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Too much medicine…

10 Sep, 14 | by Toby Hillman



A famous quote from the eminnet paediatrician Sir Cyril Chantler was published in the BMJ in 1998:

“Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous.”

As medicine progresses, it is worth keeping this in mind.  The complexity of modern medicine is one of the challenges that has led to a deal of dissolusionment with with Evidence Based Medicine movement – and the recent calls for renewal of the principles behind EBM from Trish Greenhalgh and colleagues highlights the importance of relating evidence to the individual being cared for, rather than just the guidelines that relate to the ‘perfect’ patient.

A paper recently published in the PMJ on the risk factors and features of non-variceal upper GI bleeding in inpatients, and its relation to antithrombotic drugs made me think again about my own practice, and probably the practice of a great many colleagues of mine up and down the country.

The paper examined cases of NVGIB at the University Hospital Crosshouse in South West Scotland.  The investigators looked at all cases of NVGIB in their hospital over a period of 12 months, to understand the risk factors associated with this condition, and in particular the role that antithrombotic drugs play.  The investigators split the patients into two groups – those developing NVGIB as inpatients, and those presenting to hospital with bleeding symptoms and signs.  The data were collected as part of an ongoing prospective examination of the epidemiology and management of upper GI bleeding.

The two groups showed some interesting differences – those developing bleeds as inpatients tended to be older, more likely to be female, were on more antithrombotic medication (particularly non-aspirin drugs), had more cardiovascular disease, and have higher Rockall scores than those presenting to hospital with bleeding.

The authors conclude that secondary care physicians looking after the older female population that suffers with cardiovascular disease should consider more strongly the need for prophylactic anti-ulcer therapy.

This advice would seem to be borne out by the evidence, and is a practical solution.  The paper did not examine the appropriateness of the use of anti-thrombotics in the first place – it would probably be beyond the scope of an observational study such as this.

However, as I read the paper and the conclusion – that more medicine is probably where the answer to this conundrum lies, I wondered how many of these elderly ladies derived significant benefit from the additional anti-thrombotic medicines they were prescribed.  This is pure supposition, but I wonder how many were given their new drugs in response to an admitting complaint that perhaps didn’t completely justify the use of powerful, complex, dangerous medicines?

I can easily imagine a patient presenting with some atypical sounding chest pain, some breathlessness accompanying it, who is written up for “ACS protocol” medications on admission, and spends a little time awaiting investigations to rule in or out significant cardiac disease.  After a couple of days the patient may develop their bleeding complication, and on the story goes.  The patient has probably had great protocolised medicine, and has had their risk factors assessed, and their symtpoms noted and reacted to, but perhaps their whole situation hasn’t been weighed up.  For example, the application of the “ACS protocol” to patients who don’t fit the evidence base (eg those with a history, but without ECG changes or enzyme elevation were excluded from the CURE trial after the first 3000 patients) may not be great evidence based medicine – but it is often a protocol applied to patients presenting with cardiac sounding chest pain to the acute medical unit, prior to the full information, and therefore full estimation of benefits and harms can be considered.

When we then consider the solution to this conundrum seems to be to add in further medications to offset the harms of those potentially initiated on a less than optimal basis, I wonder if we aren’t just ending up chasing our tails.

Maybe we need to come back to Sir Cyril again, and finish off his quote:

“Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous. The mystical authority of the doctor used to be essential for practice. Now we need to be open and work in partnership with our colleagues in health care and with our patients.”

It is the being open, and working in partnership with our patients that will deliver the better results.  Lets be honest – if a story doesn’t sound quite like a high-risk ACS then perhaps we could wait a bit for the evidence to back up our proposed management plan, and avoid overtreating, over medicating, and harming those at highest risk of both ‘natural’ and ‘iatrogenic’ disease.





NVGI Bleeding

Risks identified – additional drugs

Solution proposed – more drugs

Link to the NOACs and the bleeding risks associated.

Importance of balance.

Is this a cognitive bias that needs addressing – always adding.


Are you safely socialised?

26 Aug, 14 | by Toby Hillman

Social Animals

Changes in role within the medical profession are times of great upheaval.  One of the most challenging is the change from being a medical student to a fully qualified doctor.  A cohort of medical students qualifies every year around June/July time, and members of this cohort take their first steps on the wards and in clinics as junior doctors each August.  Recent guidance has enforced a period of shadowing and induction for all newly qualified junior doctors in the UK before they start their first jobs – in recognition of the fact that schemes with targeted teaching and shadowing can reduce safety incidents by a significant margin.

