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High Risk Foot and Ulcer Care in Private Practice

Discussion in 'Diabetic Foot & Wound Management' started by Jonix, Feb 7, 2013.

  1. Jonix

    Jonix Active Member

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    My private practice has traditionally, occasionally, been a port of call for patients with acute foot wounds who need to be advised what to do and who to see. It has also had a number of high risk but stable patients who requiring long-term preventative foot management.

    But recently, I am seeing an increasing trend comprising old patients who are no longer stable but find it difficult to access NHS podiatry services, and new patients actively seeking a private practice for preventative high risk foot management, also ulcer dressings when they can't get it elsewhere, or even a second opinion.

    NHS budgets are slashed, but there are implications if greater numbers of patients start to see private practice as an alternative to the NHS for management of very high risk feet, when ideally they would be seeing a team.

    Any other private practitioners seeing this kind of trend?

    What do you think of the ethics of seeing - or refusing to see - very high risk patients in private practice?

    I am mulling over these thoughts and would value real-world input.
  2. Hello Jo

    It's a trend that has been developing for a few years. Two reasons - one as you correctly point out is unmet demand/need, for whatever reason (take your pick). The other is that for many patients, NHS care is no longer the "gold standard" it used to be. I couldn't practise the way I do in the NHS and provide my patients with the dressings and products and time that I am able to in private practice. Unfortunately, is some areas, the NHS is quickly becoming healthcare for those on a budget. Podiatry is one of those areas.

  3. Jonix

    Jonix Active Member

    So.. up my game, right?

    For example, new patient walks through the door with two toes lost to OM, neuropathy, diabetes, so-so pulses.. And I know (because I go to the Diabetic Foot Conference) that the that a multi-diciplinary approach is the way to go, but the patient doesn't think so.

    Am I helping or harming by taking the case on, when ulcers are fairly inevitable?
  4. Hi Jo

    I'm not sure I upped my game - I've always tried to provide the gold standard wherever I have practised. I don't see the princple that the NHS is what we trained for - the NHS is simply an environment and one that we increasingly have little control over. When a patient presents with whatever pathology they have a choice - they can pay for the very best care/dressings/orthotics; or they can use the NHS. Sometimes there will be little difference. Sometimes the difference is enormous. Ideology and principles don't matter as much when you're not getting better.

  5. Jonix

    Jonix Active Member

    Hi Mark,

    I edited my post thinking only I would be on the forum at midnight. But I was wrong about that. Your quote was indeed my original reply!

    We trained to treat diabetic, ulcerated, neuropathic - we didn't train to pass the buck and avoid personal risk when a high risk patient shows up. This was my meaning, rather than meaning the NHS is the natural working environment :)

    It's actually my view that the patient or any of the patients I mentioned, is choosing between two imperfect options and my dilemma arises around these issues.

    With the NHS, they get the team (hopefully), but unfortunately this patient in particular perceives the team don't care about her. With a private practitioner, they get someone they think will work and communicate with them, they will likely feel more engaged for choosing their own person.

    But I am just a single-handed practitioner, not a team and my reservation is that it is hard for me to lever a patient into back the the system if need be, than it is be for those in it to just shoot the patient up the priority ladder. There are a number of reasons not least financial, that this patient would be better not to burn her bridges with the NHS.

  6. There are a number of factors that patients take into account when making a decision who is to look after their foot health - not all clinical. Waiting times, accessibility, personalities etc., are just as important to some patients than clinical outcomes and whereas the professions (and NHS) may indeed promote a team approach as best practice - that might not be seen quite the same way from the patient's perspective.

    Where it's is great to have the vascular surgeon, wound care nurse, endocrinologist, & etc., all on hand - I have to question whether this is indeed the best use of resources. It does address some issues like waiting times for investigations - and a stitch in time is always good for diabetic care - but you can (and should) have good referral pathways in private practice - via the GP, diabetic nurse - and your local NHS diabetic podiatrist - if such an entity still exists. Very often the NHS makes decisions regarding care which are arrived at from an organisational point of view rather than that of the patient.
  7. Peter

    Peter Well-Known Member

    "[B]Very often the NHS makes decisions regarding care which are arrived at from an organisational point of view rather than that of the patient"[/B]

    Nailed on the head

    "professions (and NHS) may indeed promote a team approach as best practice - that might not be seen quite the same way from the patient's perspective"

    some pts consider that too many cooks............

    some trusts however are knee deep in high risk work, that they are trimming the referral criteria to focus resources on the at risk foot.

