Prepared for practice? UK Foundation doctors' confidence in dealing with ethical issues in the workplace.

This paper investigates the medical law and ethics (MEL) learning needs of Foundation doctors (FYs) by means of a national survey developed in association with key stakeholders including the General Medical Council and Health Education England. Four hundred sevnty-nine doctors completed the survey. The average self-reported level of preparation in MEL was 63%. When asked to rate how confident they felt in approaching three cases of increasing ethical complexity, more FYs were fully confident in the more complex cases than in the more standard case. There was no apparent relationship with confidence and reported teaching at medical school. The less confident doctors were no more likely to ask for further teaching on the topic than the confident doctors. This suggests that FYs can be vulnerable when facing ethical decisions by being underprepared, not recognising their lack of ability to make a reasoned decision or by being overconfident. Educators need to be aware of this and provide practical MEL training based on trainee experiences and real-world ethics and challenge learners' views. Given the complexities of many ethical decisions, preparedness should not be seen as the ability to make a difficult decision but rather a recognition that such cases are difficult, that doubt is permissible and the solution may well be beyond the relatively inexperienced doctor. Educators and supervisors should therefore be ensuring that this is clear to their trainees. This necessitates an environment in which questions can be asked and uncertainty raised with the expectation of a supportive response.

The Transposed Femoral Vein Fistula: The Native Choice in Desperate Vascular Access.

BACKGROUND: This is a review of our experience in creating transposed femoral vein (TFV) fistulas and some of the lessons we have learnt while performing this challenging procedure over the last 5 years. METHODS: This is retrospective review of patients who underwent TFV fistula formation between January 2013 and December 2017. RESULTS: Fifteen patients underwent FV fistula formation with 4 cases being excluded from analysis. Median follow-up was 1.17 years (interquartile range 0.19-3.59 years). Primary and primary-assisted patency rates were 75% and 100% at 6 months, respectively, and 66.7% and 100% at 1 year. CONCLUSIONS: Our patient group showed good fistula patency at 1 year and did not experience any incidence of ischemic steal syndrome. We believe this to be due to careful preoperative patient assessment and meticulous surgical technique. Our experience suggests that such procedures should be performed by surgeons with vascular expertise wherever possible to reduce the incidence of complications.

Role of the femorofemoral crossover graft in acute lower limb ischemia due to acute type B aortic dissection.

Acute limb ischemia due to type B aortic dissection is rare and continues to be a management challenge. A case series is presented here with the aim of assessing the outcomes of treatment with a femorofemoral crossover graft with or without thoracic stent graft insertion. This is a combined retrospective and prospective review of nine cases of acute lower limb ischemia secondary to acute type B aortic dissection. The presenting features, radiological findings, treatment and outcomes were reviewed. Five patients had a femorofemoral crossover graft (FFXO) alone, two an FFXO with a thoracic stent graft and the eighth a thoracic and iliac stent. The other case was initially treated conservatively but subsequently required an FFXO. The mean follow-up was 16 (3-51) months. A further two thoracic stents were placed during the follow-up period. Thus five out of nine patients (56%) required aortic stenting. This series suggests that an FFXO is a reliable treatment for acute limb ischemia due to type B aortic dissection. However, these patients are often complex with ischemia in other vascular beds and are at risk of subsequent aneurysmal dilation.

Distalization of the anastomosis: an effective treatment for dialysis access-associated steal syndrome.

Steal syndrome after arteriovenous fistula formation for dialysis access can cause ischemic pain and tissue loss. This is an indication for surgical revision, usually either banding (or ligation) or the distal revascularisation and interval ligation procedure. However, banding is inexact, and distal revascularisation and interval ligation can further compromise the arterial supply to the arm. We report three cases in which an alternative approach of moving the arteriovenous anastomosis distally was used, thereby protecting arterial inflow to the hand. In all three cases, the steal resolved and the fistula remained patent.

Acute rupture of a fibromuscular dysplasia related renal artery aneurysm: emergency treatment with a covered stent.

We report the successful exclusion of a ruptured left renal artery aneurysm as a first presentation of fibromuscular dysplasia in a haemodynamically unstable 57-year-old man. The aneurysm was repaired in an emergency setting by deployment of a covered stent with a satisfactory result. Follow-up computed tomography confirmed successful exclusion of the aneurysm. A renal artery branch originating from the aneurismal sac was sacrificed with subsequent regional infarction. Our experience shows that the use of a covered stent is an effective, quick and life saving procedure in a ruptured renal artery aneurysm.

