Doctors in sport † Dental SEA † What place for ... · † Doctors in sport † Dental SEA † What place for homeopathy? ... 101 TOP TIPS IN MEDICINE cynical and otherwise FOURTH

• Doctors in sport • Dental SEA • What place for homeopathy? •

Autumn 2010

JOURNAL OF THE MEDICAL AND DENTAL DEFENCE UNION OF SCOTLAND

MEDICINEMA – DOCTORS IN FILMS

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GETTING RESEARCH PUBLISHEDan A-Z of publication strategy SECOND EDITION


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101 TOP TIPS IN MEDICINEcynical and otherwiseFOURTH EDITION


DIAGNOSIS IN ACUTE MEDICINE


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3AUTUMN 2010

IN THIS ISSUEI read recently on the web that front man of the band Kiss,Gene Simmons, has his tongue insured for $1 million. On thesame site it’s claimed that Keith Richard’s middle finger iscovered for $1.6 million while Heidi Klum’s legs are insuredfor $2.2 million – one of them for only $1 million because ithas a scar. Such policies may be mostly PR stunts but theydo reflect a genuine risk.

Imagine an orthopaedic surgeon operating on the knee ofArgentinean footballer Lionel Messi. Last year the playerearned an estimated £29.6 million. It would take some deeppockets to bear the financial risk of a medical error endingsuch an athlete’s career. It’s for this reason MDDUS hasadopted a policy of not providing indemnity to doctors currentlyemployed full-time by clubs in the English Premiership, EnglishChampionship and the Scottish Premier League. The risk tothe Union has been judged too great.

But such a policy does not mean that MDDUS is averse todoctors working with athletes and on page 14 our risk adviserPeter Johnson highlights two sports medicine courses thatcan help mitigate risk for pitch-side doctors.

Also in this issue we feature a Q&A (p. 10) with GMC chairProfessor Sir Peter Rubin in which he discusses evolving plansfor revalidation and other changes facing medical professionalsin the UK. On page 12 Adrian O’Dowd looks at growingopposition to NHS funding for homeopathic remedies, and onpage 18 David Macpherson of NES offers a primer on significantevent analysis (SEA) as a means for dentists to comply withclinical audit requirements.

And this issue’s clinical risk article takes us back to sportsmedicine with tips on managing head injuries.

Jim Killgore, editor

Cover image: Pool by George Devlin.Devlin studied at Glasgow School ofArt from 1955 to 1960 where he wonthe premier awards and top nationalscholarships from the Royal ScottishAcademy before studying extensivelyin Europe.

Last issue’s cover was mistakenly attributed toGeorge Devlin but was, in fact, Orange and Red onPink by Wilhelmina Barns-Graham (1912-2004)

Art in Healthcare (formerly Paintings in HospitalsScotland) works with hospitals and healthcarecommunities across Scotland to encourage patients,visitors and staff to enjoy and engage with the visualarts. For more information visitwww.artinhealthcare.org.uk, Scottish Charity No: SC 036222. Photograph: Roslyn Gaunt

Editor: Jim KillgoreAssociate editor: Joanne Curran

Editorial departments:MEDICAL Dr Gail GilmartinDENTAL Mr Aubrey CraigLEGAL Simon DinnickRISK Peter Johnson

Please addresscorrespondence to:

Summons EditorMDDUSMackintosh House120 Blythswood StreetGlasgow G2 4EA

[email protected]

Design and production:CMYK Design0131 556 2220www.cmyk-design.co.uk

Printing and distribution:L&S Litho

Summons is published quarterly by The Medical and Dental Defence Union of Scotland, registered in Scotland No 5093 at Mackintosh House, 120 Blythswood Street, Glasgow G2 4EA. • Tel: 0845 270 2034 • Fax: 0141 228 1208

Email: General: [email protected] • Membership services: [email protected] • Marketing:[email protected] • Website: www.mddus.com The MDDUS is not an insurance company. All the benefits of membership of MDDUS arediscretionary as set out in the Memorandum and Articles of Association.The opinions, beliefs and viewpoints expressed by the various authors in Summons are those of the authors aloneand do not necessarily reflect the opinions or policies of The Medical and Dental Defence Union of Scotland.

12HOMEOPATHYAdrian O’Dowd focuses on the

contentious issue of offeringhomeopathy “on the NHS”

14DOCTORS IN SPORTMedical negligence claims in

sport are rare but can we keepindividual risk low?

16CLINICAL RISK REDUCTIONHead injuries –avoiding the

pitfalls in diagnosis and managementof head-injured patients

18DENTAL SIGNIFICANTEVENT ANALYSIS

Clinical audit is a requirement for all dentists but it need not be a box-ticking exercise

CONTENTS

14

12

16

REGULARS4 Notice Board 6 News Digest

8 Law At Work: Be wary of job

drift. 9 Ethics: Private lives, public

debate. 10 Q&A: Professor Sir Peter

Rubin 20 Case studies: Conflicting

scenarios; Simple mistakes, big

problem; Too much information

22 Addenda: An acid bath for

scabies, Early dental marketing,

Crossword and Vignette: Sir Cyril

Astley Clarke.

4 SUMMONS

IN BRIEF CORE DENTAL CPD The University of Glasgow is runninga one-day conference designed tohelp dentists and DCPs meet GDCrequirements for verifiable coreCPD. The event is being held at theLeeds Marriott Hotel on 18November and topics include

medical emergencies, radiographyand radiation protection, legal and ethical issues, and handlingcomplaints (presented by MDDUShead of dental division, Mr AubreyCraig). For a conference leaflet and more information go towww.tinyurls.co.uk/M12585

GPST MAGAZINE LAUNCHED MDDUS has launched a newpublication aimed at GP specialisttrainees. GPST is packed with practicalarticles and features aimed at doctorsembarking on a career in generalpractice. Contact [email protected] request a PDF or print copy.

NOTICE BOARD

Donald joins MDDUS Board at London AGM

Magazine columnist and dentist RobertDonald attended his first annual generalmeeting as an MDDUS board member in September.

Robert is a full-time general dentalpractitioner based in Nairn and has beenan elected member of the BDA's ScottishDental Practice Committee since 1994. He served as chairman of the Committeefor a time and currently sits on itsexecutive. He is also an elected member of the UK General Dental PracticeCommittee and has served as Secretary of Highland LDC since 1990. He is a formerdirector of Highland Dental Plan and aformer chairman of Independent CarePlans (UK).

Robert is currently a consultant editorand columnist for Dentistry Scotland andwas a regular contributor to the ScottishDentist magazine for several years.

Mr Donald said: “I am delighted to beinvolved with the MDDUS as a non-executive director as it expands itsoperations south of the border. Havingbeen a member since qualification, I greatly appreciate the service that theunion provides.”

MDDUS held its one hundred and seventhAGM at its new London office at PembertonRow, close to the capital’s legal centre, whichopened in February of this year.

The move away from the traditionalAGM venue at our Glasgow headquartersreflects the latest membership figures for

MDDUS which reveal that for the first timein its history, the majority of theorganisation’s GP members and just under50% of all members are now basedoutside Scotland.

New equality laws come into force

Tough new laws to combat discriminationhave come into force from October 1 andwill have an effect on employment practices.

The Equality Act 2010 aims to protectthe rights of individuals and promote equalityby updating and strengthening existinglegislation. It is made up of a number ofdifferent provisions which will be introducedin stages to allow individuals andorganisations time to prepare.

The vast majority of the act’s provisionscame into force on October 1 when thevarious pieces of discrimination legislationwere brought together into one law. Theact extends its provision to:

• Third party harassment• Associative discrimination• Perceptive discrimination• Indirect discrimination

The changes mean employers face increasedresponsibilities to protect their employeesfrom harassment on the basis of race,disability, religion, sexual orientation, genderor age. The government has described thelaws as “a simple, modern and accessibleframework of discrimination law” butpractices may find them challenging toimplement.

Under the new rules, employers will beresponsible for protecting employees fromharassment from a third party. This couldbe an individual who is not an employeesuch as a locum GP. Employers will also haveto be aware of rules over discrimination byassociation where they must protectemployees from being harassed or bulliedabout someone associated with them. Thiswould mean an employer being heldresponsible if, for example, someone makesjokes about the age of an employee’spartner.

Indirect discrimination also now coversdisability and gender reassignment, whileperceived discrimination extends toemployees who are perceived as having aprotected characteristic.

The Equality Act also aims to make it more

Update your contact detailsDo we have an up-to-date email address and mobile telephone

number for you? It’s important that MDDUS is able to contact membersif necessary – and possibly at short notice. So please [email protected] with your name, membership number andmobile telephone number to allow us to update your contact details.

Dental columnist Robert Donald joins theMDDUS board

5AUTUMN 2010

NOTICE BOARD

WIN A HAND-PAINTED LES PAUL GUITAR The charity Art in Healthcare (whosupply our Summons covers) israffling a hand-painted Gibson LesPaul guitar, donated by Gibson andthe Hard Rock Café, Edinburgh. Awinner will be drawn on 31 December

with all proceeds going to thecharity. Tickets cost £1. For moreinformation go towww.artinhealthcare.org.uk PRIMARY CARE LIVE HR and employment law adviser at MDDUS, Janice Sibbald, will beone of the expert speakers at the

dedicated practice managementstream at the Primary Care LiveConference being held in London’sExCeL on September 29-30 andthen in Manchester Central onNovember 25-26. She will discussthe latest developments inemployment law legislation

including the recent changes to the retirement process and newequality laws that come into force in October (see above). Admission is free to healthcare professionals.More details atwww.tinyurl.com/39tdtrw

difficult for disabled people to be screenedout when applying for jobs by restricting thecircumstances in which an employer can askabout disability or health issues.