At other points in the medical hierarchy, there tends to be less focus on the doctors changing from one grade to another.  However, at Consultant level, the stakes rise, and organisations often spend a little more time considering how to smooth the transition from trainee to fully independent practitioner.  Mentoring – a two way learning process between a senior and junior member of a team, organisation, or even healthcare system – is a concept that many organisations have identified as being beneficial to new consultants, and mentoring programmes exist in a fair number of hospitals.  Like many relationship-based exercises, there is a deal of trial and error involved, and mentoring relationships don’t always work out perfectly.  A paper in the PMJ recently examined what makes mentoring work for new consultants.

The authors interviewed new consultants and senior leaders within acute hospitals in the Yorkshire and Humber region of England and through thematic analysis, six major themes were identified.  These included the protective nature of mentoring – both protective of patients under the care of new consultants, and of the consultants themselves; the mechanics of the process of mentoring (variability in expectations, informal and multiple mentors, the importance of personality in the mentoring relationship) and the prominence of mentoring as part of professional identity.

This last point struck me, and led me to wonder about how different specialties socialise trainees, both in their approach to interpersonal relationships at consultant level, and potentially to much wider aspects of care.

Professional socialisation is a fascinating concept – it has been studied in a diverse range of professions – from the clergy to the military – and within the medical world, plays a huge role in setting the culture of different departments, and probably specialties.  One teaching hospital training scheme I know of had a throwaway line at the back of the trainee handbook that spoke volumes about the culture of the specialty: ‘remember, you are an xxxxx-ist : keep it cocky!”  This encapsulated perfectly the culture of the trainees in that particular specialty within the region, and I now recognise this as one part of what is commonly held to be the ‘Hidden Curriculum’ of medical education.

The paper examining mentoring schemes mentions that three specialties in particular may lend themselves to more natural mentoring relationships – surgical specialties in general, gastroenterolgy, and anaesthetics.  I wonder if the craft nature of these specialties demands a closer supervision during training – where consultants are less willing to let trainees gain experience on their patients unsupervised and therefore engage in more hands-on training, engendering close working relationships? Or perhaps it is less high-brow than this, and the downtime between cases in these procedure and list-based specialties offer the opportunity for trainees and seniors to develop more meaningful relationships than in other specialties where the clinic room, or set-piece ward round is the main arena of interaction – affording less opportunity for relationship building chats and debates.

So, if certain specialties prepare new consultants better for mentoring relationships, and mentoring is thought to be a positive influence on patient and employee safety, do some specialties socialise their workforce to be unsafe, to reject a collegiate approach to work, and impair the personal development of their practitioners?  The hidden curriculum is at play in all spheres of medical life, and it pays to look around from time to time to ensure that you aren’t sleepwalking into a culture that is detrimental to the safe conduct of healthcare, but are an active participant in a culture that promotes sharing of lessons, and fosters and develops individuals as they climb the greasy pole of their medical careers.



Too much information?

15 Jul, 14 | by Toby Hillman

Information overload – by BigCBigC at


Medicine is an ever changing discipline.

One field that continues to change the face of clinical practice, and throw up new challenges is that of radiology.

The body no longer hides it’s secrets beneath skin that requires a surgeon’s skills to open up and explore, but can be encouraged to give them up through the various modalities of imaging that have been developed over the past few decades.

I remember the importance of imaging from my days as a house officer – being instructed to go and ‘lie in the scanner until they agree to do the CT’
Although perhaps I should reflect on my centrality to the team if I could be dispensed for long periods of time essentially obstructing other people’s work…

The role of radiologist has changed over time too – from gatekeeper to service provider in the eyes of one US-based specialist.  The close working relationship I have with my radiology colleagues, and my adventures into the world of imaging with my portable ultrasound remind me on a regular basis the pivotal role imaging plays in the work I do.

But, the advances of radiology throw up new challenges…

Incidental findings are both the blessing and the curse of anyone involved in the requesting, interpretation and communication of scan findings.  The report which lands in one’s inbox with just the reassuring answer one was looking for, only to have another three or four lines highlighting a completely unforseen abnormality is the start of a challenging clinical problem.  The issue tends to be outwith the usual scope of the clinical practice of the requester, and therefore usually requires the invovlement of another team to assist or advise on the next steps to further investigate, to a satisfactory conclusion for patient and clinician.

