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The art of medicine.

14 Sep, 16 | by Toby Hillman

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Doctors have a long and proud history of involvement in the arts.  There are classic tomes published by doctors – The House of God (Shem), Sherlock Holmes (Conan Doyle), The Story of San Michele (Munthe), The Master and Margarita (Bulgakov).   The profession has also produced a number of playwrights (Chekov), and poets (Keats).

This exploration of the human condition through artistic expression is perhaps to be expected from a profession that is witness to human suffering, joy and grief on an almost daily basis. Reflective practice is a hotly debated aspect of medical training at the moment, with many trainees railing against the constrained forms of reflection permitted in official log-books and e-portfolios.

Dr Alice Ong of the University Hospitals of Coventry and Warwickshire submitted the following post, and joins a long a proud tradition of physicians who have turned to the arts to mark an aspect of their work.

Memories of Arnhem:

Looking after people when they are vulnerable is a great privilege of working in healthcare.  As a geriatrician, I consider holistic care very important, and find the lives of patients as interesting as their medical conditions. Over recent years we have lost those who saw active service during World War One, bringing World War Two veterans sharply into focus.

A recent gentleman was one of a handful who can remember anything about his time during World War Two. He and others of his age represent a different era, a generation of individuals who we will sadly lose as time passes. During a routine ward round, we talked about life. He informed me that he was with the 11th Battalion of the Parachute Regiment, and that he parachuted into Arnhem in 1943.

I asked if he had ever written anything about his experiences of this period. He would have liked to, but somehow he did not feel able. I looked into his eyes. I could see he was looking back into his memory box. I could see pain and anguish. A pair of eyes, that seemed to flick back to the past. Clearly he had seen horrendous things at a young age. His eyes came back to the present, and soon we were talking about his sore knee again. I decided to write this poem for him, and for those of his generation, as a final salute to a departing generation. Poetry was something I felt could best capture the reflection I could see in his eyes, whilst they flickered between past and present during our brief conversation. Although the past was behind him as distant echoes, the memories were still vividly in the present.

Arnhem, it was Arnhem.
We got the news, just not
Long before, the drop.
Us the 11 th Battalion.
Our turn, our turn.

Parachutes, many parachutes.
Were we lads, quite ready
To jump, guns poised?
Us the 11th Battalion.
Our turn, our turn.

Friends, many friends.
We lost many, in battle
Around Arnhem, years ago.
Us the 11th Battalion.
Our turn, our turn.

Memories, buried memories.
We were scared, but fought
So bravely, without fear.
Us the 11th Battalion.
Our turn, our turn.

Gunfire, sounds of gunfire.
We can see, the smoke
All around, of grenades.
Us the 11th Battalion.
Our turn, our turn.

Farewell, fondest farewell.
We are old, and lived
A life, friends missed.
Us the 11th Battalion.
Our turn, our turn.

Culture Shock -Internship at the Iraqi Emergency Department

11 Aug, 16 | by Toby Hillman

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As I have mentioned recently, the blog is starting to evolve, and pieces from other authors are being posted here.

The following was submitted by Dr Mustafa Al-Shamsi from the ED department in Basra, Iraq.  I often write on these pages about the softer side of medical practice, but here is a frank, and stark reminder of what life can be like for colleagues in other parts of the globe.

I hope that you find this blog thought provoking, and useful as a yardstick which offers a little perspective to some of the challenges you might be facing in clinical practice at the moment.

Being an intern in an Iraqi emergency is hard and dangerous thing. You have to develop special survival skills to save yourself, and you should have an extra-talent not only in diagnosing and treating patients (despite limited facilities); but also in the way in which you manage them otherwise you will face distresses, become frustrated, and unable to keep your daily work, You may even  get offended! {1}

On my first duty at emergency department—I was shocked when my senior colleague told me ‘’the patient is your first enemy? You have to save yourself before saving him!’’. at that moment I did not understand what he meant, and I thought he was just joking with me. But as the days passed I started to realise what he meant:

Violence has a huge impact on the health practice, and it is very apparent in the  emergency room. Some patients are dangerous and manipulative. They have a criminal backgrounds that I could not handle with my limited life experience, they may be addicts, killers, and members of militia or even mass murder. You may be offended or even killed if you mess with them! They know how to target new inexperienced doctors to get what they want—the opioid and narcotic drugs most of the time. This made me fear all patients for a while but as soon as I became expert in diagnosing them, so when I received these stereotypes; I try to get a rid of them by any means to protect myself even if I do not treat them; otherwise I may get hurt!{1}

