Archive for the 'bitching' Category

Don’t worry about a thing

I got this through the post this morning:

IMG_0227

A flyer on screening for cardiovascular disease, where you can turn up and have scans done for “peace of mind” and all that bollocks.

I’ve no idea where they got my name from or why they think a 28 year old is at significant risk of stroke (must be all that cocaine use…)

It got me in a bit of a rage. These things do.

They use unproven, emotional driven language to make money out of people’s anxiety. Surely the fact that they “can see inside your arteries” impresses you?

IMG_0225

Yes it is true that being over 55 increases you risk of stroke – as does obesity, smoking and lack of exercise. But wait they’re all entirely modifiable risk factors, something you don’t have to pay 140 pound for the privilege of.

IMG_0228

My favourite bit of that photo is the fact that i don’t have to remove my clothes. Phew…

These tests are not accurate. Let me emphasise that. All tests have limitations. Some more significant than others. Lots of these tests find false positives. In other words they tell you have the disease when you don’t. When you screen a population with no symptoms (which is what screening does) then by nature you screen a population with a very low prevalence of the disease you are looking for. If you screen the whole population for pneumonia with a chest x-ray only a very small number will have the disease. If you only take a chest x-ray on people with symptoms of pneumonia then you will pick up far more.

When you screen asymptomatic patients then often the number of false positives outweighs the people actually found to have disease.

Which is why screening in the NHS is so controversial.

Some are now well-established – like breast screening for ladies of a certain age and cervical cancer screening for presumed sexually active women (incidentally they presume everyone is sexually active and therefore screen all women over 18, they just don’t phrase it that way).

Screening for prostate cancer has been less successful – all the men complained that just because they don’t have cervices and boobs that they shouldn’t be left out…

The problem with the PSA test for prostate cancer is that it leads to far too many false positives – it leads people to have prostate biopsies that confirm either no cancer or such low-grade cancer that it’s not actually going to be significant (ie you often die with prostate cancer, not because of prostate cancer).

Ask all the people who get false positive PSA tests if it gave them peace of mind.

Tests are not benign things – one trial (and i can’t find the damn reference) looked at the use of x-rays to assess low back pain. People were randomised (ie both groups were the same) to receive either x-ray or nothing. Those who received the x-ray had worse symptoms at 6 weeks. And of course the x-ray revealed nothing useful to help them. Simply by doing the x-ray these patients were worse.

IMG_0226

That is a plain old fib. Most tests are only worth ordering if you have symptoms but there are other tests that are often ordered in populations at risk – for example the screening programmes already mentioned or simple blood pressure measurement.

The goal to identify patients with significant disease before a problem occurs is very noble (even though their real goal is of course to make money) but unfortunately not possible with what they offer. Every now and again a patient or two will benefit – but over all people will not benefit and some even come to harm.

This one was my favourite – it’s not entirely clear if the Will had carotid dopplers done or not but at least they’re happy together…

IMG_0224

And just to finish: Read this if you’re interested and see what you think about peace of mind for the people found to have aneurysms in their brain.

Vernooij, M.W., et al, N Engl J Med 357(18):1821, November 1, 2007

BACKGROUND: Increasing use of MRI of the brain in clinical practice may be associated with increased detection of incidental cerebral findings of uncertain clinical significance.

METHODS: This Dutch study reports on incidental findings on high-resolution noncontrast- enhanced MRI studies of the brain performed in 2000 asymptomatic subjects aged 45-97 (mean, 63.3 years) (52.4% female) participating in a population-based cohort study.

RESULTS: Incidental findings were common, and most often included asymptomatic cerebral infarcts (7.2%), aneurysms (1.8%), and benign primary tumors (1.6%). The most urgent finding was a large chronic but asymptomatic subdural hematoma in a patient with a history of minor head trauma one month prior to participation. A possibly malignant primary tumor was identified in one subject and cerebral metastases in another. Of the 35 aneurysms, 33 were located in the anterior circulation and 32 were smaller than 7mm in diameter (believed to have a low likelihood of rupture). Operative intervention was considered to be indicated in two patients (the patient with the subdural hematoma and a patient with a 12mm aneurysm). Increasing age was associated with an increasing incidence of asymptomatic cerebral infarcts and meningiomas, and a greater median volume of white matter lesions, but not an increasing prevalence of cerebral aneurysms.

