The huge contribution made by overseas doctors

Transcription

1 The Journa of The British Internationa Doctors Association Issue No.2, Voume 24. June 2018 The huge contribution made by overseas doctors

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3 Contents BIDA Nationa Chairman s Report...4 BIDA Trainee Forum Chairperson s Report...5 BIDA G.P. Forum Chairperson s Report...5 Ceebrating the 70th Anniversary of the NHS - A Conversation Indian Doctors seen as architects, the ifebood of Britain s NHS...8 Empowering Internationa Medica Graduates...9 The Home Office: Putting patients at risk...10 The NHS needs a Roya Commission to provide a suitabe pathway for sustainabiity...11 A position statement from the ALSGBI on Robotic Surgery Transient oss of consciousness Reforming the GMC...17 Cervica Lympohadenopathy in Chidren Congratuations / Did You Know?...21 Tacking Opesity, Diabetes and Metaboic Syndrome Study Day...22 Letter to BIDA IC Deegates...23 Obituary - Dr Tasadduq Hussain...24 Letter to the Editors...25 BIDA Feowship Awards BIDA Divisiona News - North Waes / Nottingham & N. Trent...26 BIDA Sports Event 2018 Tabe Tennis & Badminton Tournament...26 bidajourna Editoria Committee: Co-Editors Mr A. Sinha Dr Ashish Dhawan Members: Dr Sanjay Arya Prof. D. Bridgen Dr B. Das Dr C. Kanneganti Dr P. Sarkar Mr C. Sevasekar Prof. S. Senapati Mrs K. Upadhyay Any photographs offered for pubication become the property of BIDA Journa and unfortunatey cannot be returned. Editoria Address: 6 Caste Rise, Hawarden, Deeside, Fintshire CH5 3QU E-mai: amitani2000@yahoo.co.in bida@btconnect.com Website: Produced on behaf of the British Internationa Doctors Association by: Graphic Design & Digita Artwork: Nick Sampe D&AD 8 Fairways, Appeton, Cheshire WA4 5HA Phone: E-mai: njcsampe1@me.com Website: Printed by: Minerva Print King Wiiam House, 202 Manchester Road, Boton, Lancashire BL3 2QS Phone: E-mai: info@minervaprint.com Website: bidajourna Editoria The Nationa Heath Service wi be ceebrating its 70th year on the 5th of Juy this year. It is the nation s most treasured estabishment. Over the years it has payed a vita roe in the ives of the society and improving the quaity of ife. In this issue, Dr Satya Sharma and Mr Nikhi Kaushik have briianty dispayed The Good and the Bad aspects of the service. What is most important is that we must appaud the vita roe every individua in the NHS has payed to maintain a cohesive service. The organisation is recognised the best free heathcare in the word. The Internationa Medica Graduates and nursing staff are the backbone of the NHS. The artice pubished in Hindustan Times acknowedges the contribution made by doctors from the South Asian subcontinent. Puskar Bura quotes his experience and has given advice on how to deveop quaities to empower their potentias. There are now grave concerns on recruitment of doctors and nurses. This has been due to a number of factors incuding the effect of Brexit, migration to Austraia and New Zeaand, a reativey high drop out rates through out training and strict Home Office reguations etc. The atter have now made headines by denying the approva of Tier 2 Visa to 100 Indian doctors that had been seected for a 3-year degree programme under Edge hi University as we as other doctors throughout the country. Sanjay Arya has quite pertinenty expained the benefits of bringing in these internationa medica graduates. He goes on to state that this woud have a negative impact on service provisions and have the potentia in putting our patients at risk. This is because their NHS saaries are too ow under immigration rues. What s changed is the Home Office s threshod for granting visas. These are doctors recruited mainy from the Caribbean, India and Pakistan. The current immigration rues that restrict recruitment of Internationa Medica graduates are adding crisis to some of NHS Trusts that are facing huge shortages. The British Internationa Doctors Association is disappointed that appying such a cap without recognising the need of the NHS wi put many areas of services in the NHS operating at fire fighting Mr. Amit Sinha FRCS (Trauma & Ortho) Co-Editor, BIDA Journa. Consutant Orthopaedic Surgeon, Gan Cwyd Hospita (North Waes NHS Trust) mode where there is greater potentia for compromising patient safety. Historicay the internationa medica graduates, in particuar, the doctors from the Indian sub-continent have been a significant contribution in sustaining the services. Given that the migrant doctors which account for over 28% of NHS workforce have been fuy trained and undergone a rigorous seection process before they are accepted by the reguatory body the GMC to practice in this country. BIDA is extremey disappointed that the present government has not shown the sensitivity at a time when the NHS is under severe crisis with regards to the medica workforce, which is resuting in the canceation of operations, outpatient appointments and ong queues in Accident and Emergency. We woud ike to wecome Dr Buddhdev Pandya MBE as the Corporate Affairs Officer for BIDA. He has two exceent artices expressing his views on setting up a NHS Commission as we as GMC reforms. Mr Sampat s journey has been a tough one. Did the GMC treat him fairy? You must read his etter. On the scientific front we focus on Katharine Hamett s review on Cervica ymphadenopathy in chidren. Dr. Anwar has given a very detaied account of Causes of Transient Loss of Consciousness (TLOC) and its management. Mr Sevasekar updates a the aparoscopic surgeons on the issue of robotic surgery. I am sure a ot of us are ooking forward to upcoming word cup in Russia this month. We at the BIDA Editoria Board woud certainy ike to wish the very best of uck to the Engand Team. Finay we hope that you enjoy this edition. Enjoy the summer and keep writing to us. Best wishes Ashish Dhawan & Amit Sinha Co-Editors, BIDA Journa Dr. Ashish Dhawan MD, MRCP Co-Editor, BIDA Journa. Consutant Cardioogist & Cardiac Eectro Physioogist, Wigan Roya Infirmary Any views or opinions that may be expressed in artices or etters appearing in BIDA Journa are those of the contributor and are not to be construed as an expression of opinion in behaf of the Editoria Committee or BIDA. Members are asked to ensure that a enquiries and correspondence reating to membership or other matters are sent directy to ODA House, 316A Buxton Road, Great Moor, Stockport SK2 7DD. (T: F: ) and not to BIDA Journa. Issue No.2, Voume 24 June 2018 BIDA Journa 3

4 BIDA Nationa Chairman s Report Dear Coeagues, It has been a very busy few weeks for the BIDA Executive Committee. BIDA has responded robusty to the unfortunate case of Dr Bawa Garba and has sent a detaied press reease with our position statement to work towards stopping scapegoating doctors for systemic faiures in the NHS. We have met GMC twice and expressed our views and are invoved in this important issue proactivey. We aso responded to Norma Wiiams review of medica mansaughter. BIDA Nationa Secretary and BIDA Journa Co-Editor Dr Ashish Dhawan speaking on ITV s Granada Reports programme about the goverment s cap on Tier 2 Visas. BIDA has condemned pubicy PM Theresa May s government s cap of Tier 2 Visas, which is causing probems to many internationa medica graduates. Our Genera Secretary, Dr. Ashish Dhawan did an exceent interview in many nationa news channes representing BIDA s views on this issue. We wi continue to work hard and put pressure on the Home Office to remove the unnecessary cap of Tier 2 Visas for IMG doctors. I have been interviewed by Puse GP magazine and our organisation s views on Racism in NHS have been pubished in their specia Apri edition. Dr Chandra Kanneganti Nationa Chairman, BIDA We have met the RCGP education committee team and have agreed on number of actions of joint working supporting internationa medica graduate GPs. I am thankfu to the RCGP for pubishing their specia program of migrant s contribution to the NHS, where they have opened a specia photo gaery about BIDA/ODA with pictures of the founder members of the ODA and detais about the history of the organisation. We are panning Our Annua AGM/ARM to be hed at the Daresbury Park Hote, Warrington, Cheshire WA4 4BB from October 12th-14th. We are currenty putting together our programme. Pease mark the dates. We ook forward to severa of our members to attend and represent their divisions. BIDA Internationa Congress preparations are going we and we are ooking forward for an exciting conference in October 2018 in Jakarta. I woud ike to wecome Mr. Buddhdev Pandya, OBE who joined our organisation as Chief Officer of Poicy to support and advise the BIDA Executive. Dr Chandra Kanneganti Nationa Chairman, BIDA Wecome to new BIDA members Name Membership No Division Dr S A Majeed Manchester Dr V Mahotra London Metropoitan Dr A Sinha Manchester Dr S Prasad Manchester Dr S Sukthankar Wigan Dr A Sukthankar Wigan Dr R Jha Rochdae & Bury Dr A Shotri Merseyside & Cheshire Dr J O Loan Merseyside & Cheshire Dr M Verma Preston & Chorey Dr R K Verma Preston & Chorey Dr V Joshi Manchester Dr P Joshi Manchester Dr K Raj Nottingham & North Trent Dr (Mrs) A Raj Nottingham & North Trent Dr B Choayi Poornamodan Stoke-on-Trent & Staffs Dr S Bhaskaran Stoke-on-Trent & Staffs Name Mr B Thomas Dr A Kumar Dr P Sinha Dr R Manghnani Dr Anju Singh Mr Vitta Rao Dr A Kudra Dr U Prakash Dr M K Shashidhara Dr M Khanna Dr S Shridhar Dr Unnat Krishna Dr Sai Piarisetti Dr P K Rao Dr J Chakravarthy Dr F Yousaf Dr M Agarwa Membership No Division Stoke-on-Trent & Staffs Woverhampton Woverhampton Merseyside & Cheshire Merseyside & Cheshire Stoke-on-Trent & Staffs Nottingham & North Trent Nottingham & North Trent Manchester Nottingham & North Trent Nottingham & North Trent Woverhampton Preston & Chorey Manchester North East Backburn Merseyside & Cheshire 4 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

5 BIDA Trainee Forum Chairperson s Dear members, Message Junior doctors are the future of the NHS, but wi no doubt be facing changes and chaenges in the years to come. Becoming a BIDA member wi aow junior doctors a unique opportunity to highight and vocaise issues that face a doctors as we as provide a patform for ethnic minority doctors to be represented. The medica educationa events that BIDA organise aim to promote a high standard of medica practice but are aso an idea opportunity to network with other ethnic minority doctors. BIDA G.P. Forum Chairperson s Report Dear friends, I hope everyone enjoyed the Roya wedding of Prince Harry to Meghan Marke. This is a andmark moment in British history in severa ways. The ceebration of diversity gave hope to countess immigrants and particuary those working in the NHS considering the hostie environment foowing Brexit. Home Office VISA restrictions Recenty the news hit the media that over 1500 visa appications from doctors wanting to work in the UK were refused by the Home Office in ast four months. We have highighted the issue. It is very concerning that we are turning doctors away when the NHS is under such tremendous pressure for recruitment. Meeting with RCGP Chair We had attended a meeting with RCGP Chair, Prof Heen Stokes- Lampard and her coeagues to discuss differentia attainment in AKT (Appied Knowedge Kit) and CSA (Cinica Skis Assessment). We have given further suggestions on training and targeted support, which were positivey received by the coege. We wi continue to work in coaboration with the coege to improve the ives of our coeagues. Meeting: GPC, Engand As your GPC representative I attended the GPC, Engand meeting. Nige Watson, who has been appointed by Jeremy Hunt to ead partnership review, gave a presentation. It s an important piece of work and aong with Dr Chandra Kanneganti fed into the discussions and raised pertinent points incuding indemnity. The review is supposed to ast neary a year and we are hoping for a positive outcome. Nationa Audit Office report The Nationa Audit Office has reeased a report on NHS Engand s management of the PCSE contract with Capita, which iustrates Capita s faiure to deiver backroom services for GP practices and individua GPs. Dr Aditi Sinha Trainee Forum Chairperson, BIDA Furthermore, mentoring in careers and training as we as the advisory services avaiabe shows BIDA s commitment to support a their members and junior doctors in particuar. Dr Aditi Sinha MBChB BSC (Hons) MRCPCH Paediatric ST4. Trainee Forum Chairperson, BIDA Dr Preeti Shuka G.P. Forum Chairperson, BIDA GPC Campaign GPC has aso aunched a campaign asking for a genera practice staff members and individua GPs who have been negativey impacted by one or more of the service ines to sign the pedge. Pease support this campaign, as it wi be used to further demonstrate how far reaching the poor deivery of PCSE (Primary Care Support Engand) is on practice staff and show the Government the number of individuas demanding for the service eve to be improved. NHS Digita Update NHS Digita has produced the quartery update on GP workforce figures. There are 316 fewer fu-time equivaent GPs in Engand since December according to new figures from NHS and 1,000 fewer GPs since September Despite that, trainees on GP training schemes, who towards the end of their training are unabe to secure a post or are having to eave the UK because many GP practices do not hod a sponsorship icense. BMA is coating exampes to forward to the Heath Committee, which wi be used as evidence that the process needs to be ooked at again and woud urge everyone to pease forward any such cases. Wesh Gov. Scheme I woud ike to end with sharing the good news that the Wesh Government is set to introduce a state-backed scheme to provide cinica negigence indemnity for GPs in Waes. This represents a very important step towards increasing the sustainabiity of genera practice in Waes. Thanks for a your support and wi continue to work hard for the coeagues and keep raising the issues important to the profession in various forums. Dr Preeti Shuka GP Partner, Ewood Medica Centre. GP Forum Chairperson, BIDA. BMA GPC Rep Issue No.2, Voume 24 June 2018 BIDA Journa 5