The overloaded emergency, and chaotic situation along with the absence of discipline makes sure that nice terms like empathy, compassion, and mercy have no place here. Doctor’s professionalism is not evaluated according to his care and scientific approach toward the patients; but rather, by how many patients he could handle per hour, and each one has his own strategy to escape from the workload. The doctors, because of the pressurised work environment, start to conceal their real personality; they become aggressive — because it is a self-defensive mechanism — and eventually the aggressive personality becomes dominant and most of them demonstrate? personate the offensive face; which subsequently disturbs the friendly relationship, and this makes me regret dealing with some of them. The health care workers are less compassionate here! When I was a student I thought that everybody would be nice to each other, but the reality is totally different. There is a lot of tension and anger. We work for about 80 hours per week in a hostile environment; the stress and work pressure just erodes people and make them different!

Being a doctor in the Iraqi health care system is like being a soldier in a war without a weapon; there are plenty of patients to help, but the resources are limited. The demand of the work environment is quantitatively and qualitatively different, the types of injuries are so severe and disabling, which makes the availability of adequate facilities and medication strain the realms of possibility. There are inadequate laboratory investigations and medications to diagnose and treat an enormous amount of conditions. The emergency department always suffers from staff shortages {2}.

The patients, on the other hand, ignore the initial symptoms of disease. Most of them are paying no attention to the nature of the disease, and usually they mistrust doctors. They act late, and only come to the emergency room when the condition becomes severe and beyond treatment. They assume that the doctor is a god who is able to cure the disease and think medication will act as a miracle. The consequence of this complex situation normally results in the assault of the health care givers—as part of grieving reaction—when patients die. The stressful aspect of being physician in Iraq is that you have to work without any security measures. I have experienced many times the insecure situation of being alone at the emergency room after mid-night; where I receive drunken guys bringing me a victim with a stab wound, and I have to deal with them; otherwise I will be attacked at any minute or even may be murdered! {3}

This dangerous and critical situation, along with absence of proper law enforcement, or laws to protect the doctors make a lot of doctors reconsider the career they have chosen. Doctors start to resign, some of them have already left Iraq, others are  seriously considering leaving their career {3}. This will need urgent intervention; otherwise these departures will compromise the health system; which already suffers from scarceness of the health care professionals.

Sitting in the emergency room makes me realise how fragile the health care system is. Nevertheless, I learned some skills, and acquired new experiences—despite this harsh environment. I am proud of all the things I have achieved up till now; I saved a lot of people, and I survived a lot of dangerous situations in my first year that made me tough enough to continue my career. Someday may be I will be in another place, and remember this experience, and use it as spark which will motivate me to continue my career.

Mustafa Talib AL-Shamsi, MD

  1. Nabil Al-Khalisi, The perils of being a doctor in Baghdad, BMJ 2010; 341:c4043, page 253.
  2. Salma A Naji AL-Hadad, Mazin Faisal Farhan Al-Jadiry, and Claudia Lefko, Paediatric cancer care in a limited-resource setting: Children’s Welfare Teaching Hospital, Medical City, Baghdad, ecancer 2016, 10:ed55 DOI: 10.3332/ecancer.2016.ed55.
  3. Matt Bradley, Iraq’s Doctors Face Threats of Violence, the Wall Street Journal. May 1, 2016.

In the land of the blind…

13 Jun, 16 | by Toby Hillman

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Leadership is one of those areas of medical training that is increasing in prevalence, and the number of schemes to ensure that medical leaders are available within the workforce is ever expanding.

Some in our profession feel that the ‘leaders’ who are ‘trained’ seem to have few leadership qualities, and even less legitimacy to lead their colleagues than those who possess ‘natural’ flare for leadership. (COI: I have been a leadership fellow in the past)

There is one very well defined team, though, in which very clear leadership is absolutely required, and in which even the most junior member of the team can display leadership, clarity of thought, and situational awareness – the cardiac arrest.

With the adoption of international algorithms, regular training days, a huge manual, rigorous testing of candidates, and mandatory updates – advanced life support has to be one of the most directive environments in which we find ourselves at work.  So leadership is required within the cardiac arrest team, to ensure that the team is working to time, maintaining compressions, and giving drugs when required – and most importantly, to review progress, determine measures of success of failure, and sadly – most often – to ‘call it’ when an attempt has failed.  Leadership skills then, would appear to be a necessary attribute of anyone on the cardiac arrest team.