Advertisements

Wrapped around your finger

OK so i bought a new condenser mic for recording. At the same time I figured i would but a wee drum key for the church drum kit so that I wouldn’t have to keep using wee Philly’s socket set to tune the toms.

So in the huge box shown below arrived the small (indestructible) metal key. And a lot of styrofoam.

img_0055

img_0054

The (delicate, expensive) mic arrived in a bag with some bubble wrap the next day.

The cost

Blogging while sleep deprived and a bit pissed off makes for good reading I expect but perhaps you say more than you meant to. I imagine this is the type of thing I’ll re tell on a comfy leather couch in about 20 years (or months depending on how it goes…)

The problem with medicine (says he, with finger pointed and all eyes watching the figure with the air of authority as he gets ready to put the world to rights…) is not neccessairily the medico-legal responsibilty.

Say that I cock up and kill someone, or miss something big or whatever – then there is a certain medico-legal responsibility that I have been negligent or incompetent and should (though not always and occasionally too often) face some kind of disciplinary action.

I figure I get paid for that kind of responsibility. That seems to be the way things work in the world, the more responsibility and education and learning you have the more you get paid. Like a top class economy crippling banker – you bring the world as we know it to an end and you still get your golden handshake…

[Although that is probably a tad unfair on the old bankers – no doubt they were unscrupulous and greedy but they were merely in the position to be so. Yes they’re bastards but I’m pretty sure we all are. Anyhow the dodgy millions they made are what paid the taxes that fund the whole NHS and now that their incomes (and tax revenues) are falling then the NHS will suffer. Anyhow it’s all a tad more complicated than a quick “bastards are bankers” “bankers are bastards” joke allows…]

Legal responsibility is one thing. Moral responsibility is a whole other kettle of fish.

You see that’s were the problem lies. I don’t give too much of a stuff about whether I’m legally responsible for a patient – fine sue me, see if i care. What I do care about is my moral responsibilty to the patient in front of me. Yes I am that self-righteously pious. It has taken years of practice believe me…

They turn up with their woes and sicknesses and it is to me they come. And me with my mythical diagnostic and healing powers, foisted upon me by a legacy of TV shows, movies and dishonest doctors, is the one that that has to give them some kind of answer and dare i say it – final solution to the whole mess. (No nazi killing reference intended…)

Do not get me wrong. I am not grumpy and moaning. I am not saying “why can’t you blood sucking parasites leave me alone and sort your own lives out and crawl into a corner and die as you best see fit”.

I enjoy the job. I enjoy that position. It is one of the highest honour and priviledges to face and speak to these people who are part scared, part hopeful, part accepting of what may lie before them.

It is the moral responsibility that I carry around with me. The simple notion that these people need sorted and that in essence is my job.

It is also what keeps me up till 3am worrying about all these little broken, sickly creatures wandering around out there in the community. It is what makes me come home and be grumpy with my house mates and my family. When you see me staring into space and grumpy and  uncommunicative I’ll either be thinking about Da or about all the patients I carry around with me in my head.

Without a doubt this is part of what makes me (i think) good at my job. It is also a large part of what makes me walk across the car park each day swearing inwardly at myself, the patients and the way we serve them.

While trying not to be too melodramatic – oh why the hell not… –  they come to me like ghosts, or apparitions, their faces, their names, their x-rays their CT scans, their veins and arteries and wounds all their weeping, worried relatives.

I have this uncanny knack of remembering every patient I’ve ever seen. Well not everyone but a scarily high proportion. I go in the cubicle and ask have i met them before then i’ll remember – you were in cubicle 4 two and a half years ago and you’d hurt your wrist and there was no fracture on the x-ray. Which is all very impressive till the patient says “oh yes but i came back a week later and the consultant said it was broken…” Which always takes me down a peg or two but I could do with that.

