I have worked as an academic orthopaedic surgeon for more than 15 years. However, during one of my career reorganisations about five years ago I somehow lost my operating lists and outpatient clinics. Nobody seemed to mind much, and I felt I was probably doing everyone else a favour, particularly as there was such an unholy battle for operating lists in the hospital at the time. I continued to see patients in the emergency department when I was teaching students. I did medical reports and soldiered away writing textbooks. Then last year, at my appraisal, I decided that I should return to full orthopaedic surgical practice, both for my own professional satisfaction and so that I could explore the practicalities of retraining surgeons who had not been operating for whatever reason or who had been suspended by the General Medical Council (GMC).It was clear to me that the quickest way to become competent in surgery again was to concentrate on retraining in a limited range of simple operations. I needed to find a busy unit which would accept me, but I also needed to be careful not …

Every now and again the tranquil progress of our little multidisciplinary team round the acute ward is disrupted by a troubled visitor: not the kind of relative who is there from the beginning and whom we get to know quite well as things move along, but a sudden, anxious presence from another world. The details vary, but the basic story doesn't, and the distress is always palpable. “I live four hundred miles away. I can't take my mum. And you can't just send her home because she lives on her own. And, um, I live four hundred miles away.” The distressed daughter from England, let us call her. Straight from the airport, deeply suspicious and obviously distraught, she requires careful handling. She explains about her job, and her family, and how she can stay for a few days at most. She doesn't want her mother just put in a home. And she lives near enough to worry but not near enough to help. We listen. Eventually, when she has got through everything she has been rehearsing all the way from somewhere like Essex, we try to explain: no rush to judgment; no precipitate discharge; no knee-jerk nursing home disposal. Suspicions may linger, but we mean what we say, and yet again we find ourselves wondering about what sort of experience of care of the elderly 400 miles away has shaped the expectations that cause such distress. We do things differently here. In Scotland the care of the elderly survived the depredations of the internal market rather better than in the south. More beds, cannily managed by a relatively confident and thriving specialty, allow a decency of provision that continues to surprise our flustered friends from the south. The NHS in general survived better in Scotland. Mrs Thatcher's whim of iron —the market solution that burst upon the NHS in 1989—seemed distant: the answer, perhaps, to problems elsewhere. With a few exceptions, enthusiasms were tactical and restrained, and largely to do with damage control. But there was something else too: something we might call the Scottish version of the Dunkirk spirit. For those not familiar with it, here it is. Two jocks, Jimmy and Wullie, are rowing home across the Channel in June 1940. After several hours of thought, Jimmy confides to his friend a strategic insight we all still recognise: “Wullie, if England surrenders, this is gonnae be a long war.”

When as a medical student you dissected a cadaver, were there things said and done that left you deeply worried about the respect that you might be shown when you are dead? Do you remember the first time that you performed a vaginal or a rectal examination? Were you in a queue of students lining up to practise on an anaesthetised patient who might or might not have known what was going to be done to them? Were you a bit embarrassed then as well? Perhaps this was expressed as ribald humour, a common defence in ethically challenging situations. Or was the examination performed on an uncomplaining conscious patient, who felt that they did not have the right to question why this nasty thing had to be done again and again? You may have felt a sense of unease at the time. You may even have decided that the procedure was wrong. But you were quickly taught that those doubts were immature and not to be heeded. And you …

The joy of being asked to review a book is that sometimes you end up reading something whose title alone would have convinced you that there were better uses of your time. Jude the Obscure would have approved of the title of this book. Some of the contents are equally woolly. However, there are three chapters that have made me think harder than I have for a long time. “Not difficult in an orthopaedic surgeon,” I hear you say. Well, I challenge anyone involved in medical school curriculum design to read the chapters by …

Paracetamol is the drug most commonly taken in overdose in the United Kingdom,1causing a substantial number of deaths.2 We have investigated the impact of the fictional portrayal of a potentially fatal paracetamol overdose in the television drama Casualty (seen by 12.8 million viewers) on short and long term knowledge related to paracetamol poisoning. View this table: Responses to questionnaire for patients presenting with overdoses in the three weeks before and the three weeks after broadcast of index Casualty episode. Values are numbers (percentages) of those who responded to question unless stated otherwise The episode (described in detail in accompanying article3) depicted a man suffering potentially fatal liver damage after an untreated paracetamol overdose. Although the particular dose (50 tablets) and delay before presentation (2 days) were mentioned, the episode did not specify minimal toxic doses or maximum safe delays. At one week and 32 weeks after this episode …

Objectives To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.Design Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods.Setting 49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire dataSubjects 4403 self poisoning patients; questionnaires completed for 1047.Main outcome measures Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers.Results Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%).Conclusions Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice Of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

Sociologically, hospital doctors are members of craft guilds. Consultants (the masters of these guilds) control their craft through the royal colleges. The junior doctors are their apprentices. Unfortunately the master/apprentice model has always been open to abuse. It is in the master's interest to extend the length of the apprenticeship. This enhances the status of the guild, holds down the number of masters, and maintains a comfortably closed shop. In Britain between the 13th and 15th centuries the length of an apprenticeship rose from seven to 16 years, and finally had to be cut back by royal statute.Length of apprenticeship still continues as a problem in hospital medicine in the late 20th century. Consultants have been taking 10 or more years in specialty training to achieve accreditation. This is far longer than necessary, if training is the only factor involved. The problem now (as it was no doubt in the 14th century) is that the large numbers of apprentices have become the backbone of the service. The reduction in junior doctors' hours, combined with the reduction in length of training, is bringing about a staffing crisis in …

The new deal on junior doctors' hours and the recommendations of the Calman report on specialist medical training will require a radical review of working practices in hospital. Not only will juniors be working fewer hours but as a result of shortened training there will be fewer of them available to provide a service. The medical work in hospitals will inevitably become more consultant based. The old system of a firm, built on a consultant leading a team of juniors, looks as if it may be the first casualty, replaced by a team of consultants and a shrinking pool of juniors. The benefits of continuity of care, provided by the juniors working long hours, will have to be provided in some other way. The importance of continuity of care for training and patient care is now being presented to our regional task force as one of the most cogent reasons why the present changes are ill considered and unworkable. But before condemning these changes out of hand it may be worth considering the real meaning of continuity of care and …

Whooper Swans were studied on their breeding grounds on the ‘meadows’ of Iceland's central plateau, and a wide range of interesting observations and behaviour while nesting are summarised in this paper.