A couple of recent papers published online in the PMJ raise separate but linked questions about leadership in this most stressful of situations.

A paper on leadership at cardiac arrests helpfully documents data that is a bit of a wake up call for those who ‘lead’ them.

Dr Robinson and colleagues studied the perceptions of leadership and team working among members of a cardiac arrest team.  They surveyed a range of members of the crash team at a n NHS Trust in London that covered two acute hospital sites.  Admirably the survey included wider members of the crash team too – healthcare assistants and nurses, as well as those who carry the crash bleep (pager).

The message I took from the data was that the leaders (SpRs / senior residents usually lead cardiac arrests in UK hospitals) thought that leadership at the cardiac arrest was good in 90% of cases, whereas the ‘followers’ (nurses) only thought that there was good leadership 28% of the time.  And perhaps best of all, 100% of the SpRs strongly agreed that they were confident in leading cardiac arrest response.

In this cohort, around 40% of all groups of respondents said they had experienced a debrief at any arrest they had attended.

The second paper, which looks to provide an answer to the questions posed by the first paper, through the use of a debriefing tool, considering the cardiac arrest response to be a missed learning opportunity  The authors again surveyed their cardiac arrest responders – and found that only about 30% had ever experienced a debrief following a cardiac arrest at their centre.  However, there was a great appetite for the opportunity to debrief in a structured way – using a tool which singles out leadership in particular as a domain of interest (93%).

I think that these two papers demonstrate that, although leadership remains one of those areas which induces feelings of revulsion amongst those who have experienced terrible role models, it is one of those skills which, instead of being inherent amongst the medical profession, requires practice.

What is worse is that those who occupy leadership positions by virtue of their grade of training appear to be mistaken as to their effectiveness, and demonstrate misplaced confidence in their abilities.

Whilst I have been fortunate enough to have had the opportunity to participate in a leadership programme, I don’t think I would anoint myself as the next great thing in the medical profession. However, the training I went through did teach me a lot about the capacity people have for self-deception, and the importance of truthful feedback from colleagues (see this blog from a while back)

I have doubts about the enthusiasm of crash to use a debriefing tool in the immediate aftermath of a cardiac arrest response, but these two studies have gone some way to reassuring me that there has been a shift in the culture of the medical profession to even be studying such subjects.  Long may it continue.

 

 

 

Turning over a new leaf

5 May, 16 | by Toby Hillman

Decayed Aspen Leaf in B&W

Via Shaun Fisher on Flick CC by 2.0

 

The PMJ blog has been running for 2 and a half years, and in that time I have looked at many aspects of medical practice and education that have been thrown up by papers published in the PMJ.

As time has gone on, we have had several submissions to the journal which seem to fit better within the blog format than as ‘fillers’ within the published journal, but do not necessarily link directly to manuscripts that are due for publication.  However, they stand in their own right as pieces of interest to the PMJ readership, and cover experiences wider than my own.

As such, you will see different ‘voices’ within the blog, and I hope that these voices will also challenge and inform about subjects that have struck them as important in their clinical lives.  In contrast to the ever increasing enforcement of reflection in clinical practice, here are vignettes and observations that demonstrate reflection, but are submitted for wider circulation, and not hidden away on the servers of an eportfolio, or appraisal folder.

So over to Dr Welsby who has submitted the following ‘jaundiced view of jaundice’:

A confused young man and had been admitted with “?Hepatitis.” He was febrile and deeply jaundiced (patients with Hepatitis A or B, once jaundice is obvious, are usually afebrile and, barring complications, often feel better).

Obviously ”liver function tests” were in order. The first liver function test was to observe that his underwear was bile stained. The usual liver function tests were mandatory but predictable. His bilirubin was obviously high, too high to be caused by haemolysis alone (because haemolytic jaundice is lemon coloured and mild whereas obstructive or hepatitic jaundice tends to be deep and greenish). His ALT was moderately raised – unsurprising because his liver was tender on palpation and his alkaline phosphatase was raised in keeping with anatomical or physiological obstructive jaundice.

Obviously a clotting screen should be undertaken but what two tests that are rarely considered to be liver function tests should be performed. Firstly, the blood urea was high. This is unusual in hepatitis because the inflamed liver tends not to make urea (in formal hepatic failure the urea is characteristically low) and his raised urea suggested a degree of renal failure. Secondly, the glucose level (it is mostly liver glycogen that keeps up the blood glucose. In formal liver failure the glucose is characteristically low and intravenous glucose is often required. Hypoglycaemia is the only liver function test that can be immediately normalised.

