Warning: Legality could be injurious to health

This particular blog post is fictional. Any resemblances to any person living or dead or incidents current or historical are purely coincidental.

Warning: Legality could be injurious to health

It was the saddest day of his life.

Let us start from the beginning. Bill was a brilliant student at A levels, he was also a stickler for formality, rules and process. This stood him well and he was very highly thought of as a scrupulous, proper, law abiding young man. He went on to study medicine, completed junior general training and got into specialty training – all very smoothly. His specialty also involved working in the operating theatres.

Bill found within a few weeks of into his registrar job that his work never ever finished at 5 pm.  Bill being Bill, thought he will simply leave at 5 pm as long as there was no patient he was directly dealing with was acutely ill. He did that for a week. Bill then found his training was getting adversely affected. Consultant ward rounds continued after 5 pm, if he did not join in he cannot learn. Patients for elective surgery were admitted after 5 pm, if he did not see them he will not be ready for them for the next day. Theatres routinely over ran easily to 7 pm sometimes longer, if he was not there he will lose out on the training.

Bill discussed this with his consultants who looked at him as though he was an alien zombie. When he insisted on resolution they told Bill that he is free to leave at 5 pm if he wished to do so, some of them insisted that he leave at 5 pm so that he did not breach his hours. Bill’s logical argument was very simple, substantial training happened after 5 pm so to take consultants’ advice and leave at 5 pm means that he will never get the training he deserved. So Bill refused to leave on the grounds of training needs and claimed payment for extra time on the basis of actual time spent working at the hospitals. Boy, this was resisted by the management. Bill was born different, his documentation was perfect, they had no choice but to pay him. The managers gave the consultants a hard time because of this issue; the consultants did not take it lightly.

The time came to ‘assess’ and ‘report’ on Bill which were used at annual progress meetings. These used to be called RITAs before now called ARCPs. Bill’s numbers, performance, success rates, patient feedback and anything clinical were spot on average. Bill’s consultant reports were full of masked vitriol on how his attitude, behaviour, cooperation, et al were not compatible with a surgical career. This was pointed out to him and he made tremendous efforts to improve. Every time he was assessed externally he had no issues on any of the ‘soft skills’ assessments. But he would not stop claiming for staying after contracted hours. Every hospital that made him work after 5 pm paid up; the consultants from the hospital wrote badly about his approach to life.

After 6 years of completed training with same average clinical rating as his peer group, Bill was denied his completion of training certificate due to five reports that faulted his attitude. Bill cannot get into the specialist register; Bill cannot be a substantive consultant in the NHS. His colleagues with his level of performance and achievement and some with lesser performance and achievement were signed off.

All because he followed the country’s law and the NHS rules. The message his colleagues got from their seniors was that people who followed the law can be severely, career damagingly punished. The message other trainers and managers got was that they can break the rules and law with impunity and use their power to penalise the person who caught them out. Bill can go to employment tribunals and the like but when he has at least half a dozen consultants who have already written badly and a dozen managers willing to write badly – he faces a lost cause. In a world where the subjective decimates the objective - he is a lost soul.

Has he learned his lessons that legal and rule based behaviour does not win and not submitting to the whims of the powerful was harmful? We do not know yet. This sounds like a case of operation successful, patient died; only here it will be training successful, career died. Bill hit the target, its the ricochet and the debris that maimed him.

Bill is at a crossroad waiting to change careers.

Oh by the way he also happens to belong to a minority ethnic group.

I think this quote from John le Carre (in his book The Constant Gardener) will probably be very appropriate here "Nobody in this story, and no outfit or corporation, thank God, is based upon an actual person or outfit in the real world. But I can tell you this; as my journey through the pharmaceutical jungle progressed, I came to realize that, by comparison with the reality, my story was as tame as a holiday postcard."

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: The loose ends such as throwing in the ethnic minority, etc are there to be filled in, if and when I get to write this story in full

How to do a ward round

Till recently there were no accepted method, standard, process, protocol or parameters on how a doctor should do a ward round for in-patients. We generally turn up, see the patient, sort problems and when the patient gets better we discharge the patient. In recent times there are emerging opinions which have led to some recommendations on ward rounds.
 
I describe my personal experience of one of the best ward rounds that I had the privilege to be a part of during my training days. I describe the ward rounds of the late Mr Suresh B Desai, Consultant Surgeon, Scunthorpe General Hospital. The following is a tribute to him.