6 Ceebrating A Conversation On the 5th of Juy 2018 Britain ceebrates the 70th birthday of its much-oved Nationa Heath Service. Aneurin Bevan, a ifeong champion of socia justice is credited as being the architect of the NHS. Prior to the estabishment of the NHS the provision of the heathcare was inextricaby bound up with reigion and money, thus disadvantaging the poor. Aneurin Bevan s vision of the NHS was that it woud: Meet the needs of everyone Be free at the point of deivery Based on cinica need and not the abiity to pay 70 years on, the NHS is sti considered the greatest achievement in the history of heathcare in the word. A itte over a decade ago Nikhi Kaushik had produced a Boywood stye fim (Bhavishya-The Future, 2006) that extoed the virtues of the NHS and touched upon inequaities that exist in the deivery of heathcare across nations. BIDA Journa Editoria team invited recenty retired GP, Dr Satyavrat Sharma and Mr Nikhi Kaushik, a Consutant Ophthamoogist for a conversation to refect upon the NHS and its pace in Goba Heath. Nikhi: Satya you have retired from the NHS after having served as Genera Practitioner cose to four decades. What has appeaed to you most about the NHS in the UK? Satya: I think the Principes and vaues that guide the NHS, are most appeaing; these being: Working together for patients Respect and dignity Commitment to quaity of care Compassion Improving ives Everyone counts By maintaining its focus on these the NHS has been abe to bring the haves and the have not s together. This, I think makes Britain a fare society where the heath care is not dependent on one s abiity to pay. Nikhi: I agree, I aso think that the poitics of the nation revoves around Heath, and the NHS is priority number one for the citizen. Satya: That is so, but we hear so much that the poiticization of the NHS is a bad thing and generay peope bame the poiticians for the perceived is of the NHS. Nikhi: This is a paradox indeed. If the NHS does not remain at the centre of poitica debate then the poiticians pu away from investing in the NHS and effectivey that opens up the gates for the private providers. I am not suggesting that there shoud be no invovement of Private providers but the NHS shoud be sustained by genera taxation if it is to deiver that reassurance to the citizen. Satya: What do you think are the major achievements of the NHS? Nikhi: There are many. In the main the severa technoogica advances we now take for granted have been deveoped and are provided under the umbrea of the NHS. To mention a few: Provision of Perinata care Universa Immunization Promotion and focus on Safety measures Action on Smoking Universa avaiabiity of Primary Care Various Screening programs Free or subsidized Drugs High Tech Medicare Satya: And I think these have produced very wecome resuts, for exampe: In 1948 the Infant Mortaity Rate in UK was 34 deaths per 1000 ive births, and now it is 3.8 deaths per 1000 ive births (2016 figures) 6 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

7 The ife expectancy in 1948 was 70.1 for women and 65.8 for men, whist in 2016 it has improved to 83.1 for women and 79.4 for men. The cancer surviva rate has markedy improved Nikhi: Absoutey and further more, there are so many technicay advanced treatments that have been deveoped by the NHS. Just to name a few: In vitro fertiisation, joint repacement surgeries and of course treatment of Cataracts with impantation of Intra-Ocuar enses; these are the amazing gifts of the NHS to humanity. Satya: With such a vauabe roe the NHS pays in our ives it is no wonder peope are sensitive about it and any tak of a threat to the NHS provokes an outcry. Nikhi: Yes and we shoud aso remember that the NHS provides a cohesive force for oca communities and the nation as such. The NHS is the fifth biggest empoyer in word; empoying 1.7 miion peope that are 2.5% of the UK popuation and that incudes a arge number of professionas ike doctors and nurses whose primary quaification is from another country. Satya: So the NHS provides a vauabe empoyment to professionas from other countries. Nikhi: Indeed it does. In March 2017, the NHS empoyed 106,430 doctors, 26% of whom had non-uk primary quaification. Satya: I wonder how this is perceived in countries from where the professiona come to work in the UK Nikhi: This is a mixed bessing as professionas benefit as they gain vauabe experience by working in the NHS that they take back to their home countries. The NHS aso provides career and future opportunities to those who make UK their home. Satya: The NHS understandaby takes a arge chunk of government expenditure. Nikhi: Absoutey, in the fisca year 2018, the NHS budget is biion pounds that is 18% of a government expenditure second ony to biggest spent that is Pensions (20%) Satya: This is interesting, so this huge spend on Pension can aso be bamed on the NHS. Nikhi: Very true, an increased ife expectancy brings its own rewards and chaenges and this must be a major concern to our poitica masters. Unfortunatey, athough we are iving onger, this extended ife requires support from the NHS and socia services. Neary haf the aduts over the age of 65 take one or more prescription medications. So we are seeing that the joy of ong ife is drowning under the burden of Iness. Satya: And that must be a big concern. How do you see the future and what wi be the big chaenges to the generation who wi care for the ever-rising buk of retired citizens? Dr Nikhi Kaushik Consutant Ophthamoogist Dr Satya Sharma MBE, DL GP, Retired Nikhi: The constanty reducing od age support ratio wi be the biggest chaenge in the immediate future and the focus I woud think wi be on a heathy drug free existence. The burden of an edery infirm popuation cannot be good for any society. Satya: I aso think we sha have to water down expectations that peope have from the NHS; and rejoice in its achievement of an increased ife span and independence iving widey. Nikhi: These virtues of the NHS must be shared with other countries too and I fee that the vision of Aneurin Bevan that of a Heath Service that meets the needs of everyone, is free at the point of deivery and based on cinica need and not on the abiity to pay, shoud be a universa dream not just imited to Britain. I think time has come for the Nationa Heath Service to inspire other nations to foow its exampe and for humanity to aim for a truy Goba Heath Service. This I beieve wi be a fitting tribute to Bevan as we ceebrate the 70th year of the NHS. BIDA shoud champion this cause! Above right: Aneurin Nye Bevan, the Labour poitician who founded the NHS in Some of his most famous quotes seem even more reevant today (beow). Issue No.2, Voume 24 June 2018 BIDA Journa 7

8 Indian Doctors seen as architects, the ifebood of Britain s Nationa Heath Service Educated under a medica syabus infuenced by the egacy of the British Empire, Indian doctors came to the UK to train and setted to pursue careers in the NHS. As Britain s Nationa Heath Service (NHS) competes 70 years, Indian doctors who worked for it over the decades are being haied not ony for their contribution but for their centraroe in its deveopment as architects and ifebood. Set up in 1948 to provide free medica services to a, NHS faced a major shortage in the initia years (as it does now), particuary in areas considered inner-city and popuated by working cass peope, where white British professionas were oathe to serve. Educated under a medica syabus infuenced by the egacy of the British Empire, Indian doctors came to the UK to train and setted to pursue careers in the NHS. Their roe is the focus of a new exhibition at the Roya Coege of Genera Practitioners (RCGP). The atest figures show there are 25,711 doctors who gained their quaifications in India, the argest country group in the NHS from outside the UK. There are as many as 1,724 doctors on the register with the surname Pate. A spokesperson for the Genera Medica Counci, which registers and reguated doctors in Britain, said, The medica profession in the UK reies on the expertise of doctors from overseas. Their contribution and the diversity of experience they bring are invauabe. Indian doctors are aso refected in popuar British cuture, for exampe The Indian Doctor, BBC s five-part teevision drama set in a south Waes mining viage in the 1960s, which starred Sanjeev Bhaskar and Ayesha Dharker and was first broadcast in Juian M Simpson, author of a book on doctors from India and South Asia, said: Doctors from the Indian subcontinent were not just contributing to the NHS, they were its very ifebood. We shoud acknowedge they were among the architects of the NHS. Described as groundbreaking, the RCGP exhibition draws on archiva research, photographs and ora history interviews with 40 genera practitioners who moved to Britain from South Asia during the eary period of NHS. RCGP president Mayur Lakhani said: Genera practice in the UK woud not be what it is today without the hard work, innovation, and Above: Sanjeev Bhaskar and Ayesha Dharker in the BBC s The Indian Doctor. Prasun Sonwakar Hindustan Times, London courage of our predecessors... Indeed, without them, our profession and the NHS might not even exist at a. Not ony were they doctors, but they became highy vaued members of the communities in which they practised. Whist many faced incredibe chaenges, our exhibition aso documents the overwhemingy positive and ifeong reationships they forged with their patients. But the story of Indian doctors in Britain has not aways been one of ceebration. There have been numerous cases of discrimination and worse, many of them were unabe to enter or progress in high-profie medica streams. The exhibition acknowedges they often faced racia discrimination and, for women, sexua and racia discrimination, when appying for jobs. Shiv Pande, who gained his medica quaification in Indore and moved to the UK in 1971 to work in cardio-thoracic surgery at the London Chest Hospita, said: Due to discrimination, I coudn t get further in cardiothoracic surgery and had to move into genera practice. But it was a nice move as I coud do more for my patients. Simpson, on whose book the exhibition is based, said: The NHS evoved during its first four decades into a system based around genera practice and primary care. By becoming famiy doctors, South Asian doctors prevented a GP recruitment crisis. It s important to aso remember that the NHS was estabished to make heathcare accessibe to those who coud not afford it. And for miions of peope, particuary in working cass communities across Britain, accessing that care meant going to see a GP from the Indian subcontinent. Besides Pande, RCGP honoured six senior doctors from south Asia at the exhibition aunch event, incuding Has Joshi, KS Bhanumathi, Krishna Rao Koripara and Sri Venugopa. Veteran Liverpoo-based Indian doctor Shiv Pande, who has been honoured with an MBE, hed senior positions in Britain's medica bodies, raised funds for victims of the Bhopa gas disaster and organised cricket coaching by India's Word Cupwinning cricketers in 1984 for Liverpoo's unempoyed youngsters. Artice reproduced by kind courtesy of The Hindustan Times. 8 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