One investigation that should not be omitted was the most important. A phone call to get a full history. He had recently been in Africa and his blood was full of falciparum malaria that would not have shown up on a routine blood count.

His parasitaemia demanded an exchange transfusion because parasitized red blood corpuscles cannot transport oxygen. Accordingly his blood was venesected and replaced by donated blood. Now, here is a question to which I have never received a sensible answer “How long does it take for stored blood, once administered, to start to transport oxygen?” Answers range between “a few hours” to “about 24 hours.” For stored blood duration of storage would obviously be relevant (someone should do an MD to investigate this). If he were given non-oxygen transporting blood there is a prospect of doing him a disservice by making him more hypoxic. This is why fresh blood is often used for such exchange transfusions.

 

Hidden in plain sight.

5 Apr, 16 | by Toby Hillman

 

Hooded Grasshopper by J.M.Garg – Own work, CC BY 3.0,

Patients do not come with diagnoses attached to their foreheads.  If only they did,  huge numbers of hospital visits and admissions could be avoided.

To overcome the ever increasing number of potential diagnoses, and the rising tide of illness encountered by our ageing populations, we rely ever more heavily on investigations to guide us to the likely diagnosis, and thereafter, management.

But what if the tests don’t tell you what you wanted to hear? what if the clinical picture says one thing, but the tests say another?  Usually this scenario starts a ‘merry’-go-round for the patient concerned.  Oligo-organists (specialists in normal terminology) become increasingly irate with each other, sending a patient on a wild goose chase from clinic to clinic, trying as hard as they can to reassure the poor patient that there is nothing wrong with their X, and it must be the Y-ologists who will hold the key to unlocking their symptoms and making that breakthrough in management.

Heart failure is one of those areas where patients can go for some time before a diagnosis is firmly settled on.  Patients don’t go to their physician complaining of heart failure.  Instead they complain of breathlessness.  It is telling that there are two distinct rating scales for dyspnoea in common usage -(MRC scale if COPD and NHYA class if Heart Failure) – it is a symptom that has become divided by a common language.

Patients with heart failure are not helped by the way in which we as a profession have been guilty of listening to ourselves, and our tests, rather than our patients.  The seemingly contradictory Heart Failure with Preserved Ejection Fraction (HFpEF) is an entity that has been hotly contested, but looks to become the predominant mode of heart failure.  A review recently published online in the PMJ into the pathophysiology and treatment of HFpEF  shows just how far we have come over the last 20-30 years in understanding that such a disease even exists, that it can be characterised using an imaging modality that was once used to cast doubt on a clinical diagnosis of heart failure.  However, despite this increased understanding, we are only just getting to know which treatments might be beneficial, or harmful for a growing cohort of patients.

As I read the review, along with bewilderment at the detail that can be obtained from a non-invasive bedside test, I was struck by the journey that HFpEF has come on in the time that I have been training and practising medicine.

I clearly recall times when I was told that I was plainly wrong when a patient with the clinical syndrome of heart failure was given a clear bill of health by an echocardiogram – causing me to doubt my skills and insight.  And yet now, we discover that by examining the heart with a different mindset, very detailed pictures of the diastolic function of a heart can be estimated, allowing patients to be treated in a more refined manner.

In addition, the review brought home the absurdity of relying solely on a single test to determine the diagnosis of a clinical syndrome.  The review outlines the risk factors for HFpEF – it is a familiar roll call of the diseases of age and lifestyle.  So the test we used to think of as the gold standard to rule out a diagnosis, has been fine-tuned, and gives a more nuanced picture, but despite advancing technology, we return to the need to treat the patient before us, and not the test result.  And in treating the person, we must treat the whole person. This includes their co-morbidities and risk factors, and not just the ones we happen to find interesting.

Perhaps the journey that the diagnosis and management of HFpEF has taken from seemingly outlandish diagnosis to the dominant mode of heart failure also reflects the journey that physicians must go on as they progress through training – from relative ignorance and lack of experience – to specialist knowledge and a narrowing of focus – and back again to a more generalist role, encompassing multi-morbidity and diagnostic uncertainty.

As we face an increasing burden of multi-morbidity, escalating healthcare costs, and increasing patient expectation, I don’t think it will be appropriate in the future to say – no, your lungs are OK, off  you go to see the heart docs. Instead, a more generalist model of care, helping patients to navigate their multiple long term conditions, to reach a balanced solution will be the standard we will aspire to.

Did you choose them, or did they choose you?