    Interestingly, if one wanted insight into future local NHS podiatry planning, one only has to listen to the commissioners of services who fail to consult the public and staff regarding what services need to be provided, and what services are able to be effectively delivered.

    an interesting OP BTW
  8. The primary issue with the NHS is that we regard the existing structure and practice as the best way - or evolving into the best way to provide healthcare in the UK. It is the only way we know really how to provide the population with the care that is needed to keep them in reasonable health. We now have this enormous workforce employed in state facilities - hospitals, offices, health centres who are constantly in a state of flux - whose professional responsibility to their patient has been subsumed by their responsibilities to the organisation. In a drive to improve services, the focus has been taken away from the patient completely and this has a direct impact on patient care- just read the report to the Mid Staffs travesty earlier this week. For lots of different reasons, the NHS is failing - and it's not just about money. More money has been spent on the NHS in the last 20 years than we can ever imagine - yet, anecdotaly at least, services get worse. Why?

    I personally like the system of health provision that operates in countries like Germany, Switzerland, Austria and the Scandinavian group. They have a health service too - but aside from some of the hospitals, most of the provision is in the private sector with group partnerships and co-operatives in comlpementing disciplines. Most of the "health service" is administrative - processing the payments to the clinicians for the services the state pays for. The rest runs by itself - by the individual practices. Much the same way that services used to run in this country too before we became fixated by management principles.

    Jo - and Peter; the trick (if that is the term) is good communication. I know most of the local GPs in my area - and a good number of specialist physicians and surgeons at my local hospital. If I wished a patient seen by one of the specialists or surgeons, I could have them seen within 48 hours - if it were neccessary. If I need any prescriptions or NHS investigations, it is a phone call or text to the patients GP. I have a radiographer and sonologist in my own practice and private X-Ray, MRI and Lab within a five mile radius. It certainly helps if you can establish a good referral pathway early on - and of course, like most pathways - its bi-directional - which is always a bonus.

    Whilst this can work for us (the clinician) - I have to agree that the current situation is not the best for the patient by any means, espcially those who cannot afford to meet the costs of their healthcare themselves. Which is what we really need to address. Not sure what the total bill for the NHS is on a yearly basis - but imagine instead giving this amount of money equally every year to the population to spend on health provision who would then have the ultimate choice....Now there's an idea...
  9. blinda

    blinda MVP

    Hi Jo,

    Yep, I think most pods will agree that there is an increase of moderate to high risk pts with diabetes presenting in private practice, for all the reasons outlined by yourself and Mark.

    I have no issues with treating them for either short or long term care. In fact, I would say that we have a duty of care to provide treatment, if it is within our scope of practice. However, I do so in conjunction with their GP and/or diabetic nurse, ie; I always send them a written report of any findings (vascular, sensory status, etc), treatment undertaken and recommendations. By maintaining a working relationship with GPs/nurses I can refer them to the MDT, if required.

    Although, as Mark said here;

    Those entities are on the decline and referral pathways are not always apparant, so it is often up to the private practitioner to create one. It is imperative to keep up to date with your local NHS Podiatry depts policies, obtain the names of your NHS colleagues and inform them of your skills and expertise. They will, usually, gratefully accept urgent referrals if, for whatever reason, the GP cannot refer them.

    At the end of the day, no word of a lie, when all is said and done; it`s a choice that pts can make, if they can afford private treatment.

  10. Jonix

    Jonix Active Member

    Interesting that not one of you thought my primary concern should be to avoid getting sued. I thought that might be the consensus of opinion. I am actually quite touched, maybe even proud, that you haven't said this, and that you are meeting these the challenges head on. Thank you for saying we have a duty of care. And that the primary change is in developing communications links with other professionals. This is a weak point for me!

    My three cases yesterday and one last Friday have left me feeling sober. These current protocols are good enough for acute, unstable, onward referrals; and for chronic stable cases. But they are not yet sufficient for chronic unstable cases. I now feel I have been complacent in thinking that when I have reached the limit of what I believe I can and should do, I refer my patient on. But what if there is no where else to send them, for what ever reason. I feel quite sad.