9 Empowering Internationa Medica Graduates Right from the inception of the NHS in 1948, the UK has been dependent upon internationa medica graduates (IMGs). With amost 1 in 3 doctors working in the UK being IMGs, the NHS owes its continuing existence to foreign graduates 1,2. Life as an IMG in the UK, however, is far from being easy. Medicine is a tough profession, more so if you are an IMG. Studies show that IMGs are more ikey to be buied in the workpace, have higher faiure rate in postgraduate exams and ARCP 3 and are more ikey to be brought before reguatory bodies and be subjected to discipinary procedures. Despite the aarming statistics, itte has been done to empower IMGs. A recent arge observationa study in the United States 4 compared differences in patient outcome of two groups of patients, one treated by IMGs and the other by US graduates. Those patients treated by the IMGs had a ower mortaity even though patient treated by IMGs had sighty more chronic condition. Needess to say, the study does have its imitations but the esson that can be earnt from this study is that IMGs need not be stigmatised. Instead they can prove to be an asset for the organisation. For this to materiaise there has to be a coective effort, right from non-imgs to organisationa bodies ike the GMC, NHS Engand and BMA. Each has a roe to pay. Often it is the subte discrimination and ack of acceptance by peers that creates a them versus us mentaity. This ceary needs to stop. Tiffin et a 5 suggests that increasing score of IELTS and PLAB woud reduce disparities in postgraduate performance between PLAB and UK graduates. As someone who has had first hand experience with IETLS, PLAB and then working in the UK, I woud disagree with that suggestion. Despite having scored 8 (out of 9) in my IELTS and having an Engish step-father, I sti strugged with communication in the workpace. An IELTS score of 7 or 7.5 woud perhaps not make much of a difference. With regards to the PLAB exam, it is not as robust as its American counterpart- the USMLE. Match rate for US residency is much ower (49.4%) for IMGs than US graduates (94%). This speaks voumes. There are many institutes in the UK that expoit the repetitiveness of questions in the PLAB exams. Therefore, it is ikey that one woud pass the PLAB exam after enroing on such a course. Perhaps, it is about time that the GMC scrap the PLAB exam and consider repacing it with a more robust exam as opposed to just increasing the pass mark. Having an IMG as a supervisor proved to be very beneficia to me. With the hep of my supervisor s experience and advice, not ony was I abe to pass my MRCP exams and step up as an executive member for the Wesh junior doctors committee. I was aso abe to tak about my insecurities and strugges with the supervisor who coud guide me in the right direction. It certainy fet ike I was thriving during my core medica training years. Perhaps, the deaneries coud pair an IMG with an IMG supervisor who can understand foreign sensibiities. A positive campaign by the ikes of BMA woud certainy hep the cause. RCP exceence award winners for the year 2016 and 2017, Dr Anu Jacob and Prof. Geeta Menon are both IMGs. Highighting achievements ike these woud hep to end the notion that care provided by foreign graduates is inferior. Last but not the east, it a bois down to the individua to empower themseves. As someone who has worked in the UK for the ast five years as an IMG, I present some suggestions for IMGs, especiay for those starting afresh: 1. Be proactive and have a growth mind-set. 2. Invest your time and money in inter-persona skis (e.g. assertiveness) and communication skis 3. Enro onto a RCP mentoring scheme (it s free of cost to trainees) 4. Face vaue and first impression are vita. Dress up smarty and aways maintain eye contact whist speaking to someone. Appearing confident makes a difference. 5. Invest in sef-hep books (e.g. 7 habits of highy effective peope by Stephen Covey, Mindset by Caro Dweck, Peak by Anders Ericsson) 6. Reading good iterature, incuding books, journas and newspapers ike the Guardian and the Teegraph not ony improves one s Engish but aso heps understand British sensibiities. 7. Be open to earning new cuture and adapting to it. Joining socia groups can be hepfu in understanding British cuture and way of ife. 8. When you need hep, have the humiity to ask for hep. Don t suffer in sience. References: Dr Puskar Bura Cinica Feow, Department of Cardioogy, Southmead Hospita, Bristo 1. BMA equaity and incusion unit. The contribution of internationa medica graduate doctors to the NHS. London: BMA Esmai, A., Simpson, J. Internationa medica graduates and quaity of care. BMJ 2017;356:j McManus, I.C., Wakeford, R. PLAB and UK graduates performance on MRCP (UK) and MRCGP examinations: data inkage study. BMJ 2015;348:g Tsugawa, Y. et a. Quaity of care deivered by genera internists in US hospitas who graduated from foreign versus US medica schoos: observationa study. BMJ 2017;356: j Tiffin, P.A. et a. Annua Review of Competence Progression (ARCP) performance of doctors who passed Professiona and Linguistic Assessments Board (PLAB) test compared with UK medica graduates: nationa data inkage study. BMJ 2014:348:g2622 Issue No.2, Voume 24 June 2018 BIDA Journa 9

10 The Home Office: Putting patients at risk MCh/MMed is a very successfu postgraduate education programme for internationa doctors, running over the ast 12 years in the UK. This is a two to three years programme which provides a structured educationa and cinica experience which cuminates in the award of a higher degree (MCh for Surgica speciaities and MMed for Medica speciaities) by Edge Hi University. Over 120 doctors have aready obtained their higher degree through this programme. Thirty five Trusts have joined this programme and doctors work in a structured rotation in their chosen speciaty. These doctors occupy posts in severa Medica discipines (A&E, Acute medicine, Edery care, Cardioogy, Gastroenteroogy etc), Psychiatry, Obstetrics & Gynaecoogy, Trauma and Orthopaedics and various other branches of surgery (ENT, Uroogy, Coorecta surgery, Cardiothoracic surgery etc). There is no doubt that we must manage immigration, but there is and wi continue to remain an on-going need to bring doctors from outside the UK for the next few years whie we train our own doctors. Brexit is ikey to make the situation worse. There are huge benefits in bringing these Internationa Doctors under this Learn, Earn and Return Programme run in coaboration with Edge Hi University and Wrightington, Wigan & Leigh NHS Foundation Trust. Dr Sanjay Arya Consutant Cardioogist Medica Director, Wrightington, Wigan & Leigh NHS Foundation Trust Direct impact on A&E performance and waiting times, at a time when NHS is strugging to meet the four hour target. Reducing premium ocum costs - One doctor vacancy requires the empoyer to use ocums to fi the gap at a cost of over 150,000 per annum, more than doube the cost of an NHS empoyee. There is going to be a huge increase in ocum costs. Impact on British trainees: There wi be a significant disruption to their training as they wi be put in a position where they wi have to work additiona hours to fi these gaps with reduced quaity of training due to increased service commitment. Mutuay beneficia to both countries through the Learn, Earn and Return programme. The UK is internationay known for deivering high quaity teaching and training to overseas doctors, many of whom have gone back with new skis improving patient care in their home country. Direct impact on cinica care to patients in areas where we strugge to recruit oca or EU doctors. No oca doctors take these non-career grade posts. Direct impact on patient safety: There are huge gaps in the rota in amost a speciaties. As a resut of these unfied rotas, there wi be a significant effect on patient care, patient safety and risk of errors happening. It is a sef-funded programme, supported by the Genera Medica Counci (GMC) and Greater Manchester Heath and Socia Care Partnership. The Home Office is not aowing us to bring these doctors to fi the huge vacancies that exist in the NHS. There are over 100 junior doctor vacancies that did not have any European Union doctor interested in fiing these positions. The consequences of the refusa of Visas to these highy quaified doctors, who have gone through an intense interview process and have passed the GMC conducted Engish Language test, are serious, both cinicay and financiay. We do not beieve that the refusa of visas for these overseas doctors has anything to do with racia discrimination. We sincerey hope that the Home Office wi reconsider their decision as the benefits are huge, and are so obvious. References: 1. The truth about... NHS Engand s Internationa GP recruitment scheme: ,600 IT workers and engineers denied UK visas: 3. Home Office FOI reveas scae of skied worker refusas due to visa cap 10 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

11 The NHS needs a Roya Commission to provide a pathway for sustainabiity The NHS wi be ceebrating 70th Anniversary of the NHS in The state funded service was founded out of a nobe idea that good heathcare shoud be avaiabe to a, regardess of weath. The NHS has aways been a poisoned chaice yet a unique pubic service, and the envy of the word. The service provision is in need of a thorough and comprehensive Dr Buddhdev Pandya MBE Chief Officer for Corporate Affairs, BIDA review that is poiticay neutra, and - taking into account it s historica experience - provide a pathway to adopt new advances in science and technoogy, whie embracing the integration of the private sector to meet the growing demands on the NHS. Buddhdev Pandya MBE says, My preference woud be for estabishing a Roya Commission, which is more appropriate since it woud provide a more cohesive approach. Recenty, The Secretary of State for Heath The Rt Hon Jeremy Hunt MP has caed for adoption of a ten-year strategy for the heath service. This is a wecomed approached since temporary soutions based on knee-jerk reactions successive governments have seemed to have added more confusion and faied in providing any sustainabe resoution for improvement in the quaity of patient care over the years. The NHS wi be ceebrating 70th Anniversary of the NHS in The state funded service was founded out of the nobe ideas that good heathcare shoud be avaiabe to a, regardess of weath. The NHS has aways been a poisoned chaice, yet a unique pubic service and an envy of the word. Many recent reports have highighted the need to take steps to avoid vauabe resources being wasted to ensure better use for improving patient care. There is a common thread through the mismanagement of human resources as we as processes; both requiring innovative and atera thinking. There are serious concerns over the current deegated responsibiities through the NHS Trusts for their abiity to pan and deivery services, capabe to meeting the needs of the changing environment. Many aspects of the functiona capacity of these bodies are under question for acking sensitivity in efficienty recognising and tacking troubed hotspots and infuencing processes to bring about ong term amicabe soution. The NHS has aso inherited a new dynamic of the contract cuture since the integration of the Private Sector (Pubic and Private Sectors Partnerships). It has compounded chaenges in many respects, invoving monitoring processes and integration of services and reated modes. It has incubated a cuture of uncertainty and fear among the workforce as they fear significant reduction of infuence in panning services in their own areas of working. It has impacted on the mora of the front-ine workers with its tota accumuative effect of creating mismatches in service panning with the avaiabiity of the resources and, for that matter baancing the demands with avaiabiity of resources. Many of the shortcomings have been inherited over decade,s as various governments have often tried short-term or popuarity measures. There was a significant absence of any coherent ong-term view on the eve of resources or changes in services required. The NHS is aso ikey to be a major pubic debating point in the coming years. Whie I agree that the NHS may need further funds given the demands on the services, my thought is that merey pouring in funds may not be an idea soution given the compexity of chaenges. The fear is genuine that most possibe increases are ikey to be sweed up in bureaucracy where the cinicians are not in the driving seat! The NHS is now facing shortages of speciaist staff, GPs and other front-ine workers. It confirms that workforce requirement needs to be a part of the ong term strategy, particuary when it is highy dependent on migrant workers. It invoves education, training, recruitment, retention and career progression and better harmonisation between these eements. What is required is a comprehensive and thorough review encompassing the past seven decades of service, as much as to consider the impact of the new advance technoogy, integration of the private sector in reation to the growing demands on the NHS. There may be a case for refecting on the service deivery structures, reguatory and monitoring regimes for improving accountabiity and transparency across the NHS. My preference woud be for estabishing a Roya Commission with more appropriate terms of reference to provide a more cohesive approach. From Brexit negotiations to the projected numbers of peope with diabetes aone, there are more compeing reasons to refect upon the fisca impications with considerations that are a poiticay neutra review of our heath services. This is the best environment to prompt a rethink of the whoe system and of how society needs to change. Here we have a situation where the NHS has been subjected to being a poitica footba; when peope disagree even on whether it has a probem, et aone the possibe soutions. A Roya Commission might be that peacemaker, an honest broker with many advantages incuding the abiity to secure the vita cross-party support needed to embed asting changes, and to de-toxify reforms that otherwise may be too poiticay dangerous to pursue. The Roya Commissions are independent governments cannot interfere once they have started and therefore sit outside poitics. They are aso powerfu and can compe peope to produce documents and other evidence in their enquiries. And we wi need the power to ask difficut questions of experts from a sections of society. We must chaenge what we think we know about the probems the NHS faces today. We must think beyond the structures and institutions of the previous century. It woud hep converge focus in identifying more productive avenues based on wider input from the critics and poitica opponents as we as the frontine professionas. At east, their grievances, suggestions and recommendations woud find a more structured path way to register concerns. There is a vaue in aowing engagement of a the stake hoders in converging on an exercise to bring about some commons consensus of views on many aspects for suggesting improvement and possibe reshaping of the NHS. A Roya Commission is a major form of an ad-hoc forma pubic inquiry into a defined issue, and avaiabe to the government to inquire into various issues. Commissions report findings in the form of advice, and recommendations made are not egay binding but can form the basis for a potentia green paper for deveoping the necessary egisation or amendments. Perhaps, a we need is to form a view and bring this to the attention of our Members of Pariament and to the Secretary of State for Heath for their consideration. Issue No.2, Voume 24 June 2018 BIDA Journa 11

