b.s.t

describe how the NHS has let people down?

There have been past issues in terms of patient care, such as those highlighted in the Francis Report. Ward to Board miscommunication led to the overreliance on data, meaning that cases of negligence on the ward were not reported. Formal statements made showed that patients were often left in soiled bedsheets, falls and minor injuries not noted and patients were not sufficiently assisted in terms of eating and drinking.

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More recently, the Junior Doctor strikes meant that many elective surgeries and outpatient appointments were cancelled. Difficulties in reaching a decision between government officials and BMA representatives meant that quality and continuity of care may have been compromised. The lack of flexibility on the government’s part, as well as the ballot decision on behalf of members of the BMA meant that industrial action was taken, to the short term detriment of patients.

***Name two medical conditions which have decreased in prevalence over the last 50-100 years?***

polio and smallpox

***If you could be any medical instrument, which would you be?***

I would consider myself like a stethoscope, because I believe that it is very important to listen to what each patient has to say, not only in making an accurate diagnosis, but also in ensuring that the investigation and management plan is properly understood. Also, many stethoscopes have two sides depending on the required purpose, similarly I believe that I can adapt my approach depending on the requirement, whether it be taking a history or breaking bad news.

***Do you think doctors should set a good example to their patients in their own lives? How or why might this be difficult?*** 

Doctors, as providers of healthcare and trusted advice within a community have the responsibility of setting a good example with regards to lifestyle and health. As someone who patients regard as well informed and consistent with knowledge, doctors should strive to be the best possible role model to patients, with regards to health.

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However, doctors are also people, and will experience their own difficulties and so it is difficult to be the perfect role model to patients. For example, although smoking is detrimental to one’s health, it provides some doctors with an effective means of relieving stress. Of course, there are many ways to relieve stress, but for doctors with extremely busy schedules, particularly when they are teaching, caring and researching, a short break to smoke is most convenient. Therefore, if doctors were to partake in such actions, which may demean the trust that patients have in them, it is important that they involve themselves in such actions, when out of sight of their patients.

***Do you think doctors and the NHS get a bad press, and if so, why?*** 

Although doctors and the NHS contribute greatly to our society, providing the population with some of the best healthcare in the world, at times they are subject to negative press. This is due to many reasons, but more recently this is often the net consequence of efforts to reduce NHS expenditure As one would imagine, patients expect the best quality of healthcare from doctors with very short waiting times and convenient costs associated with their care. However, due to more recent constrictions, the NHS is facing difficulties with an increasing population but a decreasing budget. As a consequence, patients have longer waiting times when seeing doctors, whether that is at A&E or at the GP. Although doctors still are trying their best to deliver the best care, since the overall experience for some patients at times is frustrating, often the blame is focused on doctors and medical professionals, when in reality, a lack of sound funding for our health service is an underlying issue.

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Additionally, intentional and preventable misconduct by individual doctors such as Dr Harold Shipman and more recently Dr Ian Paterson has tarnished the reputation of doctors as a whole, as well as undermining patient confidence in medical professionals.

***What do you think are the similarities and differences between being a doctor today and being a doctor 50 years ago?*** 

Over the last 50 years, Medical practice has evolved in a number of ways, changing the way Medicine is practiced.

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In particular, there have been significant advancements in investigations with blood tests, CT and MRI scans more widely available and playing a more prominent role in guiding management decisions. This is evidenced by the fact that Radiology is one of the fastest growing Medicine specialities.

Additionally, new antibiotic and medication developments in general have meant that doctors are now able to treat a wider range of conditions; although in parallel, patient expectations of medical practitioners have also increased.

On the other hand, the role of doctors in being part of the MDT and collectively assessing, investigating and managing patients has remained the same, with effective communication and patient trust of medical professionals at the centre of this.

Additionally, the importance of mentoring and training future generations of doctors remains as important today as it has done previously in order to ensure a sustainable future for this important profession.

***What are the differences between 'a cold' and 'the flu'?***

The flu is the name given to the influenza virus, a specific respiratory virus. A ‘cold’ is an umbrella term given to a group of coronaviruses, adenoviruses and rhinoviruses. There is a great degree of variability between these viruses, and within each viral type there are many subsets.

Therefore the common cold cannot be vaccinated against – nor is there a ‘cure’ for the common cold. The flu, given we know what virus it comes from, can be vaccinated against.