24 Feb, 16 | by Toby Hillman

Specialty choice algorithm via @FizzyMcFizz

 

Medical stereotypes are a well known, ranging from the hippy-esque GP, to the man-mountain of an orthopaedic surgeon, via the suave and sophisticated plastic surgeon.  I’m not entirely sure what the stereotype of a chest physician is, but I would be grateful if you could let me know…

These stereotypes, and perceptions of who goes into which specialty are deep-seated, with some of the negative associations between specialty choice and types of doctor being identified early in medical studies, and seemingly perpetuated by senior staff.  So what makes one choose a particular specialty?  It might be something to do with the types of patients being cared for, the opportunities for research, the work patterns, the remuneration, intensity of on-call, or it may be influenced by our personality.

A study published online recently by the PMJ tried to examine the contribution of personality to specialty choice in doctors working in Sweden.  The paper describes the results of a survey of Swedish medical graduates in 2013.  The Big Five Inventory was used to quantify personality traits, method of entry into medical school was also recorded, along with a number of other questions about lifestyle, economic status, involvement in research and a basic enquiry about the need for mental health treatment within the past 12 months.

The results of the study seemed to confirm the stereotypes of different specialties to a certain degree, with surgeons being more likely to score highly on conscientiousness, and lower on agreeableness than other specialty groups, and psychiatrists being more open to new experiences than the other specialty groupings.  Psychiatrists were also more likely to have required treatment for mental illness in the previous 12 months (57%) than their colleagues in other specialties (GP 42%, Hospital Service Specialties 26% and Surgeons, and Internal Medicine Specialists 25% each)

The authors recognise that personality alone is not the sole reason for a choice of specialty, but that the differences in traits between the groups of specialists, suggests some role of personality in determining ultimate choice of career path.  The authors considered the possibility of a reverse association between personality and specialty choice in that the culture of a specialists working environment may change the Doctors’ personality – leading to the observed differences.  However, this seems less likely given the usual assumption that personality is fairly fundamental and fixed over a lifetime.

As I read the paper, I thought back to my own career choice – and why I followed the path taken.  It is perhaps a little too personal to go into all of the reasoning behind my career choices here, but my career aspirations definitely changed over time.  I left medical school with thoughts of being a Trauma and Orthopaedic Surgeon (for those who know me, this may come as a shock) and I then moved through a phase wishing to be an Emergency Physician, and ultimately chose Respiratory Medicine.  At each point, there were multiple factors at play, but I certainly remember feeling more accepted in some student attachments and working environments than others.  This feeling of being ‘adopted’ into firms whilst a student, and being allowed to ‘join’ the firm once I was a doctor, I think had more of an influence than I appreciated at the time.

I therefore wonder if choice of specialty isn’t an expression of pure agency on the part of the trainee, but in fact, the other way around.  How much are students and junior colleagues ‘chosen’ by a specialty?

Lave and Wenger’s work on legitimate peripheral participation described how junior members of a community of practice become accepted and involved in the work of that community.  My feeling is that perhaps this is at play within the hidden curriculum at medical school, and our own choices about career path may be more influenced by others choice to accept us wholeheartedly into a community, or merely tolerate our presence as a fleeting member of a workforce.

In this way, personality groupings are perpetuated within the medical profession, and our stereotypes continue to live on.  If we are to facilitate the emergence of a truly diverse workforce that is happy and productive, we should not necessarily seek to eliminate these stereotypes, or encourage trainees to follow specific career paths simply based on how we interpret their personality.  Instead we should explore with trainees what draws them to a particular field of practice, and help them to see past the ‘image’ of a specialty, and make perhaps a more informed choice, taking into account how they might fit in with a particular medical tribe.

 

 

 

Look not for the fleck in your brother’s eye, but the gorilla in your own…

25 Jan, 16 | by Toby Hillman


Gorilla

Teaching for medical graduates approaching clinical exams such as the MRCP PACES exam is an anxious time.  One is expected to ‘perform’ under pressure, wary of the need to elicit signs leading to potentially outlandish diagnoses.  The breadth of knowledge and skills required to confidently identify CMV retinitis at one station, followed by a complicated communication scenario, with a subtle fasciculation to pick up on at the next is quite a task.  It is also a task that is asked of graduate trainees in almost all specialties – the clinical portion of any membership exam is a vital stepping stone on the route to full qualification and independent practice.