For the patient, the finding can be a distressing bolt from the blue – delivered by someone who is similarly surprised, and the news tends to herals a new round of investigations, referrals and appointments.   However, incidental findings can also be a huge positive in the end – especially if the incidentaloma turns out to be something that would have progressed unchecked if it had not been noticed.  Screening programmes – a notoriously difficult area of medicine almost rely on generating incidentalomas in asymptomatic patients for this very reason.  The debates which rage around screening are well covered elsewhere, and I think I can leave you to look them out for yourself.

The paper which prompted my thinking about incidentalomas was this one on the management of adrenal incidentalomas in British district general hospitals.  The authors looked at the reports of 4028 abdominal CT scans in Northumbria, and found that managment of adrenal incidentalomas was poor.  There were 75 patients with adrenal incidentalomas.  Only 13 were referred for specialist assessment, and sadly, of the 62 not referred, 26 were found to have inoperable metastatic malignancy.  The authors discuss the potential implications for patients who aren’t investigated, and also note that a significant proportion of the requests for the abdominal CT was in the staging of other malignancies.  The finding of an adrenal tumour in this context is a particular dilemma – as the consequences of delaying for biochemical evaluation can be significant, as can the consequences of not identifying a functioning adenoma, or even a phaeochromocytoma.

This dilemma encapsulates one of the challenges that modern doctors have to face – how to interpret a finding, adhere to guidance that is appropriate, and yet progress the care of the patient in a timely fashion that leads to the best outcome in that individual case.   As the role of the doctor changes over time, one key aspect of the duties we have is to take the information available to us, and advocate effectively for our patients – in partnership with them.  Therefore we owe it to our patients not to shrug our shoulders, or hang our heads when we come across the unexpected ‘gift’ of an incidental finding, but instead should try to embrace the opportunity to guide our patients through the often bewildering pathways that lead to a diagnosis.

So no, our imaging colleagues aren’t giving us too much information – it is up to us to use this immense resource wisely, and then, when unexpected findings are thrown up – it is up to us to manage them appropriately for each individual patient in their own individual context.

What’s important to you?

2 Jul, 14 | by Toby Hillman


Via Flikr/valerieBB

Patient centred, patient focused, patient oriented, co-design, co-production, co-creation, and so on…

The medical world is abuzz with the desire to make patients the central focus of all of our efforts. It is almost so blindingly obvious that patients should be at the centre of everything that we do that very often clinicians feel somewhat startled or amazed if challenged about the lack of focus on the actual wants or needs of the patient they are seeing at any particular time.

I think that physicians are carrying a few centuries of baggage when it comes to truly making the patient the centre of their business. When we look at medical practice over the years, and see how we have morphed from the days of Hippocrates, where he lived amongst his patients, understood their cultural connections, their livelihoods and social context, to the situation where we have constructed huge systems to convey patients to a highly qualified and skilled clinician to pronounce their fate after looking at the evidence of illness contained within their history, test results and imaging reports. As Foucault suggested, the patient was almost a secondary consideration, when coming under the ‘clinical gaze.’

However, these days the concept of the physician as owner, and keeper of medical knowledge – ready for dispensing at the appropriate time and place is being challenged by the democratisation of knowledge through the internet, and the empowerment this gives patients to seek alternatives, challenge received wisdom, and be so much more engaged in their own health decisions than ever before.

paper in this month’s issue has also got me thinking a bit about the sociological factors that influence what we as physicians think is important when we give advice or news to patients.

The paper in question examined the advice given to patients who suffered a stroke or TIA. Now, the DVLA issues guidance on driving restrictions for many many conditions, and for category 1 drivers, it recommends 1 month off driving, and for category 2 (HGV / public service vehicles) it recommends a year off driving.

But how good are doctors, and allied health professionals at giving this advice?

Sadly it turns out we aren’t great at it.

The knowledge of the correct duration of restrictions varied dramatically with only 28% of physicians giving the correct information, and 11% of AHPs reporting accurate information regarding driving after a TIA.  A lack of education may explain some of this poor performance – 53% of doctors, and only 18% of the AHPs had had any teaching specifically on fitness to drive after TIA or stroke.

As I was reading the paper though, I wondered if the lack of knowledge of how restrictive a condition could or should be for patients reveals a little about how patient centred we really are as a profession.  I suspect that the same group of doctors and AHPs – if asked about the correct antiplatelet regime, or the correct diagnostic workup to assess for further interventions, and how to calculate ongoing risk of stroke would have scored far higher than their knowledge about fitness to drive.  Is this truly just a lack of education? or is it that the truly patient centred stuff is sometime left till last.  We think that by knowing the very latest science revealing a marginal gain with a new medication is patient centred, as it will translate to better outcomes for the people we treat. And by ensuring that each and every patient is offered the latest imaging or potential for surgical intervention is patient centred for the same reasons.

