Archive for January, 2009

Going nuclear

“the church’s mission began as the radioactive fallout from an explosion of joy…”

Leslie newbigin
The gospel in a pluralist society

Be good or be gone

I never thought I would be one to get particularly excited about medical politics. But you get older and more frustrated with the system and dare I say it actually more idealistic.

Medical training is one of  many personal bug bears.

I got into medical school on the basis of grades and a UCAS form alone. No one spoke to me and asked me questions as to whether my personality and character and all the rest was in any way amenable to it.

I have said this before about medicine. You do not need to be smart to do this job. You need to be smart enough (echoes of outliers there…), but overall it’s not quantum physics or maths or anything truly requiring smarts.

The vast majority of what i do is talking to people and good old fashioned hard work. Grades are no reflection of this. As grades for entry to medical school continue to rise – in order to find some way of differentiating the thousands of candidates – then more and more we are producing legions of bookish docs with smarts coming out their arse but who couldn’t talk their way out of a paper bag. I’m not suggesting a better system. Just saying the one we have sucks…

I worked out in the first term of medical school that i could pass exams with little work and proceeded to spend five years getting solid below average marks. And no one pulled me up and said you should have done better.

I came out of medical school with just enough knowledge not to kill someone. And no idea how to make them better.

I have spent the past 5 years studying and learning all the things i think i should have learnt in medical school. Medical School was largely a waste of time in my case.

Hopefully that concerns you some what.

Over the past 5 years there have been significant changes in both under graduate and post graduate medical education. Not that they were perfect before but I’m pretty sure they’re a bit shit now.

Most will have heard the MTAS fiasco that made headlines a few years ago. That and the lost tribe of junior docs with few options for further training.

There as been a bit of an obsession in medical education on competencies and juniors being signed off as fit to manage and perform certain skills, procedures and conditions. No mention of them being good at it. Just as long as they’re competent.

Which brings me to this month’s EMJ editorial (yes i read a journal called the emergecny medicine journal. I’m comfortable with that. There’s a journal simply called “gut” for gasrtoenterologists…)  where someone sensible has piped up and said that maybe competencies aren’t all they’re cracked up to be and perhaps someone with all the competencies in the book mightn’t be quite what they’re cracked up to be.

Maybe i just like the cynicsm cause i’m one of the lost tribe in effectively a dead end job who in the grand scheme of things hasn’t so much as a single competency signed off.

Don’t steal our sun

Ireland kicks ass. On a sunny day that is.

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Radio Cure

Most of you will have realised by now that i am a bit of a nerd when it comes to… well everything. I am definitely a nerd when it comes to medicine. I like monitors and ultrasound machines and technology in any aspect.

And so I’ve kind of got into medical podacsting in a way. As if i don’t spend long enough in work or studying or reading uptodate i also subscribe to a number of medical podcasts.

I got into podcasts mainly through lectures and sermons on theology that I could listen to while driving round New Zealand and fed up listening to Pedro the Lion for once.

I then managed to find the wonderful Surgery ICU rounds which keeps me amused endlessly even if it is just the guy’s kids screaming in the background. It also reinforces to me that whatever faults the American health care system has, they do seem to train their doctors bloody well – there aren’t too many plastic surgeons in the UK who know their pharmacology and physiology well enough to run an ICU as well as do what many would call the main part of their job – surgery. Or maybe i’m being harsh on the surgeons in this country.

Between that and my time in the ICU in NZ and the most wonderful Bad Science and How to read a paper I’ve become a bit of an evidence based medicine junkie. This is sad i know but comforting and satisfying none the less.

I recently discovered EMRAP TV which is worth watching even for the non-medics – it seems to be bunch of Emergency Medicine docs in California led by someone who vaguely reminds me of Foy Vance who make bad jokes (well most of them) and talk about complicated medical things while taking the piss out of everything in sight. It’s an odd show.

The American College of Emergency Physicians publish their own podcast with endless comments about how if you kill anyone on their advice then it’s not their fault. Interestingly the manuscripts seem to be read by professinal voice over people with cool voices and dubious pronounciations.

The other one i follow pretty closely is one from Albany Medical centre. Who appear to have regular Grand Rounds where they have lectures and teaching for their staff, so that they’re continuing to learn and keep up with what’s happening in medicine. What a novel idea…

Though they must live in a different world, imagine taking all the docs off the floor for a few hours a week in A&E. Wouldn’t be a good plan. All the other specialities do it and it turns out all their patients survive without them and have to wait till their finished.  Not so in A&E where the painful toe for seven years has to be seen and sorted in 4 hours – Everything is an emergency it seems… Right. Stop ranting andrew…

They seem to podcast every week, lectures on everything from interpersonal violence to coding and documentation in the ED.