    Perhaps I hoped you would all say stop there don't take this any further, but you haven't. You've confirmed the title "Podiatrist" comes with responsibilities and a level of practice we can't avoid, even if we didn't expect it when we started our private practices believing we'd never have to probe a stinky ulcer again.

    When I posted this thread on the Diabetic Foot and Wound Management pages, I did so hoping maybe to hear a little of what you guys in the NHS diabetic teams might think about these very high risk patients seeing private practitioners. I hope you might stop by and let us have your thoughts. Can I change the title of the thread to reflect this? I am about to try... [EDIT] I don't think you can change the title!
  11. Jonix

    Jonix Active Member

    Not sure what the total bill for the NHS is on a yearly basis - but imagine instead giving this amount of money equally every year to the population to spend on health provision who would then have the ultimate choice....Now there's an idea...[/QUOTE]

    Often thought the same thing. Since I have been kicked off my GP's list for not having been for 10 years, I wonder who gets my share of the budget? Can I have it, pretty please?
  12. Lovefeet

    Lovefeet Banned

    First off, you a trained Podiatrist, whether working in private or NHS. The fact that you got your degree and that you are HCPC Registered, in my opinion, states that you are well enough trained in dealing with these High Risk pts, so do not doubt yourself.

    I live in this tiny bit of the UK, and the NHS Pod Dept is dire - it is just not properly managed. Urgent appointments are weeks away... So I deal with a few category 3 high risk patients privately, who have ulcers, etc but work in conjunction with the District Nurses/ GP Surgery Nurses. We seem to all manage fine with regard to treating the patients...
  13. How refreshing the honesty in your penultimate post, Jo. To be honest, from the flavour of your writing, the prospect of litigation didn't strike me as being the predominate issue. It's good that you recognise the shift in responsibiities - if you can call it that - from the NHS specialist the the general podiatric practitioner, however I share your concern that perhaps such a move may have been better structured, even supported financially. Restructuring care in this manner is essentially de facto privitisation by default, without any safeguards for those who cannot meet the cost of their ongoing care. This - rather than any clinical limitations - would be my primary concern.

    Keep smiling!
  14. blinda

    blinda MVP

    On the subject of litigation, I had a rather unpleasant experience 8 years ago; A patient with DM2 called me to say "As you always seem so interested in my drugs, I just thought I`d let you know before I see you next week that I am taking AB`s for an infection in my foot. I went to the docs yesterday as it was hurting...". Alarm bells rang as this pt had PN, so I arranged to see him the next day. He didn`t even need to remove his sock before I recognised the mis-shapened appearance of an acute Charcot Neuroarthropathy. The sudden change was alarming as I had seen this gent only 8 weeks previously and there were no clinical signs of CN.

    I reassured the pt and advised that he would need to be referred to the MDT for IV Pamidronate and offloading and that I would call his GP to request immediate referral. I duly made the polite, undemanding request by telephone that very hour. However, the GP was uninterested and advised me that "MrX is being looked after very well by our diabetic nurse and she would have told me if anything was wrong. Anyway, I saw MrX myself and have prescribed a 3 day course of AB`s, so it`s all in hand". I very politely repeated my request and the reasons why. The GP again refused and said "I have never heard of this sharker thing, I think you need to go back to looking after toenails....". Obviously, all this was documented in the pts notes, but I wanted a second opnion. So, after taking advice from a Pod manager at another Trust, I called the GP surgery again and asked to speak to a different GP and explained the situation. This GP reluctantly agreed to refer the Pt to the MDT. I hand delivered a letter to him, the same day, with my findings, tx carried out and recommendations and was satisfied that I had done all that I could.

    8 days later, I received a call from the pts neighbour, "X asked me to call you to let you know he`s recovering well after his op". I said "What op?" "Oh, didn`t you know? He was rushed into hospital 3 days after you saw him with septicaemia. After they resuscitated him, they amputated his leg".

    Neither of the GPs had made that urgent referral. A year later I received a letter of enquiry from the pts solicitor asking what treatment and action had I taken as I was the last health professional to have seen him prior to his emergency admission. They were looking to sue. Fortunatley, I had documented everything, sent them copies and the GP was taken to court. Not me.

    My point? If, in the unfortunate event of litigation, you have documented everything and can justify your clinical decisions, you should be OK. It can happen, but the threat of it should not deter us from treating and/or referring on when required. Quite the opposite, I think.

