Timothy J. David

The assessment of poorly performing doctors: the development of the assessment programmes for the General Medical Council's Performance Procedures

Modernization of medical regulation has included the introduction of the Professional Performance Procedures by the UK General Medical Council in 1995. The Council now has the power to assess any registered practitioner whose performance may be seriously deficient, thus calling registration (licensure) into question. Problems arising from ill health or conduct are dealt with under separate programmes.

The core content of the undergraduate curriculum in Manchester

To identify the core content for the new undergraduate medical curriculum in Manchester.

Child Protection Companion

There is a marked variation in the coverage of the subject of child abuse in paediatric textbooks. The standard and arguably definitive North American paediatric textbook (Nelson), contains only a short 12 page chapter (out of a total of 2618 pages) briefly reviewing the subject.1 Another North American paediatric textbook of biblical dimensions (2808 pages), Oskis Pediatrics, has a marginally longer (14 page) chapter on child maltreatment.2 In contrast, the standard and definitive UK paediatric textbook, Forfar & Arneils Textbook of Pediatrics (1985 pages), has a substantial 27 page chapter covering the various types of abuse and neglect.3 To supplement these sources, there is an assortment of textbooks devoted solely to one or more facets of child abuse. n nDo we need another book on the subject of child protection? The answer is that this is a highly original and much-needed book which fills some important gaps. It is not, however, a textbook on child abuse. There are no illustrations depicting injuries. For example, if you want to look up ‘shaken baby syndrome’, this is not the source to use. This is a handbook aimed at helping doctors in the process of child protection case management. There are chapters on important practical issues such as working with other professionals, consent and confidentiality, what to do if you are concerned that a child may be abused, documentation and recording, writing medical reports and police witness statements, court proceedings and giving evidence, and training and support for doctors. There are 18 appendices with examples of proformas, checklists, protocols, consent forms, flow charts and illustrations of how to structure medical reports. There is a chapter of practical advice on the photography of injuries. n nThe book includes a section on the recognition of maltreatment, and this helpfully sets out to provide evidence to support the advice given. Thus, for example, the book states (on the subject of bruising) that non-abusive bruising has a direct correlation to the developmental stage of the child, that boys and girls have equal rates of non-abusive bruising, and that certain areas of the body are rarely bruised at any age. All these statements are backed up by references to published evidence, where it exists, and the list of references to this section includes a recommended reading list. In addition there is a helpful list of useful websites. n nAll paediatricians need to be able to recognize the symptoms of abuse and neglect, and the RCPCH has embarked on a comprehensive programme of child protection training, of which this is an invaluable, clearly written and practical component. For those who question the relevance or utility of Royal Colleges, there could be no better example of leadership and provision of improved training than the recent efforts of the RCPCH in the field of child protection, and the team of authors and editors who contributed to this excellent resource are to be congratulated. That the RCPCH has made the publication freely available to all is particularly commendable.

The General Medical Council's Performance Procedures: peer review of performance in the workplace.

The General Medical Council procedures to assess the performance of doctors who may be seriously deficient include peer review of the doctor’s practice at the workplace and tests of competence and skills. Peer reviews are conducted by three trained assessors, two from the same speciality as the doctor being assessed, with one lay assessor. The doctor completes a portfolio to describe his/her training, experience, the circumstances of practice and self rate his/her competence and familiarity in dealing with the common problems of his/her own discipline. The assessment includes a review of the doctor’s medical records; discussion of cases selected from these records; observation of consultations for clinicians, or of relevant activities in non‐clinicians; a tour of the doctor’s workplace; interviews with at least 12 third parties (five nominated by the doctor); and structured interviews with the doctor. The content and structure of the peer review are designed to assess the doctor against the standards defined in Good Medical Practice, as applied to the doctor’s speciality. The assessment methods are based on validated instruments and gather 700–1000 judgements on each doctor. Early experience of the peer review visits has confirmed their feasibility and effectiveness.