Preoperative consent: how to make sure your practice is legal--Part two.

The Mental Capacity Act 2005 (MCA) came into force in October 2007. This is now the keystone of the law regarding the assessment of capacity to consent and the treatment of those who lack capacity to consent for themselves. The first article in this two-part series (Corfield & Pomeroy 2008) covered preoperative consent: this article discusses the MCA (with accompanying relevant case law) in more detail by the use of illustrative examples and concentrates on issues that can arise once the patient is in the operating suite.

Preoperative consent: how to make sure your practice is legal--Part one.

Perioperative practitioners encounter consent issues constantly in their practice, both in terms of the main procedure listed and procedures they will undertake personally to enable the main procedure to be carried out safely. The law on consent has previously been governed by case (common) law but is now also partly governed by the Mental Capacity Act 2005 (MCA) (HMSO 2005). The onus is on practitioners to ensure that their practice is legal. This article and the subsequent companion article aim to emphasise the key legal points.

Non-attendance at the colorectal clinic: a prospective audit.

INTRODUCTION: Non-attendance in the out-patient department has financial costs for the NHS and clinical implications to the non-attender and those awaiting an appointment. The aim of this audit was to quantify the percentage of non-attenders at colorectal clinics in a UK teaching hospital, assess which factors affected attendance, establish why individuals fail to attend and to implement appropriate change. PATIENTS AND METHODS: The number of 'did-not-attend' patients was recorded initially for 686 appointments. Non-attenders were contacted by post or telephone to ask why this was so. The study was then repeated following telephone reminders to 391 patients due to attend clinic. The 'did-not-attend' rates in the two limbs of the completed audit cycle were then compared. RESULTS: The initial study revealed a 'did-not-attend' rate of 21%, with significantly more males than females failing to attend (males, 28.6%; females, 16.9%; P = 0.001). The 'did-not-attend' rate was not significantly affected by the day of the week, time of appointment or by the weather. There were 51.7% responses to either the postal or telephone questionnaire regarding non-attendance. Of these, 27.7% did not receive an appointment letter or received it after the appointment. Hospital administration problems were cited as accounting for 34.2% of 'did-not-attends'. In the post-intervention limb, 87 patients (22%) replied to the reminder telephone call, of whom 9 (10%) cancelled their appointment and 78 (90%) confirmed that they would attend. The 'did-not-attend' rate fell to 19.7% although this was not a significant reduction. CONCLUSIONS: Telephoning patients before their appointments is labour intensive and did not significantly improve the 'did-not-attend' rate. Although hospital administration errors account for a significant number of the 'did-not-attends', patients also have a responsibility to notify the hospital if they are unable to attend.

The law, negligence and sick doctors.

Doctors often come to work when they are too unwell to care for patients adequately. Should a negligent error occur, sickness provides no legal defence. Doctors and trusts must recognize this and take appropriate action.

Interval appendicectomy after appendiceal mass or abscess in adults: what is "best practice"?

There is still much controversy surrounding whether interval appendicectomy is appropriate for adults with an appendiceal mass or abscess. The main debate centres on the recurrence rate, the complication rate of interval appendicectomy, and the potential for underlying malignancy. This review aims to assess current practice and to determine whether it is possible to define "best practice" for the asymptomatic patient who has had an appendiceal mass or abscess treated conservatively. I sent a postal questionnaire to 90 consultant general surgeons requesting information about their practice of interval appendicectomy. I also conducted a literature search confined to studies involving only adult patients. The 77.8% of questionnaires returned revealed that 53% of the surgeons perform routine interval appendicectomy, mainly because of concerns about recurrence. The preference was for open appendicectomy at 6 weeks to 3 months. The literature search revealed a recurrence rate of 10%-25%, with a complication rate of 23%. It was evident that the chances of missing malignancy are low and thorough investigation is better than interval appendicectomy in detecting colonic cancer. The practice of performing interval appendicectomy varies, with just over half of the surgeons surveyed performing this procedure routinely. The literature provides little evidence that interval appendicectomy is routinely indicated and would support the view that it is unnecessary in 75%-90% of cases. However, there is scope for further consideration of the use of laparoscopic interval appendicectomy and a randomised trial is needed to fully evaluate this issue.