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.

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…

 

Pay for what you get

If you’ve talked to me then you’ll reaise that i’m not a big fan of private health insurance.

It seems like a money-making scam for the middle-classes to feel safe from tabloid-esque medical bungling

[medical-bungling happens, i’m just not sure private insurance stops it]

This Irish Times article covers a few of the issues of ireland’s private health care situation. I’ve been quoted greater than 50% for the number of Irish people with some form of private insurance.

I’ve not worked in the Irish health care system, given some of the stories you hear from people it sounds like it may be non-existent.

Perhaps it is a place were people are dying in droves without life-saving treatments, though I somewhat doubt it. A lot of the stories I hear about people being badly treated involved them not getting treatments that don’t work anyhow, or being denied tests that they didn’t or shouldn’t have had in the first place.

There are of course all kinds of nuances and subtelties in there, and there of course lots of medical cock-ups in there too.

But the interesting point that the article raised for me was what would happen if everyone ditched their private health insurance en masse?

Naturally there’d be a few less boob jobs and a few less parental tonsillectomies (the parents just really want the child to have the tonsillectomy…) and that perhaps be no bad thing.

But then there’d be all the important stuff that really needs done, but just gets done quicker in the private system. Who would pay to pick up the slack? Could the slack even be taken up in the system as it stands?

It seems that if the Irish people all chucked in their private health insurance then the public health system would collapse under the weight.

I find that kind of scary.

Understanding salesmen

If the New England Journal of medicine turn me down I might try the Journal of Silly and Unreproducible results
Introduction
Primary prevention forms a large part of a primary care physicians work load. Numerous guidleines exist to manage high cholesterol, high blood pressure etc. Many physicians are paid by results of such targets or at least by monitoring these markers as indicators of “performance”
Risk calculators use this data to provide a risk estimate of outcomes such as heart attack or stroke over a 10 year period
These calculators typically place paients int one of three risk categories high medium or low
Little evidence exists as to whether patients have the foggiest what we mean when we tell them thy are high risk and pack them off to the pharmacy with a script for an unpronounceable pharmaceutical
Methods
We (by which I mean me) conducted a survey (n= about 10 or so…) where individuals were asked “if a doctor told you you had a high risk of MI in the next ten tears what percentage would you attribute to this?”
Inclusion criteria included bored medical students in anatomy practical, mildly intoxicated people at a fancy dress party and hosts of a dinner party and my brother’s dog lily
Exclusion criteria included those who already knew the answer and  those who could escape quickly enough to the bar before I got to them.
Results
There was 100% response rate though Lily had to be educated in the concept of numbers, self- awareness and the English language
Everyone in the study replied with a figure of between 70 and 90%
Using worst case scenarios in this calculator (selected from the top of a Google search) the highest risk was 30%
Discussion
Typical risk scores often generate a percentage of <30% for 10 year cardiovascular risk for those considered at “high-risk”. This high-risk category begins at 20%
Our (by which I mean mine) results show that there is a disconnect between what we as health care professionals mean by the term high risk
This reinforces the need to do the unthinkable and actually talk to our patients about what this actually might mean
Further research is needed in order to keep us so busy that we don’t actually find ourselves in the position of actually having to talk to the patients
Competing interests
I received no funding for this study but did find it passed an amusing half an hour on the train to Dublin on a monday morning
No individuals revived remuneration for participaing in the study though Lily received a munchie roll

Farewell to the pressure kids

Ray Moynihan writes in the BMJ on the epidemic of pre-hypertension. At it’s simplest this is best described as a pre-disease. Your blood pressure isn’t high yet but it’s on the upper level of normal.

You don’t have to look far to see whose interest such a category might serve.

Until now the definition of what constitues a condition or pre-condition, and the guidelines for treating it, have been left largely to senior members of the medical profession and their esteemed societies, often meeting in drug-company sponsored forums like the coming Vienna conference. But for people like Professor Furberg, the profession has become too close to industry. He wonders whether it may time for society at large to take more of a role in deciding who should be classified as sick.