I was teaching some PACES candidates this week, and played my usual game with them – what can I tell by observation of a patient and just watching their examination – that they miss.  This isn’t just a mean trick – I find it helps me to concentrate on what they are doing, and in turn, helps to identify additional signs that might have been missed completely, be unknown, or simply passed off as unimportant.   The gems this week included the white plaster over the bridge of the nose of a gentleman with COPD – which led to a further inspection of the surroundings  – and the tell-tale NIV mask and tubing just poking out behind a bedside cabinet.  The second was the white sheet of A4 stuck at eye level behind another patient’s head with the very large letters NBM written in green marker pen.

In both cases these clues to the wider diagnosis were staring the candidates in the face.  However, it was only when brought to the fore that their implications for the clinical context was appreciated.  So I finished the teaching session having had my fun, and the pupils might have learned a bit more about the value of careful observation, and how this can influence clinical reasoning.  It was only when I got home and read this recently published paper by Dr Welsby on the neurophysiology of failed visual perceptions that I started to consider this interaction a little more objectively and how the lessons from it could be applied in other spheres.

The paper is one of those analyses of physiology and its application to everyday life that makes medical education and medical practice so enjoyable.  Dr Welsby has taken 3 eye problems, and 7 brain problems, and presented them in such a way as to highlight why clinical experience – the act of examining patients, and the slow acquisition of the lived experience of using and applying knowledge over time – is so important in medical education – and suggests several reasons why he feels trainees today aren’t afforded the same opportunities to develop this experience as he was.

The paper can also give lessons for the more experienced clinicians, and perhaps could be used to highlight errors of clinical understanding on a much wider scale.

Essentially, the data our brains work with is flawed – and to compensate – our brains make it up, or completely miss the obvious because we were concentrating on something else.  The paper has links to two videos which are well worth looking up – this one is my favourite.  The video is a perfect demonstration of how easy it is to miss vital information, and when we apply this to the situations we work in daily – it is more impressive that we ever reach diagnoses, rather than that we sometimes get them wrong.

As one climbs the slippery pole of the medical hierarchy, it would be as well to reflect on Dr Welsby’s observations further.  Clinical experience can make what seems impossible to a first year graduate,  second nature to the fourth year registrar.  The development of this experience allows senior clinicians to spend time thinking and working on other problems – but still with the same eyes and the same brains.  Indeed – it is often successful clinicians who are chosen to lead on projects far from the clinical environment, and demand a somewhat different form of observation and synthesis of information.

As more and more clinicians are becoming involved in leadership positions, and managerial roles – those lessons learned at the bedside should not be forgotten.  If the data from our health systems is flawed – the decisions we take to modify, ‘improve’ and reform them will be as flawed as those conclusions reached by a brain compensating for the incomplete information fed to it by the eyes.

Leaders from the medical profession have a duty to both remain patient with their students who miss the ‘glaringly obvious’ but must also remain vigilant for the gorillas hiding in plain sight no matter where they find themselves.

 

 

Three pipe chest pain…

14 Dec, 15 | by Toby Hillman

SH

Medicine is no longer quite so full of time to ponder as it once seems to have been.  Rumination and consideration have taken a back seat to efficiency.  Protocols and pathways seem to be the order of the day, and once a patient is on a pathway, it can be very difficult to get them out of the diagnostic rut they have found themselves in, which more often than not is a medical cul de sac.

A paper in the PMJ on the clinical and diagnostic findings in patients with elevated CSF bilirubin set me off thinking about these dead-ends.

The paper takes a fine toothed comb to the cases of patients who underwent CSF bilirubin analysis as part of their assessment for headache over the course of a decade at two hospitals in Northern Ireland.  The paper explores some of the ins and outs of CSF analysis for possible aneurysmal SAH and gives some helpful insights.  One curiosity that stood out was the 13 patients in whom there was a complete lack of history of headache (not even simply not recorded as far as the presented data suggest) who underwent CSF bilirubin testing.  I suspect that this was over-eager requesting becuase CSF had been obtained, and all the boxes got ticked.  As far as this paper is concerned though, this practice diminishes the specificity of the test and as such erode the positive predictive value of the test.

However, my interest was piqued by the natural use of a term that will be well understood by medics who work in acute medical units, and seems to have become part of our everyday clinical language – the “CT negative headache.”  This terminology has cousins that are probably more often heard, but are just as beguiling in their simplicity and ease of use, but troubling in terms of their complete lack of detail.  These terms can be sprinkled liberally onto the discharge summary – neatly encapsulating the battery of tests that a patient was subjected to – resulting in normal findings (or non-significant ones at least) but sadly they entirely miss the point.