But i remember them all, the things we got right, the things we got wrong. Each one tells me a story.

I’m not entirely sure if all this psychotic craziness is since Da died or not. Certainly watching one of your own go through it makes you painfully aware of how important all this is. But I think I was like this to start with. Only now more so.

I sometimes I think I have a shelf-life, a period of time that I can pull this off for before it all comes crashing down around me and I end up pulling an into the wild and doing private practice as a dermatologist (awww that’s unfair on dermatologists, sorry…). I hope not.

“a man who has no memory has nothing left to hide… nothing and i like it…”

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.

I’m going to stop pretending that I didn’t break your heart

this story gets headline in the BBC Northern Ireland section as if it’s something new when we’ve been on divert as we call it maybe twice a week for the past month and have done it lots and lots of times in the past.

we’re not allowed to put up a “hospital closed” sign or anything but it means that any patients referred by GPs will get sent to other hospitals.

would be interesting to see what would happen if we did just stick up a closed sign. Very little I imagine. Pulling a randon unsubstantiated figure out of the air, I’d say that 90% of those who come through A&E in a day would be still fine (when I say fine I mean not dead – us emergency medicine doctors have a funny definition of “sick”…) the next day if they didn’t come anywhere near us.

That said, we should still be providing a decent servive for that 90% and we’re not. Believe nothing of what hospitals and politicians say about delivering normal high quality service under extreme pressure – we don’t. Let’s stop pretending we do.

Pizza and wine

Just a quick one.

1) my landlord just bought me a bottle of wine when he called for the rent. And he’s not even a patient. I’m so impressed.

2) I’m down with the old man-flu. Finally. The immune system of chmpions finally takes a hit… So i’m eating frozen pizza and watching a DVD, how low i have fallen.

[NB: Does anyone apart from my brother even remember Juiet Turner…]

Thank you for saving me

I got my first bottle of wine off a patient today. Not that I think patient’s should encourage their doctor’s to alcohol or anything, though there could be worse things.

Some people’s office’s and pigeon holes are coming down with thank you cards and pressies from patients – there is a certain speciality bias to that.

People who deliver babies get lots of gifts cause it’s generally a happy event and there’s lots of pressies being bought anyhow.

Surgeon’s get lots cause what they do to the patients is fairly dramatic and occasionally it even works (sorry, no surgeon bashing, sorry…) and you generally see lots of them over a month or two so there’s a certain relationship that develops there.

Anywhere, where you get to develop a relationship with a patient (not in any dodgy “let’s meet for dinner and a movie” type way) then there’ll be opportunities for free stuff.

Unfortunately given the nature of A&E we generally don’t develop too much of a relationship – the majority of what we do is basic management and diagnosis and then referral on for appropriate definitve care. The bit of the job that is truly ours and ours alone is the critically ill and resuscitation. Unfortunately most of our target demographic is nearly dead or technically dead and therefore not big into relationship building.

[Anaesthetists suffer a simiar problem in that they put all their patient’s to sleep and do the cross word till the butcher surgeon is all done.]

So we suffer a somewhat unfortunate lack of biccies and pressies relative the 70000 or so we see a year.

There are exceptions to this. Almost every patient of Gilly’s I review will have “a little something” for Dr Carson. But then he is truly exception as medic, Christian and human being. And he doesn’t even drink the whisky…

5 years I’ve been working now and not one pressie have I got (I once got given 20 quid which I put into the ward fund) – now I’ve got boxes of celebrations dedicated to the ward staff but nothing to me personally. Yes I’m that self-absorbed.

Till today. A young fella who I had blind luck to pick up sarcoid on got me a bottle of vino – even though it was the respiratory team who did all the real work of scopes and scans and biopsies. Seems unfair. But hey I’ll take what I can get –  deserved or not.


About

September 2017
M T W T F S S
« Sep    
 123
45678910
11121314151617
18192021222324
252627282930