For more information on the Equality Actlog onto www.tinyurl.com/2gyrk5n

For further guidance on HR andemployment law issues, contact the MDDUSEmployment Law Team on 0845 270 2034.Janice Sibbald, employment law adviser,MDDUS

Medico-legal report writingMDDUS is looking for experienced

general practitioners to prepare and writemedico-legal reports for the purpose ofassisting the organisation and itsmembers. These can be for claims fordamages, coroner’s inquests, fatal accidentinquiries or a variety of disciplinary orGMC matters. Many GPs will already beundertaking this kind of work and havesome experience in this field. Reports are,of course, paid for and the fees reflect thecurrent rates available for this work.

Experience in medico-legal work is notessential. However, we have basicrequirements for experience in generalpractice of not less than eight years andpossession of an MRCGP qualification.

If you are interested and want to knowmore please contact Dr Jim Rodger, Headof Medical Services, MDDUS, MackintoshHouse, 120 Blythswood Street, Glasgow, G2 4EA (tel. 0845 270 2034); email at [email protected]

Risk alert: delegate withcare

Should new government plans for healthcarereform in England come to pass one thing is certain –the GPs affected will be doing a lot more delegating. Howelse will they find time to run the NHS?

Delegation has been an increasing area of controversy in primary careover the last ten years with the rise of the nurse practitioner and healthcareassistant. In medico-legal terms it is a common area of risk but not due to theoverall quality of care offered by nurses and HCAs.

The GMC frames the issue clearly in Good Medical Practice: Delegation involves askinga colleague to provide treatment or care on your behalf. Although you will not beaccountable for the decisions and actions of those to whom you delegate, you will still beresponsible for the overall management of the patient, and accountable for your decisionto delegate. When you delegate care or treatment you must be satisfied that the personto whom you delegate has the qualifications, experience, knowledge and skills to providethe care or treatment involved. You must always pass on enough information aboutthe patient and the treatment they need.”

Each year MDDUS deals with many cases in which there has been a failure at theinterface between GPs/GDPs and practice staff. A typical example would be a nurseasked to syringe a patient’s ear. In one such case a practice nurse carried out the taskunder a GP’s instruction but neither had ascertained that the patient had previous earsurgery, which is an absolute contraindication. Both were named in subsequent legalaction although the nurse claimed she was just carrying out the task as ordered.

Here the case hinges on passing information but more often cases are to do with afailure to ensure that staff have appropriate training for carrying out a task such astaking blood. It is the responsibility of the GP to be satisfied that a delegated task iswithin a staff member’s competence.

A similar regulatory principle holds for members of the dental team. The GeneralDental Council states in Principles of Dental Team Working:

“If you employ, manage or lead a team, you should make sure that all the membersof your team understand their roles and responsibilities, including what decisions andactions have and have not been delegated to them…

“Only carry out a task or a type of treatment if you are sure that you have been trainedand are competent to do it.

“Only ask another member of the team to carry out a task or a type of treatment if youare confident that they have been trained and are competent to do it.”

It is clear there is a shared responsibility to ensure that all medical or dental treatmentis carried out only by appropriate and fully trained staff. But the ultimate responsibilityfor ensuring this is the case must rest with the employing GP or GDP and it is here thatany major liability will certainly be borne. Remember also to keep good records of allstaff training as proof of competence.

Professor Clive Seale, professor ofmedical sociology at Queen Mary, Universityof London, said in the BMJ: “Religion playsquite a big part in influencing what GPsthink and do when they are dealing withend-of-life care decisions... If I were apatient approaching the end of my life, Iwould want a discussion about religiousviews with my GP.”

Plans revealed for simplerrevalidation

GPs UNDERGOING revalidation will be askedto submit fewer reports than previouslythought, according to RCGP revalidationlead Professor Mike Pringle.

He said GPs will have to fill out onemulti-source feedback (MSF) questionnaireand one patient survey every five years,rather than two of each as previouslyproposed. The move was reported in GPmagazine where Professor Pringle said thepolicy decision had been made, and wouldbe outlined in the next version of the college'srevalidation guide, due to be releasedbefore Christmas.

Professor Pringle said the change was a“key area” that would make a significantdifference to GPs in revalidation. He told GP:“The decision has largely come in responseto the GPC, which has been helpful in lookingat the guidance and at where it thinks theproposals can be streamlined. It is currentlymy intention that the next version of therevalidation guide will reduce the expectationof the MSF and patient surveys.”

The changes were confirmed as the GMCclaimed its latest revalidation plans hadreceived “huge support” from both doctorsand patients. GMC chief executive NiallDickson said there was “strong backing” formany of the proposals including the moveto a more streamlined process, but headmitted there were concerns about howrevalidation will work in practice and whenit will be introduced.

A full report on the revalidationconsultation will be published on October18 which will include a timetable for theintroduction of the scheme across the UK.

6 SUMMONS

NEWS DIGEST

IN BRIEF MANDATORY CQCREGISTRATION All dental practicesin England should now begin theprocess of registering with the CareQuality Commission as more than8,5000 providers of dental serviceswill be required to register by 1 April2011. Providers applying as a

partnership or organisation will berequired to have a registered manager.The CQC has issued guidance whichis available on its website or in hardcopy. For more information visitwww.cqc.org.uk/dental or phone an adviser at the national contactcentre (NCC) on 03000 616161.

MEDICAL MANAGEMENTFACULTY PROPOSED Proposals for a new Faculty of MedicalLeadership and Management arebeing developed by the RCGP andRCP on behalf of the Academy ofMedical Royal Colleges and otherstakeholders. The faculty is intended

to prepare doctors for leadershiproles to enable them to “better deliveron their multiple commitments to the patient, to fellow professionalsand to the organisations and systemswithin which healthcare is provided”.See www.tinyurl.com/393q52ufor more details.

Doctors’ beliefs influence end-of-life care

DOCTORS who have no strong religiousbeliefs are almost twice as likely to hastenthe death of a very sick patient, accordingto new research. The report in the Journalof Medical Ethics found that doctors witha strong faith are less likely to discuss thistype of treatment with a patient.

Almost 4,000 UK doctors from a rangeof specialties responded to a survey askingabout their religious beliefs. Researchersthen asked whether they supported thelegalisation of assisted dying, whether theyhad ever provided continuous deep sedationuntil a patient’s death, whether they hadknowingly taken a decision that had hastenedthe end of a patient’s life, and whether intaking that decision they had discussed itwith the patient beforehand.

Irrespective of specialty, doctors whodescribed themselves as “extremely” or

GDC consultation on dentaleducation

A REVISED approach to dental traininghas been set out in a new GDCconsultation document. LearningOutcomes is intended to replace both theundergraduate dental curriculum set outin The First Five Years and the DCPcurricula Developing the Dental Team.

The GDC is seeking views on thedocument from various groups includingdentists, dental and DCP students, thoseinvolved in dental training and education,professional associations and otherregulatory bodies. The GDC said thecontent was guided by the priorities ofthe government White Paper Trust,assurance and safety which include:

• safety and quality of care for patients • sustaining, improving and assuring professional standards •no unnecessary burdens •UK standards with country-specific flexibility.

The council has focused on four key areas:clinical, communication, professionalismand management and leadership.Learning Outcomes sets out the GDC’sexpectations for each differentregistrant group.

Education committee chairman KevinO’Brien said: “The aim is to develop arounded professional who, in addition tobeing a competent clinician ortechnician, will have the range ofprofessional skills required to beginworking as part of a dental team and bewell prepared for independent practice.”

For more information go to www.gdc-uk.org

“very non-religious” were almost twice aslikely to report having taken these kinds ofdecisions as those with a religious belief.The most religious doctors were significantlyless likely to have discussed end-of-life caredecisions with their patients.

7AUTUMN 2010

NEWS DIGEST

TREATING SEVEREASTHMA Research reportedlast month in The Lancet hasfound that at least half ofchildren with problematic severeasthma have been misdiagnosedor are using prescribedtreatments incorrectly.

The authors conclude that athorough multidisciplinaryassessment should result in these children beingsuccessfully managed withstandard treatment. Go towww.tinyurl.com/2b9xqakfor the full citation.

ASPIRIN TO REDUCEHYPERTENSION RISKS INPREGNANCY Pregnant women athigh risk of developing hypertensivedisorders in pregnancy should beencouraged to take small doses ofaspirin to help prevent complications,according to recent NICE guidelines.

The new guidance recommends thata low dose (75mg) of aspirin shouldbe offered daily to women at highrisk of developing hypertension inpregnancy, such as those with chronickidney disease, autoimmune disease,diabetes or chronic hypertension. Goto www.guidance.nice.org.uk/CG107

GDC acts on fitness to practise delaysA 40 PER CENT rise in the GDC's fitness to practise (FtP)

case load has prompted the regulator to consult on a rule changethat will allow the employment of 50 more panel members.

The rise in case load is being blamed for a backlog and delays ingetting cases heard and the GDC is focusing resources in this area asa priority to speed up the process. FtP panel members sit on publichearings, which are the final stages of investigations into dental

professionals. Panel members can be asked to make difficultdecisions about whether the GDC should step in to set out howand if a dental professional should carry on working.

Before the Council can increase FtP panel member numbers itmust consult as this requires a change to the Council’sConstitution of Committees Rules 2009. The consultation isavailable on the GDC’s website at www.gdc-uk.org and will rununtil 22 October 2010.

Twenty years ago, not so long to many ofus in practice today, the GMC publishedthe ‘blue book’ containing its consideredwisdom on good ethical practice for themedical profession. The booklet ran to 35pages and covered, well, everything adoctor needed to know in relation toprofessional ethics, as well as informationabout the GMC’s disciplinary processes.

Today we have in the order of 20 GMCbooklets and a range of web materials,some very clever and interactive – but as Iread the recent guidance on end-of-lifedecisions it struck me that not much hasreally changed.

In the very old days – pre-GMC – medicalethics existed in a variety of forms, someancient indeed. The Hippocratic Oath, forexample, involves the physician swearingto use his abilities to benefit the sick anddo no harm, to remain free from intentionalinjustice, not to “use the knife” but to deferin this work to those who have the

necessary skill and to keep to himself allthat he sees or hears in the course oftreating a patient.

The Oath states further that there willbe no “mischief” of a sexual nature withpatients, that the physician will notadminister a deadly drug to those whorequest such, nor would he give a womanan abortive remedy. Serious attention isalso paid to allegiance with colleaguesand teaching.

