Posted by: Colin | June 5, 2010

South American Extravaganza Part 1

So med school is finished and life as a student is gone. What better way to celebrate the end than by going to South America with a fellow medic. Where to go? We, decided Colombia, Ecuador and Peru would give us the best experience as we only have 4 weeks before graduation. Unsurprisingly people a bit worried about us being kidnapped. All the more exciting we thought.

Flights booked and packed so off we went. Glasgow to Newark was fine but we realised 6 hours in Newark was a bit too long. So we popped into Manhattan for a jolly and a slice of pizza.

First on our itinerary was Time square which hasn’t changed at all since I was last there 5 years ago. Then we climbed to “Top of the Rock”, the Rockefeller building. In hindsight I think it gives a better view of Manhattan because of the unobscured views. Next we went for a summer stroll in Central Park. The stroll however turned into a march as we realised the time.

Thankfully the trains were regular and security were pleasant. Goodbye Capitalism and the West, Hello Socialism and Colombia.

Ps Photos will be added later.

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Posted by: Colin | May 7, 2010

If I were Gordon Brown

So we have a hung parliament. Here is what I would so if I was Gordon Brown.

Its amazing how geographical the election map is. Far North=Lib Dems, Lowlands/ North England= Labour, Wales= Labour , Middle England= Conservatives, London= Labour

First off, I would try to form a government with the Liberal Democrats. Some concessions may need to be made over defence, Europe and some social policies. They should accept as the manifestos of labour and Lib Dems are far similar than that of the Conservatives. Although the government wouldn’t pass the 326 line, it would be a government of majority by votes (54%).

NB. Crazily the Lib Dems got ~25% of the votes but only ~8% of the seats. Must be a better system.

Secondly, I would take the clever ideas of all three parties and try to put them into action. Since its a hung parliament there will be great need for compromise. Hopefully individual MPs will be more free to vote in accordance with their views rather than being whipped by their party. Passing these beneficial policies might bank some political capital to enable difficult fiscal decisions to be made.

Thirdly, I would call an election in a years time. This would insulate public services and taxes for a year and  not “put the economy at risk” which Gordon is so worried about.

Fourthly, after I had lost the election in a years time, I would step down and endorse David Miliband.

Posted by: Colin | April 10, 2010

Trust me I’m a junior doctor

This is for Laura.

I work in a hospital, so I’m constantly seeing people with problems. There is the people who are ill and know be they’re ill, the people who are ill and don’t know be they’re ill, the people who aren’t ill but think be they’re ill and finally the people who aren’t ill and know be they’re not ill. You get skilled at who falls into each category. The ones who are ill and don’t know their ill are the most worrying since they won’t tell you their getting iller and if you make it obvious you’re worried about them then the D word or C word becomes unavoidable. But mainly its the regulars that are the most infuriating.

In many way you have to admire them. They have chosen a difficult task of concentrating a lifetime of fun activities into their early adult life. Sadly the Puritans were right. Fun kills.

Then there are the crumblies: old people whose health is so fragile that anything minor will knock them off their perch. Then they are the people who insist on paging you when you are having lunch or trying to explain the C word to a patient.

Everybody thinks the consultants are like House. Many of them are arrogant, self-absorbed greys but none have a cool cane or play the guitar on the ward. Personally I think life is more like scrubs. Mainly because its true we’re a bunch of self-­absorbed people. Every day you hear great stories from patients about the trials they’ve had in their life (when you’ve geot time to listen). Gnerally great stuff. After all who is more trustworthy than a doctor. But if you want the best gossip make friends with the nurses.

After all the hospital is our life. Medicine is slightly incidental.

Posted by: Colin | April 6, 2010

Digital Economy Bill

So the DEB is having its 2nd reading in the House of Commons today. Essentially the bill want to protect copyright of digital material and increase the benefit of producing such desired material. I have three main issues with this bill.

Firstly, the bill will entitle OFCOM to delegate to other agencies the power to cancel someone’s access to the internet. In the 21st century that is some sentence, not dissimilar to banning people from using the Royal Mail 50 years ago. This is after both Labour and Tories pledging to make more services available online and cancel other postal services to cost cut (cheques for example). Now that sort of sentence may be fitting if legal diligence is performed. But here’s the catch. No court proceedings are necessary.

Secondly, clause 43 seems to be heading in the opposite direction. Basically it wants to allow organisations to be able to use material where the creator is unknown or cannot be contacted (so called orphan material). Sounds logical. In the absence of the cretor being compensated for their contribution, the material can be used. Fair enough. But the problem lies in defining what a “diligent search for the owner is.” Because it is so ill defined, owners of material will be less protected by the law thus undermining the purpose of the bill.