Association between novel GM-CSF gene polymorphisms and the frequency and severity of atopic dermatitis

BACKGROUNDnGenetic factors are known to be important in determining an individuals predisposition to atopic dermatitis. The specific genes that are clinically important in this process are still largely unknown.nnnOBJECTIVEnBecause dendritic cells initiate immune responses and thus are critical to the priming of an individual to potential allergens, we hypothesized that genetic factors controlling the activity of these cells determine an individuals propensity to atopic dermatitis.nnnMETHODSnWe studied known functional polymorphisms of the IL-1beta and TNF-alpha genes and describe novel polymorphisms of the GM-CSF gene in 113 children with atopic dermatitis and 114 controls. All 3 factors are known to be important modulators of the function of skin Langerhans (dendritic) cells.nnnRESULTSnThe inheritance of a homozygous GM-CSF -677*C/C genotype was associated with complete absence of severe atopic dermatitis within this cohort of children (P <.001). Furthermore, the odds ratio of having atopic dermatitis in children who were not of this genotype was 7.5 (2.2-25).nnnCONCLUSIONnThe GM-CSF genotype is an important genetic marker predicting an individuals predisposition to atopic dermatitis.

Avoidable pitfalls when writing medical reports for court proceedings in cases of suspected child abuse

Avoiding pitfallsnnAll paediatricians, paediatric radiologists, paediatric pathologists, forensic pathologists, and many other specialists have to deal with cases of suspected child abuse, and in terms of the generation of complaints from families this is a high risk activity. Many complaints are devoid of merit, but in some cases a complaint is justified because of a faulty approach. This review draws attention to the avoidable pitfalls associated with report writing when child abuse is under consideration (see box 1).nn### Box 1: Common medical issues that may arise in child protection cases nnnnnnThe modern guidance on the duties of experts in cases of suspected child abuse stems in part from a care proceedings case heard in 1990. A 3 month old baby was admitted to hospital with serious injuries comprising subdural haemorrhages of more than one age, damage to the brain, multiple rib fractures, and multiple limb fractures. Despite the evidence pointing to child abuse, a number of experts from various disciplines offered a variety of unjustified or highly improbable alternative medical explanations (including abnormally fragile bones) for the injuries. The judge was highly critical of some of the expert reports and evidence given in court, and in his published judgment he gave clear advice concerning the duties of an …

Hazards of challenge tests in atopic dermatitis

It is sometimes desirable to perform challenges with foods or food additives in children with atopic dermatitis (AD). Such challenges can be open, single-blind, or double-blind. The need for this time-consuming and unwieldy procedure is partly attributable to the lack of any other reliable clinical or laboratory test. The failure to develop a simple test can be ascribed to the numerous immunological and pharmacological mechanisms which operate in food or additive intolerance. Some sort of test is required chiefly because parents observations about food intolerence are notoriously unreliable (1-3). Challenge tests are fraught with difficulties, but perhaps the most serious hazard is that the procedure may arrive at the wrong answer, leading to the inappropriate inclusion or exclusion of an item from the childs diet. Possible hazards are briefly described below, with attention given to the final one which has caused us particular problems-anaphylactic shock (4).

Non-accidental head injury - the evidence.