    As I said before, I have on occasion bypassed the GP and directly referred pts to the MDT when required. But, you raise a very important question above; I would also like to know how our NHS colleagues feel they could support private practitioners in treating and/or referring high risk pts. How`s about starting a new thread on this, Jo?

  15. Jonix

    Jonix Active Member

    Hi Blinda,

    What horrible thing to happen. I have had some frustrating experiences, none come close to that.... As you say - you documented everything. But what a shame it did not get acted upon. Huge respect to you for the lengths you went to on that day.

    May I ask you all one more thing on this topic..

    NICE guidelines. I recently managed to get one of my patients (a different one, several weeks ago, who had developed an ulcer over Christmas) seen at short notice by the Podiatry team because of NICE guidelines:


    "Care of people with foot care emergencies and foot ulcers
    Foot care emergency (new ulceration, swelling, discolouration)

    "Refer to multidisciplinary foot care team within 24 hours
    Expect that team, as a minimum, to:
    investigate and treat vascular insufficiency
    initiate and supervise wound management
    use dressings and debridement as indicated
    use systemic antibiotic therapy for cellulitis or bone infection as indicated
    ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts
    try to achieve optimal glucose levels and control of risk factors for cardiovascular disease.

    Actually, I've just noticed in private practice we can do, or (now we have upped our game with GPs etc), arrange for, quite a lot of what is on the guidelines. But what about the rest. Have we done our jobs properly if we don't attempt to get our patients into the MDFT, and should we all interpret all this as literally as I am?

    (NB. I have been told I am like a dog with a bone at times, although the person who said it did so in a nice way....!)

    Thanks again for your views on this.

  16. Jo

    The NICE Guidelines set out what we can expect from a MDFT - you can determine your responsibilities from your scope of practice. My experience of dedicated NHS teams is variable - there are some excellent units, some not so great. One of the primary problems for patients is access - especially those with mobility issues. The other is capacity which impacts on optimal treatment/dressing times. Although we understand that speed is of the essence in High Risk management - and the NICE guidelines reflect that , the reality is that fast access and expedited management/investigations are not always that great - and there can be a number of reasons aside from the above which can contribute to delays.

    When considering referral - I look at what I can achieve myself first - whether that be by local management regime, investigations (ultrasound, bacteriology, radiography etc), systemic ABs via the GP and practice nurse. In fact, wherever possible, my primary aim would be to keep the patient away from the NHS MDFT unless I think they would have a better outcome or where I cannot organise the care I need for them elsewhere. Regrettably, I am beginning to think that in some areas, NHS care is grossly inferior to that which is available in the private sector - the experience from many patients in recent times testament to that.

    Provided you undertake good effective safe practice and know where and when to refer on if necessary, then I don't think you need trouble yourself unduly with any ethical or moral considerations.

  17. blinda

    blinda MVP

  18. Jonix

    Jonix Active Member

    You guys are pretty inspiring.

    I am taking all this on board and mulling over it, particularly my links with GPs etc....

    Thank you again for your replies.

    And guess what? No new foot ulcers came in today !!
  19. mburton

    mburton Active Member

    Reading this thread has left me quite depressed. Why? As one who has worked in the NHS for over 20 years, a good few of these years as a diabetes podiatrist, I know of the dedication of most of the colleagues I have worked with over the years - not just the podiatrists, but also the extended MDT members.
    Sadly though, Blinda's experience is still not uncommon and well done her for following that one up so thoroughly - NHS podiatrists also experience a similar attitude from ignorant GPs and/or consultants from time to time, it is extremely frustrating and disappointing.

    It seems to me that there is good, bad and indifferent practice everywhere, whether in Private Practice OR the NHS, but if you work within a Diabetes MDT you should have the experience and post-graduate qualification to support you in that role. You also have a framework of colleagues to give you a second opinion and supply all the additional help that a patient with a diabetic foot ulcer or charcot arthropathy will require for a positive outcome.

    Mark is obviously able to provide a good service for his high risk patients but I'm sure most patients eg with ulcers that require 2x dressings a week would find the cost involved to be difficult. I often feel extremely glad that this is not a consideration for me when I am deciding when to get a patient back for review.