Much of this resonates in modern times.The blue book covers many of the sameissues; for example, personal responsibilityto act in the patient’s interests, to maintainconfidentiality, not to abuse professionalprivileges in personal dealings with patients,to refer to appropriate specialists and todesist from disparaging colleagues.Mention is also made of complying withabortion legislation.

None of this is surprising in a field whichhas been around in one guise or anotherfor some 5,000 years (I am not includingprehistoric remedies but the AncientEgyptians had formalised medical practice).Basic ethical codes such as beneficence,non-malfeasance, respect for autonomyand justice are common threads and onewould expect these codes to have stoodthe test of time.

So in considering GMC guidance todaywhat has changed?

There is certainly a lot of detailedexplanation about the circumstancesdoctors face in their day-to-day practiceand what would be the most appropriateaction. There is often a range of next bestoptions too. Today medicine comprises ahuge variety of different specialities and

each has its own particular factors whichmay lead to difficult professional ethicaldecisions; for example, the neonatologistwill have very different considerationscompared to a sexual health physician. Thenew guidance reflects this broadened scope.

For years medical professionals havesought clarity from the GMC on makingappropriate choices and avoiding potentialdisciplinary challenges – and the GMC hasresponded. We now have a lot ofdescriptive guidance. Some of it may notbe terribly helpful, depending on the fieldin which you practice. But the coreguidance remains in Good Medical Practice.

Doctors are still required to make thepatient’s care their priority, respect patientsand not discriminate unfairly, maintainconfidentiality and act with honesty andintegrity. Please forgive this very briefsummary but this piece does not allowtoo much detail – which I hope is notnecessary to make the final point.

Keeping abreast of the most up-to-datedetailed guidance from the GMC can provechallenging – especially if it appears thatsome of the guidance is not for you.However, it is essential that we are awareof the profession’s stance on importantissues.

No doubt the ‘blue book’ lives on in GoodMedical Practice and practitioners shouldat least be familiar with that publication– it covers all the basics. And whilst mostof us would find no surprises in there it isimportant to be reminded of thestandards we hold as a profession. Anylack of awareness of these standardsmay well lead to significantdifficulty.

OPINION

By Dr Gail Gilmartin,Senior Medical Adviser, MDDUS

Blue book redux

LAW AT WORK

8 SUMMONS

IT IS ARGUABLY a manager’s greatestwish that the staff he or she manage notonly do a good job – but also take on extraresponsibilities without bidding and for noextra pay. Yet there can be some unforeseendisadvantages to such willing horses.

Most job descriptions these days containa clause stating that the employee will beexpected to take on such reasonable extraduties as are allocated to them by theirmanager. If such flexibility is not built intothe contract of employment there is a riskthat employees may insist that any extraduties are not their responsibility and/orthat they require extra recompense forundertaking them. In any case, there is anargument that, in the event of a dispute onthe matter, such flexibility might be impliedinto contracts of employment, even if therequirement is not expressly stated in thedocumentation.

More common is the situation where therange of duties undertaken is not formallyamended but the employee drifts intoperforming work that needs to be doneand the manager simply allows them to doso, for convenience. In the majority of cases,this is unproblematic.

However, a downside of allowing this‘job drift’ is that the best and most willingperformers get the heaviest workloads –with the risk for them of burnout (or, atleast, diminishing productivity). It alsomeans that other staff who might requiredevelopment (or, indeed, to be kept fullyoccupied) avoid these tasks.

Another risk, of course, is that staff whoare taking on ‘extra’ duties (albeit with theacquiescence of their manager) may findthat the new duties are more interesting,amenable or even taxing, than their original“mundane and boring” work. It is a naturalprogression from this to allowing the moremundane work to slip down their list ofpriorities and the manager then finds thatmistakes or missed deadlines are creepinginto the staff member’s performance.

From the viewpoint of the staff member,there can be a risk that, having agreed tocarry out extra work over and above theirnormal duties, it becomes over time an

Law At Work is MDDUS preferred supplier of employment

law and health and safety services. For more information

and contact details please visit www.lawatwork.co.uk

BE WARY OF JOB DRIFTIan Watson

implied part of their contract ofemployment. In other words, they aretransformed from being willing volunteersinto press-ganged workers. Naturally, thiscan play into the hands of an unscrupulousemployer. Conversely, allowing a drift awayfrom an employee’s basic contractual dutiesto more interesting work can mean that aclever employee can argue, after anappropriate period of time has elapsed,that the new duties are now contractualand old duties have ‘dropped off’ their jobdescription.

All of this suggests that allowing staffto carry out more stretching or importanttasks can be a vital part of maintainingmotivation and loyalty to the organisation– or meeting a short-term need in theworkplace. However, as the list ofdisadvantages above suggest, it might beimportant for any such job drift to be donerelatively formally and in a planned wayrather than pragmatically or chaotically (oreven by stealth).

The annual appraisal review process cangive manager and staff member theopportunity to review the relevance of theformal job description. It is perfectlylegitimate (indeed, essential) for such a

discussion – about exactly what theemployee does day to day – to precede anyassessment of how they have performedthose duties in the past review period. Ifthere is agreement at the appraisal meetingthat the job description needs to berevisited and the new role formalised in anamendment to the contract ofemployment, then this can be a logicalagreed action resulting from the annualappraisal. The contract will have been variedby agreement and will then be legallybinding on both parties. Of course, thispermanent change may have implicationsfor grading of the job or, possibly, thesalary of the job holder.

If it is agreed at the appraisal that thejob drift was a mistake or only intended tobe short term, or that these duties shouldmore usefully be performed by someoneelse, the arrangement can be terminatedwithout contractual implication for eitherparty.

The message is – don’t look a willingworker in the mouth, but ensure that youdon’t flog that horse to death!

Ian Watson is training services manager atLaw At Work

ETHICS

9AUTUMN 2010

IT’S THE TIME of year when I am star-struck. I am a panelist on the programmeInside the Ethics Committee. As a passionateRadio 4 listener, spotting Jenni Murray inthe loo, Evan Davis in the BBC canteen andsharing a studio with the Woman’s Hourcooker cause me much excitement. Asidefrom glimpsing radio idols, participating inthe series has been fulfilling and thought-provoking, prompting reflection on therelationship between ethics and the media.

Ethics is (despite what medical studentssometimes feel) a sexy subject. People’slives become ‘stories’ daily. Ethical debatesrage in the news, on discussion programmes,in broadsheet editorials and tabloid headlines.Ethical issues are a rich source for dramaticwork: Inside the Ethics Committee has beenaccompanied by three plays.

Requests from journalists and producersare common in my working life yet I confessto ambivalence about ethics and itspresentation in the media. Whilst I believeethics should be public and inclusive, mediawork must be undertaken responsibly,authentically and honestly. When doneproperly, the media can provide a uniquevehicle for ethical discussion.

Most ethical decisions neither are, norshould be, the preserve of ethicists. Peoplemake moral choices every day and not justin relation to healthcare. Clinicians and

patients share values and negotiate prioritiesroutinely in surgeries, clinics and wardsacross the land. The perspectives of thosewho make and live with these daily choicesare rarely well-captured. In situations wherethe media becomes involved, there can bedistortion, distress and misunderstanding.Yet, I have learned from my work withRadio 4 in ways I never imagined when Ioriginally agreed to participate six years ago.

The experience of hearing people’s stories,really hearing them properly, is immeasurablyvaluable. Clinical practice and bioethics areproblem-focused. From the earliest days,clinicians learn to sift information, seekingkey points, looking for patterns and listeningfor alarm bells. A skill quickly acquired andrequired in clinical training is the ability topresent, and respond to, a ‘case’. We learnhow to translate unstructured descriptionsinto histories, disparate subjectivity intoobjectively discernible signs and emotionsinto manageable agendas. We turn toconsultation models and mnemonics toassist in navigating the messy anddiscomforting worlds of patients.

Many clinicians do this well and havefinely-honed communication skills and anabundance of empathy, but even the bestwill rarely have time to hear the multiplevoices and perspectives that imbue moraldecisions in healthcare. Both the words andthe expression of words matter in ethicsand medicine. Yet, we are adept at inferring,assuming and even imposing meaning:individual experience is quickly bundledup in concepts such as autonomy, rights,utilitarianism and best interests.

Consider Emily and Callum, whoseexperiences were discussed in the finalepisode of Inside the Ethics Committee. The subject was chronic pain, end-of-lifedecision-making and assisted dying. I havetaught and written about the issues raisedin the programme often. In preparation, Imentally listed relevant concepts that shouldinform the discussion including acts andomissions, the doctrine of double effect,the nature of the therapeutic relationshipand the notion of futility.

However, when in the studio hearingEmily and Callum’s stories, the perceptionsand anxieties of the clinical team, theemotions and competing priorities, mytextbook analysis seemed inadequate.Ethical concepts appeared a simplisticresponse to the palpable discomfort,uncertainty, hope, expectation and fear.A good decision was not one that neatlyparceled the life and death of Emily into anethico-legal framework. Her words werecentral, her story was unique, messy,changing, unclear and, at times, redolentwith contradiction and regret. We wereprivileged to share it. The experiences ofEmily, Callum and the clinical team involvedwere not just another vignette to illustratecore ethical concepts at the end of life.

In the programme, clinicians, patientsand families come together as equals andall share a common task, namely reflectingon, explaining and describing theirexperiences in their own words. The vestigesof daily clinical practice are stripped awayand what remains is the stuff of life (anddeath). It is an exercise in revealing thatwhich is hidden, in sharing that whichwould otherwise not be known and inacknowledging diversity and disagreement.

Working with the media has led me torevisit what I take for granted, to attend tothe emotion of ethical decision-making, tolisten to every carefully-chosen word andto engage with multiple meanings. Whilst Iam not keen on sound bites, I do believethat sound bites and, when we are used tobeing the expert dealing with that whichappears routine, it is important to bereminded of its power.

