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.
"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.
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).
References
(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
Hypertension2008;51:657-662
(3)Clark CE., taylor R., Shore...
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).
References
(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
Hypertension2008;51:657-662
(3)Clark CE., taylor R., Shore A Ukoumunne O., campbell JL
Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis
Lancet 2012;379:905-914
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...
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. Addressing the use of language in the care of people with diabetes: position statement of the English Advisory Group. 2018; 35(12):1630-1634
3. Costa DSJ, Mercieca-Bebber R, Tesson S, Seidler Z et al. BMJ Open. Patient, client, consumer, survivor or other alternatives? A scoping review of preferred terms for labelling individuals who access healthcare across settings. 2019 Mar 7;9(3):e025166.
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...
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 a myriad of diseases as opposed to OSCEs which allow students to go through the same scope and criteria for assessment.(2) However, we feel CWE provide a far more realistic scenario, which would be more representative of situations faced by foundation doctors. The incorporation of various workplace-based learning methods (such as CWE) promote self-directed learning while reliably assessing a broad discipline of everyday clinical encounters.(3) Furthermore, CWEs allows students to see patients with real clinical signs which can otherwise be difficult to simulate.
Kanneganti et al. mention the role of asynchronous and synchronous e-learning in CME. Similarly, KCL uses a variety of online teaching to facilitate student learning including live online lectures and seminars as well as uploaded recordings of previously held webinars. Kanneganti et al. describe the disparity in online teaching between different CME programmes which we have also found reflects the inconsistency in hospital site-specific teaching that we receive as medical students on our placements. We are spread across a total of 15 different sites for our clinical placements meaning that the level of online teaching can vary significantly depending on resources. In order to combat this, our university has now made recordings of site-specific online teaching available to all students through a central platform, allowing them access to a variety of resources regardless of their placement site. Similarly, sharing resources across training programs may be beneficial for the learning of speciality trainees’ at the NUH.
Kanneganti et al. describe how the NUH has continued to provide surgical exposure for residents through the use of surgical videos with technical pointers from experienced faculty. However, this form of passive learning may not be as beneficial in a hands-on specialty such as surgery. Alternatively, at one KCL’s hospital site, virtual simulation using virtual reality headsets has been used for students to experience the approach to emergency medical scenarios. The platform allows students to respond in real time and interact not only with the patient but with a virtual nurse and bedside medical equipment, replicating a real life scenario. This leads to the exciting possibility of virtual platforms being adapted for a myriad of medical and surgical scenarios. Virtual platforms such as this could be useful beyond the pandemic. In the absence of real life patients, virtual platforms may aid trainees with their core clinical competencies by providing a variety of realistic simulated scenarios.(4)
The COVID-19 pandemic has had lasting consequences on medical education around the world for both medical students and trainee doctors. However, the challenges of teaching during this pandemic have been eased through the use of new innovations and technologies. With different approaches being taken in various parts of the world, it is important to learn from each other’s adaptations in medical education to continually evolve during these unprecedented times.
References:
1. Kanneganti A, Sia C-H, Ashokka B, Ooi SBS. (2020) Continuing medical education during a pandemic: an academic institution’s experience. Postgraduate Medical Journal 2020;96:384-386.
2. Zayyan M. (2011). Objective structured clinical examination: the assessment of choice. Oman medical journal, 26(4), 219–222.
3. Liu C. (2012). An introduction to workplace-based assessments. Gastroenterology and hepatology from bed to bench, 5(1), 24–28.
4. Pottle J. (2019). Virtual reality and the transformation of medical education. Future healthcare journal, 6(3), 181–185.
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...
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 times.
Throughout medical school we are taught that we must be resilient. Our response to a negative stimulus must be to keep a stiff upper lip and carry on. When faced with stress and a high workload, we must learn to handle this and perform to a high standard. Although these are all fundamental skills that we look forward to putting into practice, we feel that many medical schools neglect the importance of encouraging students to develop the strategies required to ameliorate burnout.