Thirdly, it will have serious implications for free wi-fi around Britain. Many of these wi-fi centres make massive contributions to our daily lives. They allow work to be done on the move and stimulate trade for thousands of small businesses.

Got a reply within 48 hours

Bring on the election...

So I thought I’d finish with fallacies in my MP’s arguments.

Protection of the creative/ media industries“: She quotes 1.2 million jobs being lost in the EU. That’s a big number but it really doesn’t address the implications in the UK. I very much doubt that the bill protect current jobs or stimulate further jobs. Indeed, Mandelson has been rabbiting on about innovation this, entrepreneur that and yet the letter states its unnecessary to consult the most innovative companies in the last 10 years. He and many of these MPs don’t appreciate that traditional copyright law can’t  practically applied to the internet (I’m not saying it shouldn’t be applied). Likewise, traditional business practice can’t be applied either.

Ps Neil I beat you to it.

Posted by: Colin | March 27, 2010

Three evolving needs in healthcare

On my GP placement I talked with a consultant from an IT company specialising in telehealth. Over lunch we talked about the impact of telehealth, increased computerisation and the importance of releasing raw data (Conservative have made this part of their election manifesto).

Telehealth is when equipment is installed into the home to benefit well-being in a variety of fashions. It allows early indicators of illness to be identified and reported to specialists remotely. This way the patient can be ask not to worry, take a intervention personally or seeking expert help from their GP or hospital physician. Importantly it seems to be cost effective with a benefit to funding ratio of 5:1. That is an impressive statistic as the inverse care law is being realised and populations around the world are aging. Currently there are large studies being undertaken in the US and UK aimed at COPD and other condition which grace hospital beds regularly.

Computerisation of healthcare has taken leaps and bounds in general practice over the last decade. It is starting to be utilised in the more complex environments of hospitals (electronic prescriptions: August 2010). Hopefully this will reduce prescription errors and create a better system. One aspect I think is most important is being able to have an accurate summary of a patients care instantly. When writing cases it was often hard to correlate what the patient said with the content of their notes (especially when they have several volumes). Searching through the paper data was tedious and inefficient. The scope for improvements in care are enormous. Grade scales can be done instantly, reminders (eg all those stroke assessments), comparisons and collection of data for automated studies.

These automated audits and studies could be anonymised and the data given on a centralised system for everyone to analyse. I watched a recent video on TED about how mapping improved after the Haiti disaster. Basically a satellite was deployed over the capital, Port-au-Prince. It streamed data regularly for people around the world to update the current poor mapping of the area. Within hours of the data bring release there was an accurate representation of the area which improved as the relief effort arrived. Relief workers used these maps/ data to target their efforts and coordination on the ground. This idea could be translated into healthcare in an accessible and free platform. The data could be displayed beautifully to allow greater awareness of the problems in well-being and health. Then the changing expectations of health could era in the 5th wave of healthcare.

Posted by: Colin | March 25, 2010

AFTERnow: Nice little site

Public health largely gets a bad press throughout med school and beyond. This may be because it is a vastly different discipline from traditional medical education. When learning about a disease the content is largely an agreed logical progression of facts (ASSPITE). Public health is influenced by a mess of different fields all requiring an alternative set of skills. Indeed history, psychology, ecology, epidemiology, biostatistics, health services, economics and politics all have a role in the subject.

With finals finished and studying but a horrid memory, it was nice to get a link to this website. It reminded me that a health professional’s job is to improve health/ well bring and not just fill in those discharge forms correctly.

Ps Phil Hanlon is a cool dude.

Posted by: Colin | March 7, 2010

Bad Science: Blood Service

This is an old entry which was never completed. As finals are over I decided to finish it. Today I had an acute care day at the med school. It was on the subject of blood transfusions. The overriding message I got was;

“Check everything carefully before transfusing”

“The blood transfusion service is not evidence based.”

Both are understandable. The first could obviously leads to catastrophic results if incompatible donor blood is transfused into a patient. The second, however, I thought was very interesting.  During the lecture I started to consider why this might be. Here is what I came up with;

  1. Often blood is a life saving intervention. Any prospective studies wouldn’t be ethically sound therefore the necessary data is simply not available. I haven’t done literature searches but blood prescribing seems to be art which is left up to the caring clinician with few absolute indications. In fact this was recognised as a problem and in 2002 when an initiative (SIRS) was set up aimed at reviewing and stimulating research.
  2. Blood transfusions have a long history (~300 years). Practice is difficult to change when it has been established for such a long time.
  3. The nature of blood transfusions have few parallels in medicine. Blood donation is optimistically an altruistic act and pessimistically a form of insurance. The connection is not just the blood but what the blood represents; liquid life. This direct link between two humans gives it reverence and subsequently society treats it differently.