House Surgeons should come in at 8 am and had till 9 am to prepare for the ward rounds (time was defined - nothing woolly there); the job was defined:

- Get an updated list of in-patients including admissions through other consultants emergency takes, outliers and consultation requests from other consultants
- Write in the patient notes the results of investigations or have the investigation results on hand ready to be written in the notes
- Deal with any really dire emergencies where the physiology was really poor

Registrars should come in at 8.30 am and had till 9 am; their job was defined:

- Help the house surgeon deal with dire emergencies if there were any
- Talk to the nurses to identify any issues that arose overnight for the in-patients

Mr Desai would arrive at 9 am to the male ward. If there were any dire emergencies the registrar (and not anyone else) would continue to deal with it. Otherwise the whole team started the ward round. The whole team included the ward sister and the nurse who looks after the patient apart from the house surgeon, medical students if any, clinical attachment doctors if any and other healthcare staff as relevant. What I call a ward round kit followed the team - this included the notes trolley, all investigation request forms, a dictaphone, gloves, gel, stationery (continuation sheets, consultation request forms), some house surgeons used to take canulation trays as well.

Every patient was seen - well that is what a ward round is for.

But what then happened was simply brilliant. 

Everything that the patient needed as a result of the consultant visit was completed before moving on to see another patient.

If a patient needed bloods to be repeated immediately it was done right there in front of the consultant, bloods need to be repeated in the afternoon or the next day the forms were done right there, any other test requests (X-ray, CT, ECG, etc) were done then and there. Any communication with other teams/speciality's consultants/registrars they were bleeped or rung, spoken to or if they were not available a message was left with their secretaries. Letters needing dictation though this was rare was done right there. A canula that needed doing was done then and there. Every work that was generated as a result of Mr Desai's ward round was done in the presence of Mr Desai or if appropriate by Mr Desai himself as soon as it was generated before moving on to the next patient for whom again the same process applied.

This made the ward round quite long. When most other consultant ward rounds took less than an hour (which was reasonable by surgical standards), Mr Desai's ward round took all morning (his ward rounds were in the morning). It was initially frustrating. But soon junior doctors realised that there were not many 'to do lists' not many things to actually pending. We were not running like headless chicken after the ward round. We ended up having more time for the doctors mess, more time for learning, more time for everything else.

Any really abnormal results were acted upon at the earliest as anyone would. The next time the house surgeon had any serious work was at 3.30 pm to check on any changes to patient's status which were not already informed and to check on investigation results that were not direly abnormal and to act on it. Barring a late finish in theatres Mr Desai would always visit the wards and speak to the senior nurse at 5 pm every day and conducted the equivalent of a board round. Any patients that needed to come to the attention of the on-call teams were noted - Mr Desai would speak to the on-call consultant and Mr Desai's registrar would speak to the on-call registrar. 5.30 pm we were gone.

I do not know the precise results of Mr Desai's work. All I know was that everyone including me was of the impression that his work was good. It was organised, it was thorough and all elective work was directly consultant delivered or delivered in the presence of a consultant. An aside which could be a nugget as a mark of the quality of his work: all his patients who were having elective major surgery were seen by the physiotherapist with a special emphasis on chest physio - blowing balloons et al - it was no wonder we thought his patients did well.

I did not know about lean concepts in 1994. When I later became aware of lean I realised that this is a single piece flow ward round if there was ever such a thing described.

I recommend it.

© HEMADRI

 
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PS: I have heard a number of patients credit Mr Desai with commencing gastrointestinal endoscopy, vascular surgery, endo-urology and triple assessment breast clinic service at Scunthorpe; I am sure he played a major part in these. I know of a few patients who still remember him and praise him.

End of management (long version)

A shorter crisp version (about 600 words) is published in the FMLM (blog http://www.fmlm.ac.uk/blog/makani-hemadri/end-management)  for which this topic was originally written. This is the rambling 1500 word extended narcissistic version. You are welcome to it ...  

It is important to read Alan Murray’s ‘The End of Management’ Corporate bureaucracy is becoming obsolete. Why managers should act like venture capitalists; in the WSJ. Here is the link: http://online.wsj.com/article/SB10001424052748704476104575439723695579664.html

Once you have read this blog post gets its context and then you can read this either as a commentary of the WSJ article as relevant to NHS or on its own. This blog is deliberately off-key, the topic is such, bear with me. Compared to many healthcare systems we do quite well in the NHS. Could we do better? Of course yes but how we do that will define our future.