Deborah Bowman is a senior lecturer inmedical ethics and law at St George’s,University of London

PRIVATE LIVES,PUBLIC DEBATEDeborah Bowman

10 SUMMONS

Revalidation, the newgovernment white paper onNHS reform, the PMETBmerger – it’s a crucial stagein the development of theGeneral Medical Council.Here Professor Sir Peter Rubinreflects on the challenging roleof GMC chair

P ROFESSOR Sir Peter Rubin has hada hugely varied career in medicine.He has been involved in extensive

research on the safe and effective use ofdrugs in pregnancy, written books on clinicalpharmacology and helped establish theNottingham Veterinary School, the first newvet school in the UK for over half a century.

But it was partly chance that led him tothe GMC in 1998. Professor Rubin was deanof the faculty of medicine and health sciencesat Nottingham when it was the University’sturn to nominate a dean to the Council. Sincethen he has never looked back.

He remains professor of therapeutics atNottingham and consultant physician at theQueen’s Medical Centre and a non-

executive director of Nottingham HealthAuthority. In June 2010 he was awarded aknighthood for services to medicine in TheQueen’s Birthday Honours List.

Why has the decision been made toextend the pilot period for revalidation?The Health Secretary, Andrew Lansley,recently extended the piloting phase for afurther year in England so we can beabsolutely confident that local systems ofappraisal and clinical governance, on whichrevalidation will be based, are in place andworking effectively. We need not only toensure that revalidation adds value for bothpatients and doctors but is also practicaland workable in the context of the pressured

and busy environments in which mostdoctors work. Revalidation will only beintroduced once we are satisfied that thelocal systems necessary to support doctorsin meeting the requirements ofrevalidation have been properly tested. Weare determined to get it right and want astraightforward process which is genuinelyhelpful for doctors, patients and employers.

Will revalidation stand solely on thequality of local appraisal systems?The annual appraisal will be the main wayin which doctors will demonstrate that theyare up to date and fit to practise in theirchosen field. We know, however, that thequality of appraisal in different parts of the

Leading ina time ofchange

11AUTUMN 2010

UK is inconsistent at the moment and thisneeds to change. At least part of everydoctor’s annual appraisal should involvean evaluation of their performance againstthe professional standards set by the GMC.For most doctors, this annual evaluation oftheir practice through appraisal will benothing new. In future, it will help themand their appraisers to link their performanceto national standards and identify any areasfor action and address any concerns longbefore they are required to revalidate.

How would you respond to the worry thatrevalidation will eat up valuable clinicaltime with the administrative burden?We know it needs to be simple. Revalidationrelies primarily on appraisal, which in turnis based on showing that we as doctors areup to date in our area of practice. Much ofthat is to do with continuing medicaleducation, which we all do anyway.Recording what you’ve done as you goalong, for example in an e-portfolio as I do,will help enormously to minimise the timespent in preparing for appraisal. Multisource(360 degree) feedback should be done onceor twice in a five-year cycle. With a bit ofplanning, it can again be pretty smooth –for example, I send MSF forms to newpatients coming to my hypertension clinicand collate the replies periodically.

How about the concern that revalidationmay be used to settle old scores within aPCT or other health organisation?No one should face discrimination or unfairtreatment in the workplace. All of thestakeholders involved in the introductionof revalidation, including the GMC, arefully committed to ensuring thatrevalidation is a fair and transparent processfor all doctors.

In the responsible officer draft regulations,which have now been laid before Parliament,the Department of Health requires the PCT,or other 'designated bodies' to ensure thereis no ‘conflict of interest’ or ‘appearance ofbias’ between practitioners and theresponsible officer appointed. The regulationsalso place a duty on organisations to appointan additional responsible officer where thereis a conflict of interest or an appearance ofbias between a doctor and the first appointedresponsible officer.

We have also developed a Good MedicalPractice Framework for appraisal andassessment to be used in all appraisals fordoctors, which should help to ensure furtherconsistency in the process.

What do you see as the main benefit in themerger of the PMETB (PostgraduateMedical Education and Training Board)with the GMC?For the first time ever, one UK organisationsets the standards for all stages of medicaleducation and training, operates the registerof doctors and ensures they are competentand fit to practise. The GMC can ensurethat every stage of education and trainingsuccessfully prepares the doctor for the nextone and standards are continually improved.Our education strategy 2011-2013, whichwe are in the process of developing, will setout exactly how we will do this.

How do you feel being the chair of the GMCat this crucial stage in its development?I feel hugely privileged to be doing this jobat this time. Leading change is what I enjoymost and there’s certainly a lot of change tolead right now! Medical colleagues oftenlook askance when I say that I look forwardto going to work at the GMC, but it’s true.

We deal with fascinating, varied andimportant issues and the breadth of ouractivities – spanning education, registration,standards and fitness to practise – ensuresthere’s rarely a dull moment.

What inspired you to go into medicine?I was the first member of my family to goto university, so there was no professionaltradition to follow. I really enjoyed scienceat school and I liked people. Medicineseemed like a good idea and my teachersencouraged me to go for it. Most of theLondon medical schools turned me downwithout interview. St Mary’s offered me aplace (having ascertained what position Iplayed at rugby!) but very kindly suggestedI should go to Cambridge, which I did.

How can the UK do more to encouragemedical students from lower incomebackgrounds?I think raising the aspirations of youngpeople well before they make career choicesis key. Universities can play a part – andmany medical schools have a variety ofschemes to try and widen access. However,if people don’t apply to medical school theywon’t get in. We’ve also got to accept thatthe financial landscape is very different tothe one in which I chose medicine – I had afull student grant which in today’s moneywas around £5500 per year and paid no fees.For many young people, the prospect ofaccumulating a large debt is going to be amajor disincentive, but medical schools inthe UK in general don’t have the hugeendowments enjoyed by the top institutionsin, for example, the USA which can providesignificant scholarships.

What are the main differences betweenthe GMC of today and the GMC whenyou started your career?I don’t think the GMC crossed my mindwhen I started my career! I ended up onthe GMC rather randomly in 1998, when itwas Nottingham’s turn to nominate a deanof a medical school to the huge Council of

104 people. I have to say that I entered aworld that seemed pretty detached from theone in which I lived and worked. We’veundergone enormous change in the last 10years and continue to do so. In the past, wehave too often been reactive and inwardlooking, but we are now far more ready totake a stand on tricky issues – for examplelanguage testing for graduates fromelsewhere in the EU. I think we are now amuch more outward-facing organisation,but I know we have a way to go to ensurethat we communicate effectively andappropriately with those who pay for us.

Interview by Jim Killgore, editor ofMDDUS Summons

Q&A

“In the past, we (the GMC) have too often been reactive

and inward looking, but we are now far more ready to

take a stand on tricky issues…”

More than 400 GPs in the UK practise homeopathy, treatingaround 200,000 NHS patients per year this way. The NHSspends approximately £4 million a year on homeopathy fortreatments and funding of the homeopathic hospitals – around0.001 per cent of the £11 billion drugs budget.

Despite its firm footing in the NHS, homeopathy hasprompted strong criticism for receiving NHS funding, initiallyemerging at the BMA’s junior doctors’ conference in May andthen again at the full BMA annual conference in June.

One of the most notable and outspoken critics addressingthe conference was Dr Tom Dolphin, vice chair of the BMA’sjunior doctors’ committee.

Dr Dolphin says: “I don’t have a huge problem with the useof placebos as they clearly do have benefits for patients. Theproblem I have with homeopathy is that it is dressing up placebowith pseudo-science, which if you look at it, is farcical. Myopinion of homeopathy is that it is nonsense and has no basisin clinical reality.

“Because of that, patients are being misled into thinkingthere’s more to it than there is. In over 100 clinical trials, it’snever been shown to be any better than placebo.”

He accepts that the £4million being spent by the NHS onhomeopathy is not a huge amount from the NHS’s overallbudget, but adds: “It is a waste of NHS resources and havingit supported by the government gives it an undue legitimacy.I’d like to think in an era of austerity that things that haveshown in many clinical trials to have no benefit would bestopped.”

Dr Mary McCarthy, a GP from Shropshire, who proposed themotion said at the conference: “Homeopathy can do harm – itcan divert people from conventional medicine.

“We are not asking for homeopathy to be stopped. What weare asking is that it’s not funded by scarce NHS resources.”

Why ban something that works?However, other doctors at the conference spoke in favour ofhomeopathy, such as Dr John Garner, a GP from Edinburgh,who said: “Some patients find benefit and relief in homeopathictreatments be it placebo effect or not.

12 SUMMONS

Offering homeopathy “on the NHS” is a highly contentious issueamong medical professionals today. Adrian O’Dowd looks at thecurrent state of debate

HOMEOPATHY sounds harmless. Its very nature isbased on treatments that are highly diluted and non-toxic versions of an original substance.

But what is a benign and popular range of treatments for somepeople has recently provoked a perhaps surprisingly strong andangry reaction from parts of the medical profession.

Some doctors want an end to any NHS funding for suchtreatments and to stop pharmacists from labeling homeopathicproducts as ‘medicines’.

A storm erupted at this year’s BMA annual conference inJune where during one of the longest and most animated debates,delegates voted overwhelmingly for an anti-homeopathy motion.

Prior to the debate, supporters of homeopathy gathered infront of the conference venue in Brighton with banners andplacards to let doctors entering the building know their viewsand urge them not to vote for the motion.

Despite this, three quarters of the doctors there agreed thatin the absence of valid scientific evidence of benefit, there shouldbe no further commissioning of, nor funding for, homeopathicremedies or hospitals in the NHS.

Even more (82 per cent) voted in another part of the motionthat no UK training post should include a placement inhomeopathy, and 63 per cent agreed that pharmacists shouldremove homeopathic remedies from shelves if they are presentedas ‘medicines’ and only sell them if clearly labelled as ‘placebos’.

Homeopaths were surprised at the degree of animosity voicedat the conference about the treatments and are now worried thatthe next generation of doctors is becoming more conservativeand intransigent.