Symptoms differ too – expect a runny nose, congested nose or a sore throat from a cold, compared to a range of more pronounced symptoms from influenza. It may affect the lungs and joints, and can cause symptoms ranging from fever through to respiratory failure and death.

Both colds and flu normally go on for around 7-10 days, but flu symptoms may continue for another 2 or 3 weeks after this – even if the flu virus itself has been eradicated.

Treatment is different too – for colds, we just treat the symptoms with decongestants and painkillers. Influenza is treatable with antivirals if caught quickly.

***What are the differences between a stroke and a myocardial infarction?***

A stroke is when the blood supply to the brain is interrupted. A stroke may be ischaemic (when the blood supply is blocked by a clot) or haemorrhagic (when a blood vessel in the brain bursts and bleeds). A ‘mini stroke’ or transient ischaemic attack, is when a clot temporarily blocks a vessel.

An MI (or myocardial infarction) is normally the result of coronary artery disease, and is when the arteries that supply blood to the heart become blocked due to clots forming around fatty buildups (called plaque). This causes a lack of oxygen and nutrients to be supplied to the heart – and in turn tissue death in the heart.

The symptoms of a heart attack frequently include chest pain, pain radiating down the left arm, shortness of breath, cold sweats, nausea and dizziness. Symptoms of stroke (and a helpful reminder of what to do) are often remembered using the acronym FAST – which stands for Face drooping, Arm weakness, Speech difficulty and Time (to call 999.)

The treatment for a heart attack may be medication and lifestyle changes, or it may involve surgery – like a coronary artery bypass graft, or angioplasty.

Ischaemic stroke may be treated with medication to break up blood clots, and haemorrhagic strokes are treated with surgery to repair the damaged vessel.

***What are the different types of medication error?***

Medication errors fall into four broad categories. These are: knowledge based errors, rule based errors, action based errors and memory based errors.

Knowledge based errors are due to a lack of knowledge on the drug being prescribed, or the patient to whom the drug is being given.  An example would be giving penicillin to a patient who is allergic to it. These errors can be avoided by better education, cross-checking of prescriptions, and computerised prescribing systems.

Rule based errors involve misapplying a rule, or using an incorrect rule – an example being injecting diclofenac into the lateral thigh, instead of the buttocks.

Action based errors – or slips – involve a mistaken action. An example would be picking up a box of diazepam in place of alprazolam. These errors can be reduced by cross checking and ensuring medicines are clearly labelled.

Memory based errors – or lapses – involve simply forgetting a vital piece of information. An example would be prescribing a patient a drug that they were allergic to, having momentarily forgotten about the allergy.

***What are the key features of cancerous cells and what are the routes through which cancers can spread?***

Cancer cells have an irregular cell shape and multiple enlarged nucleoli. They exhibit uncontrolled growth, being self-sufficient in growth signals and with insensitivity to anti-growth signals. They also remain immature and undifferentiated (i.e. they do not develop into a mature cell), and resist programmed cell death. They also have the ability to spread throughout the body (metastasise).

Metastasis occurs through four routes.

Lymphatic spread is the transport of tumour cells to regional lymph nodes near the tumour, and eventually throughout the body. The nearest node to the primary tumour is called the sentinel lymph node Hematogenous metastasis is spread through blood vessels – typically via veins rather than arteries. Transcoelemic metastasis involves spread into the cavities of the body; canalicular spread involves spaces like the urinary system or bile ducts. Different cancer types will be more or less likely to spread through different routes.

***What is the MDT and explain the role of 5 key MDT members***

MDT stands for multidisciplinary team. The MDT is crucial to integrated patient care, enabling successful collaboration of of professionals across the health and social care professions. Five team members are as follows:

Doctors – doctors assess patients, request/perform investigations, prescribe medications and perform procedures. In conjunction with the patient , they strategise the direction that treatment will take.

Nurses: a nurse’s role involves planning, administering and evaluating patient care – such as diet, medications, monitoring vital signs, and ensuring record keeping.

Pharmacists: a clinical pharmacist is responsible for ensuring correct prescribing – be it checking that medications are correct, or that they follow national or local guidelines.

Physician associate: a physician associate is a medically trained healthcare professional who works alongside doctors to provide medical care. They can see patients, formulate diagnoses, and perform procedures. However, they cannot prescribe and must work within a scope and with a dedicated medical supervisor.