We are the management and we will tell you how to end management!?!?!

At a broader level, in the NHS there are no examples that I can think of where corporate structure or management has been ‘ended’. The previous government did good work with top down waiting times and so on; the present government is attempting top down radical change in organisational structures. The government is trying to get us do differently. When individuals try to do something creative, the organisations and the NHS as a whole tries to look at 'where and how it fits in with the overall plan'. But in the public sector there is the government not just wanting us to do different but also telling us how precisely to do it; with organisations 'encouraging innovation and creativity' only if it fits in with pre-defined policies. But that is what modern business is trying not to do; modern thinking in management is not telling people what to do but to let people to do things first and the management to amplify the good ideas.

Thinking of me vs thinking of you

At the narrower level, trainees (I am talking about all trainees in the clinical areas- not just doctors) are taught to think of how they are learning and improving themselves; never to explicitly think about their contribution to the organisation. In fact, often people think that their contribution to healthcare as such starts only when they stop becoming trainees. By that time the mind set becomes so fixed in thinking inwardly about the self and not outwardly about others that it becomes very difficult for the rest of their lives. Careerism becomes the mantra for many people in healthcare; we always thought this was the case in the private sector - true but that trend is changing in some areas. 

Best with limits

This leads to people taking very defensive attitudes. Most people in healthcare management are either numerically shy or numerically illiterate. They are unwilling to make a personal numerical prediction on their or their department/division/directorate’s improvement based on a measurable internal parameter due to the fear that they may be unable to stand by it. In any case most of the numbers are geared towards predefined reporting parameters. People who work in the NHS also seem to think that they are somehow very altruistic and have a high sense of entitlement. That attitude is even more profound in the clinicians with clinicians tending to believe that they express their altruism by their very individualistic approaches to healthcare. It is also possible that there are certain kind of people who are drawn to public services (possibly risk averse, change shy, rule-bound, authority loving, service minded and so on) and it would be difficult to use the same methods as for instance in Google to achieve a new management approach.

At both the above levels, healthcare and NHS is thought to be too important and too costly to be creative or innovative; the phrase used is 'risk'. Healthcare especially in Europe and even more so in UK has innumerable external controllers and bodies telling people what to do and how to do it that it simply chokes off creativity even before it begins. In other industries there is an obligation to do some degree of statutory reporting with no real controls on how they do their business.

So, it seems like what the above WSJ article is saying is not possible in UK healthcare at all. There seems no space that is available or can be created for those concepts to happen without falling foul of something or someone. But there lies the opportunity as well to ‘end management’ and create self-sustaining systems.

Blue skies

Hence, I can now boldly enter the imaginary world to explore how the 'wisdom of the crowds' can be harnessed. I think the way to do it is to disengage from current conventions and demonstrate its success. That does not mean rebelling, non-cooperating, behaving illegally, not concentrating, becoming disenchanted or any such thing. It is using our own methods to satisfy our requirements and our clients’ requirement rather than using a method or doing a thing to satisfy an external definition. 

For instance when the roads around Birmingham were choking instead of building a new road, they opened the hard shoulder to traffic which in other roads is actually illegal; peak time traffic situation has improved since in that area. Compare that with an example of the situation in some hospitals where they buy yet another business intelligence interface/data-mining tool to provide information at service line specialty level when the managers and clinicians often feel that human connectivity was the issue that needed resolving to enable their older software to be used effectively. Often the tool is not really the problem, our thinking is.

Let us assume for example that one of our services is not accredited by some specialty society because we did not meet one or more of their requirements in the way they wanted. Normally the tendency would be either to stop that service or to work very hard to meet that accreditation standard. However, if our results in that particular specialty or aspect is better than anywhere else, would we as an organisation, anyone in the specialty society or the general society as a whole be unhappy? Certainly not. In this scenario the badge of not being accredited becomes a badge of honour. The problem is we do not think like that in the NHS. We probably should.

Like the Birmingham roads, what 'illegal' things could we do to make ourselves better?

Obviously we should disengage and develop only if it is beneficial to our hospital and patients and we are able to track it and prove it contemporaneously.

Is this an example of wisdom of the crowds in the real world of healthcare?