12 A position statement from the Association of Laparoscopic Surgeons of Great Britain and Ireand (ALSGBI) on Robotic Surgery Mr C R Sevasekar Consutant in coorecta, peritonea and pevic oncoogy, The Christie NHS Foundation Trust, Manchester, UK Summary Association of Laparoscopic surgeons of Great Britain and Ireand (ALSGBI) has been in the forefront of the deveopment in minima access surgery in the United Kingdom. ALSGBI provides a structure for training to promote safe practice of muti-professiona minima access surgery. Robotics in surgery has been in cinica use for some time and the association fuy understands the need to embrace robotics in surgery but fee a cautious approach in the introduction to cinica practice based on the cinica and cost evidence with training for surgeon and the team to perform the procedure competenty. There shoud be a strong cinica governance arrangements ocay and NHS shoud adopt the technoogy appraisa guidance provided by Nationa institute for heath and cinica exceence (NICE). The cost of the current robotic system is a huge financia chaenge however, ALSGBI beieves in estabishing high voume centres which wi enabe estabishing and sustaining high quaity service and aso provide centres of exceence in high quaity training. The training needs to be team based, structured and accredited. The cinica outcomes shoud be defined, measured and recorded prospectivey in cinica trias or through a nationa registry. Introduction Robots have been used in assisting surgeons to perform surgica tasks in orthopaedics, neurosurgery and cardiac surgery for some time however there has been exponentia increase in the use and popuarity foowing the introduction of robotic prostatectomy. Nowadays robotics is widey used in genera surgery, gynaecoogy and head and neck surgery. Cinica appication Despite the increased popuarity of robotic prostatectomy which is recommended by NICE as the technique of choice, there is no unequivoca evidence to show its superiority over traditiona aparoscopic surgery in other surgica procedures. Further trias are required to ascertain the ong-term benefits of robotic surgery in oncoogy, functiona outcomes incuding QoL and to assess the cost effectiveness. In other pevic surgeries the use of robot has shown margina benefit but has invoved greater costs and onger operating times. In 2000, the Da Vinci robot was approved by FDA for use in aparoscopic surgery. The Da Vinci system overcomes some of the imitations of the standard aparoscopy and aows for precise dissection in a narrow confined space, hence the increasing appication in robotic assisted aparoscopic prostatectomy. The advantages incude stabe operator controed camera system; high definition 3-D magnified view, articuating instruments with seven degrees of freedom, improved ergonomics, motion scaing and tremor fitration. The short term benefits are mainy reated to reduced wound reated compications. However robotic surgery is more expensive than aparoscopic surgery and open surgery. There is some evidence to suggest robotics may reduce the earning curve and may enabe open surgeons to take up minima access surgery. Athough the initia set up costs are high, increased competition from manufacturers and wider dissemination of the technoogy may drive the costs down in future. Robotic technoogy is rapidy evoving with the deveopment of new robotic prototypes for singe incision surgery. Robots designed for specific procedures rather than current generic system wi enabe procedure specific improved outcomes with decreased compications aong with cost effectiveness in future. Training in Robotics Currenty in the UK, knowedge and skis are acquired through speciaty training or on pre- or post-cct feowships. Operative experience can be gained by mentored practice or by the use of simuators. Trainees must have satisfactory knowedge of the specific characteristics of the robotic patform and trained by the appropriatey trained and experienced trainers. Equay important in robotic surgery is the team training with the robot. At present apart from few robotic prostat feowships most of the robot training is provided by the manufacturer of the singe currenty commerciay avaiabe and approved surgica robot. Ideay heath care providers shoud have the abiity and the resources to train surgica teams in a aspects of surgica care incuding robotics. Training in aparoscopic coorecta surgery has been streamined using the moduar approach and through the LAPCO programme ( Simiar training mode needs to be estabished for robotic surgery. There are some unique considerations such as port pacement where coisions of the arms have to be avoided, additiona arm under the surgeon contro, increased reiance on visua cues due to ack of tactie feedback with the current system. In addition, team training with enhanced communication is needed between various members as the surgeon is away from the patient, scrub team and the anaesthetist. There is a huge amount of iterature on cacuating the earning curve based on surgica competency and patient outcomes in aparoscopic surgery. Simiar methodoogies need to be adopted in achieving competency in robotic surgery. Using the cusum and operating time, appropriatey cases is thought be the required to achieve competency in robotic recta resections based on prior experience in minima access surgery. The association woud recommend a competency based training in robotic surgery based on the European robotic uroogica society feowship programme and the European academy of robotic coorecta surgery. The training needs to be a standardised structured programme with assessment of knowedge by competing the Intuitive surgica onine robotic training modue, foowed by training in the wet ab incuding anima and human cadaver training. Non-technica skis training for the teams is important foowed by team observation visit to a proctor site foowed by few proctored cases +/- assessment of 12 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

13 technica competence by video anaysis with ongoing audit of the cinica practice. Quaity Assurance As a new technoogy, robotic surgery shoud be subjected to the a the currenty defined quaity indicators for surgica practice incuding mortaity, oncoogica safety, compications, and quaity of ife assessments and foow the NICE approved process of assessing cinica and cost effectiveness. Standardisation of surgica training and its appication is vita to ensure that newer technoogies are vaidated appropriatey. Concusion Robotic surgery with the Da Vinci surgica system is increasingy used in a wide range of surgica speciaties. This technoogy aims to improve outcomes when compared to open surgery and to overcome some of the imitations of aparoscopic techniques. Despite increasing use, apart from prostatic surgery there is no unequivoca evidence to show the superiority of robotic surgery over the traditiona aparoscopic techniques. As there is a greater focus on eary intervention and quaity of ife, there is ikey to be deveopment of robotic patforms for procedure specific or patforms for specific parts of the procedure rather than the currenty avaiabe singe robotic system used in a speciaties to cover the entire surgica procedure. At the same time there is advancement in aparoscopic surgery with 3-D technoogy and improved instrumentation. An area of considerabe interest, unique to robotic patforms is the abiity to integrate eectronic systems such as cross-sectiona imaging and programmabe parameters into a robot, aowing 3-D esion definition, potting no-go anatomica danger zones faciitating dissection in the idea pane in oncosurgery. In training, robotics ends itsef to teementoring as a training too. Estabishing sma number of accredited, adequatey resources, high voume centres of exceence with the additiona remit of deivering training woud provide a suitabe framework for training in robotic surgery in the UK simiar to the modes estabished for training in aparoscopic coorecta surgery. Contributors Mr Peter Sedman Mr Simon Dexter Mr David Mahon Mr Donad Menzies Mr Pau Leeder ALSGBI President ALSGBI President Eect Honorary Secretary Honorary Treasurer Director of Education Do you want to see the cearer picture? Woud you ike to know what s going on? Then keep in touch! For a the BIDA news, views, reviews and a great dea more, simpy go to www. bidaonine.co.uk Issue No.2, Voume 24 June 2018 BIDA Journa 13

14 Transient Loss of Consciousness and differentiation among important causes Dr Amir Shahzad Anwar Cardioogy Registrar North West Deanery Dr. Ashish Dhawan MD, MRCP Consutant Cardioogist & Cardiac Eectrophysioogist, Wigan Roya Infirmary Consciousness is the state of awareness of the sef and the environment (2) and has two components : content (awareness) and arousa (degree of wakefuness from deepy unconsciousness to fuy awake. As a person cannot be aware without being awake, hence these two aspects are not independent. Considering this definition, unconsciousness might aso have content and arousa parts but this is not cinicay reevant. If unconsciousness were aso used for content, then the word woud aso cover the menta state during absence and partia compex seizures: wherein patients have impaired awareness, and content is affected. Such forms of epiepsy do not usuay cause coapse, however. Patients appear awake ; meaning the arousa aspect is unaffected. The term unconsciousness is not used for these conditions and the internationa League Against Epiepsy (ILAE) uses impaired consciousness to describe consciousness in these states. Partia compex seizures and absences therefore do not usuay enter the differentia diagnosis, needed to distinguish cinicay between the principe causes of syncope and epiepsy. TLOC can be defined as a transient, sef imited oss of consciousness usuay eading to a coapse. The Oxford Engish dictionary aso defines backout as temporary oss of consciousness, and backout is vauabe parance for everyday communication with patients and between doctors. Backout does not prejudice the underying cause of oss of consciousness. Unike TLOC it is commony used in everyday Engish, and widey understood by patients, reatives and doctors. Causes of TLOC: Causes of coapse and TLOC are given in Figure 1.1. The causes of TLOC are syncope, epiepsy and psychogenic backouts, with some very rare exceptions. Athough psychogenic backouts are not reay backouts, they ony appear to be syncope. A these causes have distinguishing cinica features but misdiagnosis occurs frequenty, and it is known that epiepsy is commony diagnosed in patients with syncope(1). Misdiagnosis of epiepsy occurs because syncope is often convusive with abnorma movements and incontinence(2). This is discussed ater in detai. a) Syncope Syncope is the most common cause TLOC. The word syncope is derived from the Greek words, syn meaning with and the verb koptein meaning to cut or more appropriatey in this case to interrupt (3). There has been a ot of confusion in defining syncope. Van Dijk (4) et a has described the condition in detai. Syncope must be distinguished from TLOC itsef and recognized as a common cause of TLOC. In some conditions, consciousness appears to be ost, which is probaby the case in psychogenic backouts. Many causes of TLOC are not due to syncope (Fig 1.2), but many past definitions of syncope are very unhepfu, because they confuse syncope and TLOC. For exampe, in the Framingham study and in many medica textbooks, syncope is defined as a sudden oss of consciousness associated with inabiity to maintain postura tone, foowed by spontaneous recovery. This is not a definition of syncope, but a definition of TLOC/backout. In some pubications, even stroke, TIA and epiepsy were considered among causes of syncope, but TIAs specificay do not cause TLOC. More recenty, definitions more cosey detai the underying pathophysioogy. Syncope is now defined by the European Society of Cardioogy as a TLOC due to transient goba cerebra hypoperfusion characterized by rapid onset, short duration and spontaneous recovery (3). Thus, syncope is ony diagnosed if abrupt oss of cerebra bood fow is thought to be the cause of TLOC, and not simpy in TLOC. Causes of syncope are mentioned in tabe 1.1 Three most common causes of syncope are: refex syncope, syncope due to orthostatic hypotension, and syncope with cardiac/ cardiopumonary cause. 14 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