Note to self: Don’t die

[If you’ve sat and talked to me lately you’ll realise that this has been floating round my head for a while. Time to fumble with the words for it.]
I spend a lot of time thinking about medicine. Sometimes I think I’d prefer to spend my time thinking about medicine than practising it.
My thinking about medicine has changed fairly significantly since I started on this 11 years ago.
I entered medical school as a naive enthusiastic teenager doing medicine because I didn’t have any better ideas.
I spent 5 years pissing about, playing footy, music and mario-kart and enjoyed it thoroughly and learnt nothing.
I started work as an only slightly less naive 23 year old and made lots of mistakes and had my eyes opened to the ravages of disease that run rampant through these fragile, scared human beings.
I learnt the techniques and the lingo and threw all that tehnology had to throw at people often because it was easier to do something than stop and talk and think.
And then I moved to NZ and had an ocean of space and time to learn, think and work with some cool people and it started to have a big impact on what I thought about it.
I saw people declared brain dead and their organs removed and lives saved because of it. I watched many people pass from life to death. I had patients I really, really liked die on me just a few months after we’d busted a gut (sometimes literally) to get them better.
I spoke to endless relatives, I perfected my sympathetic active listening. I told lots of people their loved ones were dead.
I came home and dad got sick and I experinced most of the above from a relatives point of view. He always said “why not me?”
Dad died.
I went back to work a slightly different doctor. I wept a lot easier. I got incredibly angry at some of the regular stresses, discomforts and humiliation that we put patients through on a regular basis.
I got good at my job. I’m pehaps not the person to ask but I think I got pretty good at it.
And all through this I thought and read. Vonnegut,  Hauerwas, Marilynne Robinson, Wendell Berry . I listened to lots of podcasts on evidence based medicine and came away thinking that even the “evidence” doesn’t support most of the silly things we do. At least not in a way that the people we do the things to would care about if we told them the truth.
I got married. I quit work and the space between changed me again.
Let me try to summarise where I stand and I’ll see if I can unpack it later over a few posts:
  • In modern (for the sake of this I mean the past 50/60 years, though it is more apparent recently) society we believe in a certain sense of entitlement – an entitlement to our four score years and ten. Pensions, retirement, leisure time have all contributed to it, but I beleive modern medicine is the most powerful driving force behind this idea that all human beings have a right to 80 years of health and die peacefully in their sleep
  • as a result  we are unsure of what to make of it and feel no way of understanding our own deaths or those of others in the context of the narratives we identify with in many other aspects of our lives. To try and simplify – we let medicine tell us who we are, how we should live and how we should die.
  • we attribute to modern medicine power and glory because we believe it deserves it. Doctors are happy to show us how wonderful they are and we are keen to believe their story.
  • those with faith convictions often appear as scared and confused by early death as non-believers. People who believe in the sovereignty and goodness of God often seem to find their hope in medicine than God. Or put it this way – God will do fine if medicine doesn’t work.
  • In allowing modern medicine such significance and power in our lives and society (sometimes with better reasons than others) we do violence to our own and others humanity
  • as cynical and critical as I am of big pharma I also believe that doctors (often the most powerul lobby amongst health professionals) are key to this.
  • having said that I believe that the medical-industrial-complex is only so because we want it that way. We want to believe the narrative we’re being sold.
I’m not about to quit the profession or anything – I love the job, in fact I feel more than ever the weight and importance of the job and our relation to how we define health and health care.
It does affect me personally though. Whether I like it or not, part of my identity is linked to this. This affects who I am.
These are just some things that have been going through my head. If anyone has any thoughts of how I could develop this a bit further – in the context of books or even how I could study this in an academic setting then I’d love to hear from you.

So nice so smart

Back in the day when I used to hang out with real live people and tell them their chest pain wasn’t anything serious, little old rears used to tell me “you’ll go far young man, you’ve a lovely way with you”.

After I’d disconnected their nitrous and stopped their morphine I would make this joke, asking them “which would you prefer a nice doctor or a good one”.

I used to be suspicious that the two were mutually exclusive but I’d much prefer a humble doctor to both.

God, medicine and suffering

Myself and a friend are hosting a Forum in our church in a few weeks looking at the topic “playing God in the end of life”. We’ll be talking largely about ethical issues regarding end of life in regards to modern medicine.

Thinking about this scares me. When I think of its importance to those dying and bereaved, I see it contrasted with so much of what we do as doctors. I am increasingly coming to the opinion that we are losing our way in our aims and goals in medicine. The responsibility for this lies with both society and the medical establishment.

As usual it appears that someone else has thought these thoughts much better before I did.

In God, medicine and suffering, Hauerwas talks a lot about how we talk and act around suffering and what we have come to believe – both as a society and a church.

It’s a dangerous book to read as a medic, it just might change how you look at what you do. Books are like that. Christianity is like that.

I’ll leave you a few quotes to mull over as I continue to do so. No doubt you’ll hear more on this.

Sickness is a problem because it challenges our most precious and profound belief that humanity as in fact become a god.

and

I think childhood suffering bothers us so deeply because we assume that children lack a life story which potentially gives their illness some meaning.

and

Our medical technologies have outrun the spiritual resources of our society, which lacks all sense of how life might properly end.