But what happens when a patient having had a TIA gets home, and only discovers by themselves that they have invalidated their insurance by not informing the DVLA of their condition, or suddenly discovers they can’t drive to the social club or shops any more – but weren’t prepared for this whilst at the hospital undergoing scans and treatments?  It may not seem very cutting edge or advanced in terms of medical practice, but actually understanding the impact of an illness on the social and spiritual as well as the physical being before us will make us truly patient centred.

So yes, keeping up to date with the latest advances in medical technology are a vital  part of lifelong learning, but ensuring that we pay attention to what is important to our patients is also key to being a truly patient-centred clinician.


What do all those numbers really mean doc?

15 Jun, 14 | by Toby Hillman


What is ‘normal’

Go into hospital nowadays, and you will do well to escape without having a blood test of some sort.  Very often these are routine tests, which give doctors an overview of the state of play. There might be a few wayward figures here or there – but the doctors will ignore them, or explain them away as part of the normal variation of homeostasis.

In the PMJ this month the spotlight turns to one biomarker that is commonly requested when patients are admitted to hospital.  Indeed, the troponin is one test which I see regularly used completely out of context, and providing information which is often difficult to assimilate into the clinical picture.  The paper – an analysis of >11000 admissions to a large medical facility in Dublin, Ireland has examined troponin results for all admissions under the medical (but not cardiology) service from January 2011 to October 2012.

Now, the troponin is a test that has undergone a change over the time that it has been available to clinicians in everyday practice.  I can remember taking serial CKs in patients with suspected myocardial ischaemia, and my joy at the troponin becoming available for use in my potential CCU patients.  I can also remember the many patients who have been admitted to hospital for 12 hours just to see what their troponin will be – a clear case of a biomarker dictating practise, rather than been a tool for me to use.  And I have many memories of strained conversations with colleagues about the meaning of a mildly raised troponin which had been requested as part of a bundle of tests at the point of admission – without any real thought being given to how one might interpret the results.

These strained conversations have altered in tpne over the years as the blind faith in the value of troponin to indicate ischaemic heart disease which accompanied the hype of the test when it was first released, has been eroded by realisation that troponin is no way near as specific as we were once led to believe – and interpretation now requires quite a lot of Bayesian reasoning to clear the waters.

The article looking at troponin tests on the acute medical take makes a fascinating read, and helps provide some data to the consideration of the not uncommon problem – “well what do I do with this result now?”

The answer in the case of an unexpected elevated troponin is to consider the overall clinical context, and attempt to understand where the physiological stress has proceeded from, as this study shows a significant association between elevated troponin and mortality:

Exponential relationship between high-sensitivity troponin assay (hsTnT) results and in-hospital mortality.

So – a helpful paper looking at a common clinical scenario, and providing a fairly robust argument for how to approach the problem.

But one of the most fascinating parts of this analysis is the determination of what is ‘normal’ and why do we love to have such binary answers to complex questions?

The manufacturers of the assay employed recommend a cut-off of 14ng/L for the normal range. But, given that the test isn’t as specific for myocardial injury as they would like – a figure of ≥53ng/L should be used to indicate myocardial ischaemia. For the purposes of the published study a figure of <25ng/L is used as the cut-of for normal, and ≥25 as ‘positive.’

The persistence of a desire to classify a test result that the outcome of this large observational study indicate is a sliding scale, indicating physiological stress, rather than any specific disease process (in this study that effectively excluded cardiac disorders as the presenting complaint) into normal and abnormal categories belies a huge cognitive bias that we all carry around with us. Essentially we like to make judgements based on prior experience, heuristics, and easily interpreted chunks of information – what David Khaneman would call a ‘System 1″ or ‘fast” process. We do this regularly with a high degree of accuracy when on the acute take.

What this paper could be seen to do is boil down a clinical problem into another readily available answer, that can be applied in everyday practice – to me, it is a reminder of the blind faith I used to have in a test that I and it’s manufacturers understood poorly, and drove clinical protocols and pathways, rather than me applying some critical thinking to my actions, and their results – and using the test to its best effect.  I wonder how many more biomarkers we will see undergoing this sort of evolution.