15 Due to head trauma Concussion, oss of consciousness is usuay transient with a variabe duration. Not due to head trauma Disorders are not aways transient. If they are, they are not necessariy sef imted or short ived. Exampes are: Intoxication, Metaboic disorders, subarachnoid hemorrhage, epiepsy etc. Syncope Generaised epiepsy Stea or vertibrobasiar TIA (TLOC rare, other neuroogica symptoms present) Figure 1.2: Syncope in reation to rea and apparent oss of consciousness Refex (neutray mediated) syncope Vasovaga: Mediated by emotiona distress: fear, pain, instrumentation, bood phobia, or by orthostatic stress Situationa: cough, sneeze, gastrointestina stimuation (swaow, defaecation, viscera pain), micturition (post micturition), post exercise, post prandia, others (e.g., aughter, brass instrument paying, weightifting) Carotid sinus syncope Atypica forms (without apparent triggers and/or atypica presentation) Syncope due to orthostatic hypotension Primary autonomic faiure: pure autonomic faiure, mutisystem atrophy, Parkinson s disease with autonomic faiure, Lewy body dementia Secondary autonomic faiure: diabetes, amyoidosis, uraemia, and spina cord injuries Drug induced orthostatic hypotension: acoho, vasodiators, diuretics, phenothiazines, antidepressants Voume depetion: haemorrhage, diarrhoea, vomiting, sat depetion Cardiac Syncope (cardiovascuar) Arrhythmia as primary cause: Bradycardia: sinus node dysfunction (incuding bradycardia/tachycardia syndrome), atrioventricuar conduction system disease, impanted device mafunction Tachycardia: supraventricuar, ventricuar (idiopathic, secondary to structura heart disease, or to channeopathies) Drug induced bradycardias and tachycardias Structura disease: Cardiac: cardiac vavuar disease, acute myocardia infarction/ischemia. Hypertrophic cardiomyopathy, cardiac masses (atria myxoma, tumours etc.), pericardia disease/ tamponade, congenita anomaies of coronary arteries, prosthetic vave dysfunction Others: pumonary emboism, acute aortic dissection, pumonary Hypertension Tabe 1.1: Causes of Syncope(5) Refex syncope Norma cardiovascuar refexes maintain the bood pressure and cerebra perfusion, and a major component of this is the maintenance of periphera arterioar tone. Arterioar tone is maintained by sympathetic outfow, mainy to skeeta musce capiary beds. Sudden oss of this tone causes bood to rush into skeeta musce, and away from other organs. When the body is upright, the effect on the brain is maximised, because of the orthostatic effect which further reduces perfusion pressure to the upper parts of the body. Cerebra hypoperfusion, especiay if marked and abrupt, resuts in oss of function with oss of consciousness, and affects the anti-gravity musces suppied by the motor cortex which is the highest part of the brain. This characterises vasodepressor of refex syncope. However, there is a variabe component of cardioinhibition. This is characterised by abrupt vaga stimuation, sowing or even stopping the heart, transienty. If both mechanisms occur in same individua, it is caed mixed type of refex syncope. There has been much debate as to whether decreased cardiac output or vasodiation is the dominant hypotensive mechanism preceding vasovaga syncope. Wieing et a (6) did an anaysis of cassica papers and concuded that reduction in cardiac output, rather than vasodiation, may be the primary cause of hypotension of vasovaga syncope. Refex Syncope is characteristicay spontaneous without a good expanation, or associated with certain stimui, such as the sight of bood or a neede. Sometime there are other specific situations with specific provocateurs causing refex syncope such as micturition or cough syncope. Different types are described in tabe1. Conditions misdiagnosed as syncope: The most important differentia diagnoses for syncope are epiepsy and psychogenic backouts. Metaboic disorders may cause coapse and atered consciousness, but they rarey correct themseves rapidy and spontaneousy as syncope does. In other very rare circumstances, such as catapexy, there is no TLOC, athough consciousness is affected. The most important principe in the differentia diagnosis of patients with backouts is that diagnosis is based predominanty on cinica evauation. This shoud be backed up by a 12-ead ECG in a cases, and ony a few patients are typicay diagnosed with more sophisticated and expensive testing. Hence, the important cinica features are discussed beow. Tabe 1.2 summarises the conditions misdiagnosed as syncope. Disorders with partia or compete LOC but without goba cerebra hypoperfusion Epiepsy Metaboic disorders incuding hypogycaemia, hypoxia, hyperventiations with hypocapnia Intoxication Disorders without impairment of oss of consciousness Catapexy (Sudden and transient episode of musce weakness due to some trigger such as aughing, crying and terror, consciousness is not affected) Drop attacks (Sudden spontaneous fas whie standing or waking with compete recovery in seconds or minutes) Fas Functiona: (Psychogenic pseudosyncope) TIA of carotid origin Tabe 1.2: Conditions incorrecty diagnosed as syncope b) Epiepsy Epiepsy is conceptuay defined as a disorder of the brain characterized by an enduring predisposition to generate epieptic seizures and by the neurobioogic, cognitive, psychoogica and socia consequences of this condition (7). There is requirement of at east one epieptic seizure, which is a transient occurrence of signs and/or symptoms due to abnorma excessive or synchronous neurona activity of the brain. More recenty a practica cinica definition of epiepsy has been agreed by Internationa League against Epiepsy (ILEA) and is described by any of the foowing conditions (8) ; 1. At east two unprovoked (or refex) seizures occurring >24 h apart 2. One unprovoked (or refex) seizure and a probabiity of further seizures simiar to genera recurrence risk (at east 60%) after unprovoked seizures, occurring over the ext 10 years. 3. Diagnosis of an epiepsy syndrome Epiepsy is not necessariy ife-ong and is considered to be resoved if a person has been seizure free for 10 years, with 5 years free of antiepieptic medications, or when that person has passed the age of an age-dependent epiepsy syndrome. Many cinicians beieve that two documented unprovoked seizures are required for the diagnosis. Cruciay, generaised epiepsy is a cause of TLOC, but there is no change to cerebra perfusion in the pathogenesis of it. Other forms of epiepsy shoud not cause confusion with syncope or psychogenic backouts as they tend not cause coapse with TLOC. c) Psychogenic Seizures The term psychogenic syncope is a misnomer. "Psychogenic pseudosyncope (PPS), is a better term, but can sti cause confusion. Using syncope can impy to some that cerebra perfusion is impaired, and to others that there is TLOC. Many different terms have been used, incuding sef-induced syncope (4). Rueber and Eger (9) described it as episodes of atered movement, sensation, or experience simiar to epiepsy, but caused by psychoogica process and not associated with abnorma eectrica discharges in the brain. Unfortunatey, whist this excudes epiepsy, it doesn t excude syncope. Psychogenic pseudosyncope refers to episodes when patients appear unconscious but are not. Reated terms are psychogenic seizure, psychogenic coma or pseudo-unconsciousness, depending on the cinica presentation. Three psychiatric conditions may underie psychogenic pseudosyncope. One is conversion disorder, in which patients have unexpained somatic symptoms, suggesting a neuroogica or genera medica condition. As a rue, the symptoms cannot, after appropriate investigation, be fuy expained by a genera medica condition, the effects of a substance, or Issue No.2, Voume 24 June 2018 BIDA Journa 15

16 16 Transient Loss of Consciousness and differentiation among important causes as a cuturay sanctioned behaviour or experience (4). Secondy, in a factitious disorder, symptoms are intentionay produced, with the motivation being to assume a sick roe (4). In maingering, the motivation of symptom production is an externa incentive, such as economic gain or ega responsibiity (4). Maingering is probaby very rare today and care shoud be taken to abe this a cause as it wi be counterproductive. Psychogenic backouts usuay ast much onger than syncope: patients may ie on the foor for many minutes; 15 min is not exceptiona. Other cues are a high frequency of attacks in a day, and the ack of a recognizabe trigger. Injury does not excude psychogenic backouts: trauma was reported in 50% in pseudoseizures (10). The eyes are often open in epieptic seizures and syncope but are usuay cosed in psychogenic backouts. Fu documentation of attacks is needed to aid diagnosis. This is extremey difficut to organize. Parameters required to assess fuy are posture and musce tone (video recording or neuroogica investigation), BP, HR, and EEG. Functiona disorders combine apparent unconsciousness with oss of motor contro, whie norma BP, HR, and EEG rue out syncope and most forms of epiepsy. Increased heart rate in reation to the apparent oss of consciousness has been suggested by Leiden group (11) as important recognizing feature in patients with psychogenic syncopee. Same group has aso shown that frequent, ong attacks with the eyes cosed during apparent TLOC are pathognomonic for PPS (12,13). Having objective physioogica data is extremey usefu in confirming the diagnosis. Giving a psychogenic diagnosis to patients may be difficut, but objective data are invauabe. A psychoogica expanation may impy to patients that they are personay responsibe or that they simuate attacks on purpose. However, psychogenic backout patients see their attacks as invountary, (as they probaby are). Stressing that attacks are as invountary as syncope or an epieptic seizure avoids stigmatization, avoids counterproductive cashes, and provides a therapeutic opening. A further feature of psychogenic backouts is that many sufferers have aso been sufferers of physica and sexua abuse in chidhood (2). Many patients, perhaps a, with psychogenic syncope have had and may continue to have refex syncope (14) : Abnorma Limb Movements and distinguishing different types of TLOC: Generaized seizures produce TLOC and shoud be distinguished from syncope. Generaized seizures may be tonic, conic, myoconic, tonic-conic, or atonic, depending on the predominant musce activity observed during the seizure. A generaized seizure is a British Internationa Doctors Association Issue No.2, Voume 24 June 2018 Cinica findings suggest the diagnosis Epiepsy ikey Syncope ikey Symptoms before the event Aura (Such as a funny sme) Nausea, vomiting, abdomina discomfort, feeing of cod, sweating (neuray mediated) Findings during oss of consciousness (as observed by an eyewitness) Symptoms after the event Tabe 1.3: Cinica features distinguishing epiepsy and syncope seizure whose initia semioogy indicates, or is consistent with, more than minima invovement of both hemispheres (15) and this is naturay a very expert judgement to make a cinica diagnosis. Athough oss of consciousness is not incuded in the definition, abnorma neurona activity of major parts of both hemispheres generay resuts in oss of consciousness. Myoconic seizures are the soe exception, as these seizures usuay present without affecting consciousness. Tonic refers to a sustained increase in musce contraction asting a few seconds to minutes. Myoconus is defined as a sudden, brief (< 100 ms) invountary singe or mutipe contraction(s) of musce(s) or musce groups of variabe topography (axia, proxima imb, dista), and is thus fitting or random. Conic refers to a myoconus that is reguary repetitive, invoves the same musce groups, at a frequency of ~2 3/s, and is proonged, so that these movements are more repetitive and reguar. Tonic-conic refers to a sequence consisting of a tonic foowed by a conic phase. Finay, atonic seizures are characterized by a sudden oss or diminution of musce tone without apparent preceding myoconic or tonic event asting 1 to 2 s, invoving head trunk jaw, or imb muscuature. Atonic attacks are rare and occur amost ony in sma chidren. Both syncope and psychogenic backouts are commony associated with imb and facia movements (2). Criticay, stiffness and myoconus are not restricted to epiepsy. They were observed in 90 % of heathy subjects who intentionay provoked syncope (16). Observations of such movements is reported in 12 % (17) to 46 % (18) of fainting bood donors. Abnorma movements mimicking a seizure can be produced because of cerebra anoxia and can be easiy confused with tonic-conic movements of epiepsy. This is convusive syncope which has resuted in misdiagnosis of epiepsy. Lempert et a induced this phenomenon in heathy medica students whie observing the effect through video cameras (16). Simiar movements can be produced during tit tabe induced Refex Syncope (Zaidi et a. (1) ). Caution is needed Tonic-conic movements are usuay proonged and their onset coincides with oss of consciousness. Hemiatera conic movement Cear automatism such as chewing or ip smaking or frothing at the mouth (partia seizure) Tongue biting a) Latera epiepsy b) Tip refex syncope Bue face Proonged confusion Aching musces therefore when using the word seizure to describe abnorma movements in TLOC, since many physicians woud equate seizure with epieptic attack potentiay giving rise to a misdiagnosis. Interestingy, the ILAE does not restrict the use of seizure to epieptic attacks. With the focus on carefu history taking and cinica diagnosis, expert working groups have defined distinguishing features. ESC guideines (2009) (10) have described some distinguishing cinica features between epiepsy and syncope (Tabe 1.3). Concusion: Tonic conic movements are aways of short duration (<15 s) and they start after the oss of consciousness Usuay of short duration Nausea, vomiting, paor (neuray mediated) It is important to appropriatey differentiate causes of oss of consciousness. Appropriate history taking and cinica examination pay an important roe. By doing this high and risk patient can be identified and unnecessary hospita admissions can be prevented. References: 1. Zaidi A, Cough P, Cooper P, Scheepers B, Fitzpatrick AP. Misdiagnosis of epiepsy: many seizure-ike attacks have a cardiovascuar cause. J Am Co Cardio. 2000;36(1): Fitzpatrick AP, Cooper P. Diagnosis and management of patients with backouts. Heart Br Card Soc Apr;92(4): Brignoe M, Aboni P, Benditt D, Bergfedt L, Banc JJ, Boch Thomsen PE, et a. Guideines on management (diagnosis and treatment) of syncope. Eur Heart J Aug;22(15): Thijs RD, Wieing W, Kaufmann H, van Dijk G. Defining and cassifying syncope. Cin Auton Res Off J Cin Auton Res Soc Oct;14 Supp 1: Brignoe M, Aboni P, Benditt D, Bergfedt L, Banc JJ, Boch Thomsen PE, et a. Task force on syncope, European Society of Cardioogy. Part 1. The initia evauation of patients with syncope. Eur Eur Pacing Arrhythm Card Eectrophysio J Work Groups Card Pacing Arrhythm Card Ce Eectrophysio Eur Soc Cardio Oct;3(4): Wieing W, Jardine DL, de Lange FJ, Brignoe M, Niesen HB, Stewart J, et a. Cardiac output and vasodiation in the vasovaga response: An anaysis of the cassic papers. Heart Rhythm Off J Heart Rhythm Soc Mar;13(3): Fisher RS, van Emde Boas W, Bume W, Eger C, Genton P, Lee P, et a. Epieptic seizures and epiepsy: definitions proposed by the Internationa League Against Epiepsy (ILAE) and the Internationa Bureau for Epiepsy (IBE). Epiepsia Apr;46(4): Fisher RS, Acevedo C, Arzimanogou A, Bogacz A, Cross JH, Eger CE, et a. ILAE officia report: a practica cinica definition of epiepsy. Epiepsia Apr;55(4): A compete isting of a the references used in this artice is avaiabe from the Editors on request.