Thinking about this is no abstract theological exercise. Hauerwas contends that that is the whole problem with how people talk about the problem of evil – they fabricate an abstract god and abstract suffering to puzzle the brain.

The God we worship and the Bible we read talks about it and struggles with it. We have actual people, actual suffering, actual incarnation. It forms a very different question.

Kevin spoke really lucidly on this a few weeks ago while I was in the midst of reading the book.

Anyhow. My contention is that we are more interested in curing rather than caring. Even if curing will often one of the best ways to care we far too often start at the wrong place.

I don’t need no doctor

Doctors like illness. They like diagnosing and managing it even if they don’t fix it. It’s a puzzle to be be played with and solved.

I suspect the fact that the illness is attached to a patient is being increasingly forgotten or pushed aside in the pursuit of the illness.

We would learn more how best to serve our patients by reading more novels than textbooks.

We have lost our way in caring and our “success” in medicine has led us to pursue curing instead.

There are terribly dull courses in medical schools taught by sociologists who try to address the ideas of humanity with terms such as “the biopsychosocial model of health”. This seems to be the art of making the incredibly obvious increasingly complicated and interminably dull.

Having said this I believe we are raising a generation of doctors with great knowledge and decision making but with barely a trace of humanity, and I believe this is happening because we train children to be doctors.

Or maybe they are more fairly called adolescents more interested in drinking, parties and fucking than they are in understanding what they are entering into.

The patients that they deal with come from a world that they have no comprehension of – one filled with fear, pain suffering and loss. This is a world that they will come to understand in their own lives but by careers and personalities they will defend themselves from it till it can no longer be avoided. Many patients will pass through their hands before then.

I know this because I was that child training to be a doctor. I still am in many ways.

Two of my best friends trained as doctors in their mid/late twenties with a degree and some life and some pain and comprehension of beauty behind them. I am immensely proud of them for the way they have approached it and the humanity and understanding that they so clearly bring.

I’m not sure what the answer is to this (though a fundamental re-understanding both by society and the medical profession about what medicine is and should be would help…)  but I wonder if graduate entry would make an impact.

The beginning stages of…

[Brief note – this is not intended as any kind of commentary or criticism about the hugely controversial and emotive issue surrounding beginning of life issues. If I seem flippant it is not my intention]

In preparation for the new job I’ve been doing a bit of reading. I’ve even covered the most feared of subjects – molecular biology. Remarkable what your brain can learn only to forget entirely, and how quickly it comes back when you read it again.

I’ve also covered some embryology which I find one of the more mind-boggingly amazing parts of our existence. Sure all kinds of mammals do embryology they just don’t grow up and study it and reflect upon it.

In work (Emergency medicine – my real work as I call it) we see lots of concerned young women who are in the really early stages of pregnancy (say 6-8 weeks) who turn up with some tummy pain and a bit of bleeding (say less than a period). They’re all concerned that they’re having a miscarriage. Which indeed many of them are. Once I’ve satisfied myself it’s not an etopic pregnancy – which is what will kill them if I miss it – they generally go home with some follow up with the gynae folk. Some of these women will go on to miscarry (though certainly not all) and I tell them this and explain that 20% of early pregnancies miscarry and 95% go on to have a normal pregnancy in the next couple of years.

But in reading about the staggeringly tiny collections of cells that go on to be embryos and foetuses and babies and toddlers and all the varied parts of our humanity – I was thinking surely lots of these pregnancies/conceptions never make it to a missed period (the usual reason people do the pregnancy test in the first place).

This study looked at just that (back when I was already 7 years past the most risky part of my life) measuring pregnancy tests daily on women who were trying to get pregnant (however you do that… I’ll ask Wylie…).

They found lots of sub-clinical pregnancies (enough to cause a big HCG rise – ie implantation – but failing before anyone missed a period) that mis-carried before anyone thought they were pregant. Overall 30% miscarried and 70% of these were before anyone thought they were pregnant.

When combined with another study it’s estimated that 50% of conceptions do not result in a live birth. This surprised me – I imagine because this is one of the things that I was told in medical school but wasn’t paying attention at the time. On reflection that was probably most of the time.

So maybe it is possible to be a little bit pregnant after all.

Timestretched

I was back in work on Saturday for another shift and some time on-call.

It was lovely actually, which always surprises me. Good bunch of new docs and it wasn’t as crazy as it often was. I came away having made a lot less of the compromises that I normally have to make that make me hate the job.