Pathways are designed with an end diagnosis in mind, and if a patient flows along the pathway, ticking the boxes as they go, or being forced to occupy them (the crime of procrustes) then they may usefully end up with the correct treatment, given in a standardised way with utmost efficiency.  However, there are few pathways with “diagnostic uncertainty” as the start point.  There are even fewer that allow one to consider all of the alternative diagnoses (the CSF paper above reminds us that there are over 100 causes of sudden and severe headache described) that might contribute to the clinical conundrum facing us.

As such – if your patient comes to hospital nowadays with chest pain, they may well go home with a diagnosis of chest pain (troponin negative).  This has not necessarily helped many of the players in this scene.  If the patient’s main concern was specifically that they were having a heart attack – this could be reassuring.  However, if I was the GP who had asked for the opinion of their local specialist service, I might feel a little short-changed.  Negative diagnoses do not contribute a great deal to a positive outcome.  Instead, it might be more helpful for the patient to go home with at least a list of possible or probable alternatives – costochondritis, or oesophageal spasm, or dyspepsia, or my personal favourite when I see it – the slipped rib syndrome

Negative diagnoses are undoubtedly here to stay – it is just too easy to be able to exclude the killer diagnoses, assure yourself and your patient that they are safe, and then send them on their way.  However, as educators, and as clinicians we must ensure that our adherence to guidelines, protocols and pathways do not allow our curiosity to atrophy, and through our own acceptance of the negative diagnosis, let this practice to be seen as the norm.

Sherlock Holmes used to rate problems by the number of bowls of tobacco required to think them through – in the world of multi-morbidity there are plenty of three pipe problems to be faced.  And whilst I don’t lament the passing of the ward smoking room, I think there is definitely something to be said for bringing back the art of the positive diagnosis, even if it requires a little rumination, and wandering from a well-marked pathway.

 

Aiming for ‘normal’

14 Nov, 15 | by Toby Hillman

Don Quixote via scriptingnews on flickr.com

Normal ranges are papered to the door of almost every clinical medical student’s lavatory door or fridge, inside the cover of every notebook in the wards – accompanying every result on the EHR – everywhere we are told confidently what normal is. But as this paper studying the laboratory findings of several thousand inpatients at a hospital in North London highlights – ‘normal’ is not as clear cut as it may initially seem.

A paper from the hospitals looked at in this study was the subject of a previous blog  which highlighted the variation in practice and often poor implementation of ivestigations into the cause of low sodium values in patients acutely admitted to the three hospitals involved.

This paper has taken a signal from a previous one and has now produced data that questions the validity of the 135-145 range for serum sodium.

The authors noted during their previous studies that many of the patients acutely admitted to the hospital had low sodium results, whilst a cohort of patients from care homes had higher values, and seemed to be dehydrated.  The mortality for patients being admitted rose with increaing sodium concentrations – but the break-point in the graph was within the normal range. So we have a population whose results don’t fit the ‘normal’ range, and a ‘normal’ range that seems associated with increasing mortality:

 

Locally estimated regression (locally weighted scatter plot smoother, LOWESS) plot of serum sodium against mortality for inpatients aged under 65 and 65 and older.

 

Clearly these retrospective observational studies shouldn’t have lab managers running around redefining normality and encourage us all to drive our patients’ sodium to the lower half of normal in an attempt to save lives…

BUT and it is a big but that deserves capital letters – we do need to work out who defined normality.  Thankfully Prof McKee and his colleagues have done a bit of digging for us and give a potted history of the normal range for sodium measurement. And it turns out that this range – embedded in millions of memories the world over is actually based on comparatively few data points – the first papers used about a hundred healthy volunteers using flame photometry – a technology that is largely superceded by more accurate methods.  The subsequent studies they refer to us up to a 1000 measurements (often in multiple sub-groups) from which they drew their conclusions.

How can this be? Surely we don’t just take decades old evidence and allow it to heavily influence our treatment plans, delay discharges and so on?

In this case the answer seems to be… yes.  However, this is not the only sphere of medicine where old data continues to heavily influence current practice.

Oxygen is one of the most commonly administered, but not prescribed, drugs in the formulary. In COPD it is one of the few drugs that has evidence for influencing mortality, rather than simply altering a trajectory of decline…

And the evidence for this? It is predominantly based on an MRC funded study from the late 1970s that included 87 patients.  That evidence was enough to change practice, and alter lives I am sure, but it probably would not stand up to scrutiny for the basis of a major shift in practice nowadays.  The linked paper on sodium measurements, for example looks at more than 100000 samples and trials of therapy in COPD looking to demonstrate a mortality benefit now need to have thousands of patients (the TORCH trial enrolled 6200)

So what is truly normal, are any of our favourite ‘common sense’ treatments justified in modern medicince, do we do anything right in our every day practice?