17 The GMC needs reforms to improve confidence in the medica profession. It needs to repace outdated, cumbersome and infexibe egisation with new streamined processes to deiver a mode of reguation that is fexibe to the needs of the modern workforce. Dr Buddhdev Pandya MBE Chief Officer for Corporate Affairs, BIDA The Chief Executive of the Genera Medica Counci Mr Charie Massey said, Patients and the profession deserve better than this and it is time for the government to find the time to make the egisation fit for the word we ive in. Earier this year, I pubicy expressed the view in support of estabishing a Roya Commission for undertaking a thorough and comprehensive review of our NHS to suggest pathways to make the services more efficient and fit for embracing modern advances in medicina science and technoogy for improving patient care. The Chief Executive of the reguatory body - the GMC, for the medica doctors has aso highighting the need for repacing an outdated, cumbersome and infexibe egisation prevents the GMC from supporting doctors and protecting patients. news/31512.asp Having spent neary two and the haf-decade working in support of the physicians, I agree with Mr Charie Massey, the CE of GMC that patients and the profession deserve better than this and it is time for the government to find the time to make the egisation fit for the word we ive in. In a GMC press reease, Mr Massey, Chief Executive of the Genera Medica Counci, said: Successive governments have repeatedy promised to reform the GMC s egisative framework and repeatedy faied to deiver. The need for reform is growing acuter with each year that passes. It is crucia the government now takes the opportunity to commit to reform as it considers responses to its consutation. He saw their ambition to innovate and act at pace hampered by current egisation; which is a far too cumbersome process and prescriptive. Having spent considerabe time with many doctors caught into the maze of accusation of wrongdoings whie supporting these doctors, particuary the internationa medica graduates, I beieve that toerating of the cuture of racia discrimination and equaity is sti prevaiing. Both the GMC and CQC are often obivious to the eve of buying and management maice inficted against the individua professiona compainant. By the time the defence mechanism kicks in, it is too ate to retrieve any damage done to the career of the professiona. I share the view that many incidences coud be better deat with in other ways when currenty it is reported that around 75% of our investigations cosed with no further action. The oca Trusts are i-prepared to identify hot-spots and tacke the issues to arrest acceeration to reporting stage to the GMC without compromising patient safety. The impact is hugey underestimated for this causes needess distress for both doctors and patients. It is aso a waste of resources. The changes cannot be achieved through piecemea changes to egisation. We shoud aso wecome the views of the Bow Group Heath Research Feow, Jon Staney, who has caed for reform comes in a response to the government s recent consutation on professiona reguation. It cites the GMC, patients, the medica profession, other reguators and the poitica parties across the UK the caed for a new, high-eve egisative framework that deivers autonomy and fexibiity so they can better protect patients, support doctors, improve medica education and deiver for the wider heath system across the UK. The Bow Group considers the proper reguation of doctors to be essentia to the confidence required of the medica profession The Bow Group notes that overseas and ethnic minority doctors are more ikey to be struck off and that this shapes the pubic s view. It cas for urgenty examined by Pariament to consider amendments to the Medica Act. It is 70th Anniversary of the NHS this year and I wish to echo the views of the Bow Group that emphasises that the patients and the profession deserve better than this and it is time for the government to find the time to make the egisation fit for the word we ive in. Issue No.2, Voume 24 June 2018 BIDA Journa 17

18 Cervica Lymphadenopathy in Chidren Introduction Lymphadenopathy is defined as the disease of ymph nodes whereby there is an atypica number, size or consistency of nodes (1). Lymphadenopathy with signs of infammation is typicay referred to as Lymphadenitis (2). Enargement of cervica ymph nodes (LNs) is a common presenting sign in chidren and can present a diagnostic chaenge. Studies have found that many as 38-45% of heathy chidren have papabe neck LNs (3). Whist benign pathoogy is more common, maignancies are possibe and a source of significant parenta concern/anxiety. A structured approach aows for consistency in management and can aay parenta concerns. There are numerous causes of ymphadenopathy (tabe 1). In contrast to aduts, infective and congenita aetioogy are more prevaent in chidren (4). In this artice we discuss the anatomy, pathophysioogy, aetioogy, and suggest an evidence based, practica approach to the investigation and management of cervica ymphadenopathy in chidren. Anatomy Anatomica division of ymph nodes based on the American Medica Association Consensus statement (figure 1) can indicate the source of primary pathoogy due to ymphatic drainage and aows for communication between coeagues at MDT discussions. Pathophysioogy Lymph nodes are structured coections of immune ces that act as a fiter for antigens in extraceuar fuid (6). There are numerous ymphocytes and antigen-presenting ces in LNs which hep to identify and fiter antigens found in paces such as the bood, skin and gastrointestina tract. Neonates start with scarcey detectibe LNs but this rapidy changes in chidhood. In contrast to aduts, chidren have a very variabe LN mass due to the constant exposure to new pathogens (7). In the first 12 years of ife, ymphoid mass increases rapidy in size to doube that of an adut at puberty (8). During adoescence, atrophy of this mass occurs and continues into adut ife (6). The mechanism of ymphadenopathy is frequenty divided into the foowing (2) : Reactive hyperpasia of ymph node ces in response to a stimuus e.g. vira ymphadenitis The inward migration of infammatory ces in response to bacteria infection Tumour invasion into the ymphoid tissue e.g. metastases and ymphoma Aetioogy There are numerous causes of paediatric cervica ymphadenopathy (tabe 1). Citak et a found that out of 282 chidren studied with cervica ymphadenopathy that had benign disease, ony 36% had a specific identifiabe aetioogy. Of these, the most prevaent causes were Cytomegaovirus, Infectious Mononuceosis and Acute Lymphadenitis (9). In another study by Bozak et a, the most common maignant cause for cervica ymphadenopathy found was Lymphoma, which was mainy in oder chidren (10). History and Examination In chidren presenting with a neck mass, a comprehensive history and head and neck examination shoud aways be carried out to hep narrow down a diagnosis. This shoud incude the assessment of periphera LNs and a genera physica examination (11). As seen in tabe 2, there are many differentia diagnoses of neck masses in chidren. Patient age is a key factor in ascertaining diagnoses as different disease processes have characteristic age associations. 18 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

19 Miss Katharine Hamett Core Surgica Trainee, ENT, Backpoo Teaching Hospitas NHS Foundation Trust Mr Nei Kiick ENT Speciaist Registrar, Backpoo Teaching Hospitas NHS Foundation Trust Dr Vineeta Joshi Consutant Paediatrics, Wigan, Wrightington & Leigh NHS Foundation Trust Mr Vikas Maik Consutant ENT Surgeon, Backpoo Teaching Hospitas NHS Foundation Trust Above, to r: Miss Katharine Hamett, Dr Vineeta Joshi and Mr Vikas Maik Infections History of immunisations, medications, foreign trave and pets may aso hep to determine diagnosis e.g. in cat-scratch disease, parasites etc. A study by Neidzieska et a found that the most common associated symptom of chidren with cervica ymphadenopathy was fever, occurring in 24.1% (4). Maignancy The history shoud incude onset, duration and speed of growth of the LN, as this may hep to determine the ikey diagnosis. For exampe, in HL, there is sow growth in LNs, whereas the change is more rapid in NHL (10). Duration and size of the esion is significant because a esion present for greater than 4 weeks has an eevated probabiity of being maignant in nature (12). A cohort study by S. Bozak et a found that predictive factors for maignancy were LNs greater than 30mm, rubbery textured nodes, eevated serum CRP and LDH and increased growth in the node at foow-up (10). Position of the ymph node is aso significant as supracavicuar nodes in chidren are usuay indicative of maignancy (10). The site of the sweing, incuding whether it is uniatera or biatera is aso usefu in determining cause. Autoimmune Diseases A sma subset of patients with ymphadenopathy wi have an autoimmune aetioogy. Systemic features such as a fever persisting beyond 5 days, strawberry cooured tongue with fissuring of ips, biatera conjunctivitis (non-puruent), angioedema with induration on the hands and feet and dysmorphic-ooking skin rashes are signs of Kawasaki disease (13). SLE A B C Figure 2 (A/B/C) demonstrates agorithms created by Rizzi et a to assist in the diagnosis and management of neck masses in chidren (11). Issue No.2, Voume 24 June 2018 BIDA Journa 19

20 Cervica Lymphadenopathy in Chidren often presents with the characteristic maar rash, ymphadenopathy, fever, weight oss, fatigue and occasionay Raynaud s phenomenon (14). Joint management with the Paediatric team is essentia. Investigation and Management Studies suggest that chidren with LNs measuring ess than 20mm diameter, with no red fag symptoms or with obvious signs of infection can be observed for days (15). If there is enargement or the node does not regress, further investigations shoud be done incuding at east the basic serum tests and appropriate imaging. Bood Tests: Boods tests shoud incude FBC, U&Es and CRP to assess for infective pathoogy. Tria with antibiotic therapy is then often adopted if infection markers are eevated. Microbioogy: Specific seroogica tests for CMV, HIV, EBV and Bartonea may aso be done based upon the presenting history. Tubercuosis (TB) testing can be performed if the chid is at risk. A throat swab may aso hep identify infective oropharyngea causes and hep guide treatment. Imaging: Utrasound is a vauabe too to assess enarged LNs in chidren due to ack of radiation exposure, ease of access and simpicity to perform in trained hands. Chest X-Rays may be required to identify changes associated with diseases such as Histiocytosis, Sarcoidosis or TB (15). Surgery: If after 4 weeks there is no improvement, an excisiona biopsy is the next step (15). Excisiona biopsy is the god standard as fine neede aspiration is often chaenging to execute in an awake chid and is frequenty nondiagnostic (4). References: 1. Lymphadenopathy. Sahai, Shashi. 5, May 2013, Paediatrics in Review, Vo Husson, Robert N. Lymphadenopathy and Lymphadenitis. [book auth.] Jeffrey M Bergeson. Pediatric Infectious Diseases: The Requisites in Pediatrics. 1st Edition. Phiadephia : Mosby Inc, Affiiate of Esevier Inc, 2008, pp Papabe ymph nodes of the neck in Swedish schoochidren. Larsson, L O, et a. 10, 1994, Acta Paediatra, Vo. 83, pp Cervica ymphadenopathy in chidren Incidence and diagnostic management. Niedzieska, Grazyna, et a. 1, s.. : Esevier Ireand Ltd, 2006, Internationa Journa of Pediatric Otorhinoaryngoogy, Vo. 71, pp Consensus Statement on the Cassification and Terminoogy of Neck Dissection. Robbins, Thomas K, et a. 5, s.. : American Medica Association, May 2008, Otoaryngoogy - Head and Surgery, Vo. 134, pp Kanwar, Vikramjit S. Lymphadenopathy. Medscape. [Onine] [Cited: August 14, 2016.] 7. Unexpained cervica ymphadenopathy in chidren: predictive factors for maignancy. Wang, Jingfu, et a. 4, s.. : Eservier Inc, 2010, Journa of Pediatric Surgery, Vo. 45, pp Pizzo, P A and Popack, D G. Principes and Practice of Paediatric Oncoogy. Phiadephia : Lippincott, A retrospective chart review of evauation of the cervica ymphadenopathies in chidren. Citak, Evan Cagar, et a. 5, s.. : Esevier Ireand Ltd, 2011, Auris Nasus Larynx, Vo. 38, pp Cervica ymphadenopathies in chidren: A prospective cinica cohort study. Bozak, Serdar, et a. s.. : Esevier Ireand Ltd, 2016, Internationa Journa of Paediatric Otorhinoaryngoogy, Vo. 82, pp Differentia Diagnoses of Neck Masses. [book auth.] Mark D Rizzi, Raph F Wetmore and Wiiam P Potsic. [ed.] Sixth. Cummings Otoaryngoogy. s.. : Esevier Inc, 2015, pp Evauation of Periphera Lymphadenopathy in Chidren. Oguz, Aynur, et a. 7, 2006, Paediatric Haematoogy and Oncoogy, Vo. 23, pp Intravenous immunogobuin, pharmacogenomics, and Kawasaki disease. Kuo, Ho-Chang, et a. 1, s.. : Esevier, 2014, Journa of Microbioogy, Immunoogy and Infection, Vo. 49, pp Mina, Rina and Brunner, Hermione. SLE in Chidren. Systemic Lupus Erythematosus. s.. : Esevier, 2011, pp McCain, Kenneth L. Periphera ymphadenopathy in chidren: Evauation and diagnostic approach. UptoDate. [Onine] [Cited: August 15th, 2016.] Chidhood Cervica Lymphadenopathy. Leung AK, Robson WL. 1, Jan-Feb 2004, Journa of Paediatric Heath Care, Vo. 18, pp Lee, K.J. Essentia Otoaryngoogy, Head & Neck Surgery. 9th edition. s.. : McGraw-Hi Companies, Inc, BIDA 2018 ARM & AGM BIDA AGM 2018 A REMINDER - WE LL SEE YOU THERE! The 43rd Annua Genera Meeting of the British Internationa Doctors Association wi be hed onsunday 14th October 2018 at the The Daresbury Park Hote, Warrington, Cheshire WA4 4BB Hosted by BIDA s Merseyside and Cheshire Division. (A fuy paid members are cordiay invited to attend, but pease note that prior notification to Centra Office is required). 20 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