A 10-week-old baby boy, born at term after a normal delivery and well at birth, had been in the sole care of his stepfather for 4 days, as had a 2-year-old daughter of the step-father, the baby’s mother having gone away to visit relatives. At about 20.15 h, 1 h after receiving a feed, the baby was noticed by his stepfather to be in a collapsed state, unconscious and not breathing, and an ambulance was called. Cardiopulmonary resuscitation was commenced by the ambulance crew, and continued when he arrived at hospital. He remained unconscious, he made no respiratory efforts, and he required artificial ventilation on a paediatric intensive care unit. He was found to have a large number of retinal haemorrhages in both eyes, and a CT scan 8 h after hospitalisation showed bilateral thin-film subdural haemorrhages and radiological evidence of severe hypoxic– ischaemic brain damage. The latter was regarded as being non-recoverable, intensive care was withdrawn, and he died at 10.30 h the day after his collapse. A postmortem examination and the CT scan documented the above injuries (neuropathology showed acute but with foci of older subdural bleeding) and indicated that in addition there were five recent rib fractures (left ribs 3–5 posteriorly and right ribs 6–7 posteriorly), a large perimacular retinal fold in the left retina, and subscalp bruising in the area of the anterior fontanelle and the occipital area. Further history from the step-father was that the child had been placed in the middle of a double bed, on top of the duvet, and that when the step-father found him he was on the thick pile carpet just next to the bed, apparently having fallen from a height of 20 cm. 10 days later, in response to the suggestion that the baby had been violently shaken, the step-father said that upon finding the baby collapsed he had gently shaken the baby a few times. The opinion of the treating clinicians and a number of independent experts was that this was a baby whose injuries were the result of non-accidental injury. Family proceedings were commenced in order to protect the 2-year-old girl. Expert forensic, neuroand eye pathologists instructed on behalf of the girl’s father were of the view that the baby’s injuries were likely to have resulted from the fall from the bed to the carpet, or alternatively from the step-father’s efforts to revive the infant; other possibilities being apnoea and cerebral anoxia and cardiac arrest resulting from gastrooesophageal reflux or overly rough rocking of the baby in a baby rocker by the 2-year-old girl, the scalp bruising allegedly being the result of palpation of the baby’s fontanelles by the treating paediatricians. The rib fractures were attributed to cardio-pulmonary resuscitation. This short review looks at the type of evidence that might help one to distinguish between the differing opinions offered as to the cause of this child’s injuries.

Children with atopic dermatitis who carry toxin-positive Staphylococcus aureus strains have an expansion of blood CD5 - B lymphocytes without an increase in disease severity

Toxin‐positive strains of Staphylococcus aureus (Tu2003+u2003S. aureus) are present on the skin of some but not all patients with atopic dermatitis. Many staphylococcal toxins are superantigens, which can stimulate the immune response and thus may potentially lead to the very high levels of IgE characteristic of this condition, as well as exacerbating the clinical disease. The aim of this study was to determine whether the presence of Tu2003+u2003S. aureus on the skin of children with atopic dermatitis was associated with in vivo evidence of a heightened humoral immune response, higher IgE levels and more severe clinical disease. Toxin gene expression in S. aureus isolated from the eczematous lesions of 28 children with atopic dermatitis was assessed by PCR. Clinical and immune data were also collected from this cohort. Thirteen of the 28 children (46%) were colonized with Tu2003+u2003S. aureus strains. The presence of Tu2003+u2003S. aureus was associated with a significant expansion in peripheral blood CD5− B cells (Pu2003=u20030·01), and the more toxin types identified the greater the B‐cell expansion (Pu2003=u20030·002). However, in this cohort of children with atopic dermatitis, despite th in vivo expansion of B cells in children harbouring Tu2003+u2003S. aureus, there was no associated increase in IgE levels or in clinical disease severity scores.

Oxygen consumption during sleep in atopic dermatitis.

Measurements of oxygen consumption (VO2) were made during sleep in 10 patients with atopic dermatitis. Two groups of healthy children acted as controls. All subjects were studied in bed in an environmental temperature of 24-26 degrees C, and sleep was confirmed during continuous electroencephalographic monitoring. Mean (SD) values of VO2 in sleeping patients who were not scratching ranged from 4.0 (0.4) to 7.4 (0.7), which was not statistically significantly different from control values which ranged from 3.24 (0.3) to 5.56 (0.4). During scratching (while asleep), which occurred in nine out of 10 patients with atopic dermatitis, the mean values of VO2 ranged from 4.5 (0.04) to 10.4 (2.7), and this was significantly higher than the non-scratching patients and the control values. Scratching during sleep in children with atopic dermatitis is associated with increased VO2.