Archive for the 'medicine' Category

Medicine as virtue formation

[cross posted from over there…]

Did you see this? Atul Gawande’s speech at commencement at Harvard Medical school a few weeks back.

If you want something to go well with it then read this by David Brooks in the NY Times.

If you want something heavier than that then read this or even this but then it starts getting really dense.

Let me give you a few starters from Gawande:

The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors

His advice:

  • measure where you succeed and fail; become interested in data (see his book Better)
  • develop abilities to provide solutions for systems problems that come from the data (he quotes the check list idea)
  • be able to get colleagues to work like a “pit-crew” for patients; he mentions humility, team work and  discipline
These values are the opposite of autonomy, independency, self-sufficiency.
Which leads me to David Brooks:
If you sample some of the commencement addresses being broadcast on C-Span these days, you see that many graduates are told to: Follow your passion, chart your own course, march to the beat of your own drummer, follow your dreams and find yourself. This is the litany of expressive individualism, which is still the dominant note in American culture.
and my favourite:
Most people don’t form a self and then lead a life. They are called by a problem, and the self is constructed gradually by their calling.
Stanley Hauerwas, who is the major reason I’m studying for a theology masters talks a lot about the practice of medicine as being a much better place for moral formation than seminary. Health care in its very existence is a moral practice that is a bridge between the healthy and sick so that the sick are not alone; that the sick know that they are still part of their community of fellow humans. In order to maintain medicine as a morally significant practice; as a deeply human process, and not descend to become a group of “technicians” requires many of the navigational skills (or as I’d prefer – virtues) that both Brooks and Gawande suggest.
Advertisements

The art of medicine

What do we mean when we invoke the subtle and ever so nebulous “art of medicine”?

Most people consider it an essential skill and part of being a good doctor to be able to correctly apply the art of medicine in the appropriate situation.

When we invoke the art of medicine with either patients or colleagues I think it can mean one of the following:

  • we’re about to do something that the doc who sent them in; the guidelines; the evidence; the protocols, would tell us not to do
  • the evidence tells us to do two different and mutually exclusive things
  • there is no evidence to what we’re about to do
  • we don’t know what’s wrong with the patient and we’ve just made up a diagnosis
  • we’ve got bored and done this

Calling it art is perhaps appropriating more value from the word “art” than is justified. But calling it bullshit wouldn’t go down to well either.

Perhaps for emergency docs it’s more like what Jerry Hoffman means in this talk that the art in medicine (my term not his) is our ability to make decisions in the absence of information.

The willingness to make and act on decisions made in the absence of adequate information requires a certain mixture of 2 things. One perhaps more valuable than the other

  • character; in the big muscular, practised Aristotelian sense
  • balls like a bull on steroids; though I find it odd that making a call as an act of bravado can be considered a positive trait
I confess that in any given moment I’m not entirely sure which of the two facets is at work in any resus room decision I make.

The website all 4 of you have been waiting for

This is my attempt to stay engaged with my vocation while I’m on my “clinical hiatus” as I call it.

Seeing as I have the time and I’m doing the study anyhow I may as well put it out there. Though I suspect it’ll largely be derivative re-posting from LifeInTheFastLane, it’ll keep the medical rants and journal articles on one site and keep those of you who come here for the pictures of the garden and stories about my brother’s dog happy.

I’d be interested if any of the non-medics could suggest a diagnosis for the x-ray on the banner of the new site.

emergencymedicineireland.com

Welcome to the working week

My time here is over for a while. Till September at least and then they’re taking me back for another 8 months for more anatomy teaching. Me teaching them I hope…

I’ll also be moonlighting at this

So between now and then I’m gloriously unemployed.

Well not exactly. I’ll be heading back north to work at my old shop in Craigavon.

I’ve missed the work I must say. The anatomy stuff was/is a lot of fun. You learn a lot and teaching is a lot of fun, but now it’s over I find myself getting a little bit restless and needing a bit of a challenge.

Dealing with patients is good for you. In the way that being amongst people is good for you. People are good for you because it’s hard bloody work. Good, hard, bloody work.

In emergency depts. the work is often literally, good, hard, bloody work.

Stanley tells me that medicine is a moral act. I’m inclined to agree with him. Moral acts require virtue (at least that’s my take from reading the first half of this) and medicine has certainly been morally formational for me.

If patients were people that I just happened to come in contact with, i could go around believing that I owed them no real duty as human beings. It would of course be untrue, but I live like that most of the time.

When I’m in a hospital as a certain professional, there exists a certain covenant (as Paul Ramsey would have termed it), a relationship that is more clearly defined and understood by both parties.

When I talk to patients if I want to practice virtue before them, it requires all kind of moral energy. Patients have a tendency to kick your sinful, selfish little ass and remind you of what it means to love people.

On most days I could do with my ass kicked in such a way.

[The photo above is the famous Vesalius one. Worth reading the link about him. There’s lots of that kind of thing on the display in the Long Room in TCD at the minute, including the skeleton of Cornelius McGrath, borrowed from our “office”. Incidentally, an 8 ft wall mount of the Vesalius hung on the wall of our dissection room, one of the many things we might not have room for in the new building on Pearse St.]

Comfortably Numb

I’m reading the patient as person by Paul Ramsey, trying to get the most out of my access to TCD’s library before they kick me out in April. I found Ramsey through Hauerwas who both praised and gave some serious critique to “patient as person”.