Clearly yes, there have been huge improvements in survival from many diseases over the decades, and common medical practices are clearly successful at identifying pathology, seeking out the underlying disease, and then targeting that.  However, when confidently stating that something is the correct strategy to pursue, we should also be mindful that our convictions might just be based on less than solid ground.  And this uncertainty is at the heart of a healtyh academic examination of our medical practice on a daily basis.

We should not be paralysed by doubt, but we should have a healthy degree of scepticism when appraising both existing practices (the PANTHER IPF trial is perhaps one of the most significant turnarounds of recommended practice triggered by high quality trial evidence) and when new technology comes along (see this blog on troponins in acute medicine.)

So next time you are on a ward round, and find yourself struggling to guide a patient towards ‘normal’ for a biochemical test, or some other finding that we all ‘know’ to be true – you should perhaps make a mental note and work out from the evidence if all we are doing is tilting at windmills, because that is what we have always done, or if there is a genuine reason to strive for that particular outcome.

Wait – did I just hear a zebra going past?

13 Oct, 15 | by Toby Hillman

‘Making a zebra’ by Jurvetson on Flickr (cc 2.0)

There is an often quoted medical witticism, that originated in 1940’s Maryland:

‘When you hear hoofbeats behind you, don’t expect to see a zebra’  

Suffice to say, there aren’t many zebras in Maryland…

In the rough and tumble of acute medical admissions, there are an increasing number of horses in the herd to contend with, and often they come in fairly sizeable herds – multimorbidity is now the norm, and single organ pathology increasingly rare.  Among the horses though, there are occasional zebras.

A paper in the PMJ published online recently explores the features of one of these zebras.  The paper looks at the current state of knowledge about non-convulsive status epilepticus (NCSE).

Non-convulsive status epilepticus is one of those pathologies that sets the mind to thinking – the very name seems a little contradictory.  However, it is a very real pathology and can be incredibly disabling.  As the authors point out, this is a disease that is tricky for many reasons – not least that there is no accepted definition of what constitutes NCSE, and to make a confident diagnosis, one probably requires access to EEG monitoring and a specialist neurological opinion.  So not easy then, for the layman to identify and manage. The incidence of NCSE though, means that those dealing with acutely unwell patients on the medical take ought to be aware of NCSE as a differential diagnosis, and when it would be appropriate to take a second look at the source of all those hoofbeats.

Risk factors for NCSE in the elderly include being female, having a history of epilepsy, neurological injury ( eg stroke), recent withdrawal of long-term benzodiazepines, and having some characteristic clinical signs.  The suggested investigation at this point is then a thorough drug history, review of metabolic derangement, and then to progress to an EEG if one is available in a timely fashion.  The interpretation of the EEG is somewhat beset by pitfalls, but remains the most objective way to reach a conclusion in a tricky situation.

All this is very well, but the ‘half empty’ reader may feel that the paper suggests that this problem, that could affect up to 43 patients per 100,000 is bound to go unrecognised, and therefore untreated as it is poorly defined, and difficult to diagnose.  To assume that because a condition is a challenge to diagnose and manage, the generalist can simply file under ‘too difficult’ would be a shame, and a failing.

The authors use a fantastic phrase that I hope will resonate with jobbing clinicians – ultimately clinical judgement rather than exact criteria is key.

Clinical judgement is one of those qualities one is asked to assess in trainees – a quality that has been lauded and viewed with suspicion over the years, but remains central to clinical practice.  To me, clinical judgement is the synthesis of knowledge about both the patient being considered, their symptoms, signs, and preferences, along with knowledge of up-to-date evidence of therapeutic strategies to formulate a management plan that provides the best outcome – as defined by the needs of the patient.

In the world of multi-morbidity, clinical judgement and one’s ability to interpret available evidence in the context of the patient in front of you is the key clinical skill that can be lost by slavish adherence to criteria, scoring systems, and guidelines.  As the practice of medicine develops, the nuances of how to apply clinical judgement will change, but ultimately this quality continues to be a defining feature of the medical profession.  To maintain a high standard of clinical judgement, one must continue learning – especially about zebras – it would be a shame not to recognise one when it gallops up behind you.

 

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