    In fact, wherever possible, my primary aim would be to keep the patient away from the NHS MDFT
    By doing this you are denying your patient access to specialist advice on diabetes management( medication, vascular services, diet etc) and specialist footwear, unless they are happy to pay for that too - I suspect that those who can are an elite few. It is sad that you have so little confidence in your local MDFT Mark, but don't tar us all with the same brush! It's a fact of life that the NHS is struggling financially, and that gold standards may therefore struggle to be achieved, but even where gold standards are not being met by the organisation there may well be individuals within the team that are going well beyond contractual commitments to help their patients.

    My advice to Jonix, for what it's worth, is to do what you are comfortable with according to your knowledge and experience (remember,first do no harm!), but would exhort you to make contact with your local MDFT. They will hopefully be delighted for you to refer diabetic foot problems urgently to them, and if they are any good will keep you informed of the outcome - the patient may well come back to you once the problem has resolved and will have increased trust in your professionalism. The outcome can often be drastic if the referral is not made promptly as Blinda has illustrated only too well.

    PS stinky ulcers are just my cup of tea;-)
  20. Hi Mo

    I share your concern and disappointment - it's sad and infuriating to witness the decline in care standards throughout the NHS and of course there are regional variations in departments where despite funding restrictions, there are excellent examples of individual commitment. Whilst access to individual specialisms within the team should be excellent once the patient in in the hospital - access to the hospital is often a major factor for many patients especially where mobility is restricted. Ideally, the MDFT would delegate the dressing regime to their colleagues in the community NHS clinics, but the reality is that the capacity for woundcare community clinics is no where near adequate in many areas, which makes the optimal dressing change frequency for some patients, impossible. The other issue is initial access. I try to see my diabetic patients who call with a flagged concern within 24 hours - the same day is possible. Not sure how that compares with Raigmore these days but south of the border, in most NHS trusts, that is simply not possible.

    If a private practitioner with sufficient scope of practice skills can offer the high-risk patient the first line of care and management with the dressings of choice at intervals commensurate with recommended guidelines - and the patient is able and willing to meet these costs, then that is an extremely valuable service all round - as it takes pressure directly off hard-pressed local community NHS podiatry services, many of whom would collapse if it wasn't for the care provided in the private sector. The reality is that many patients who cannot afford our fees are having to, somehow - either by borrowing, doing without or coming to an arrangement with their clinician - because they simply have no choice. Waiting times are too long or there is no access to NHS care. That is the reality for many people - not just in podiatry or diabetic care either.

    My despair lies in the realisation that there is another agenda going on which is the predominant force in healthcare in the UK - forget the NHS plan (remember that?) and local reorganisations or AQP or GP Fundholding - it is the disposal of one of our most valuable assets to the multinational money-men without any concern for patient welfare or those who have dedicated their working life to the organisation, that is the biggest disgrace. Optimising local service care pathways and utilising the service of colleagues in private practice, would be wonderful, Mo. But prevailing conditions make that rather difficult and until then I guess we just have to hope that all of us - wherever we work - have the confidence and ability to manage our care - including onward referral - for these vulnerable patients, until a better system exists.

    Is it snowing up there yet?
  21. Jonix

    Jonix Active Member

    Hi Mo,

    Thank you for loving smelly ulcers and thanks for sticking up for the NHS! As you say, different standards everywhere. Though I orientated towards biomechanics, I've have had some good stints working on MDFTs. They were excellent teams, and I strongly believe that in an ideal world, patients would have access to this when needed. But what do I do, when I find that I am a bit stuck? That is what I have been figuring out. By changing what I do, maybe I can get better results.

    Errr, not my first impression! But my recent list of situations come from different trusts. And I only know the patient's side of things. But the patient I fought for using NICE guidelines bounced back into my clinic 3 weeks later and the lesion was still open (I bounced her right back again). But I have been toying with the idea of writing to ask if I can spend a couple of days with the local team, and you seem to have confirmed that this is a good idea.

    In any case, now I have raised this issue on here and with myself, I am going to have to increase my own competency level. Not with the wound assessment and debridement, I am fairly sure that's up to scratch. My experience of specialist dressings would not be good enough, though hopefully I will never do enough of this work to gain the depth of experience you need.