21 Congratuations! Congratuations to Dr Sangeeta Ahuja, who has been appointed as the Consu Genera at St Petersburg. She is the daughter of Dr Satish Ahuja and Late Dr Raj Kumari Ahuja from Wigan. She graduated with a PhD from the London Schoo of Economics and Poitica Science. She has hed severa distinguished posts in the Dipomatic service since Her current post in the Foreign office in Russia can be regarded as second ony to the British ambassador based in Moscow. Mrs Ahuja is married to Jan Hofheiz and has three chidren. She started her dipomatic career as a Desk officer with the Africa department. She then moved on to become a Second Secretary in Ankara between 2000 ti 2003, before securing the roe of the Section Head in the European Directorate. She progressed to the Poish capita as the First Consu and served as the Consu Genera for a brief period and remained there ti She was then posted to Washington DC as the First Consu fufiing her roe in the Foreign and Commonweath Office. Her father, Dr Satish Ahuja is a Genera Practitioner in Wigan since He has been an active member of BIDA and has served as Vice President and Treasurer of BIDA in Our compiments to the Ahuja famiy for this proud achievement. Congratuations to Professor Dr Shiv Pande MBE DL JP FRCGP, who has been appointed as Visiting Professor at Boton University. He has been a committed member of BIDA (Previousy ODA) having served the organisation as an Executive officer in various capacities, incuding as Nationa Chairman between 2002 and Wecome to BIDA for Mr Buddhdev Pandya MBE, who has been appointed as the Chief officer for Corporate Affairs for BIDA. Mr Pandya has years of experience in poicies and campaigns reating to racia justice, equaity and corporate governance. As Chief Officer, his roe wi be an advisory one in supporting the officers of BIDA. Mr Pandya has served as Director of Poicy and Governance at The British Indian Psychiatric Association. He is aso the pubisher of 'Gujarat UK Journa' for the Indian diaspora. and key - movers and shakers in India. He was Director of the British Association of Physicians of Indian Origin (BAPIO), a nationa body that he had heped to estabish. He aso heped to deveop and became managing editor for pubishing 'The Physician', its medica journa. He was aso chief editor of Asian Lite, an award-winning ethnic pubication. Did you know? Air poution is now one of the main causes of premature death in the UK, second ony to smoking. There have been 40,000 deaths annuay reated to air poution causing mutipe medica conditions in both chidren and aduts. Further evidence has inked materna poycycic aromatic hydrocarbons (PAH) to menta heath probems in chidren of primary schoo age. Diese exhausts are the main cause. (BMJ 2016:355:i6726) Coecting garbage invoves breathing in microbes. A Danish study finds that these become highy concentrated in the cabs of bin orries. There are 111 times as many fungi and 7.7 times as many bacteria in the cab air of the orry as compared to the air outside. Most of the fungi are Peniciium spp, and fortunatey most of the bacteria are harmess. (Ann Occup Hyg 2016) Issue No.2, Voume 24 June 2018 BIDA Journa 21

22 For Physicians, Surgeons, GPs and AHPs Tuesday 10th Juy 2018 at The Mayo Buiding, Saford Roya NHS Foundation Trust Stott Lane, Saford M6 8HD 8:45 to 9:00: Wecome: Mr Chris Brooks Group Medica Director, Northern Aiance Introduction: Mr Siba Senapati Chairman of Obesity Awareness & Support, OASIS-GB Session 1: Chair: Prof. Martin Gibson 9:00 to 9:25: Current obesity epidemic and its effects on heath and we-being Dr Akhee Syed Consutant Endocrinoogist Saford Roya NHS Foundation Trust 9:25 to 9:50: Obesity and Seep Disorders: is there a reationship? Dr Victoria Cooper Principa Seep Physioogist, Saford Roya NHS Foundation Trust 9:50 to 10:15: Obesity and Kidneys Dr Smeeta Sinha Honorary Senior Lecturer University of Manchester 10:15 to 10:40: Is obesity a Psychiatric Disorder? Dr J S Bamrah Consutant Psychiatrist and Honorary Reader University of Manchester 10:40 to 11:00: Coffee Break Session 2: Chair: Dr Biswamohan Misra 11:00 to 11:20: Ethnicity, Cuture and Diabetes Dr Naveed Younis Consutant in Diabetes/Endocrinoogy Manchester University NHS Foundation Trust 11:20 to 11:40: Obesity, Lipoproteins, Microangiopathy and the effect of Bariatric Surgery Dr Handrean Soran Consutant Physician and Endocrinoogist, Manchester University NHS Foundation Trust 11:40 to 12:00: Current innovative medica management of Obesity Prof John New Professor of Medicine, Saford Roya NHS Foundation Trust 12:00 to 12:20: Roe of surgery in tacking obesity, diabetes and metaboic syndrome Prof Siba Senapati Consutant Upper GI and Bariatric Surgeon, Saford Roya Hospita 12:20 to 12:40: Pane Discussion / Q&A Pane of 2nd Session Lecturers 12:40 to 13:40: Lunch Session 3: Chair: Dr Akhee Syed 13:40 to 14:05: Tacking Diabesity Roe of Genera practitioner and Commissioner Dr Naresh Kanumii Diabetes Network Lead for Greater Manchester and East Cheshire 14:05 to 14:30: A Patient s experience of Bariatric and Metaboic Surgery TBC 14:30 to 14:55: Roe of gut microbiota in diabesity: can we ater it? Prof Andrew McBain Professor of Microbioogy University of Manchester 14:55 to 15:20: Pubic Heath Interventions in the Management of Obesity TBC 15:20 to 16:30: Discussions Prof Siba Senapati Consutant Upper GI and Bariatric Surgeon, Saford Roya Hospita 16:30 to 16:40: Vote of Thanks Mr Jack Carney Co-chair, OASIS-GB Supported by 22 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

23 Letter to the Editors (The experience and views expressed are soey of the author and are not be construed as an expression of opinion on behaf of the Editoria Committee of BIDA) Dear Editor, Is the Genera Medica Counci reay draconian or are they fairest of a heath organisations in the UK? Performing needess operations has recenty attracted ot of judicia and media attention foowing the conviction of a doctor for performing needess breast surgery (1). The case resuted in a huge amount of money being offered to those affected (2). At this juncture, it is important to anayse if this conviction is an isoated incident or is the practice of performing needess operations a common pace. Is payment by resuts enticing organisations and individuas to perform more interventions than necessariy required? Coud the number of needess surgeries be arger in procedures in which the chances of adverse outcomes are ess? The three times higher rate of knee arthroscopy in one part of Scotand as compared to another (3) and the overa higher rate of knee arthroscopies in Engand as compared to Scotand a show that needess surgica interventions are more common than what may be perceived (4). Over time it has become both the cuture and expectation that medica consutation shoud be foowed with an investigation or intervention. The heath professiona has a need to both themseves and the patient to be seen to be doing something. This in addition to rewards for increased payment for increased numbers of performed procedures, can together fue unnecessary interventions. The author has had a difficut journey in the course of the ast 15 years when attempting to highight needess interventions. The author faced numerous investigations, was forced to resign from an NHS Trust and had his practicing privieges terminated from a private hospita for bringing to ight the practice of needess surgica interventions. During this same period the author was referred to the Genera Medica Counci on two occasions. The Genera Medica Counci's main purpose is to protect patients. None of the compaints to the GMC were from patients, but rather were from co-working heath professionas. In addition to being investigated by the oca hospita trust on mutipe occasions, the author was referred to Nationa Cinica Assessment Service (NCAS). It was assumed that an organisation ike NCAS woud be fair in it s assessment but unfortunatey this wasn t the case. As part of the assessment, 64 patients were asked to rate the author on a scae of 0 to 5 on the quaity of care they received from him. In spite of the author receiving a score of 4.84 compared to the previousy pubished average of 4.55 (5), the NCAS's opinion was that the author s interaction with patients was not adequate. The author beieves that the NCAS does not have the right to ignore an objective opinion by patients and repace it with a subjective opinion by its assessors. If the subjective opinion of the assessors supersedes the objective opinion of the 64 patients then the exercise of requesting these patients to give their opinion is farcica. Despite questioning the nature of the NCAS report, the author accepted the offer to retrain. The retraining was described by an NCAS advisor as one of the best that the advisor had seen in his experience. However foowing competion of retraining, the author returned to the parent Trust to find that the same Cinica Director with whom he had been having difficuties was sti in post even after a period of 9 years. It is possibe to hod a view that a person who has been at the sharp end of many investigations may not have the credibiity or the authority to provide a feedback of the investigations or the investigating bodies. However such a feedback can hep us move from a bame cuture to a just cuture. The author aso accepts that any such opinion from the one who has been investigated on numerous occasions is bound to be subjective and cannot be purey objective as there is no scae to measure fairness. In the author s persona opinion the Genera Medica Counci has been the most fair in its deaings as compared to the NHS Trust, the Nationa Cinica Assessment Service (NCAS) and the Private Independent Hospita. This persona view though subjective is important because it is generay assumed that the Genera Medica Counci is very Draconian and punitive to doctors especiay from ethnic minority backgrounds and doctors who've graduated from outside the United Kingdom. An investigation into one s practice is stressfu (6). There have been concerns that GMC's fitness to practice proceedings has ed to increased suicides among the doctors being investigated (7). The author accepts that investigations into one's practice is very stressfu but equay wishes to reassure other doctors on the sharp end of investigations that the GMC seemed to be the fairest of them a. Unconscious bias (8) is universa. It can affect investigators. It is possibe that the Genera Medica Counci has been the fairest because it is more aware of unconscious bias and has taken steps to combat and avoid this bias. The author wishes to raise the foowing questions as food for thought: Is puraity of thought accepted by peers even if it affects earnings? Can authorities sience whiste-bowers with the use of unwarranted investigations? Are the organisations that investigate individuas aways fair or coud unconscious bias affect the outcome? And finay did Paterson escape the net (9) since 1996 because of unconscious racia bias. As a Caucasian did he fit the pattern of a respectabe genuine doctor and woud a back and ethic minority doctor been brought to check much earier? Dearing J, Brenke IJ. Incidence of knee arthroscopy in patients over 60 years of age in Scotand. Surgeon Jun;8(3): Hamiton DF, Howie CR. Knee arthroscopy: infuence of system for deivering heathcare on procedure rates. BMJ Sep24; Archer JC, McAvoy P. Factors that might undermine the vaidity of patient and muti-source feedback. Med Educ Sep;45(9): Bourne T et a. Doctors' experiences and their perception of the most stressfu aspects of compaints processes in the UK: an anaysis of quaitative survey data. BMJ Open Ju 4;6(7):e Casey D, Choong KA. Suicide whist under GMC's fitness to practise investigation: Were those deaths preventabe? J Forensic Leg Med Jan;37: Kapur N. Unconscious bias harms patients and staff. BMJ Nov 26;351:h P.S. The author is wiing to discose the fina NCAS report to authorities for verification of facts stated above. The author aso encourages readers to visit to have a greater understanding of unconscious bias. Mr George Ampat Consutant Orthopaedic Surgeon Issue No.2, Voume 24 June 2018 BIDA Journa 23