50% of what you are taught is wrong…

30 May, 14 | by Toby Hillman

Glass Half Full by baileyraeweaver courtesy of Flickr Creative Commons.

Photo by baileyraeweaver courtesy of Flickr Creative Commons.

There is a phrase in medical education which often gets aired at the welcoming lecture to medical school:

“50% of what we teach you over the next five years will be wrong, or inaccurate. Sadly, we don’t know which 50%”

Quite why those welcoming students to a rigorous, physically and mentally demanding degree course would openly admit that 50% of what is on the syllabus is likely to be wrong is not clear.  Is it simply a reflection on their own career paths, and a lament for wasted hours of poring over books? a thinly veiled plea to the students not to take learning every cause and sign of clubbing too seriously, and ensure that they also enjoy their studies? or is this phrase a recognition of the ever advancing nature of medical knowledge.  If medical advances keep pace with Moore’s Law of the computing world.

This phrase has been called to mind a few times whilst reading through papers in the PMJ recently.  There is a couplet of papers looking at Eosinophilic Oesophagitis – a disease entity that has only really come to be widely recognised in the past decade or so ( in my medical school general text it garners a mere 5 or 6 sentences ) having been described first in 1978. One paper outlines the presentation and pathogenesis and the other covers the investigation and management of the condition. The presentation of eosinophilic oesophagitis can be varied, and difficult to tease apart from other conditions that can demonstrate very similar characteristics, and yet have a significantly different underlying pathology and requirement for treatment.

This overlap of presentations is not exclusive to eosinophilic gastroenteritis. As we understand diseases in greater and greater detail – we begin to recognise that the labels of the past may not be as accurate or helpful as we once thought.  In respiratory medicine, the two giants of obstructive airways disease – Asthma and COPD are becoming ever more blurred – as we see ever more advanced treatments helping in sub-populations, often determined by the inflammatory cells which inhabit the airways.  With this detail of understanding available more routinely to clinicians, the old labels become less helpful. A paper in Thorax recently called for clinicians to consider scrapping the terms Asthma and COPD - a sign perhaps of things to come in the post-genomic era of modern medicine, where we are more and more exact in our definitions of disease, partly because the treatments we are developing are more and more exact

Lung cancer is another field that is changing at a blistering pace. A recent republished article in the PMJ questioned the need for even asking if patients have smoked when considering their treatment for lung cancer.  The thesis is that smoking doesn’t correlate well with the driver mutations found in lung cancer genotypes, and therefore can’t predict suitability for, or response to treatment. This isn’t to say that smoking isn’t an important factor in the development of lung cancer – but it demonstrates how our understanding of a disease process has been revolutionised by technology which a few years ago was far out of reach, and is now routine practice.

Indeed – it will not be long before personalised therapies for different diseases will be based not on crude groupings like age, sex, or smoking habits, but will be guided by genomic studies of target organs – the age of truly personalised medicine is very nearly upon us.

Medical progress then is unrelenting, and all of what went before was wrong or useless.  Well, not exactly.  Foucault – a French Philosopher who considered medicine in some detail- used the term episteme to describe the unconscious structures underlying the production of knowledge in any given time and place.  So we can only develop knowledge which is available to us at the time we are studying.  Moreover, as new technologies reveal more about the nature of disease, and challenge received wisdoms of old, we are slowly changing the episteme in which we live, and enable further discoveries in diverse fields to be made.

As I read general medical journals, and discover new areas of science, medical practice and read about ‘new’ diseases or therapies, the papers which erode my ignorance reassures me that the medical world doesn’t stay still, but that the relentless pursuit of new knowledge allows us to bring greater understanding to the illnesses that afflict the patients we see day to day.

By appreciating that we can only be taught what is known when we are in medical school, the 50% rule is actually a reassuring acceptance of reality, and I think, a call to lifelong learning.


Yes to one thing… no to the others.

13 May, 14 | by Toby Hillman



Wellcome Library, London

One of the perennial problems that faces doctors who are in direct contact with patients is time management.  It is the one resource we all have to allocate, and with the multitude of different roles we all have to play – parent / sibling / doctor / teacher / friend / spouse / club captain / society president / charity trustee / or anything else for that matter – it can be difficult.

As a junior house officer (FY1 in modern parlance in the UK) I can remember literally running between patients on my first on call shift – simply to try to get everything done that was required.  It was only when I became more experienced and could prioritise, work smarter and effectively allocate my time that my shifts became significantly less sweaty, and I felt more confident in my work.