    I could do with another notch up on my vascular assessment, it would carry more weight and make me more convincing. And I will also have also established a higher minimum standard of assessment for at-risk feet in my clinic. Upping my level of direct communication with GPs and my local NHS podiatry trust if possible, is now a no-brainer after what has been said on this thread.

    PS Next time I get that warning whiff, I'll remember there are smelly ulcer lovers everywhere, I just need to free my soul and join them!
  22. Jonix

    Jonix Active Member

    For vascular, I just use my hands, my eyes and a doppler. Would you think it excessive if I started routinely using ABI?
  23. Mo & Jo - one other advantage with practice led care over the NHS is continuity with the same clinician. I know comprehensive, objective note writing is the norm but there's nothing like having the same pair of eyes looking at the problem each week to accurately assess the management regime. I know dedicated clinician caseloads are terribly unfashionable these days - but they served the patient well, mostly.
  24. Jonix

    Jonix Active Member

    As Mark said.. Appointments same day. That's what does it. If you want your clinic to be free of high risk patients, have a less flexible booking system!
  25. Jonix

    Jonix Active Member

    You also take the journey with them. Not just diabetes but also I have had a cancer patient..

    (come to think of it I have done a lot of ongoing ulcer care, though with only a small number of patients and there was always some kind of hospital support to call upon, however distantly)
  26. Fraoch

    Fraoch Active Member

    Jo I wish you all the best in your path to creating a referral network.

    I've enjoyed reading this thread, the points brought up, the great thoughts and insights from our colleagues.

    As an ex-pat it's been very interesting to see how much the NHS has changed since I left GB shores 12 years ago. I can understand your hesitancy and "fear" of being faced with difficult cases and no apparent network of help.

    I had similar issues when I started up in my current clinic eight years ago. Many of our clients are high risk, no in-roads to specialists (even though I work in a hospital) and many of our clients without a GP. There were no foot clinics as I knew them and the few options that existed....... well it was a game of chance and a long wait list to get onto any of that.

    So interestingly I was now faced with patients who were forced to pay for what i had always believed should be for free. Everything I'd been taught in Brighton and practiced for the NHS was no longer a reality.

    But I must say I have enjoyed the challenges of forging links. Watching clients go on when bigger help was required, seeing them again further down the road.

    I think you have a marvellous opportunity to set yourself up as a centre of excellence. As you have already experienced there is an excellent virtual network of help and advice from the Arena.

  27. mburton

    mburton Active Member

    I have been toying with the idea of writing to ask if I can spend a couple of days with the local team, and you seem to have confirmed that this is a good idea.

    Hope this is something you can organise Jonix: for all sorts of reasons it will be invaluable to you, and the MDFTs that I have experienced are all very used to such requests. Good luck with that, seems to me your patients are lucky in having such a committed and reflective pod.

    Would you think it excessive if I started routinely using ABI

    Yes, waste of your valuable time especially for diabetic pts.

    Mo & Jo - one other advantage with practice led care over the NHS is continuity with the same clinician. I know comprehensive, objective note writing is the norm but there's nothing like having the same pair of eyes looking at the problem each week to accurately assess the management regime. I know dedicated clinician caseloads are terribly unfashionable these days - but they served the patient well, mostly.

    Mark,I absolutely agree with you - as long as those eyes are up-to-speed with current/evidence-based practice. However, high risk ulcers often take months to resolve, if ever, and it can be very helpful to have a second opinion from someone you respect on occasion, just to ensure you have overlooked nothing.

    BTW, we've only had one fall of snow worth the description so far this winter, that was 10 days ago and was gone by the end of the next day. Must be global warming right enough ;-)
  28. Jonix

    Jonix Active Member

    Hello Froach,

    That level of responsibility - especially when patients had no one else to go to and have to make sacrifices to pay their fees - that would be outside anyone's comfort zone. It sounds like for a while you were a few miles past your comfort zone. A steep learning curve. It is both amazing and humbling too I guess, that there are a feet, legs and lives on the planet a bit longer because of your work.

    A centre of excellence?? haha, I'll let you know.............!! There have been fantastic replies on this thread and as I said before, the replies were the polar opposite of what I expected, And of course that exhortation to me to form that network.


    I posted my letter to the head of department this evening and if I don't hear, I'll follow it up...


    I just noticed you suggested I re-post this in a slightly different way to try and get a bit more input from people working in MDFTs. I'll try and do that.

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