Effective treatment or placebo?Homeopathy – a system of healing which claims to help thenatural tendency of the body to heal itself – was first proposedin 1796 by German doctor Samuel Hahnemann.

Some forms of complementary medicine includinghomeopathy have been integrated with the NHS ever since itstarted in 1948 and there are four NHS homeopathic hospitalsin Bristol, Glasgow, Liverpool and London, which treat 55,000patients a year collectively.

What place forhomeopathy?

DEBATE

13AUTUMN 2010

know there are homeopathic treatments that might not workat all. I would want to try the best for the patient.”

Asked why he thinks there is real antipathy to homeopathyin some parts of the medical profession, he says: “I think it’sbecause there isn’t a scientific basis to the theory of why it works.In 100 or 200 years time, we will discover why it works but atthe moment we don’t know why.”

Dr Jagger believes more should be spent by the NHS onhomeopathy and argues that the homeopathic hospitals havean important part to play.

“These hospitals do an enormous amount of good work thatwould be far more expensively addressed elsewhere. Homeopathyis a very useful adjunct to what we’ve got and we would be lostwithout it.”

Political argumentOpposition to homeopathy also emerged earlier this year whenMPs on the House of Commons’ Science and Technology SelectCommittee published a report of their inquiry into homeopathy1

in February, calling for a ban on NHS funding. MPs on thecommittee urged the government to withdraw NHS funding forsuch treatments and for the medicines regulator to stop licensinghomeopathic products. For doctors to prescribe a homeopathictreatment was damaging the integrity of the doctor-patientrelationship, said the committee.

Despite this, in July, the Department of Health published itsofficial response2 to the report and rejected the MPs call, sayingit supported NHS funding for homeopathy. The Departmentsaid the use of homeopathy on the NHS did not amount to a“risk to patient trust, choice or safety”.

Public health minister, Anne Milton said: “We believe inpatients being able to make informed choices about theirtreatment, and in a clinician being able to prescribe the treatmentthey feel most appropriate in particular circumstances, whichincludes complementary or alternative treatments such ashomeopathy.”

Homeopathy, it seems, has for now won the argument to stay.

Adrian O’Dowd is a freelance medical journalist

WEB LINKS

1 http://tinyurl.com/329mk2e

2 http://tinyurl.com/2vmv6pt

“We have a duty to support patients if something works forthem. This [ban] would deprive patients who have found benefitfrom homeopathic remedies in their current treatments. ”

Organisations like the British Homeopathic Association andthe Faculty of Homeopathy, which represents doctors whopractise homeopathy, were also not impressed with some ofthe comments made during the BMA debate.

Dr Graham Jagger, a GP and NHS primary care representativeon the board of the Faculty, says: “To stop NHS funding forhomeopathy is not going to save very much money at all.”

Dr Jagger feels the BMA debate reflects a shift in attitudes.He says: “We’ve been going through a change of junior doctors’training that has unsettled the whole medical profession quite radically.

“The doctors are becoming a lot more conservative and morereactionary. It’s almost like a dark ages that we are going into.Doctors now have to look as if they’ve got their roots firmlyon the ground and can’t look as if they are free thinkers orlateral thinkers.”

Dr Jagger says he has never been keen on placebos, but adds:“There is a placebo effect in everything. I don’t switch on myplacebo hat just when I do prescribing for homeopathy.

“Most of what I am doing might have some placebo effect;if I prescribe an aspirin, it will have a placebo effect as much asif I prescribed a homeopathic tablet. But I wouldn’t prescribeplacebo as a treatment.”

Dr Jagger says he tends to recommend homeopathic treatmentto patients instead of conventional medicine in about 10 percent of cases. In situations where a patient chooses a homeopathictreatment rather than conventional medicine, he believes theredoes not need to be an ethical dilemma for doctors.

“There needn’t be a dilemma as long as we are treatingsomething that we feel is going to respond and is not dangerousto do,” he says.

“If someone came in with malaria, for example, and saidthey’d rather have homeopathy, I’d say no. We know thatthere are conventional treatments that work very well and we

"We are not asking for homeopathy to be

stopped. What we are asking is that it’s not

funded by scarce NHS resources." - Dr Mary McCarthy

14 SUMMONS

I N 2003, a relatively unknown Manchester United youthplayer named Benjamin Collett had his right leg broken intwo places in a tackle by Gary Smith of Middlesbrough FC.

The injury ended his career and later lead to a suit for damagesagainst Smith and his club.

In the court case Sir Alex Ferguson would testify that Colletthad an “outstanding chance” of becoming a full-timeprofessional. Lawyers for the young player would contendthat in his prime Collete would have earned more than £13,000a week and could have played until the age of 35 in either ofthe top two divisions in England. On the basis of Collet’searning potential the court award him £4.3m in damages.

In this case the liability for the injury was borne by anopposing player and his club but consider an alternativescenario where the negligent actions of a doctor had endedthe player’s career. Would a court have ruled any differently?

To some doctors, sports medicine is the ultimate career –exciting, rewarding and glamorous. But it is also a professionwhere there is a constant need to mitigate the risk of somethinggoing wrong, not only to protect athletes but also to avoid thepotentially severe financial implications should an adverseincident end in court.

The level of riskTop football players in the English Premier league are believedto be earning over £100k per week and a few Scottish PremierLeague players may be earning over £30k per week. Transferfees are regularly reported at well over £5m. The potential lossof earning is clearly very high and it is not just footballers thatcarry the risk.

One internet search ranked association football as sixth in

the top ten highest paid worldwide sports. This would implythat doctors could be working with other sports professionalswho are more highly paid than footballers, for example boxersand formula one racing drivers. However, the overall frequencyand volume of medical treatment in these sports is likely to bemuch lower and UK association football remains thepredominant sport in terms of medico-legal risk in bothlikelihood and impact.

There have been a few well-publicised cases. In 2008 lawyersfor former footballer Brian Welsh negotiated a “substantialsum” after a negligence claim against a club doctor atHibernian FC. Welsh was given a steroid injection by thedoctor when he suffered pain during a game in 1998. He allegedthat the injection into his left Achilles tendon caused injurythat effectively ended his career in football. The case was settledwithout the doctor admitting liability.

Doctors working with top professional footballers face a clearrisk of major medical negligence settlement costs. This is notsomething that MDDUS as an organisation can ignore and itis only sensible that we limit the exposure of our membershipto very large claims. Our policy is that we do not indemnifydoctors who are currently employed full-time by the EnglishPremiership, English Championship and the Scottish PremierLeague (non-indemnity membership is still available).

Reducing risk in sports medicineSuch a policy does not mean that MDDUS is averse to doctorsworking with other athletes. But we do encourage sportsdoctors to obtain appropriate training or a recognisedqualification related to working with sports professionals andamateurs. A number of sports medicine courses are run either

Doctorsin sportMDDUS provides protection tomany members who workregularly with athletes, saysMDDUS risk manager PeterJohnson. Medical negligenceclaims in sport are rare but canwe keep individual risk low?

RISK MANAGEMENT

PHOTOGRAPH: LEE SMITH/ACTION IMAGES

15AUTUMN 2010

in association with the Football Association (FA) in Englandor the Scottish Football Association (SFA) in Scotland.

One such course provider is REMO (Resuscitation andEmergency Management Onfield) which is based in England.It was established in 2001 when the British Olympic Associationand the United Kingdom Association of Doctors in Sportcommissioned the development of an immediate medical careand resuscitation course tailored specifically for doctors andphysiotherapists working in sport. The first REMO course waspiloted in 2002 for doctors working in Olympic sport and wasthe first of its kind developed specifically for medical staffcovering elite teams.

REMO provides training for medical practitioners coveringover 25 different sports ranging from judo to football to rowing.The focus is on initial assessment and emergency managementof an injured or unwell athlete. Topics covered during thetwo-day course include airway management, basic andadvanced life support, automated external defibrillation,spinal immobilisation, orthopaedic emergencies andmanagement of head injuries and maxillofacial trauma. Eachsession begins with a detailed introductory lecture before apractical session with time for instruction and feedback.

Over 500 people have completed the REMO course and it isnow a compulsory qualification for UK specialist trainees insports and exercise medicine. REMO also runs a coursespecifically for healthcare staff working in professional football.AREA (Advanced Resuscitation and Emergency Aid) wascommissioned by the Football Association in 2008 and thecourse has now become a mandatory qualification for allmedical staff required to run on to the pitch to attend injuredplayers in the Premier League.

REMO holds to the principle that course presenters should“only teach what they do” and all lecturers are specialists intheir field. The course has been accredited with the Faculty ofSports and Exercise Medicine at the Royal College of Surgeonsin Ireland and it is recognised for 11.5 CME points. It is currentlyunder review for accreditation with the Faculty of ImmediateMedical Care at The Royal College of Surgeons of Edinburgh.

SportPromoteMDDUS in Scotland has formed an association withSportPromote. This course provider based at Hampden Parkin Glasgow also focuses on the management of the acutelyinjured or unwell athlete and is run by emergency medicineconsultant Dr Jonny Gordon. All SportPromote faculty areconsultants in their respective specialties including emergencymedicine, cardiology, intensive care and maxillofacial surgery.The structure is similar to the REMO course, each topic beingcovered by a lecture followed with a practical session usefulfor both doctors and physiotherapists.

Topics covered include basic as well as advanced life supportwith key skills including airway management and safedefibrillation using automated external defibrillators.Emphasis is also placed on the immediate assessment andmanagement of cervical spine injuries including immobilisationand safe extrication of the athlete from the pitch. There are alsosessions on trauma management including head and facialinjuries and other medical emergencies such as diabetes andseizures. Wound management and medical kit requirementsare also covered.

Assessment for the course involves MCQs and a practicalexamination, and the course manuals are tailored for bothdoctors and physiotherapists. Successful completion of thecourse earns 9 CPD points from the Royal College of Surgeonsof Edinburgh, and SportPromote is also CORAS approved forgeneral practitioners by NHS Education in Scotland.

MDDUS is keen to endorse the SportPromote course as weview such training as a valuable risk management tool inhelping to reduce potential claims related to sports injuries.See below for contact information for both SportPromote andREMO.