As we progress up the career structure of medicine, doctors tend to acquire new roles and responsibilities which take up more time, and can stretch ones resources significantly.  The most consistent advice I had when I was appointed to a consultant job was – say NO to everything for at least the first six months (and in some cases the first year.)  It is a little worrying that the main bit of advice for new consultants is to say NO – but highlights the fact that as a new face in an organisation, with seemingly a lot of time on their hands (whilst clinics are set up, and services start to gear up) most new appointees are keen to show willing, and take on projects which rapidly snowball and can overwhelm.

This month’s PMJ has a great article which should almost be on the key texts list of all postgraduate training schemes.

The paper is all about time management, and how to recapture time for what YOU want to do, not what your colleagues or boss want you to do.

The advice is all very useful – and perhaps the most important bit is beyond the tools and tricks for managing time – prioritising tasks and the like, but it is actually around the importance of goal setting.  It is easy to be very busy, but not necessarily make forward progress towards a defined end point.  If we can make time (ironic I know) to reflect on our priorities, and our desires for the future – both for work and for home, we are in a far stronger place to assess options and opportunities and how they fit into this scheme.  This process of goal setting can be difficult, and working on it alone can lead to skewed ideas about what will be profitable, and what is even possible.

This is where I have found mentoring and coaching input to be invaluable in the past.  The process of active reflection with a mentor or coach can help to crystallise ones thinking into genuine priorities and goals, and formulate a framework for assessing new opportunities as to how well they help one achieve what you have decided on as a goal.  Mentoring and coaching is often seen as a slightly left-field activity within medicine, but if you discuss personal development with any board level doctor or manager in the NHS and you will find that almost all of them will have regular coaching or mentoring sessions to assist them in their roles.  Oliver Warren and Ruth Carnall wrote a useful piece in the PMJ in 2011 which covers mentoring and coaching – and its relevance for medical trainees.

And now for my advice… the one thing which tends to keep me on the straight and narrow when considering my time management (or lack of) and my work-life balance, is that:  saying yes to one activity or project intrinsically implies saying no to something else. The decision about what you say yes to, or no to  is up to you, but we shouldn’t fool ourselves that we can do everything all of the time…


Is there any such thing as “IRL” ?

28 Apr, 14 | by Toby Hillman

Image via

Social media is all pervasive – it is nigh on impossible to see an advertisement nowadays without a hastag, facebook, pinterest or twitter handle attached.  Social media has been credited with sparking revolutions, riots and bringing down criminals, and is even used by the Pope to spread his message to the world.

Perhaps it isn’t terribly surprising that medical students are enthusiastic users, with over 90% reporting regular use in some studies.  The varied subjects covered on social media make it perfect for sharing not only pictures of cats, but also valuable educational materials and lessons.  Indeed, there is a conference specifically aimed at those who work in critical care and use social media (SMACC) – it is well worth checking out #tags like #RespEd and #FOAMed on twitter for up to the minute reviews of new developments in medicine, and medical education.

There is, of course a double edge to this particular sword.

In a profession which is renowned for using dark humour as a coping strategy for the difficult situations which are it’s core business, it can be easy for users of social media to fall foul of the usual standards expected in day to day life.  Various organisations, including the GMC and RCGP have offered guidance on social media use in the medical profession – here and here

For younger members of our profession, who are growing up with social media as a normal part of life, concerns not for patients, but for themselves may be around the corner.

Residency programmes in the US have previously been surveyed about their willingness to use internet searches to find background information on applicants through their social media profiles (see here). 10% already use social media searches to inform their selection processes, and nearly 60% did not indicate that using these methods would constitute any violation of the applicants privacy.

When the potential recipients of such attention are asked, the responses are somewhat different.  Medical students in the US were surveyed for their attitudes towards the screening of their social media profile (Facebook specifically) in a study recently published in PMJ.  The question being reported was part of a larger survey into medical student use of Facebook.  The students were asked if a posting on Facebook with pictures showing the student intoxicated, wearing a lewd halloween costume should have any bearing on their application for a residency programme.

The respondents didn’t share the views of the residency programmes – with a third of respondents indicating that such pictures should have no influence on their application as they are irrelevant, and only 2.8% feeling that such pictures would be sufficient for an application to be rejected due to the pictures alone.

So we have 60% of residency programmes feeling that they have the right to screen social media for background on their applicants, and 33.7% of applicants thinking that photos of themselves displaying unprofessional conduct are irrelevant.