     Finally let me try a hypothetical yet hopefully practical proposition to disengage and demonstrate. There is a focus on Unplanned emergency re-admissions and we may not get paid for such re-admissions. I am aware of some of the things that we have started doing to tackle this issue. Let me put to you a potentially disruptive solution in the 'end of management' mode 

     

      a) not offering routine follow-ups for any patient who is discharged from the ward (medical, surgical, post-operative) 

and instead

b) Guaranteeing a clinic slot within a defined time (48 hours to one week as agreed) should the patient choose to contact us.

My hypothesis is, this approach will reduce unplanned emergency readmissions as the issue is often/mostly to with patient concerns on access (rather than real life-threatening matters); the 'routine' follow up itself is mostly to satisfy clinicians habit rather than a scientific finding that all complications in all patients happens precisely 3 months after seeing the doctor and hence patients need a 3 months appointment. This will also clear up the 'congestion' we have in our clinics. 

Okay, where is the 'wisdom of the crowd' here? The crowd in our example is the patient; and the wisdom is the patients’ knowledge about their own health on what is wrong with them and they should be able to access us when they find something wrong with them. This is of course one step further than the current thinking on 'crowd' which is usually the employees in a large organisation. We even need to change the definition of crowd to suit our requirement. 

Rambling ambiguity and the threads of new systems

We can predict that the conventional management methods will not work in the 21st century. End of management as we know it is not chaos as many would like us to believe. New models are not apparent or clear yet. Perhaps there may not be one new model; possibly there may not be a well defined model at all. There are emerging themes; democratisation of data, data mining, crowd sourcing, coping with anti-knowledge, cloud care and dumb-terminals, many more............ It is not these themes that are important; it is how we implement these themes that are relevant. We can be told how to do it thus not ‘ending management’ or we can show how we do it.

Thank you for getting to this sentence of the blog. If you thought this was rambling ambiguity, I am grateful for your attention and will do better next time. If there are some threads that we can build on then I have achieved my aim.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Examinations for doctors - time to think differently

I wrote the article below in 2006. I was not blogging at that time so it just lived in my computer. When you read it please be in a 2006 frame of mind. The article 14, the new rules for surgical exit exam, the impeding new contracts for doctors especially for SAS doctors and so on.

Once you have read it, cross reference it to the recent GP exam results.

We need an end to the monopoly of examination providers for post-graduate doctors. We need a plurality of avenues to demonstrate knowledge.  Why should every university in UK not have a knowledge test for specialist doctors?

The link to the intercollegiate website cited in the article will not work, you may want to search their website for the current link or otherwise check with them.

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THE EXIT EXAMINATIONS: IS IT TIME TO HAVE A DIFFERENT THINKING?

The surgical royal colleges have decided to allow any candidate who is able to muster the references of two consultant surgeons to take the intercollegiate exit examination. The colleges would see this as a response to the changes in the rules that have happened due the PMETB to allow a fair opportunity to anyone who wants to demonstrate their proficiency in surgical knowledge. The General and Specialist Medical Practise Order that created the PMETB was passed in April 2003 and there have been wide consultations before and since. It has taken three years to arrange a new format which is likely to change again very soon, in view of the MMC reforms.

While it is clear that the 'standard of knowledge' should be the same for surgeons entering the specialist register one has to question if the actual examination should also be the same. Whether different formats for differing groups/sub-specialties were considered is not known. Whether any surgeons who are not in training were consulted before these changes is not known. If any of the 'mediated entry' candidates who have taken these examinations in the past were consulted is not known. A close look seems to reveal the need to have some radical, new and different thinking about who should take which examinations and who should offer them.

HISTORY OF WHO PASSED AND WHO FAILED

The point about consulting the past candidates is rather important. The evidence for the importance lies in the figures available in the Intercollegiate Speciality Boards website (http://www.intercollegiate.org.uk/html/results.html) where between 1998 and 2001 the overall pass rates in the intercollegiate surgical exit examinations was 70% for mediated entry candidates, 76% for type two trainees and 96% for type one trainees. We should keep aside the issue of mediated entry candidates for just a moment and look at the glaring difference of pass rate between type 1 and type 2 trainees. Most type two trainees worked to similar rotas in similar hospitals with similar consultants and mostly for similar number of years. Some differences do exist in their pathways such as type one trainees spending more time in teaching hospitals and type one trainees having experience in some research, while many type 2 trainees also have such exposure not all of them do. Opportunities for courses, learning etc are all similar. However, when it comes to examinations type 2 trainees did not do well. It begs many obvious questions, the foremost of which is why trainees with such similar pathways did not fare similarly at the examinations. If type 2 surgical trainees had equivalent training to type 1 trainees, as an admission to the examination implied till recently, why did they not do well? If we accept that the examination was a true reflection of their training and knowledge then was the process that selected them was wrong? If we accept that their pathways were not as similar as described here then why were they allowed into the examination on the basis of ‘end of training’ ‘exit’ examination? Knowing that type 2 candidates fared badly what changes were made to address that situation? If they were genuinely poor why were they selected into specialist registrar posts, if they continued to be poor why were they not stopped from progressing through their training which enabled them to take the examination?