Peter Johnson is risk manager at MDDUS

• SportPromote – further information can be found atwww.sportpromote.co.uk or by contacting Dr Jonny Gordonat the Victoria Infirmary ([email protected]).

• REMO – for further information go to www.remosports.comor email [email protected]

Main: Dr Jonny Gordonof SportPromote attendsCeltic and Scotland’sShaun Maloney.Above right:Participants atSportPromote course

will have sustained permanent brain damageor remain in a persistent vegetative state.

Head injury accounts for half of all deathsamong adolescent males aged between 15and 19 years, and if death occurs after a roadtraffic accident there is a 75 per cent chanceit will be directly attributable to the headinjury itself.

It is important to appreciate that patientswho have sustained head injuries are oftenthe subject of medico-legal action in oneform or another. It is therefore vital thatdoctors who treat head-injured patientshave a thorough understanding of theprinciples of management and the medico-legal consequences that might flow fromthe injury.

The NICE guidelines are essentialreading for all those who may be calledupon to treat head-injured patients. Hereyou can find guidance on:

• Pre-hospital management

16 SUMMONS

• Initial assessment in the emergencydepartment

• Criteria for imaging and its urgency foradults and children

• Investigation of cervical spine injuries• Admission criteria• When to involve a neurosurgeon• Organisation of transfer of patients

between referring hospital andneuroscience unit

• Advice about long-term problems andsupport services.

If you read nothing else, study the QuickReference Guide on head injury which canbe downloaded from the NICE website1.

Surgical pathologyIt is important for all clinicians who managehead-injured patients to have a basicunderstanding of the surgical pathology.

Head injury is traditionally divided intoprimary and secondary brain injury. Primary

Professor Paul Marks offers advice on avoiding pitfalls in thediagnosis and management of head-injured patients

Managing head injuries

T HIS article attempts to highlightsome of the problems, both clinicaland medico-legal, that may arise

when managing head injuries. It is notpossible in a review of this length toprovide comprehensive guidance on allaspects of this complex topic. Interestedreaders are advised to consult standardtexts and, in particular, the NICEguidelines for head injury management.

Scale of the problemHead injury is the commonest cause ofdeath amongst young adults in developedcountries. Each year in the UK,approximately one million people willreceive treatment for mild to severe headinjuries in accident and emergencydepartments. Of these, 100,000 will beadmitted for observation or specifictreatment. In 5 per cent of those admittedto hospital, a neurosurgical opinion will besought. Of those referrals, 1,500 individuals

CLINICAL RISK REDUCTION

17AUTUMN 2010

brain injury occurs at the time of impact.It is divided into contusions and lacerationsof the brain on the one hand and diffuseaxonal or shearing injury on the other.Apart from preventative measures, such aswearing crash helmets, adhering to speedlimits and so forth, there is nothing thatcan be done about such primary damage.

Secondary brain damage such as swelling,oedema, haematoma formation, epilepsyand infection are initiated by the primarydamage and it is the goal of the clinician toavoid or minimise such damage, althoughthis may not always prove possible.

Assessment of a head-injured patientrequires a careful history and examination.Details of the mechanism of the injury areimportant and should be obtained fromappropriate witnesses as well as thepatient. For example, a blow to the headwith a heavy spanner is more likely toresult in a compound depressed fracturethan an assault with fists.

The initial neurological examination isof vital importance not only because itenables the severity of the injury to begauged but also because it provides abaseline of neurological function fromwhich any improvement or deteriorationcan be measured.

The assessment should include theGlasgow Coma Scale (GCS), recording ofvital signs and recording of the presence orabsence of focal neurological deficit. It isvital that you have a clear and thoroughunderstanding of the GCS and know howto derive the overall score from each of thethree parameters that constitute it. Despitebeing in existence since 1974, our unitcontinues to receive referrals that quote aGCS of 1 or 2!

Frequently asked questionsHead-injured patients and their relativeswill invariably want to know the timeframe during which recovery can takeplace. It is generally held that spontaneousimprovement can take place for up to twoyears after a traumatic brain injury.Problems that persist thereafter can beregarded as being fixed, i.e. they shouldneither improve nor deteriorate.

Another common question which isimportant to address is the likelihood ofdeveloping post-traumatic epilepsy.Traditionally this is divided into earlypost-traumatic epilepsy, which arises up

to seven days after the injury, and latepost-traumatic epilepsy, which arises atany time thereafter.

Risk factors for the development of latepost-traumatic epilepsy include: early post-traumatic fits, structural brain damage,penetrating injuries and a period of post-traumatic amnesia greater than 24 hours.

The most widely cited paper on the riskand likelihood of developing post-traumatic epilepsy is by Annegers2 and hisgroup and this makes essential reading foranyone who is engaged in medico-legalreporting on head-injured patients.

Medico-legal issuesHead injuries feature commonly amongclinical negligence claims and some canresult in high-value damage payouts orsettlement costs. Among the mostfrequent reasons for negligence claims are:• delay in diagnosis• failure to appreciate the severity of the injury• delay in transfer to a neurosurgical centre• missed spinal injury• incorrect attribution of loss of

consciousness to alcohol or drugs.

Many categories of clinician are calledupon to assess patients who have sustainedhead injuries. As in all areas of practice,accurate note keeping is essential and canprovide a valuable safeguard and defenceto subsequent complaints and litigation.Ensure that all entries in the clinicalrecords are timed and dated.

A thorough understanding of the NICEguideline for managing head-injuredpatients and the maintenance of a highindex of suspicion, especially in intoxicatedpatients with head injuries, will mitigateagainst inappropriate management and thetragedy of a death occurring when asurgically remediable condition is missed.

Professor Paul Marks is a consultantneurosurgeon at Leeds General Infirmaryand HM Deputy Coroner, West Yorkshire(Western District). He is also a visitingprofessor and associate at LeedsMetropolitan University Law School

Practice points• All head injuries should be regarded

as serious or potentially life-threatening.

• Head injuries are associated with acervical spine injury until provenotherwise.

• The purpose of observation is to seta baseline from which improvementor deterioration can be assessed.

• Minor head injury may be a source ofconsiderable morbidity.

• A head injury does not just affect the patient; the family and society may also be seriously affected.

References

1 www.nice.org.uk/CG56

2 Annegers JF et al. A population-based study of

seizures after traumatic brain injuries. NEJM

(1998):338;1:20-24

Medico-legal issues toconsider in head injury• Treatment of victims of crime• Criminal Injuries Compensation

Authority (CICA) reports• Negligence surrounding management• Personal injury compensation claims• DVLA forms

Above: This man fell 3 metres andsustained a head injury. He complainedof neck pain persistently but thisJefferson fracture of C1 shown on thisCT scan was missed on plain radiologyof the cervical spine.

Opposite: This 33 year old was assaultedwhilst intoxicated with alcohol. He wassent home from an A & E Departmentby taxi only to return 30 minutes laterhaving had a fit whilst getting out of thevehicle! His CT scan shows extensive bilateral frontal contusions.

18

Making a SEA change

M any dentists view clinical audit as a necessary evil – “it’sdone because we have to”. Indeed, the General DentalService (GDS) terms of service require us to complete

15 hours of audit in every three-year cycle, though recent figuressuggest that less than 50 per cent of dentists have done so.

Last year an NHS document distributed to all practices stated:“where a dentist did not undertake the required 15 hours ofclinical audit activities under the 1996 regulations he/she willrequire to complete 5 hours of clinical audit activities before31 July 2011’’. No doubt many of us will be looking for 5 hoursof clinical audit very soon.

My article in the last issue of Summons argued that a well-structured, meaningful clinical audit can greatly improve apractice but if you still find the prospect daunting then significantevent analysis (SEA) may be your answer! Not only will GDSaccept SEAs for the full 15-hour clinical audit requirement, it’salso a process that you can make an almost instant start onand one that will be directly relevant to your practice.

What is an SEA?A significant event can be described as “any event thought byanyone in the healthcare team to be significant in the care ofpatients or the conduct of the practice or organisation”(Pringle et al). Significant event analysis has been around foryears in the military and aviation Industry. Not only areaccidents fully investigated but any near misses are alsoanalysed for useful information to contribute to protocolstowards improving passenger safety.

To this day there are approximately 30,000 near missesreported annually in the aviation industry. Similar figures alsoexist in medicine, and Science Daily reported in 2008 thatmedical errors cost the US $8.8 billion and resulted in 238,337potentially preventable deaths between 2004 to 2006. Lessonscan be learned from these accidents, errors and near misses.

The Oxford English Dictionary defines significant as“extensive or important enough to merit attention.” This coversjust about anything as long as one of your team members

considers it important enough to merit further study. Analysisis simply a systematic process to ascertain what can be learnedabout the event and what changes might be made to fosterimprovement.

We can basically analyse almost any kind of significantevent. Let’s break them into four main groups:

1. A near miss (incident) – e.g. forgetting not to wear latexgloves in treating an allergic patient but no harm done asthis is realised in time.

2. An adverse event (accident) – e.g. forgetting not to wearlatex gloves and the patient has an allergic reaction.

3. An error – e.g. wrong patient records or records notwritten up correctly to indicate latex allergy, however noharm done.

4. Good practice – e.g. notes clearly indicate latex risk androbust protocol in place to ensure the patient is notexposed to latex; correct procedure carried out.

I’m sure you can already think of more examples from yourday-to-day practice of all four of these. Such events caninvolve almost anything from lab work to staff training, fromdata protection to patient safety. Should you have lots ofpotential SEAs already, it is suggested that they be prioritisedon the basis of consequences (actual or potential) for thequality and safety of patient care.

Why analyse significant events?In the case of a good event, that’s easy – we would all like tobottle the formula that makes our day run like clockwork andrepeat it on a regular basis. When something goes wrong (oralmost does) we want to make sure it doesn’t happen again.Without proper systematic analysis, it’s too easy for us tojump to conclusions – to blame a nurse or that lab!

