, allowing and submitting. This latter connotation implies that a patient ‘receives’ the diagnosis - rather than being empowered to work with the doctor towards a meaningful interpretation of their symptoms and/or resolution of them. Use of the term ‘patient’ by healthcare workers may then lead to the medicalisation of thought towards the individual (semantic determinism). Conversely, surveys have suggested that people prefer to be called a patient [3]. This may reflect the lack of adequate alternative descriptors. To be a ‘patient’ may also be advantageous as it will then clarify to the health care professional and the legal system, the unique obligation they have to that individual. Perhaps, as with ‘diagnosis’, we should seek permission from the individuals themselves whether to refer to them as patients?

    1. Launer J. Postgrad Med J. 2021 Jan;97(1143):67-68. doi: 10.1136/postgradmedj-2020-139298.
    2. Cooper A., Kanumilli N., Hill J., Holt R.I.G et al. Diabetic Medicine. Language matters. Addressin...

    Show More
  • A reply to: Continuing Medical education during a pandemic: an academic institution’s experience

    Dear Editor,

    We read with great interest the article by Kanneganti et al. exploring ‘Continuing Medical Education during a pandemic: an academic institution’s experience’. As medical students at King’s College London (KCL) in the United Kingdom, our anecdotal experience parallels the findings of Kanneganti et al., who analyse the innovative changes to medical education in Singapore.(1) Although, Kanneganti et al. focus on continuing medical education (CME) for speciality training, as senior medical students we have found that the challenges of COVID-19 have also altered our intended medical education experience, specifically our clinical training.

    Kanneganti et al. mention the successful move of CME to online platforms, including Objective Structured Clinical Exams (OSCE) but acknowledge the difficulty in simulating clinical signs. Unlike the National University Hospital (NUH) in Singapore, KCL has chosen not to deliver OSCEs online and instead have adapted the traditional OSCE assessments into Clinical Workplace Examinations (CWE). This assesses clinical competency on one real-life patient where final year medical students undertake an in-depth history and clinical examination in a forty-five minute period. This is a stark contrast to the traditional multiple station format. Some may argue that this new format is unable to assess a wide variety of skills. Furthermore, it is far more challenging to standardise the CWE as students have different patients with...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More
  • 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...

    Show More