During this pandemic, medical students have been expected to continue conducting research, clinical audits, studying for finals, amongst other tasks as part of our education. Despite these responsibilities, many students have taken this time away from hospitals to create COVID-19 response organisations within their communities, especially for ethnic group minorities who may be marginalised in these times of uncertainty. We have also been called upon as essential workers to volunteer in COVID-19 hospitals and many of us have risen to the challenge. Those of us who have volunteered on the frontlines have been exposed to the reality of emergency medicine, the stresses of a constantly changing healthcare system as well as the emotional burden of witnessing the deaths of patients as well as some of our senior colleagues.
The activities many of us usually partake in for stress mitigation such as practicing sports and social activities have not been available. A broader conversation about how doctors and students have juggled their responsibilities and mental health during this pandemic is needed. Dr Launer mentions that ‘the conditions for burnout are set early on’ in medical training. We agree and further suggest that the many years of education in medical school is an opportunity for prospective doctors to learn how to build a strong foundation for stress management which can continue on into medical training.
From our perspective, medical schools should put more emphasis on modules correlating the stresses of medical school with real-life medicine. This is likely to ensure that students enter employment with some insight into the possible pressures that lie ahead. It is important to facilitate conversations between doctors and students about the reality of burnout and what realistically can be done to manage stress. Furthermore, students should be encouraged to reach out for help more openly and frequently when needed - deconstructing the false narrative of pride and unrelenting strength amongst doctors begins in medical school.
Moving forwards, it is important to implement the lessons learnt during this pandemic before they are forgotten. The importance of a multi-disciplinary team, adaptability and quick thinking, communication and unity, have left the theoretical realm and become a living example to many students watching the NHS grapple with COVID-19. Although there will be uncertainty surrounding the structure of medical education going forwards, there are many learning points for students to take. We suggest universities across the country implement these reflections into future personal development curriculums as an important case study of resilience and stress-management.
References
1. Launer J. Burnout in the age of COVID-19. 2020.
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...
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 this platform for their presentations and discussions. The lectures and seminars shared through this platform are made available online for later view by students. Students can repeatedly go through these videos and clarify their doubts in next online class. Group dynamics is integral to deep learning. Although online platforms are the need of the hour, group dynamics of think, pair and share is difficult to replicate among students on online platforms during teaching learning. It appears as if we are missing bull’s eye.
‘‘Medical education is not just a program for building knowledge and skills in its recipients; it is also an experience which creates attitude and expectations’’. 4 This statement by famous medical educationist, Abraham Flexner is all the more relevant in today’s era of social distancing and online medical education, in the wake of COVID pandemic. Although development of clinical skills, attitude and communication in medical students is hard to replicate without direct contact with patients; students can learn clinical and surgical skills from their teachers using videoconferencing and by small group teaching maintaining social distance.1 Attributes like attitude and communication skills can not be practised using online portals, but on real patients in indoor setting maintaining social and physical distancing norms.
As we know , group dynamics is integral to deep learning. Although online platforms are the need of the hour, group dynamics of think, pair and share is difficult to replicate among students on online platforms during teaching learning. It appears as if we are missing bull’s eye.
References
1.Kanneganti A, Sia C-H, Ashokka B, Ooi SBS. Continuing medical education during a
pandemic: an academic institution’s experience. Postgraduate Medical Journal 2020;96
:384-386.
2.Raghvan H . Higher Education in the Year 2020-21 : How Should It Be ? University
News 2020 ; Vol. 58: 25 .
3. Ferrel M N, Ryan J J. The Impact of COVID-19 on Medical Education. Cureus 12(3):
e7492.
4. Flexner A. An Autobiography . New York, NY: Simon and Schuster; 1960.
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...
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 dissertations and are deprived of attending any conferences or workshops for widening the horizon.
4. This pandemic has been extended for a long time; in the majority countries and no one known when would it end. Hence, many PG trainees would lose a significant amount of their PG course time, leading to inadequate training, and practical experience. Therefore, these COVID affected PGs are likely to be inadequately trained and shall not be able to provide skillful and sound treatment confidently, even after clearing the exit exams (3).
5. Due to the fear of acquiring COVID-19, the PGs to devoid of ‘face to face’ interactions with the patients leading to severe impact on their clinical teaching (4).