Occupational therapist: occupational therapists have a degree in Occupational Therapy. They work in the rehabilitation of patients, with the goal of helping recovery in occupational and day-to-day skills. They also assess patient function across areas that are relevant to their return to everyday life, and develop a program to help them as needed.

***Name two medical conditions which are more prevalent in paediatrics compared to adults and explain why this is the case***

Asthma – asthma is more prevalent in children than adults, and more prevalent in boys than girls. Those with asthma often also suffer from eczema and hay fever – a genetic tendency towards allergic diseases that is called atopy. Exactly why asthma is more common in the young is still up for debate, but theories centre around either poor air quality or the hygiene hypothesis. Genetics and increased eagerness on the behalf of doctors to diagnose asthma are also given as possible reasons.  Poor air quality could be either due to tobacco smoking, or increased pollution from cars and industry. The hygiene hypothesis states that those who are more exposed to a range of infections, and a range of differential and beneficial microbes, are less likely to suffer asthma and allergies.

Croup – croup occurs in around 7% of children annually during their first five years. It’s more common in atopic children, and is almost always due to a viral infection. The infection in turn leads to inflammation, and the (partial) blocking of the trachea. It presents with a barking cough and wheezing. Croup is a paediatric disease – and presents less as children grow older. This is because as the trachea grows larger inflammation is less likely to block it and cause breathing problems.

***Name two medical conditions which are more prevalent in the elderly and explain why this is the case*** 

Alzheimer’s – Alzheimer’s is the most common cause of dementia. It’s a degenerative brain disease seemingly caused by buildup of beta-amyloid plaque and tau tangles. It is irreversible and progressive. It is most common in those over the age of 65, affecting 1 in 15 people over 65 and 1 in 6 over 80. It’s a disease of the elderly because buildup of beta-amyloid plaque and tau tangle happens gradually over time.

Heart Failure – heart failure is a syndrome, rather than a single pathological process. The following features constitute heart failure: symptoms including breathlessness, exhaustion at rest and fatigue; signs of fluid retention; and objective evidence of abnormality of heart structure or function. Incidence increases steeply with age, and the average age at diagnosis is 77. This is due to a range of underlying reasons, which become more common with increasing age, including: coronary artery disease, ventricular hypertrophy and atrial fibrillation (an irregular heart rhythm).

***are you aware of any countries which have a legal market for live organs (ie. Where organs can be bought and sold by living individuals)?***

Regarding a legal market for organs, I believe that Iran has such a policy where non-essential organs can be sold by living individuals. The potential benefits to this are a greater supply of organs with Iran having generally high rates of organ transplants, as well as adhering to religious restrictions where organs cannot be donated after death. Additionally, this helps to eliminate the ‘black market’ for live organs which is increasingly prevalent worldwide. A potential disadvantage of this, is that it is arguably a policy which may pressure the poorer members of society to donate their non-essential organs (eg. one kidney) in order to sustain their livelihood, rather than due to a true desire to donate an organ.

***What are the differences between IVF and IUI.***

IUI stands for intrauterine insemination and involves the insertion of processed and concentrated motile sperm directly into the uterus. The process is performed one or two times in the days after ovulation. IVF involves the stimulation of the ovaries to produce multiple eggs, then the removal of these eggs and their fertilisation *in vitro,* and the fertilised embryos being placed in the uterus. In IVF, medication is given to develop multiple eggs (ideally around 15). In IUI, a woman will only develop one or two eggs.

IUI combats infertility by giving medication if needed to ensure one or two eggs are provided, and placing the sperm near their target. IVF uses ICSI (intracytoplasmic sperm injection) to inject sperm straight into an egg, meaning only one healthy sperm is needed. Egg quality is also likely to be good due to medications provided. Genetic testing can be used to reduce the risk of miscarriage.

***What is hospital care like from a patient's perspective?***

The hospital environment and behaviour of health care providers within the hospital can predict patients’ perception of care quality.

An inpatient – depending on the cause of their admission – will likely spend the vast majority of time in their hospital bed. In the average UK hospital, they will probably be in a room with a few other patients. In certain wards, or if they have certain conditions, they will receive their own side room.

In their room, the patient has plenty of time to note the organisation of the hospital. They will see whether ward rounds are well-organised, whether they happen regularly, and whether the team seems efficient. A kind, caring team is noticed; as is a team that is simply in a hurry to get through a process.