And as ridiculous as it sounds it was the lecture on coding and documentation that really caught my ear (?).

People in America get sick the same way they do in Ireland. The difference is when they get sick here, they turn up at their GP or A&E or wherever and they just say their name and address and get sick and they get literally thousands pounds of care and they go home and get on with their life and think no more about the cost.

In America, you get thousands (and often thousands more) of pounds of care and everything is written down and recorded and you get a nice big bill at the end of the day and someone has to pay for it. The sheer scale of the billing and charging process is simply mind-boggling.

Driving back from Portstewart listening to this guy lecturing the residents on how to fill the charts properly to make sure that they actually get paid for the work they do, and at the same time warning them all against fraudulently claiming care they’ve not actually provided.

I find it hard enough simply looking after the patients I see, never mind thinking about the endless reams of paper work and charging aspects of it. Never have i been so glad to be in the chaotic mess of the NHS. How i love you so…

So next time you see me in the car, you’ll realise I’m rocking out to life-threatining dermatoses…

Sweet soul music

I was never into classical music. It was all dead guys and bow ties and harpsichords. In my ignorance I claimed that classical music, while technically proficient lacked soul. As if somehow skinny guys with guitars had the market sewn up on that one.

Sigh.

I was raised on Simon & Garfunkel, though mainly Simon with a bit of Bright Eyes (no not that one…) thrown in for good measure, long with Abba, Neil Diamond, The Beatles and Buddy Holly. I figure that’s not bad for growing up in the eighties. I give thanks for my parents music taste.

My lasting memory of classical music is off the old Hamlet ads. That and a brief flirtation with some complication album that had some Elgar in it that taught me all new levels of melancholy – I was 16 that was what I lived for at the time it seemed.

I think the main problem I had with classical music is my ignorance. I mean you can’t just look at the titles cause they’re all numbered numerically. You’ve no idea what they’re about really except what number they are and what key they’re in.

And I miss lyrics. I miss lovely little self-deprecating bridges and resolving choruses and shouty backing vocals. I have no point of reference with classical music.

Though I am perhaps learning.

Thanks to the wonders of Spotify (via the office) I can now get any music I want streamed online – I can hook you up with an invite if you’re interested… With my level of ignorance I can simply type Classical music and be presented with reams of the stuff in all it’s “western European dead guy in a wig” glory.

Now there are strict rules for when you play it. The house will be empty, and tidied, and I will have a clear agenda ahead of me, largely involving coffee and books. It is also good to revise to. It is even good for lying down on the sofa and simply plain listening to. Which is something I do far too rarely and too often use music as a literal soundtrack to whatever else I’m doing with my life.

Anyhow the dead guys rock. Someone get me my harpsichord.

You only live once

[Inspired by a lovely little article here]

Something me and CW and Skeeno were chatting about over dinner a few weeks ago. What defines health? What is the state of health that we are aiming to acheive? Is there such a thing as ideal health?

Me and CW are fairly passionate about what we do, more so as time goes on it seems. Medics don’t often talk about this in work situations – at least that seems to be what I find. Most seem pretty focused either on the shift at hand or more depressingly their careers. It is not that often I chat to a doc about the fundamental aspects of what we do everyday. I do this more everyday. Maybe this just reflects how much I’m frustrated with my job. Who knows.

Anyhow. Back to definitions of health. This will naturally have cross over with a slightly larger question – what’s the definition and point of life itself? What are we aiming towards and why do we do any of it? This is a huge topic and I suppose I’d prefer to avoid the wider picture and focus on the health aspect.

Back in medical school we had all these nonsense lectures that I never went to that were titled “the man in society” (how did they git away with “man in society” in the early noughties, surely it shoul have been “the person in society” given how PC they were) which were largely about the sociology behind medicine. Despite either hating or missing or dismissing all those lectures as touchy feely nonsense I have to confess that in retrospect they were all true.

The concept of health is undeniably holistic. Which is of course a fashionable word. I tend to describe such concepts as making the remarkably obvious exceptionally complicated.

People are not so easily defined as pathologies. Doctors study and treat pathologies and occasionally we make some impact on those pathologies – though I would stress how occasional that is.

Patients have lives and relationships and desires and hopes and ambitions and fears despite their ejection fraction of 15% or their incipient renal failure.

I spent a good 5 minutes the other day encouraging an 80 year old to keep smoking. What’s it going to do? Kill him?

If you’re 80 and mobile and continent and conscious you’re doing pretty well. You’ll be dead within 10 years. Why stop what you do everyday and enjoy.