But it may be that the problem lies much closer to home.Perhaps it is a training gap or even poor communication. A structure reduces speculation and conjecture and focuses

CLINICAL AUDIT

Clinical audit is an unavoidable requirement for all dentists – but itneed not be a box-ticking exercise, says David MacPherson of NES

A good defenceIf you and your team follow the seven steps and answer thefour questions of the structured analysis in as much detail asis possible and practical, then you can’t go far wrong.Educational feedback adds further validity to your findingsand, of course, peer review is high on the GDC’s wish list forrevalidation. Make sure your SEA is relevant, full of detailand legible (ideally typed).

From a medico-legal perspective, SEAs can bevery valuable. They immediately demonstrate aproactive approach to an incident or a complaintand can show how you came about whateverimprovements you have subsequently made.When something has gone wrong, the production

of a SEA will add to your defence by demonstratingreflection and empathy. You will be able to show how andwhy you have changed your protocols and reduced the risk ofnegative events reoccurring.

More information on SEAs can be found in section 13 of theNES Complete Audit Pack. Access at www.tinyurl.com/29ke6p2

David MacPherson is a Practice Development Plan (PDP)CPD tutor with NES

Sources

Pringle M, Bradley C P, Carmichael C M, Wallis H, Moore A. Significant Event

Auditing. RCGP Occasional Paper 70. 1995

Bowie P, McKay J, Dalgetty E, Lough M: A qualitative study of why general

practitioners may participate in significant event analysis and peer assessment.

Qual Saf Health Care 2005; 14:185-9.

Bowie P, McKay J, Norrie J, Lough M. Awareness and analysis of a signifi-

cant event by general practitioners: a cross sectional survey.

Qual Saf Health Care 2004; 13(2):102–107

more on the factual evidence. Any resulting change inpractice is likely to be more positive than just “we must try harder”.

Analysis helps us view incidents as important learning andquality improvement opportunities. It allows us to gain insightinto what happened and take appropriate action. SEA is a highlyflexible, non-threatening and team-based method of identifyingtraining, managing risk and enhancing patient safety.

Do it rightThere are seven steps to a good SEA:

Step 1 – Identify your significant event.Step 2 – Collect and collate as much information as possible

relating to the event for all people involved.Step 3 – Convene a meeting with a non-threatening, no

blame, egalitarian approach, focusing on theeducational outcome.

Step 4 – Undertake a structured analysis (see below).Step 5 – Monitor the progress of all actions/changes agreed

upon as a result of the analysis.Step 6 – Write up the SEA.Step 7 – Seek educational feedback – peer review.

A good SEA will be relevant and can be a lifelong learningtool. The framework for the structural analysis is outlined in the following four questions:1. What happened? Describe what actually happened indetail and chronological order. Consider, for instance, how it happened, where it happened, who was involved and whatthe impact or potential impact was on the patient, the team,organisation and/or others.2. Why did it happen? Describe the main andunderlying reasons – both positive and negative –that contributed to why the event happened.Consider, for instance, the professionalism of theteam, the lack of a system or a failing in a system, lackof knowledge or the complexity and uncertaintyassociated with the event.3. What has been learned? Demonstrate that reflection and learning have taken place on an individual or team basis and that relevant team members have been involved in the analysis of the event. Consider, for instance: a lack of education and training; the need to follow systems orprocedures; the vital importance of team working or effectivecommunication.4. What has changed? Outline the actions agreed andimplemented, where this is relevant or feasible. Consider, for instance: if a protocol has been amended, updated orintroduced; how was this done and who was involved; howwill this change be monitored. It is also good practice toattach any documentary evidence of change, e.g. a letter ofapology to a patient or a new protocol.

“Any resulting change in practice is likely to be

more positive than just – we must try harder”

AUTUMN 2010

20 SUMMONS

CASEstudies

These studies are based on actual cases from MDDUS files and are

published in Summons to highlight common pitfalls and encourage

proactive risk management and best practice. Details have been

changed to maintain confidentiality

BACKGROUND: Mr P, 45 years old, attendshis general practice complaining of epigastricpain after taking ibuprofen for cold sores. DrA examines the patient and records “tenderepigastrum but otherwise soft abdomen”.There is no bowel or bladder disturbance.The GP advises the patient that the pain willlikely settle with an antacid but to comeback if there is no improvement.

Two days later Mr P returns to the practiceworrying he might have appendicitis. Thistime he sees Dr B who records “moderateepigastric pain following ingestion ofibuprofen, also vomiting”. On examination thepatient has a tender upper abdomen but noguarding, with normal bowel sounds. Dr Bmakes a diagnosis of acute gastritis andprescribes omeprazole and metoclopramide.He advises Mr P again to return if there is noimprovement.

Four days later Mr P returns to thepractice. This time he is seen by Dr C whorecords pain now mainly in the right iliacfossa (RIF) with associated nausea, vomitingand diarrhoea. On examination the abdomenis tender over the RIF with rebound. Dr Crefers the patient to A&E where CT confirmsa diagnosis of acute appendicitis withappendicular abscess.

Mr P undergoes an exploratory laparotomyduring which the necrotic appendix isdebrided and the abdomen lavaged. A drainis inserted in the RIF prior to closure of thewound. After a prolonged hospital stay Mr Pis discharged but later has to be readmittedwith complications, adding to his pain anddistress.

A few months later the surgery is notifiedof a claim of damages against Dr B forclinical negligence in failing to diagnosis andrefer acute appendicitis.

ANALYSIS/OUTCOME: In the letter ofclaim Mr P presents a different version ofthe consultation with Dr B than that

recorded in the notes. He claims on returningto the surgery the pain in his abdomen wasso agonising he could “barely walk” and alsothat it had moved from the epigastric areato “just below the right side of my stomach”.Dr B disputes this account.

MDDUS commissions medico-legal reportsfrom both an expert GP and a surgeon. TheGP report finds that given the symptoms andsigns recorded in Dr B’s consultation with MrP it would not have been reasonable to referthe patient to a surgeon at that stage. Butthis opinion discounts the patient’s claim asto RIF pain and states in regard to the twoconflicting accounts that it is “for the courtto decide on issues of fact”.

The expert opinion of the surgeon confirmsthat had Mr P been referred to the hospitalwith RIF pain after his consultation with DrB it is unlikely the appendix would haveperforated. The patient would have requiredno more than a simple procedure followed bya relatively rapid recovery.

Presented with these reports Mr P and hissolicitors are still determined to press aheadwith the claim but indicate a willingness to

settle. In the meantime Dr B growsincreasingly stressed and worried over thecase and is eventually signed off work. He iskeen for a quick resolution.

MDDUS lawyers decide that on balancethere is a risk in litigation that the courtmight give credence to the patient’s accountof the consultation with Dr B and awardsignificant damages along with legal costs. Itis judged best for the Union and the memberto pursue a modest settlement withoutadmission of liability.

KEY POINTS● Early stage appendicitis is difficult to

diagnose and can present with painanywhere in the abdominal cavity butoften localising to the RIF.

● Be sure to record any relevant negativesigns on examination if there is anysuspicion – i.e. ‘no RIF pain’.

● Decisions to settle or legally contestclaims are often judgement calls basedon litigation risk.

● Members’ views are taken into accountwhen deciding whether to settle a claim.

DIAGNOSIS AND REFERRAL:CONFLICTING SCENARIOS

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BACKGROUND: A 56-year-old driver, Mrs A,is injured after being hit by a car in a roadtraffic accident. She makes numerous visitsto her GP, Dr L, for treatment to back andneck injuries which cause her considerablepain and difficulty. Mrs A then lodges acompensation claim with the other motorist’sinsurance company. Dr L receives a courtorder asking for disclosure of Mrs A’smedical records which detail the nature andextent of her injury and treatment followingthe crash.

Dr L responds to the order by sending theinsurance company Mrs A’s entire medicalrecord. But a short time later, Mrs A writesto Dr L alleging he has breached doctor-patient confidentiality by disclosing the fullmedical record instead of only the sectionrelating to the crash injuries.

Mrs A alleges that some informationcontained in her full medical file was used

against her by the insurance company whowent on to raise a counter-claim. This meantshe was forced to accept a poorersettlement and she demands compensationfrom Dr L.

ANALYSIS/OUTCOME: MDDUS, acting onbehalf of Dr L, explains to Mrs A that the

wording of the court order was ambiguousand that Dr L was acting in what he thoughtwas the best interests of his patient bydisclosing the record. MDDUS also points outthat, while this was an unfortunate situation,none of the information Dr L disclosed wasinaccurate. Following discussions with MrsA’s solicitors, MDDUS agrees a smallsettlement without admission of liability onthe part of Dr L.

KEY POINTS● Read carefully any official request for

disclosure of personal patientinformation. Contact an MDDUS adviserif in doubt.

● Provide only the minimum informationnecessary when complying with a courtorder for disclosure of records.

● Document your reasons for making adisclosure.

21AUTUMN 2010

TREATMENT:SIMPLE MISTAKES, BIG PROBLEM

CONFIDENTIALITY:TOO MUCH INFORMATION

BACKGROUND: Dentist Mr P is calledbefore the Professional ConductCommittee of the General Dental Councilto face charges about his treatment ofthree patients. Mr P is charged withfailing to take adequate dental histories,failing to carry out and record basicperiodontal examinations (BPE), failingto diagnose caries in one patient, failingto treat an abscess in a second patientand providing inappropriate treatmentto a third.

ANALYSIS/OUTCOME: Mr P is advised by a team consisting of asolicitor, dental adviser and barrister. At the committee hearing headmits having not routinely undertaken a BPE at every examinationbut gives evidence that he has since changed his practice. The chargeof failing to take dental histories is not upheld as Mr P, backed by hisnurse, explains his normal practice, including full dental charting, andthis is confirmed from practice records.

Among the specific cases, Mr P is criticised for not carrying outthorough checks on a patient, Miss T, who he had seen on six occasionsand who had extensive caries. Mr P had placed a veneer but ischarged with having missed caries on the mesial side of the tooth. Hehad no notes to support his claim that he had made thorough checks.