The general atmosphere of the wards has an effect too. Are they well-decorated, and has thought been given to paintings and other such decor? Numerous studies have been done on the impact of art and design on patients’ sense of wellbeing.

Hospitals can be overwhelming for a patient – many are large, with little help to navigate them, and not enough thought given to making them a pleasant place to stay.

***What are some viable solutions to the shortage of healthcare professionals in rural areas?***

The health of those in rural areas is generally worse than that of those in urban areas and linked to increased poverty rates. The shortage of healthcare professionals is one of many issues affecting rural areas, such that the WHO set up its International Development Programme to bring about change to rural areas, focusing on resources, opportunities, education and health.

Even in countries where most people live rurally, healthcare remains focused in cities.

The first step toward encouraging more rural healthcare workers is reaching out to community colleges and schools, to encourage those from rural areas to enter healthcare. Studies have shown that come from these areas are more likely to return to them. Universities should ensure placements are readily available in rural areas for their medical and healthcare students. Indeed, a ‘rural’ rotation would emphasise the importance of family health.

The positives of working rurally should be spelled out (i.e. in workshops and lectures) to medical and health students, and those in early training – lower cost of living, proximity to cities without associated costs, a better space to raise children, and an abundance of leisure activities.

‘Golden handshakes’ are currently offered for some rural positions, but are likely more of a short term fix than long term solution. Ensuring the NHS emphasises the importance of equivalent wages for those in primary and secondary care would perhaps be more helpful.

***How do you know when you've learned enough?***

Learning *enough* is a personal choice or feeling as much as an objective level. If you were to judge based on examinations, then a C might be enough for some, and only an A\* enough for others. Therefore, one needs to understand one’s objectives, and what those objectives require.

If your objective requires three As at A-level, keep practising with past-papers until you’re overshooting the required mark, significantly, every time, and no questions appear that you are not confident on. When you’re at university, perhaps ‘learning enough’ will be similar; you’ve taken the time to learn each topic well enough that you’re confident on it.

As a healthcare professional, out of university, ‘learning enough’ becomes harder to pin down. You’ll still have exams, but must now ensure your knowledge is updated and can guarantee patient safety. Medicine, and healthcare as a whole, require life-long learning.

So perhaps you’ll never have learnt ‘enough’ – there are always new journal articles and advancements to discover, and old knowledge to refresh.

***Why do we give antibiotics for bacterial infections and not viral infections?***

Bacteria are complex single-celled organisms, with a cell-wall, capable of replication. Viruses consist of a protein coat encapsulating genetic material. They cannot survive or reproduce without a host cell.

Antibiotics may be bacteriostatic (they stop bacterial reproduction), bactericidal (they kill bacteria) or both. They may be broad-spectrum or narrow-spectrum. Most antibiotics work by inhibiting cell wall synthesis or protein synthesis, or they may work on certain enzymes found in bacteria.

Antibiotics are therefore ineffective against viruses because they are purpose-built for bacteria; the processes that they act against don’t happen in viruses. Instead, antivirals can be used; they act by inhibiting viral reproductive cycles.

***Why do you think HIV/AIDS is more prevalent in Africa than Europe or North America?***

This is a difficult question – the obvious answers of higher rate of injectable drug use, or more promiscuous behaviour, are seemingly not correct. A study in Botswana found that the average citizen has sex with between 1 and 3 people a year; hardly a big enough difference from America to justify a population having 33% infection rate vs 1% in the US. Most Africans with AIDS claim not to use drugs, nor have large numbers of sexual partners.

One theory that explains the prevalence is that of concurrent partners. This may allow the spread of disease through a population much more quickly. However, the most part of the literature now states that concurrent relationships are not more common in African than elsewhere.

Some traditional practises like widow inheritance and sexual cleansing have been found to increase the likelihood of HIV transmission.

Another possible factor is male circumcision – several studies have suggested that it protects both men and their partners from infection with HIV; it is not practised in southern or eastern African countries.

It seems likely that gender norms, and especially the male view of sex, may be the real cause of the increased prevalence of HIV in Africa. The idea that men ‘already’ know about sex and don’t need to be told more about it, normalisation of multiple concurrent sexual partners, and homosexuality being driven underground, and therefore entirely untested, may all be social factors that are contributory.