6. Although, virtual teaching and learning has become popular in these difficult times, still the experience of clinical examination and attending the surgical procedures physically cannot be replaced by any virtual means (5).
7. There has also been undue mental stress of the PGs for the reasons mentioned above, and also for their redeployment duties in the non-specialty areas.
2. Lal H, Sharma DK, Patralekh MK, Jain VK, Maini L. Outpatient Department practices in orthopaedics amidst COVID-19: The evolving model [published online ahead of print, 2020 May 18]. J ClinOrthop Trauma. 2020; 10.1016/j.jcot.2020.05.009.
3. Dougherty PJ , Jain AK. Orthopaedic Surgery Education in India. Clin Orthop Relat Res 2014; 472:410–414.
4. Kumar S, Tuli SM. Orthopedic education: Indian perspective. Indian J Orthop. 2008;42 (3): 245-246.
5. Palan J, Roberts V, Bloch B, Kulkarni A, Bhowal B, Dias J: The use of a virtual learning environment in promoting virtual journal clubs and case-based discussions in trauma and orthopaedic postgraduate medical education: The sleicester experience. J Bone Joint Surg Br 2012; 94:1170-1175.
Predicated improvement on steroids
Philip D Welsby Philipwelsby@aol.com
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...
Predicated improvement on steroids
Philip D Welsby Philipwelsby@aol.com
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 symptoms promptly responded, this time to 60mg prednisolone.
Some observations of interest.
I was able to advise my rheumatologist that if he ever felt significant but less than definite symptoms he would initially feel better on steroids. This is true - I felt better than I felt I should. Anyone would feel better initially even if he or she had a condition that would soon be made a lot worse by the steroids.
Whilst I was aware of steroid psychosis I was not prepared for the “spaced-out“ feeling of not being perfectly in touch with reality
As a clarinet player I observed that in retrospect both presentations were associated with subliminal impairment of facility in tonguing the reed and facility in finger movement (Welsby’s sign) when playing all but two “standard pieces.” Firstly, the opening ascending wail (glissando to musicians) of Gershwin’s Rhapsody in Blue does not require finger agility, rather the ability to slow the ascent using throat and lips whilst sliding the fingers off the note holes. So that was fine. Of interest George Gershwin did not write this wail: he arranged the Rhapsody for two pianos and it was Ross Gorman, a Klezmer clarinet player in Paul Whiteman’s jazz band, who as a joke on Gershwin, converted Gershwin’s chromatic run into a glissando. Secondly, playing the famous 4 minutes 33 seconds of John Cage’s famous piece 4” minutes 33 seconds” of total silence posed no problems. Of interest is the outrageous but hardly known joke in the name. How many seconds are there in 4 minutes 33 seconds? The answer is 273. Put a minus sign in front of the 273 and you have… absolute zero.
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...
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 rotations around different specialties on clinical placements gives a unique learning experience, exploring the core knowledge of the specialty and enabling students to refine their communication skills. These rotations are designed to help prepare them for their examinations as well as equip them with the skills needed to be good junior doctors. Some students may miss the opportunity to gain experience in a particular specialty that they are considering pursuing as a career, and some may miss specialties they had not previously considered. Many students will also be disappointed to be missing out on their medical elective. This is a unique challenge and opportunity to discover global medicine that many clinicians have fond memories of several years later.
Going forward, there are multiple unanswered questions which are creating a lot of uncertainty for medical students. Will they get the opportunity to experience the placements that have been missed? With the disruption to exams, how will the Foundation Programme application be affected, and how will this differ between medical schools? What will the NHS look like, and how will it be operating on their return to placement? Will they be fully prepared for being a junior doctor when the time comes?
Whilst the COVID-19 outbreak has created a lot of uncertainty, it has also provided medical students a unique opportunity to gain skills in other areas of healthcare. A prime example of this is at Aalborg University and Aalborg University Hospital in Denmark, where medical students were enrolled in fast-track courses to work as ventilator therapy assistants, nursing assistants, and those in their final year employed as temporary residents. Teaching became digitally based and new portfolios were developed for students to complete to showcase what learning activities had been achieved during the pandemic (3). With approximately two thirds of students working in one of those three roles within two weeks, the mobilisation demonstrated by Aalborg University is impressive and shows medical students can be valuable assets.