24 OBITUARY Dr Tasadduq Hussain MBBS, FRCS 5th June th February 2018 Tasadduq Hussain was born on June 5th 1930 to Soghra and Qurban Hussain about the time that Maharana Bhupa Singh ascended the throne in Udaipur. He was aso bessed with three younger sisters and a younger brother Fatima, Hamida, Themida and Siraj. Tasadduq was educated at Vidyabhavan Schoo in Udaipur and aways spoke fondy of his schoo days. His speciaist subjects were Urdu Literature and Engish; he had a wide Engish vocabuary and a passion for Urdu poetry. Cycing seemed to pay a big part of his eary ife. In India in the 1940s having a cyce was a bit ike having a sports car. No-one ese at his schoo had one so he was the envy of the entire cass. It was a priviege he did not squander and it seems he was amost gued to it from the age of 8 to 17. He woud reguary take his sma cousins on his bike and cyce around Karachi pointing out a the sights. After eaving schoo Tasadduq traveed to Pakistan to visit famiy, but just as he arrived in 1947 the Partition of India was announced and he was unabe at that time to return to Udaipur. He therefore undertook his University career in Pakistan and gained entry to Karachi Medica Coege quaifying as a doctor in He returned to his beoved Udaipur to take up a post in the oca hospita, but when it was discovered that his degree was from Pakistan, he was tod he coud not practise uness he acquired a medica dipoma from India or another recognised country. This was the impetus that saw him on a fight to London in May He quicky embraced the vibrant cuture of his new home and embarked upon a surgica internship. He met his future wife, Sharifa Dawood, when they were both working in Waes in They were married in 1963 and had 2 chidren Sofia and Nasir Hussain. With his famiy in tow, he worked a round the United Kingdom from London to Cardiff, from Dorset to Northshieds, but he finay setted in Scotand where he woud remain for the rest of his adut ife. Once he had attained his professiona degree in surgery he fourished in the word of orthopaedics. Very much a practica speciaty, this suited him down to the ground. He was bod and unafraid to tacke difficut probems. This combination couped with his amost imitess capacity for hard work meant that he quicky became the most experienced and capabe registrar in his department and, athough at that time there was sti a degree of prejudice within the profession, he was so we thought of by his consutants, they supported and pushed through his appication to become a consutant himsef, amongst some of the first Indians in the UK to achieve this position. He obtained his consutant post in Hairmyres Hospita, East Kibride and this became his home and his famiy for the next 20 years. During these working years and beyond he forged many asting friendships and aways went the extra mie to wecome and befriend fok arriving in the UK for the first time, trying to find their feet and integrate into the oca cuture. He was aso a great traveer and he and his wife and famiy roamed extensivey around the word experiencing many different cutures. Without doubt his greatest passion in the 2nd haf of his ife was horticuture cuminating in him being featured on nationa TV in a programme about Britain s best gardens and he reguary won prizes in horticutura shows. It woud be a chaenge for anyone to find a more generous, more sefess, industrious, egaitarian, gregarious and unique individua than Tasadduq Hussain. He sprinked these quaities tendery and carefuy a over the word just as he sprinked his beoved pants and fowers tendery and carefuy with water. And he cutivated and cherished not ony thousands of beautifu booms, but aso his chidren, his grandchidren, his oya and oving extended famiy and many, many friends. He ed a ong and compex ife but was, at heart, a simpe man. And the simpest part of Tasadduq was the unconditiona and instinctive ove of his famiy and friends. And his friends were his famiy anyway. He was a man who woud think twice about paying fu price for a potted pant, but woud, without a moment s hesitation, avish time, money and effort onto anyone who asked for it, or whom he simpy thought needed it. He did this, not for approva, or to buid up a compex web of favours for persona gain, or to impress peope. He did it simpy because he was Tasadduq. Tasadduq Hussain passed away on February 28th He is survived by his oving famiy: Sharifa, his wife, his 2 chidren, Sofia and Nasir Hussain and his five grandchidren, Catriona, Robbie, Euan, Lewis and Michae. 24 British Internationa Doctors Association Issue No.2, Voume 24 June 2018

25 BIDA FELLOWSHIP AWARDS 2018 Dear Coeagues, As you know BIDA awards Feowships to some members who have made an outstanding contribution to the Association. These awards are made at the ARM/AGM in the Autumn and if you woud ike to nominate a member from your division, pease do so, but kindy note that nominations are to be received no ater than Friday 29th June It woud be of assistance if the nomination coud be supported by a brief CV of the nominee. I ook forward to receiving your nominations. Yours sincerey Dr Birendra Sinha Nationa President BIDA ODA House 316A Buxton Road, Great Moor, Stockport SK2 7DD Teephone: Fax: Emai: bida@btconnect.com Website: bidajourna Write to the editoria team today at: 6 Caste Rise, Hawarden, Deeside, Fintshire CH5 3QU Contact us via e-mai at amitani2000@yahoo.co.in or bida@btconnect.com Visit BIDA s website: For BIDA news and views, issues, the atest Scientific artices, and so much more, keep in touch with us today. THIS IS YOUR MAGAZINE USE IT! Issue No.2, Voume 24 June 2018 BIDA Journa 25

26 Divisiona News North Waes Division Educationa Meeting North Waes Division ed by Dr Jay Nankani has been organising reguar educationa meetings for its members. We recenty had Dr Sumit Guati, Consutant Anaesthetist from Liverpoo, who gave an iuminating tak on Pain management & the roe of Opioids. This was attended by a arge number of BIDA members. Photo (from eft to right) Mr N Kaushik, Mr P Anandaram, Mr A Sinha, Dr S Guati, and Dr J Nankani. Nottingham and North Trent Division Barn Dance Dr Rahu Mohan, Chairman, Nottinghamshire and Trent Division and his team organised a Barn Dance event on 24th March. It was attended by 60 members who found it reay quite enjoyabe and had a fun-fied evening. It was a pure Scottish touch, which was brought to Nottingham. BIDA Sports Event 2018 Nationa Badminton & Tabe Tennis Tournament 26 The North-East BIDA Division hosted this year s BIDA Nationa Tabe Tennis and Badminton Championships at Thornaby Paviion at Thornaby. The venue is in the outskirts of Stockton town. This year we combined the event of the two sports. We had a good attendance of around 60 payers with famiy members, who a participated in the event. We had representation from our executive committee: Dr Sarup Taya (Chair), Dr Ram Singh, Dr Prathish Thakkar and mysef (Viswanath YKS). This year s winners are as foows: Nationa Tabe Tennis: Singes Mr Sarang Sapre - Merseyside (God Meda) Dr Prathish Thakkar - North-East (Runner Up) Doubes Dr Chakrapani Kauri and Dr Vikram Narua - North East (God Meda) Dr Suni Sapre and Sarang Sapre - Merseyside (Runner Up) Nationa Badminton: Singes Dr Chakrapani Kauri - North East (God Meda) Dr Jaganath Chakravarthy - (Runner Up) Doubes Dr Jaganath Chakravarthy & Dr Chakrapani Kauri - North East (God Meda) Dr Amit Chauhan and Dr Prathish Thakkar - North East (Runner Up) British Internationa Doctors Association Issue No.2, Voume 24 June 2018 Congratuations to the winners and thank you to a the payers who participated in the games, and aso to the famiy members. We are ooking forward to receiving the trophies at BIDA s Nationa A.G.M. Mr Viswanath YKS North East BIDA

27 13th BIDA INTERNATIONAL CONGRESS JAKARTA & BALI, INDONESIA (22nd to 23rd October 2018) BRITISH INTERNATIONAL DOCTORS ASSOCIATION OAN: ODA HOUSE, 316A BUXTON ROAD, GREAT MOOR, STOCKPORT SK2 7DD TEL: Mandarin Orienta Hote, Jakarta Laguna Resort and Spa, Bai FULL PACKAGE (Congress and Touring) Price: per person (Twin or Doube share) per singe person per chid (in parent s room) per person (Adut, 12 years or over with extra, based upon tripe-sharing) CONFERENCE PACKAGE Price: per person (Adut, Twin or Doube share) per singe room per chid (2-11 years Sharing with 2 fu paying Aduts) per person (Adut, 12 years or over with extra, based upon tripe-sharing) Price incudes: Fuy ATOL protected Hoiday. Return Internationa fights on schedued airines with departures from Manchester and London Heathrow. One-way Domestic fight on schedued airines with departures from Jakarta to Denpasar (Bai). Return transfers: airport hote airport. Cutura Wecome to Indonesia at Jakarta Airport. Wecome Dinner and enjoy the Cutura Event. 3 nights accommodation at the Mandarin Orienta (5 Star) Hote in Jakarta. 2 fu days Conference package at the hote. Fu day Jakarta Tour (for Spouses & Non-attendees) on day one of conference. Fu day Jakarta Tour (for Spouses & Non-attendees) on day two of conference. Price incudes: Fuy ATOL protected Hoiday. Return Internationa fights on a schedue airines with departures from Manchester and London Heathrow. Return transfers: airport hote airport. Cutura Wecome to Indonesia at Jakarta Airport. Wecome Dinner and enjoy the Cutura Event. 3 nights accommodation at the Mandarin Orienta (5 Star) Hote in Jakarta. 2 fu days Conference package at the hote. Conference Venue avaiabe from (2 Fu days). Morning and afternoon coffee break with refreshment. Buffet unch at function room. Fu day Jakarta Tour (for Spouses & Non-attendees) on day one of conference. Fu day Jakarta Tour (for Spouses & Non-attendees) on day two of conference. 1 Gaa Dinner with Loca Beer, Soft Drinks & Juice. 1 Gaa Dinner with Loca Beer, Soft Drinks & Juice. 6 nights accommodation at the Laguna Resort and Spa in Bai. 1 Dinner incuding oca performance with instruments and DJ music. Interna fights Jakarta to Denpasar in economy cass. Tour of Uuwatu Tempe, Pandawa Beach, Kecak and Fire Dance Performance. Dinner incuded at Jimabaran Bay. Fu day Tour, Heartand of Bai, with Lunch at Batur Lakes. Fu day Traditiona Viage Sightseeing. Fu day Ubud Town & Tanah Lot Tempe and unch at oca restaurant. Excusive Cruise to Lembongan isand with snorkeing equipment, Viage tour, Unimited Banana Boat, Semi- Submersibe cora viewer, BBQ unch, snack on the way back, 3 gasses of beverages (1 Soft Drink, 1 Beer, 1 House wine) private cruise and private beach cub on the isand. OTHER INFORMATION Currency: Indonesian Rupiah 1 = (Approx). Weather: Sunny 30 Degrees in Jakarta and around 27 Degrees in Bai. Packages are excusive to BIDA members. Non-BIDA members are wecome to join at a suppement of per person. For bookings and enquiries, pease contact BIDA Centra Office, or ca Boton Trave on the phone numbers detaied beow. LIMITED AVAILABILITY! Cosing Date for bookings: As soon as a paces are fied (first come, first served basis) or 15th March 2018 (whichever is earier). in association with 129 Turner Road, Edgware, Middesex, HA8 6AS E-mai: saes@botontrave.com Website: Teephone: / / Issue No.2, Voume 24 June 2018 BIDA Journa 27

28 The British Internationa Doctors Association (BIDA) is a professiona doctors' association. Its soe objective is promoting Equaity and Fairness for a doctors and dentists working throughout the UK. BIDA s mission is to achieve equa treatment of a doctors and dentists based on their competence and merit, irrespective of their race, gender, sexua orientation, reigion, country of origin or schoo of graduation. u u If you beieve in this mission and woud ike to be part of this endeavour, join us! You wi make professiona contacts, gaining the opportunity to network with peope who can impact your profession, and giving you access to new opportunities, friends and information. In addition to being part of a group of ike-minded professionas, and having the recognition of your peers, specific member benefits incude: Attending BIDA-organised internationa, nationa and regiona conferences, seminars, meetings and many other educationa and socia activities Constant access to pastora support Nominations for exceence awards BIDA Journa, our Scientific journa, compete with news, interviews and much more. If you are interested in joining BIDA, or woud simpy ike to know more about us, pease either write to BIDA, ODA House, 316A Buxton Road, Great Moor, Stockport, SK2 7DD or e-mai us at bida@btconnect.com, or contact us through our website at the address beow. We ook forward to hearing from you!