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There has been a change in the doctor–patient relationship, with a shift from the paternalistic approach to one of increased patient autonomy. Women wish to be aware of not only the common complications of intervention but also the rare complications, and this influences consent. The case of Chester versus Ashfar (England) involved a paucity of information leading to harm. Communication needs to be effective, with education forming a part of the process of consent, and taking place not only at clinic visits but also throughout pregnancy. Consent is a meeting of both ethical and legal concepts.

The study aims to determine if a vaginal examination improves diagnostic accuracy when assessing women who present to the ED with vaginal bleeding in the first trimester of pregnancy.One hundred and thirty-five women with first trimester bleeding were randomised to have a vaginal examination (n = 61) or not (n = 74). They were given a provisional diagnosis, and then a final diagnosis after ultrasound, beta-human chorionic gonadotropin and gynaecological follow up. The provisional diagnosis was considered accurate if it matched the final diagnosis.The provisional and final diagnoses matched in a little over half of the cases, and there was no statistical difference between the two groups (χ(2) = 0.005, P = 0.94).In a stable patient presenting to the ED with first trimester bleeding, clinical diagnosis is highly inaccurate and is not improved by vaginal examination. Routine vaginal examination is not necessary as part of the initial patient assessment.

The Emergency Care Summary (ECS) was introduced in 2006 to allow aspects of the general practitioner (GP; family doctor, equivalent to primary care physician) medical record to be viewed in hospitals and out-of-hours centers in Scotland. Records were automatically uploaded unless patients actively opted out. This study investigated patient awareness and acceptance of this process.This was a questionnaire survey of patients in a GP surgery (office) in Paisley, Scotland.Survey results indicated that 42 percent of patients were aware of the ECS, and 16 percent said that they recognized the leaflet posted to households. Of those who recognized the leaflet, 92 percent said they were happy for their record to be part of the system, while the others did not realize their record was to be included. Having read the leaflet, 97 percent said that they were happy for their record to be included in the ECS.This study shows that most patients were not aware of the Emergency Care Summary or did not remember seeing the leaflet posted to households. Having read the leaflet, the vast majority of patients were happy for their records to be included in the system. The low awareness of the ECS calls into question the validity of an implied consent model using an information leaflet distributed by post.

EDITOR—The British Heart Foundation was criticised by the Independent on Sunday last year for using pension funds that invested in tobacco companies.1 A spokesperson for the BMA commented that charities promoting health should, as a matter of principle, avoid investment in tobacco companies and that “charities campaigning against …

[Extract] To the editor: The Guidelines for the management of acute coronary syndromes 20061 state: "Enoxaparin may be used in conjunction with fibrin-specific fibrinolytic agents in patients under the age of 75 years, provided they do not have significant renal dysfunction. An intravenous bolus dose of 30mg followed by a 1mg/kg subcutaneous injection every 12 hours in combination with tenecteplase is the most comprehensively studied therapy."

AGAINST The NHS is astonishing. It provides a high level of care to a whole population based on need and not want. It is free to all at the point of contact. It is remarkably cost efficient, despite what the government and private healthcare groups would lead you to believe. Even the oft quoted article comparing Kaiser Permanente with the NHS found that the NHS was better, and its contrary conclusions have been comprehensively repudiated. It is commonly accepted that countries with effective healthcare systems have a high primary care index, and the United Kingdom has one of the highest in the world. GPs …

Ten years ago, I crashed into a rock-face. I'd fallen asleep at the wheel of my car while on holiday in Scotland. My car was a write off, but I escaped with a grazed knee. At that time, I'd been working for several years as a junior hospital doctor, most recently in a busy obstetrics unit. For some time, I'd had the feeling that my life had gone sour: I felt empty inside, I was losing my ability to care, and I hated what my job was doing to me. The car accident seemed like a message: if you keep driving on and on when you need to stop, you're likely to crash. I was severely burnt out, and it took a crisis to prompt necessary change. When I got back from my holiday I handed in my resignation. While many doctors do leave the profession well before retirement age, we may not have to reach the point of choosing between medicine and having a life. Instead, we can practise strategies to prevent burnout and protect our quality of life at work. ### Awareness of the problem Burnout is “a state of physical, emotional and mental exhaustion caused by long term involvement in situations that are emotionally demanding.”(1) While we may all feel worn out by work at times, burnout is when we feel so chronically ground down that our life and work suffer. Doctors are a high risk group: a recent study of general practitioners showed that nearly 60% felt that their physical health had suffered as a result of overwork.(2) In its more severe forms burnout leads to a lack of interest in work, complete disillusionment, hostility to patients, and feelings of hopelessness. Both the sufferer and the …

Sarvodaya is a Sri Lankan development organisation, with a philosophy strongly grounded in Buddhism. It combines the Primary Health Care approach with a holistic conceptualisation of health, and aims for a self reliant system of village communities in which the basic needs of all are met. This article describes the organisation and its role in health care, attempting to draw lessons relevant to the West.