When so many questions exist in the issue of type 2 registrars, there are even more for mediated entry candidates of the past and especially possibly for non-training post holding candidates of the future.

THE DEBATE IS INTERNATIONAL AND ABOUT THE FUTURE

The debate is not simply about the present UK based SAS doctors, FTTA, LAT and LAS posts who intend to take these examinations under the new regulations. The future also demands some answers. Some of the colleges have taken upon themselves to hold these examinations in many parts of the world. The demand for such examinations exists. Would the colleges allow non-training doctors from abroad to sit the intercollegiate exit examinations? This opens an even wider debate whether surgeons not in non-training posts from anywhere in the world would be allowed entry in to the specialist register partly on the basis of a test of knowledge that UK Royal Colleges offered. That is not to say that such surgeons should not be allowed but to wonder if the GMC, PMETB and royal colleges have the resources to probe the credentials of such candidates so thoroughly that the British public can be assured of quality in real time practise and not success in a paper work exercise. Perhaps the easy way out is to ‘rule’ on application, that the applicant is in need of further training, which is in reality will be difficult and expensive to challenge by overseas applicants.

INTENTION VS REALITY

The law in the form of the PMETB rules allows for various types of demonstration of knowledge, specifically to enable a variety of suitable candidates to enter the specialist register. The surgical colleges instead of taking the cue and innovating, have changed the entry criteria and the format to allow non-training surgeons to sit the same examination. Instead of exploring and enabling diversity that the law demanded the situation is now quite simply similar to tying the hands of a challenger and then putting him into the boxing ring. The example of an SAS doing excellent breast work for years taking the exit examination as an opportunity and achieving a predictable failure can be foreseen very clearly. To state that it is the responsibility of the candidate to ready themselves in all aspects before appearing for the examination sounds very reasonable but in reality very cynical. To then retrain the candidate due to a PMETB refusal or an examination failure and on the successful completion of 'training' and/or 'examination' only to be employed to the same job but possibly a higher title seems bad logic and an extreme waste of resources.

There is also a general perception that the current format of the new examination could be interpreted as being that of a different standard than the recently expired one. There is a suspicion that the goal posts are set differently in preparation for the MMC changes.

MONOPOLY

In the UK there is only one form of test of knowledge. There is only one body that provides it. This situation may be appreciated as offering uniformity. On the other hand it could also be considered as a monopoly of provision. The general view of monopolistic provision is that it is unhealthy. The intercollegiate format could also be perceived as cartelisation of sorts. The reality of a very small number of people involved in taking these examinations may prevent such a thought stream from developing into meaningful progress.

Surely the royal colleges have huge experience in designing examinations and though a challenge could devise a range of 'fit for purpose' examinations which would be of equivalent standards to enter the specialist register. The law allows it though does not require the colleges to do so. Coming from a different angle would it not be logical to wonder why a breast specialist has not taken a specific exit examination in breast surgery and so on? The urologist does.

More and more of assessments are being delegated and devolved to local deaneries who then sub-delegate to individual trusts and consultants in the form of in the work place assessments. As a logical futuristic extension some consideration may be given to decentralising the test of knowledge to be provided by a range of alternative providers. This may be not only a great market opportunity but also an opportunity to demonstrate leadership and vision, for universities and private educational systems to device such tailored high standard tests of knowledge as they have already done in the CME/CPD areas.

CONCLUSION

No one argues the need for good knowledge before entering the specialist register; it is no doubt a must. The entire debate is about the demonstration of that knowledge. The intercollegiate surgical exit examination is one of them but it is probably suited only for the current type one trainees. That examination's suitability for others including type 2 trainees and their derivatives, the future MMC defined ST post holders, SAS surgeons, MMC generated non-training post holding surgeons, overseas non-training post holding surgeons is unclear, though many will take it due to lack of alternatives. There may also be reluctance on the part of the ‘higher’ authorities to accept alternatives.