Our esteemed leadership had put this up in the tea room:

Many of you will be aware from this blog and general knowledge that we have a target of 4 hours from when the patient arrives at the ED until they are disposed of (an appropriate term for a target that dehumanises patients that much) at either admission to a ward or discharge.

We have lots of patients who breach on a marginal basis eg they get admitted at 4hrs 2mins or something like that.

So in their wisdom and cunning the powers that be have decided that telling us the target has changed to 3 hrs 30 mins will help cut out these marginal breaches.

The target of course has not changed (for now). Surely they must know that we know that. Though perhaps the fact this poster exists at all is a testament to how stupid they must think we are.

Incidentally i think it’s a great thing that patients should wait less than 4 hours in the ED but not because of a target, simply because it’s the right thing to do. I bust my ass in work to see patients in less than 4 hours, not because of a target but because it is the right thing to do.

And yes I am a better person than you.

Note to self: Don’t die

Atul Gawande is an endocrine surgeon in North American who has a good way with words. For a doctor at least.

His two books – Complications and Better are a wonderful inspiration for someone who genuinely cares about how the job is done (as an aside if you were a dermatologist with similar passions you could never get the stories to make the books interesting. That seems unfair). His call to audit our practice – to measure something got me all excited about audit and research.

He made news headlines (with lots of other folk) with the surgical safety checklist. A mixture of almost comedic routine and common sense that should help stop the surgeon leaving his car keys in your abdomen.

He writes regularly in the New Yorker and this piece about end-of-life care caught my eye. Both morally and personally I have an interest in this.

On the inability of medicine to consistently “save lives”

We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

The USA spends a colossal amount on people in the last 6 months of their lives. This would be great if it helped them but it’s not clear it does. The following comment belies the different attitude between the UK and the USA on ICU admission. I worked in ICU for a over a year and we were deliberately choosy about who we would bring to intensive care – partly a resource issue but largely because we put people through horrible things in ICU and for a lot of people it simply won’t work. In the US it seems as if ICU is a frequent option for those who might be allowed to pass on without a tube in their throats in the UK.

I spoke to Dr. Gregory Thompson, a critical-care specialist at Gundersen Lutheran Hospital, while he was on I.C.U. duty one recent evening, and he ran through his list of patients with me. In most respects, the patients were like those found in any I.C.U.—terribly sick and living through the most perilous days of their lives. There was a young woman with multiple organ failure from a devastating case of pneumonia, a man in his mid-sixties with a ruptured colon that had caused a rampaging infection and a heart attack. Yet these patients were completely different from those in other I.C.U.s I’d seen: none had a terminal disease; none battled the final stages of metastatic cancer or untreatable heart failure or dementia.

I find the article interesting as it’s one of the few articles that talks about how we deal with dying in the terminally ill as opposed to how we bring about death in the terminally ill.

Gawande nails the underlying issue that both the medical profession and society needs to learn:

But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.
The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.
This is what I think what medicine is here to do (primairily and given here without thinking out all the implications) our role – is to relieve suffering in whatever form we find it.

Crawling with idiots

Following on from this in the BMJ

People like me are crippling the NHS, sucking money from it like leech. Honestly.

I have abandoned my secure pension and holiday priviledges and study leave to become a mercenary.

For those who don’t know what a locum doctor is, it’s kind of similar to a substitute teacher.

Someone on the regular staff is sick or on a course or not present for any number of reasons so we need someone to cover.

Sometimes this gap in the staffing can be filled by other people in the department. frequently the gap is left unfilled and everyone just has to work harder. (or simply the patients wait longer, it’s not like people were sitting twiddling their fingers…)

If the hole in staffing is big enough then we try to get a locum doctor in.

Lots of different types of doctors make up locums.

1) people already in the same department who are looking some overtime – these folk are probably the best to get as they know how the department runs inside out and they have a certain loyalty or commitment to the job already so they often really make the effort

2) people from different specialties/departments who want to keep their experience broad and earn a bit of extra cash – this can range from GPs wanting a bit of hospital experience to guys who are now into specialty training but who did a bit of emergency medicine at some point and are able to work at a lower level in emergency medicine

3) people on time out in a research or academic job who are looking to keep up their skills and supplement their income – these guys tend to be enthusiastic and motivated (motivated enough to do research for a bit!) – this is the category I currently fall into. I’m also working in my old ED (emergency department) so i feel extra wonderful…

4) locum agency staff – often we know very little about who these guys are. Often the locum agencies don’t know. This can range from highly qualified and motivated individuals to guys who have a medical qualification form somewhere but have never managed to obtain an NHS job. Language skills are highly variable and knowledge of both how the NHS works and how the department works is sometimes sorely lacking.