This gap in the perception of the importance of social media in revealing underlying attitudes, and even ethical viewpoints is important.

Medical students of old were famously badly behaved – Doctor in the House made great use of this reputation to win a BAFTA in 1955.  Those medical students are now grown up, and helping to administer training programmes.  The behaviours of todays medical students are probably not vastly different from those a few decades ago, but it is the exposure of them to the wider world which seems to be disagreeable.  The use and abuse of alcohol, dark humour, irreverent behaviour still goes on, but now that pictures of these activities can fly around the world in a split second and remain online in perpetuity, they take on a new significance.  What were once seen as rites of passage in medical school, are now seen as grounds for dismissal or rejection.

The advice given in the paper, is sound, to a point – students should be aware that there is little privacy on the internet, that future employers can find information easily, that online information is nigh on impossible to delete, and that their online activities can affect their professional reputation.

But one piece of advice which sits less comfortably with me is that students should ensure they know how to keep their activities behind privacy settings.  This is clearly a pragmatic approach, and sensible advice for individuals, but it does not address the heart of the issue.  It seems that if we put up screens around our activities, we might shroud them once again from the public, and save students from public embarrassment, but we won’t have made any progress in understanding why there is such a powerful hidden curriculum in medical education, and what effects it has on out trainees.

Just because social media exists in the ‘virtual’ online world, we should not forget that, actually there is no virtual, online, or alternative reality, there is only IRL

(IRL = in real life for those who aren’t up to speed…)


It’s all the little things.

13 Apr, 14 | by Toby Hillman

This week I have been privileged to be at “the Forum” or to give it it’s full title, the 19th International Forum on Quality and Safety in Healthcare.

The Forum is an impressive event – there were over 3000 delegates from 78 countries, and over the week the virtual presence of the event was significant. At one point delegates were asked to refrain from ‘pledging’ at the top of the Arc de Triomphe as the authorities were concerned that there was some sort of effort to start a revolution (which was sort of the intention, but not in the way they thought….)

The keynote speakers were impressive, global leaders in patient safety, healthcare improvement, and have led some of the revolutions in how we deliver healthcare, and how we think about healthcare in the last few decades. The delegates were impressive too – leaders of national, international and global efforts to improve care for patients.

The keynotes I attended often included a call for action – Maureen Bisognano  @maureenbis asked us to strive to reach escape velocity, not just 10% better but 10 times better than we are doing at the moment – to break the shackles that hold back improvement, and flip to a new way of “doing” healthcare. Indeed – she asked us to move beyond healthcare, and start to focus on health as the outcome we need to improve.

On Thursday was the turn of a giant in healthcare – Don Berwick [@donberwickforMA] to rally the troops. Don’s call to arms was a little different though, and, I felt, was a big risk. Instead of concentrating on the technical tasks of improvement, the challenge of balancing ever more demand with ever higher costs, and diminishing resource, he took us all to a different place.

Don spoke from the heart about his grandson, and the visceral joy it brings him to be with Caleb. And building on Maureen’s wish to see health as the goal, Don set out the case (medical and scientific) for flipping healthcare, and encouraged us to consider how we could wholeheartedly aim for health and wellbeing. He name checked gurus in what might be considered alternative thinking on healthcare, and used a word which was new to me, but got me excited – salutogenesis. (In later conversations with other delegates, it seems I am behind the curve on this one) the keythemes he wished to see included in the debate in the future are in there slide below:


But what about the hard thump of reality that is waiting for me when I get home? I don’t think I will be able to go to my medical director an say outright that we need to create a salutogenetic environment in our hospital and expect to be taken up on the scheme immediately. So for the non-superstar improvers, those who haven’t sparked revolutions yet? What did the conference hold for them?

Well, this was in fact the true message of this conference for me. The big, bold visions and calls to action were great, and my experience would have been less rich without them. BUT – taking a bit of time out to see the posters, and listening to the messages from many sessions on how to implement change, capture learning, use data effectively, I got a very different message.

It is all very well aiming for 10 times improvement in outcomes by flipping healthcare, and helping our patients achieving wellness, but the road to all of this is made up of tiny steps. Be that the simple, but massively influential #hellomynameis idea from Kate Granger @grangerkate or the rearrangement of clinical equipment stores to reduce time taken to get kit together from 2min41s to 26s) at St George’s Hospital, or learning how to tell your story to engage others – it is only through many thousands and millions of small changes, all anchored in the visions set out by the big players that we will achieve any of that vision.