Ramsey speaks very positively about consent. With plenty of good reasons, however i’m not sure I agree with his “canon of loyalty” and joint adventuring (borrowed from Reinhold Niebuhr) as it seems to suggest that as long as it’s consensual then people can commit all kinds of violence against themselves.

With that in mind I was listening to the wonderful Joe Lex in a talk called “who was ringer and did he lactate?” (a medical joke…) where he goes through the history of some of the big names in the history of medicine.

Most amusing was the story of Bier (of the block) and Hildebrandt who were investigating the use of cocaine in spinal anaesthesia, and indeed attempting to inject cocaine into the space surrounding the spinal cord (I’m not sure even the most inventive crack addicts are into this).

Like all good medical stories, they used each other as subjects. First Hildebrandt performed a spinal tap or lumbar puncture (LP) on Bier only to find that the syringe of cocaine didn’t fit the needle and the procedure was abandoned while their friend Luer (of Luer lock fame) came up with the appropriate adaptor.

On their second attempt Bier performed the LP on Hildebrandt with success and attained profound anaesthesia of the lower limbs. Note that Hildebrandt was fully conscious, just couldn’t move or feel his legs

Let me quote

After 7 minutes: Needle pricks in the thigh were felt as pressure; tickling of the soles of the feet was hardly felt

He followed this by sticking needles into the thigh till he hit the femur and then stubbing out cigars on his legs and recording the heat but not pain felt by his friend.

Pulling out pubic hairs was felt in the form of elevation of a skinfold; pulling of chest hair above the nipples caused vivid pain

And to quote a New Scientist article on the experiment

He smashed a heavy iron hammer into Hildebrandt’s shin bone and then, when that failed to have any effect, gave his testicles a sharp tug. In a final burst of enthusiasm, Bier stabbed the thigh right to the bone, squashed hard on a testicle and, for good measure, rained blows on Hildebrandt’s shin with his knuckles.

Following the LP Hildebrandt developed the well-known post-LP headache and had to take the day off work, he never mentioned how sore his legs were, never mind any other unmentionables.

Too young to die

For all the poor people that I quizzed over “what high-risk means” when it comes to heart attacks and strokes…

These guys are great at this type of thing. Highly recommend the podcast if you’re interested.

PROGNOSTIC VALUE OF THE DUKE TREADMILL SCORE FOR EMERGENCY DEPARTMENT PATIENTS WITH CHEST PAIN The Journal of Emergency Medicine, Vol. 39, No. 2, pp. 135–143, 2010

This paper deserves a rant, just for the sake of its ridiculous use of numbers

Most people who come to an Emergency Dept. with chest pain do absolutely fine in the long run

A small number will be having/had a heart attack. we can usually pick up these pretty well.

Some people have chest pain but not heart attack but go on to have a big heart attack over the next few months. These are the tricky ones (and unfortunately there’s a lot of them). They look well, their tests tell us they haven’t had a heart attack but the question is are they at big risk for having one in the next few months.

We have no good test for this. No matter what people might say, we don’t.

Our gold-standard test has become the angiogram, where we use dye and x-rays to look at the lining of arteries to see if they’re narrowed. While useful, it still doesn’t tell us if someone is going to have a heart attack in 2 months.

So in this slightly grey area we have to work out what’s best to do.

There is big, big money in this for someone who can work it out. And we’re already throwing big money at it.

One of the tests that has been around for a while now is the exercise stress test (EST) where we get people to run on a treadmill while we take an ECG to see if we can induce angina. Hardly the most hi-tech but hey…

It certainly is +ve more often if the person is going to have a heart attack in the next 30 days, but it’s not good enough for us to make a decision on. If all the test gives us is enough info to guess, then maybe we’re just better guessing without the test – in other words clinical judgement.

This paper took 170 of the kind of patients we’re interested in. In the ED with chest pain and an ECG that doesn’t make a decision for us and a troponin that tells us they haven’t had a heart attack.

They all got an EST and they used the Duke scoring system to stratify them low, medium and high risk.

They followed them (not in a creepy way) for 30 days to see if they had an adverse event.

And this is where it gets a bit dubious. I care about whether the patient dies or has a heart attack in the next 30 days. And they measured that, but they also measured if people got an angiogram and 1) that’s not really an adverse event in the same sense, and 2) it’s a bit subjectve; someone has to decide to do the angio, it’s not like it just happens spontaneously as part of the natural history of the disease

So this skews all their figures. They found a 3.5% adverse event rate and guess what – it was largely made of angios. Only 2 people had an MI in the next 30 days.

Especially seeing as most of the angios occurred while the patient was in hospital not when they were rushed back in a week later

With such a low adverse event rate it makes a farce of going on to calculate sensitivity and specificity, which they do anyhow.

Even more farcical is the dreaded -ve predictive value. Very basically this is the percentage chance after the test that nothing bad will happen to the patient.

They calculate it as 99.2%.

Which is nonsense. In their cohort if you simply sent them all home without the EST the percentage chance of them not having a heart attack in the next 30 days would have been 98.8%

Beware the -ve predictive value

They conclude wonderful things about their results and suggest that the EST is useful.

Did I mention that it was sponsored by a medical diagnostics company…

 


About

November 2017
M T W T F S S
« Sep    
 12345
6789101112
13141516171819
20212223242526
27282930