[GP locums and consultant and long-term locums are a slightly different kettle of fish, I mainly refer to middle-grade and junior-grade doctors]

We are also using an ever increasing number of locum doctors. There are lots of reasons for that. I agree part of the blame falls at the feet of EWTD and MMC but there are simply greater demands and expectations on the services we provide. The change in the visa rules leading to a greater restriction in how non-EU doctors work in the UK has also left us short staffed (roughly half of doctors in the UK trained overseas).

The EU regulations that allow free movement and recognition of medical registration means that regulation of EU doctors is to a certain degree out of the hands of the GMC. The best example being this doctor who has been struck off the UK medical registrar but is allowed to freely practice in Germany.

In our department there are two big gaps in staffing. The looming (come change-over in August) gap is that of juniors. No one, it seems, wants to do emergency medicine in Northern Ireland. The training jobs were massively undersubscribed leading the NI deanery to take a trip to India on a recruitment drive.

The junior staff see a large number of our 78000 patients. Will be interesting to see how many juniors we get.

The other main staffing issue is the middle-grade rota. This consists of people who are further on in their training (registrars) but not yet consultants and staff grade doctors (or speciality doctors as we’re called these days). Staff grades are doctors with experience in their specialty, able to work without supervision but haven’t (for any number of reasons) done consultant training.

I’m pretty convinced that middle-grades in our department see the majority of patients (though I’d love solid numbers to back that up). The business of seeing the patients and getting the waiting room emptied and supervising the juniors largely falls to us. Naturally I think we’re the most important part of the department…

[NB the consultants are hardly ornaments in the department but a lot of their day to day job isn’t seeing patient after patient, nor do i think it should be]

We have funding for 8 middle-grade doctors. We had 5 up until I quit in June and now they have 4. To my knowledge the gap is being made up by locums (a group that I now form a part of!).

If we had a fully and consistently staffed rota I think the place would run pretty well but the problem is we can’t fill the posts. No one wants to do non-training middle-grade jobs. Quite frankly it’s too much work for not enough reward (either career or financial) for most people. ED jobs are really tough. Without doubt the toughest of all the jobs I’ve ever worked.

So we will become increasingly dependent on locums and will pay these staff often up to 4 times what the permanent staff are getting. Despite the fact that some of the locums we are paying for this are of dubious value for money to say the least.

I will get (in my opinion) extremely well paid for the few locum shifts I do this summer, in a place I love to work in. But the more the NHS employs locums like me the less likely it will be able to afford the contented and permanent staff it needs.

Take the money and run

Lots of drugs have two names. one short and catchy and marketable and the other long and difficult to pronounce.
For example Tamiflu/Oseltamivir – the names that caught the head lines in 2009. It took me a few weeks to get fluent with oseltamavir whereas just tamiflu rolled off the tongue (and flew off Roche’s shelves and into government stockpiles). Even the name Tamiflu implies its role – it’s a drug that cures flu right?
Drug companies put millions, sometimes billions into development of a new drug and subsequently they get a patent on it. So for the first 15 years (or so) they have exclusive rights to the chemical and can charge effectively what they want for it.
This explains the huge pressure to prove that new is better. That crappy old paracetamol just isn’t up to the job, we need new drugs, and the new drugs are always better.
I’m glad we put people to sleep with propofol and not ether any more (though why we can’t use ketamine like most of planet earth I don’t know…) that was a definite step forward but I’m pretty sure the difference between omeprazole and esomeprazole is as minimal as the difference in names.
The office does a good rant on the “me too” drugs of stereoisomers.
Once a patent runs out then anyone can make the drug and sell it at a competitve price (therefore often reducing the cost by 10 times) to purchasers. These are called generics. In general (with a very few important exceptions) these are identical to the branded drugs
But for doctors time is precious and they read too many drug ads and meet too many drug reps and they tend to remember the short snappy name and not the long hard to pronounce one. So when they prescribe the drug they write the short snappy name and the pharmacist is obliged to dispense what the doctor has written. Even when the generic form costs  a tenth of the price.
The department of health, in a rare moment of common sense has decided that pharmacists should be able to automatically substitute the cheaper generic drug even when the doctor has prescribed the expensive branded version (remember these are the same chemicals, with the same effects, just with different names).
Reading back over that it kind of seems crazy that we didn’t start doing this years ago.

Like eating glass

I’m sure the patient’s consent was obtained for this video…

[Via LITFL]


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August 2022
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