Similar initiatives have taken place in the UK with final year medical students given the option to ‘opt in’ to their medical careers slightly earlier than planned in the newly created Interim F1 (FiY1) posts. It is anticipated that FiY1 doctors will join the clinical teams and perform tasks including note-taking, ordering investigations and basic procedures whilst under supervision (4). Although it is no doubt daunting for the new FiY1s, their commitment to taking up this role should allow for a smooth transition into commencing formal F1 training come August.
Medical students in lower years who would like to have an active role during the pandemic have been encouraged to take up positions as health care assistants (HCAs). In doing so they will continue to get exposure to a hospital-based environment and develop a greater understanding of the individual roles within the wider healthcare team. The work is team based and has frequent patient contact, mainly orientating around personal care, which contributes to improving communication with patients as well as colleagues. Research completed by Norwich Medical School has shown that medical students who have worked as HCAs found the experience promoted empathy, built confidence and helped them become more ‘ward smart’ (5). Working on the NHS front line, exposed to new and unfamiliar challenges, should help to establish key skills of resilience and determination at an early stage in their careers.
At the time of writing, the UK is still “mid-pandemic”. While the world is left to speculate about how to best navigate the new normal left in the wake of COVID-19, medical students are no different. Universities have been working hard to keep in regular contact with their students and have been proactive in making extra support available to students who may be struggling to cope during these uncertain times. Resuming teaching at medical schools to its previous normality may be extremely difficult, maybe even impossible, but medical schools still have a duty to patients to produce doctors that have sufficient training. The COVID-19 pandemic has created a testing time for us all and is likely to have lasting effects on healthcare globally. Healthcare professionals have embraced the challenges presented to them, and now medical students must do the same.
References:
1. Ding A, Zhang Y. Impact of cancelling foundation year rotations due to the covid-19 outbreak in the UK. Postgraduate Medical Journal Published Online First: 20 April 2020. doi: 10.1136/postgradmedj-2020-137775.
2. Bodies awarding UK medical degrees - GMC. Available from: https://www.gmc-uk.org/education/how-we-quality-assure/medical-schools/b...
3. Rasmussen S, Sperling P, Poulsen MS, Emmersen J, Andersen S. Medical students for health-care staff shortages during the COVID-19 pandemic. Lancet. 2020 May;395(10234):e79–80.
4. UK Foundation Programme 2020: Allocations to Interim F1 Posts. Available from: https://healtheducationengland.sharepoint.com/UKFPO/Website Documentation/Forms/AllItems.aspx?id=%2FUKFPO%2FWebsite Documentation%2FCOVID-19%2FEarly Allocation of Qualified Medical Students_April 2020.pdf&parent=%2FUKFPO%2FWebsite Documentation%2FCOVID-19&p=true&originalPath=aHR0cHM6Ly9oZWFsdGhlZHVjYXRpb25lbmdsYW5kLnNoYXJlcG9pbnQuY29tLzpiOi9nL1VLRlBPL0VSb1dUNUNCYmtoQXBPbjlfOEtHN3QwQk15dTV1RVlWQ05JQmRPVWl0M0NHeUE_cnRpbWU9MDVUaEpPancxMGc
5. Davison E, Lindqvist S. Medical students working as health care assistants: an evaluation. Clin Teach. 2019 Nov 7;16:1–7. doi: 10.1111/tct.13108.
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.
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.
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).
References
(1) Giles TG., Egan P
Show MoreInter-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
Hypertension2008;51:657-662
(3)Clark CE., taylor R., Shore...
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.
Show More2. Cooper A., Kanumilli N., Hill J., Holt R.I.G et al. Diabetic Medicine. Language matters. Addressin...
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 MoreDear 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 MoreWe 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 MoreIn 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 MorePredicated improvement on steroids
Philip D Welsby
Philipwelsby@aol.com
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?
Show MoreTen 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...
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.
Show MoreThere 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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