The third argument and how it affects guidelines is what I pondered on most.

We all know that the UK has a blood deficit. I tried to find figures on the amount of blood we import from other countries but couldn’t find any. Figures aside, it is a lot (~20%-50%). For some blood types the transfusion service only has stores enough for a few days and in others a fortnight’s worth. That sounds very low but blood is also held in health board locations.

The significance of blood being regarded as such a symbolic gift is that the transfusion service’s mandate is that blood must be safe no matter the cost. There are lots of tests done of blood donations (Hep B/C, HIV, HTLV, Syphilis, CMV, ABO, Rh, blood group titre levels) and some optional tests (Malaria, T. Cruz, West Nile). On top of the testing there are processing techniques (filtering, removal of WBC, irradiation etc) aimed at minimising unidentifiable pathogens like prions. These processing techniques got a lot of attention after the vCJD scares and are the trigger for the changes in the system.

vCJD is thought to have a subclinical prevalence of 1/20,000. Since 1996, 18 people have thought to have contracted vCJD directly from a transfusion. vCJD is a nasty neurological condition which causes dementia, UMN signs, cerebellar signs and mental disturbances. Sadly there isn’t an effective treatment. This is a regrettable iatrogenic outcome but let us consider the costs to the system.

The figures speak for themselves and one must remember that those 18 patients are since 1996 when we became aware of vCJD. I couldn’t find any QUALYs or economic indicators but needless to say they would be in the 10s of millions. That’s in contrast to the £20,000-£30,000 NICE normally allocates per QUALY for a health intervention.

The question I can’t shake is whether we overvalue the symbolic value of blood and has the NHS let it cloud prudent care provision?

Posted by: Colin | March 6, 2010

Foundation Programme Application 2010

I thought it might be helpful for my fellow medics who are going through the foundation programme next year to have my answers for the application process so they have an idea what the UKFP are after.

Question 1: Additional educational qualifications (0 Points)

Question 2: Describe a case from your clinical experience that you have observed in the first 24 hours from hospital admission. How did members of different professional teams interact and how did this contribute to effective patient care? What did you learn from this that will influence your future practice as a new doctor? (10 points)

“During my elective in Kingstown, St Vincent I met a 4 year old girl who presented with focal neurological signs. She was an HIV orphan, a known carrier and unwilling to feed or take medications. There was one sister from the orphanage who she would allow to feed her. Sadly, the sister couldn’t stay at the hospital for meal times. The paediatric consultant suspected cerebral toxoplasmosis and worried that poor nutrition would worsen her resistance.

On admission the entire ward wanted to help the young girl. Within an hour there was a team meeting where individual roles were agreed upon. A nurse volunteered to read stories and play music to her. The junior doctor was inventive with his preparations to disguise the medication. The consultant organised a security badge to allow out of hours entry for the sister. Over the next 24hrs her condition improved with medication, she started talking and within 72hrs she was taking meals from a nurse.

This experience heightened my understanding of the interdisciplinary nature of care and importance of empowering each member of the team. As a FY doctor I will use the inventiveness and supportive care showed in this case to improve patient outcomes.”

Question 3: Describe a memorable experience of being taught and how this has shaped your thinking about teaching. Identify a particular situation in which you might be teaching as a doctor in the future. Describe how you might apply what you have learned to maximise the effectiveness of your teaching. (4 points)

“During my paediatric placement I organised teaching for my group with an FY following a cancelled session. The FY began by asking us what we would like to be taught. This was an unusual approach as teaching is often dependant on the doctor’s agenda. Instead a student centred method focuses on improving areas of difficulty. This encourages students to address their strengths and weaknesses. This reflective element improves motivation for the session, future recall of information and a balanced knowledge base.

If a teaching doctor was unavailable I would enjoy the opportunity to instruct students (clinical responsibilities willing). I would start by understanding any learning objectives the students had and do my best to facilitate their completion by furnishing a positive learning environment. I would achieve this by ingraining my enthusiasm in the students and challenging their knowledge in a supportive fashion.