Any healthcare decision or intervention is a balance of pros and cons. Of you’re thirty with two young kids and a bad family history of heart attacks then I’d happily spend as much time as needed persuading you to stop smoking – presuming of course that you think seeing your kids grow up and develop as something that is vital to you. As a paternalistic and well educated medical professional I have decided that what you’ll miss and find hard about not smoking is nothing compared to the joy of bouncing your first grandchild on your knee.

Trust me I’m a doctor.

Health is more complicated than cholesterol levels and life expectancy. Our patients need and want us to advocate for their health. Maybe we should ask them what that means occasionally.

I know what I know

Hotels are like a bit of a different world. These little boxes of isolation around the world. Where all manner of indiscretions, infidelities and illegality appear to take place (I’ve seen movies, I’ve seen what happens).

Not that these things ever seem to happen when I go to hotels, no one dies, police never charge down the door looking for drug dealers. Such is life.

Instead I sit around fantasizing about ordering a room service sandwich at 4am and unwrapping all the little miniature bars of soap. Endlessly satisfying.

My personal bug bear is the little sachets of instant coffee. Yes it’s all well and good having a kettle and a few cups but what’s the use if it’s some shitty instant coffee stuff. I despair.

Every hotel you go to you’ll find a nice copy of a Gideon bible in one drawer of the bedside cabinet (something I always remember when travelling so i don’t need to bring me own…) yet in this place you’ll find the Gideon’s in one bedside cabinet and a guide to Buddhism in the other one. It’s a double room so there’s a big double bed with two bedside cabinets. Maybe the husband and wife go to bed convinced Muslims and wake up the next morning a different religion. Neat idea really. If I get a chance I’ll expound a bit on the guide to Buddhism. I’m an ulsterman – I’m nothing if not ignorant.

I’m back in a hotel cause I’m down in Dublin for the (hopefully) third and final part of my membership of the college of emergency medicine (we’re not a royal college yet, we’re too much of a baby speciality in the world of medicine yet) – which if I pass it will give me the privilege of spending 2 or 3 hundred pounds a year to be a member of said college. I’m not sure what else I get for it. Well I suppose I get a few more letters after my name making me the esteemed and confused Nelly And I MB BCh BaO MCEM 5M SwIM bADGe… Da would be proud.

To become a member of the college of emergency medicine (and I know you’re both gagging to…) you have to undergo a series of trials each more fiendish than the next, solving puzzles and surviving death defying trials… OK well maybe not…

It comes in three parts, the first is multiple choice (or multiple guess depending on your level of knowledge). I passed this first time with a comfortable margin of 1%.

Part B is a nice little short note style question format. Thankfully, and surprisingly based on real-life situations that you might encounter everyday in work. This is unlike some exam situations when you’re given the case of the 98 year old pregnant lady with sickle cell trait who is also Jehovah Witness and was born with no kidneys, one lung and two heads, who presents with a ruptured aortic abdominal aneurysm who is too drowsy to consent to surgery and blood transfusion…

Part B was fine. I passed it despite thrombolysing the pregnant lady with the large inferolateral MI. Yes, I hear you cry, of course she should have undergone primary PCI and screw the radiation effects on a third trimester foetus. Next time I see a pregnant lady with an inferolateral MI I’ll do better, honest…

Part C is somewhat like your driving test. I’m sure you remember,  deep in the midst of time the concept of mirror, signal, manoeuvre. Though I suspect it is now text, change the track on the ipod, manoeuvre…

There are lots of things that you read in medical textbooks and read in medical books that you neither see nor do in real life. I haven’t done tactile vocal fremitus on a patient for a long time. largely since the invention of this new and fancy chest x-ray thingy. It’s great. Who knows what they’ll come up with next.

So now that it’s an exam I’m expected to go back to do all the things I learnt (well what I was supposed to learn instead of playing footy, reading CS Lewis and dreaming about pretty girls) in medical school. Though largely, useless it has at least finally given me a decent understanding and performance at a neurological examination. This has been a pleasant surprise.

I expect to fail it despite the time I’ve spent perfecting my instrument suturing technique on my grey fleece in the hotel room. Though I might get lucky.

Anyhow. Studying done. I can run through my planned cranial nerve examination in a neat mnemonic in less than 30 seconds. I am ready to nail this sucker. I say that now.

I tried the pub next door to study in (you doubt me but pubs and indie music are great study aids i find…) , which was empty and horrible and flitted between Joy Division and Enrique Iglesias and both so loud that i couldn’t drown it out with astral weeks, no matter how hard I tried. I abandoned it for the hotel lobby which is at least quiet though doesn’t appear to stock any salt and vinegar crisps.

Buddha and bed methinks.


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January 2009
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