Mr P is also charged with failing to treat an abscess in a patient,

Mr G. The dentist claims that Mr Gdeclined definitive treatment, butthe dental records do not reflectthe patient’s refusal of root canaltherapy.

Mr P is also criticised for usingthe “out-of-date” practice of leavinga tooth open to drain. He claims tohave done so because the patient,Mrs K, had been too frightened tocomplete the original treatmentafter he had made a hole andwidened the canal. No note was

made of her refusal or the advice given and the patient did notattend for further treatment, despite Mr P’s efforts to contact her.

The GDC ultimately finds Mr P guilty of misconduct as the failuresfall well below the standard expected of a competent GDP. But as thetest for impaired fitness to practise is for current impairment, evidencepresented by MDDUS on Mr P’s behalf illustrates significant changesin his practice and the dentist is found to be currently unimpaired.KEY POINTS● Record BPE codes at each routine examination. A visual

examination, even if recorded, is insufficient.● Consider completing a dental history proforma for each patient.● Maintain full records including treatment provided and refusal of

treatment along with the circumstances of refusal.

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ADDENDA

Object obscura:early dental marketingThis dental advertising card from the early 1900sshows how the basic appeal and marketingtechniques of cosmetic dentistry have changedlittle over a century – although a drawing isperhaps less convincing than a glossy photograph.But why would The American Dental Co beoffering treatment in Swindon? In a blog fromthe Wellcome Library where the card can befound, Lalita Kaplish writes: “A little historicalresearch reveals that the high regard forAmerican dentistry in the UK around this timegoes back to the Great Exhibition of 1851 in London, when American dentists won tophonours for their displays of artificial teeth,crowns and bridgework.”

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See answers online at www.mddus.com. Go to the Notice Board pageunder News and Events.

Crossword

From the archives:an acid bath for scabiesIn August of this year The National Archivescompleted a major project to catalogue anddigitise a selection of Victorian workhouserecords. Living the Poor Life is now availableonline and records correspondence betweennineteenth century local and national poorlaw authorities – providing an “unrivalledsource of raw history” on the life andexperience of the nineteenth century poor.

One story found in the records is that ofa young boy named Henry Cartwright. In1839 his mother was committed to theBroomsgrove workhouse in Worcestershirealong with Henry and his three siblings, asshe was unable to support her family. Afew months later Henry was taken to thenurses employed at the workhouse alongwith over a dozen other children, allsuffering from the “itch”, a colloquial termfor scabies.

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A respected local surgeon named ThomasS Fletcher who provided medical care tothe workhouse instructed the nurse to dressthe affected areas of skin with a “whiteointment” but this caused pain, swellingand loose teeth so was discontinued.Treatment with brimstone and treacle alsofailed so Fletcher prescribed immersion in acaustic solution of “sulphuret of potassium”or potassium sulphate.

A nurse named Sarah Chambers was leftto administer the treatment unsupervised.Most of the children were unaffected by thebath but Henry emerged badly scalded asthough burnt. A few days later he died.

At the coroner’s inquest a number ofdoctors testified that use of potassiumsulphate in a bath, ointment or lotion for theitch was not uncommon. It was the strengthof solution used by Nurse Chambers thatcaused the boy’s death.

The jury of the coroner found thatFletcher’s failure to properly supervise thetreatment was “injudicious and negligent”.The surgeon was “admonished in suitableterms” but avoided being sacked for hisactions by the Bromsgrove Poor Law Unionbecause of his “previous unblemishedprofessional record, and kind attention topauper patients”.

Search The National Archive for otherstories from workhouse records at:www.tinyurl.com/poorlife

ACROSS1. Airways inflammation8. Lumps on toes9. Washbowl10. Gums11. Twin, like Dolly12. Genus of mite15. Intestines17. Lent his name to regional ileitis18. Exposure to silver dust21. Adult-onset diabetes (abbr.)22. Shoulder muscle23. HIV combination therapy drug

DOWN2. Quarrel (3-2)3. Children’s hospice in Hampshire4. Member of light cavalry5. Primary cause of lung cancer6. Phase of cardiac cycle7. Comprehend8. Prevents tuberculosis (3,7)13. Dodged14. Anonymous16. Enrage19. Paints gold20. Buy back (2-3)

AN interest in butterflies formed therather unlikely basis for one of the 20thcentury’s most significant discoveries inpreventive medicine.

Sir Cyril Astley Clarke’s breakthrough iscredited with saving hundreds ofthousands of lives since it was first usedaround 1975 – and it all began with hisinterest in lepidoptery. The Leicester-bornphysician and geneticist built on hisresearch into the inheritance of wingpatterns in butterflies to eventuallydevelop a method of preventing RhHaemolytic disease of the newborn.

The life-saving method – which involvesadministering antibody injections duringpregnancy – was developed by SirCyril and his team with a little helpfrom his wife Frieda (known as Féoto her family). It was said to havebeen Féo’s suggestion to injectRh antibodies – the very thingswhich cause Rh – that provedthe key to successfullypreventing the disease.

Numerous accolades followedthis landmark achievementincluding a CBE in 1969, aknighthood in 1974 and theAlbert Lasker Award for ClinicalMedical Research in 1980. Latterly,he was awarded the Linnean Medalin 1981 by the Linnean Society ofLondon and the Buchanan Medal in1990 from the Royal Society “for hisinnovative studies on haemolytic disease ofthe newborn which culminated in newtherapies leading to the elimination of thismajor foetal disease”. He was alsopresident of the Royal College of Physicianswhile in retirement from 1972 to 1977.

Sir Cyril was born in 1907 and educatedat Oundle, Cambridge and Guy’s Hospitalwhere he qualified in 1932. After a numberof staff appointments at Guy’s he workedin medical insurance and sailed at theweekends at Itchenor, West Sussex wherehe first met Féo. They married in 1934 andhad three sons. In a touching tribute at herfuneral in 1998, he wrote a note on hercoffin which read: “The prettiest girl inSussex.”

He served throughout the Second World

worked together in the early 1950s on theevolution mimicry in swallowtail butterfliesand also extended the work of HBDKettlewell by studying the black andpeppered moths on the Wirral peninsula.

Their genetic research naturallyprogressed into medicine and the firststudies were on the influence of the ABOblood groups on the risk of developingpeptic ulcers. They had noted theinheritance of butterfly coat colour andpattern was controlled by a group of linked genes called polygenes. This led to Clarke’s interest in Rhesus blood groups in man, which have a similar

method of inheritance.The culmination of the work ofClarke and his team was the eventual

discovery of the pioneering Rhdisease prevention method whichinvolved giving Rh-negativewomen inter-muscular injectionsof anti-RhD antibodies duringpregnancy to prevent Rhdisease in their newborn babies.The achievement was of greatimportance and typified SirCyril’s flair and willingness to tackle problems that were

sometimes outside his field of expertise. In a tribute to Sir Cyril in the

BMJ following his death, one of his sons described some of his many

accolades: “He succeeded Lord Cohen of Birkenhead to the Liverpool medicinechair in 1965, transforming thedepartment into one of the finest. Cyrilbecame the first non-London Royal Collegepresident. He initiated its research unit andfundamental changes in the MRCP.”

He told how his father had “boundlessenergy, charm, unusual intelligence, greatimpatience, and wit”, adding: “He once told me he had failed to reach the House of Lords because he had infuriated a GPpeer by indicating an association betweendeaths from meningococcal meningitis and Thursday afternoons, the GP’straditional half day. He added with a grin: ‘Sic transit gloria mundi.’ [So passesthe glory of the world]”.

War as a medical specialist in the RoyalNaval Volunteer Reserve, rising to the rankof Lieutenant Commander. After the war,he became a medical registrar inBirmingham and later a consultant at the David Lewis Northern Hospital inLiverpool. His life appeared set for NHSpractice in Liverpool with private rooms in Rodney Street. But in the 1950s, hisinterests turned to genetics and hedeveloped his lifelong passion for

lepidoptera. In 1958 he became reader inmedicine at the University of Liverpool andin 1963 he established and directed theuniversity’s Nuffield Unit of MedicalGenetics and two years later he was madeprofessor of medicine. He held the lattertwo posts until his retirement in 1972.

Sir Cyril’s research contributions werebroad and he perfected a technique ofhand mating butterflies which enabled himto produce rare hybrids. This remarkablefeat attracted the attention of PhilipSheppard, a brilliant young lecturer inOxford who moved to Liverpool asprofessor of genetics. The two men

23AUTUMN 2010

ADDENDA

Vignette: physician, researcher and geneticistSir Cyril Astley Clarke (1907 – 2000)

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More information will be available soon!

WANT TO READ MORE…?

If you would like to be put on the mailing list for any MDDUS publication, or to receive a sample copy, contact Karen Walsh on [email protected]

We have recently expanded our range of publications bylaunching new titles aimed at practice managers, GPtrainees, junior doctors and trainee dentists. These resourcesoffer medico- and dento-legal advice on how to manage

risk in your day-to-day work, as well as general interestfeatures and case studies.

We also produce the MDDUS e-Monthly email newsletterfor all members plus the monthly eFYi for doctors in training.

GPST – This journal, launched inSeptember 2010, aims to helptrainee GPs face the dailychallenges of general practice.Advice focuses on improvingareas such as communication andconsulting skills, while generalfeatures offer a perspective fromworking GPs.

FYi – This publication is for finalyear medical students anddoctors in foundation years 1 and2. Practical articles focus on arange of topics from breakingbad news to patient handovers,while other features highlight thevaried work done by leadingmedics from various specialties.

SoundBite – Final year dentalstudents and dentists in theirfirst two years of post-graduatetraining will find this a valuablesource of practical advice on howto improve professional skills.Launched in summer 2010, it alsoincludes careers information andgeneral interest features fromaround the dental world.

Practice Manager – Aninformative resource for practicemanagers to help you run yourmedical or dental practice. Itoffers advice on how to handlechallenging situations on thefrontline of general practice aswell as highlighting HR andhealth and safety issues.

MDDUS publishes a number of membership magazines in addition to our main title, Summons.

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