Depending on the topic we had covered I would direct the students to relevant background reading and clinical guidelines. Finally I would give constructive feedback on the student’s performance and make an action plan for any improvements. Equally I would encourage honest feedback on my performance and take measures to improve my future teaching sessions.”

Question 4: You are one of two foundation doctors on a ward round. The registrar identifies a minor error made by your colleague and makes inappropriate critical comments in front of the patient and the healthcare team. Your colleague is visibly distressed. What actions would you take and how would you prioritise these? What actions do you believe your colleague should take in relation to these comments? How might you address a minor error made by a more junior colleague in the future? (6 points)

“My first priority would be to ensure the patient’s continuing confidence in the team’s care. Firstly I would recognise the mistake and address any consequences of the fault. I would then attend to any worries or queries from the patient. After the mistake itself had been addressed I would try to disarm the situation with small talk or humour. After the patient encounter I would delay the ward round to resolve the potential ill feelings between my colleagues.

I would encourage my fellow FY colleague to discuss the inappropriate comments with the registrar as soon he/she is capable in a neutral area. The FY should extend his apologies for the mistake and inquire why the registrar felt it necessary to address the mistake in such an inappropriate manner. When both doctors feel the situation is resolved we would return to the ward round. Afterwards, we could consider any changes to prevent future errors including recognising professional limits. Later on in the day, I would ensure there were no continuing ill feelings in the team.

If I noticed an error by a colleague I would take a few minutes to discuss the mistake with him/her personally in a private area.”

Question 5: Describe one example from your medical training when you received feedback on an aspect of your performance. Explain how that feedback altered your subsequent practice. How will you use this experience to develop a specific aspect of your foundation training? (6 points)

“During my general practice placement I led two clinics a week. At the beginning of the block I had a tendency to practice overly defensive medicine. After a discussion with my supervisor and careful thought, I identified this was a remnant of my hospital based teaching where investigations are more accessible and advantageous. I recognised the change in setting required a change in approach. I established this early and it became a learning objective throughout the placement. My tutor and I agreed to address this by discussing the treatment plan of each patient immediately after each consultation. This vastly improved my clinical judgement as it gave greater emphasis on pragmatic decisions based on the entire clinical picture. By the end of the placement I felt comfortable in using time as a tool to add in my care of the patients I saw.

In my foundation years it is important to be able to recognise patients who require urgent intervention, those who can wait and those who need minimal treatment. This experience developed my skills in identifying these patients groups and prioritising their management. The placement also made me more aware of scarcity and my role in utilising healthcare resources.”

Question 6: At times, the patient and the medical team have different ideas on the management of the patient’s illness, because of personal, social or cultural views held by the patient. Describe a clinical case where you have observed this. Identify the factors that contributed to these differing views. Why is it important to understand these differences in your practice as a foundation doctor? (10 points)

“In my 3rd year I interviewed and examined a patient who had a suspected bronchial carcinoma. The respiratory physicians wanted to investigate further and get a tissue diagnosis via CT guided biopsy. The patient however declined any investigations. His rational was that “he didn’t want anyone sticking needles into his chest.” At the time it was unclear whether this was denial of his illness or acceptance of his condition.

The medical personnel’s agenda, was to get a diagnosis and start treatment. The patient’s agenda, however was to avoid the health care system and continue his daily living. At the time I found it challenging to understand his rational and accept his refusal of treatment.

Sensitivity to patient’s fears is important in maintaining a therapeutic relationship. Counselling and support in such times assists patients in their treatment dilemmas. In this case, it was important to be understanding to ensure the patient’s continuing contact with the chest team. This allowed prompt healthcare interventions throughout his disease sequalae.

As a result of my contact with this patient I am more appreciative of patient’s autonomy. I feel more able to provide a therapeutic relationship free from my own views whatever the circumstances.”

Posted by: Colin | February 27, 2010

One Of My Favourite Poems: If

IF you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don’t deal in lies,
Or being hated, don’t give way to hating,
And yet don’t look too good, nor talk too wise:

IF you can dream – and not make dreams your master;
If you can think – and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same;
If you can bear to hear the truth you’ve spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build ’em up with worn-out tools:

IF you can make one heap of all your winnings
And risk it on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breathe a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: ‘Hold on!’

IF you can talk with crowds and keep your virtue,
‘ Or walk with Kings – nor lose the common touch,
if neither foes nor loving friends can hurt you,
If all men count with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds’ worth of distance run,
Yours is the Earth and everything that’s in it,
And – which is more – you’ll be a Man, my son!”

Posted by: Colin | February 27, 2010

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