The greatest moments for my own learning came through chatting about a problem I have to deal with at work with a few other delegates – very small, very personal, but it will start to introduce the changes my Hospital needs to make to reach a vision of enhancing health in the population it serves, not just delivering more and more health-care.

So – as one of the many quotes I noted at the conference says – we need to keep our feet on the ground, and our heads in the stars.

I hope that you will be able to make use of the conference resources or the ideas that delegates broadcast via the #quality2014 tag on twitter (even if you out don’t sign up its worth looking at twitter as a reference source for events like this) to start out on your own small change – however small that might seem.


Is it all in your head? – not quite…

31 Mar, 14 | by Toby Hillman


A paper in the current issue of the Postgraduate Medical Journal tackles a relatively modern concern: chronic postsurgical pain.

With the advent of modern anaesthetics, and advances in surgical technique, the potential for surgical intervention to tackle disease exploded.  Indeed, there is now a whole industry based on surgically changing the way people look, which in the early days of surgery would have been almost unthinkable. For example, Samuel Pepys put off an operation for his bladder stone (which caused great pain and many infections) for many years before submitting to be cut by Thomas Hollier. [The lithotomy is now a rare beast, having been superseded by less invasive means of removing stones from the urinary tract.]

So surgery is now a much more accessible, and much safer option for the management of disease than it once was.  However, it is not without its problems, and one which may have been under-represented for many years is that of ongoing pain.  The incidence of chronic pain is quite remarkable, with up to 35% of patients undergoing hernia repair reporting pain more than 3 months after their surgery, and higher percentages in patients  undergoing cardiac or thoracic surgery, and even in cholecystectomy rates of CPSP of up to 50% have been reported.

The paper discusses the pathophysiology of pain, and strategies to reduce the likelihood of developing chronic pain. The concepts of central sensitisation, secondary hyperalgesia, wind-up potentiation and pre-emptive and preventative analgesia are of great interest.

However, as one progresses through the article, a change takes place.  One is guided into the realm of the pain clinic.  Here, it is recognised that pain is not simple, it cannot be neatly captured in a line diagram of the spinothalamic tracts, but that pain is a multi-faceted experience for each patient, that can be influenced by a whole range of factors.  The physical risk factors identified for the development of chronic postsurgical pain are important to note, including surgical technique, repeat surgery, and radiation to the surgical site, but what struck me more was the number of risk factors which could be described as relating to mental wellbeing.  Six of the listed risk factors relate to mental state.

This key component of chronic postsurgical pain is borne out by the authors as they discuss the importance of the fear-avoidance model, and how anticipation, and fear have measurable influences on pain perception – confirmed through neuro-imaging studies.  These insights into the development of a chronic condition, and how patients respond to their pain is hugely important, and their application extends beyond chronic postsurgical pain.

One of the key interventions the authors highlight is the provision of information to patients who are undergoing surgery to enable them to understand what they were experiencing post-operatively.  The paper refernced was the report of an experiment conducted about 50 years ago   that examined the effect of an enthusiastic anaesthetist discussing the expected levels of post-operative pain, non-pharmacological methods of alleviating that pain, and a daily reinforcement of this message.  The results are quite impressive, with a reduction in narcotics required, improved comfort, and a 2.7 day reduction in length of stay.

It is on similar techniques that the enhanced recovery programmes employed by many NHS trusts are founded. Essentially, patients are encouraged to take an active role in understanding their condition, the surgery they are undergoing, and are briefed as to what is normal with regards to pain and limitation post-operatively.

The key intervention for me here is that patients are fore-warned about what they are likely to experience, they are given ‘permission’ to be in pain – and to know that this is not a harbinger of doom, or that they are doing irreparable damage to their newly fashioned wounds.  By being up-front about these experiences, fear is dissipated, patients are empowered, and outcomes tend to be better, even though the surgical technique, anaesthetic technique, post-operative pain regime and environment are all pretty much the same.  The major difference is that the patient has been offered some psychological protection, even if it is not labelled as such.

The lessons learned through the experiences of surgical patients over the years can be translated across many spheres of medicine – the marriage of body and mind is not always perfect, and yet, if we only pay attention to one side of the equation, our patients may well pay the price in the longer term. It is a shame that the lessons published in 1964 are not more widely employed, although the tide is changin.  I am convinced that psychological interventions can play a hugely important part in enabling patients to cope with their long-term conditions, of all sorts.

Despite being the calling card of politicians recently, it really is true that there is not such thing as health, without mental health.

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