It is time to realise that 'similar' and 'equivalent' do not have to mean doing the same things or taking the same examinations. It is possibly the time to wonder about the paucity of alternatives to demonstrate knowledge. With the large increase in the number of medical students and the possibility of expansion of ‘consultant’ numbers, it is time for the good and great of the medical profession, though the surgical example is illustrated here, to lead in thinking, policy and practise rather than to react and respond as shown repeatedly with some of the glowing examples such as Calman, EWTD, PMETB and MMC amongst many others, with many issues arising from them still remaining unresolved.

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©M HEMADRI 

Follow me on twitter @HemadriTweets

Demanding consultant delivered acute care

Who should deal with the most urgent and severe emergencies?

The following runs in every healthcare worker's mind but we usually do nothing about this. Let me describe it.

First time elective referrals at out patients for major conditions gets seen usually by consultants
First time elective major operations usually done by consultants (especially the major ones)

However,
Redo operations after complications due to first time elective surgery - quite often done by registrars or 'middle grades'
First time major emergencies in Resuscitation rooms and dire post operative emergencies in wards and ICUs are usually dealt with by registrars or 'middle grades'

Is that logical? Is that sensible?

Of course in some specialties like vascular, neonatal and a few other, the senior most persons often deal with the most dire things but I am talking about most specialties. For instance in internal medicine an elective referral for a chronic cough or chest pain will normally be seen by a consultant but a severe acid base imbalance, a pneumothorax, undiagnosed sepsis will be first seen often by very junior doctors fresh out of medical school or if the patient was extremely lucky by a registrar or middle grade.

This anomaly should be addressed. But it will not be easy to address. Clinical severity of the condition and clinical severity of any potential adverse outcomes should decide who will see/treat the patient and not mere availability, convenience, historical residual legacies and other administrative/managerial issues. This will demand consultant delivered care (not consultant 'led' care). People will rightly be concerned about the cost; it would be important to recognise that the improvement in clinical quality and the enhanced clinical accountability for outcomes could result in lower overall costs. If on the other hand there was a clear increase in quality the richer economies should accept that as the new benchmark for cost.

Success in Healthcare will depend on the proper utilisation of its very valuable human resource; the utilisation of the human resource should be exclusively based on clinical need - more severe the presenting situation - the more senior should be the primary attending human resource.

Here is where patients could play a part in improving the quality for themselves and in shifting the culture within healthcare. Patients and families could use the consent process to influence better care. Consent is a legal requirement before professionals can provide care hence any caveats in that legal process carries significant weight. Patients and families may or may not be able to define what should be done but they can define what cannot be done; for instance you cannot say you have to be given a blood transfusion but you can say that you should not be given a blood transfusion.  In the same manner I think patients probably cannot demand that only a fully trained healthcare profession should treat them but can possibly decline to accept care from anyone who is not fully trained without them being directly supervised.

For instance my living will or perhaps my consent to treatment form could say 'I, having worked hard and paid my taxes, when I am ill, expect to be treated and cared for at every stage by fully trained clinical staff; if that does not happen I will take it as having possibly received substandard care. Being a responsible citizen and supporter of NHS I am aware of the need for trainees to learn so that future specialists can be created; I will allow trainees to care for me at any time as long as their trainer is physically present and actively training the trainee in a hands-on manner. If the trainer is not physically present and actively involved (for instance if it is a surgical operation the trainer must be scrubbed up and assisting the trainee) I shall consider it as a breach of my right to have received the highest quality of healthcare that I expect and a breach of the consent that I have provided' (** Caution: Using aforesaid statement is likely to negatively affect your healthcare and risk an adverse outcome. The statement is used to make a point and not necessarily for practical use**)

It is patients' choice, let us take it seriously. If you thought this was a bit too assertive - pause for a few seconds and reflect on the day when my above sentences will be cut and pasted by every patient on to their consents and living wills. Or even better, pause and think of what you would want for your child, spouse or parent when they are facing the most dire emergency circumstances of their life perhaps after something that had already gone wrong. Would you want someone who has left medical school recently (though they are very good trainees and keen to learn) or someone for whom you have already paid upwards of £1million to become fully trained and employed to care for you, when you are facing a potentially resolvable life threatening condition? I rest my case.

©M HEMADRI