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 The importance of caste!

11 Aug, 17 | by jbanning

Dr Sagarika Kamath
Assistant Professor
Manipal University, India

Dr Rajesh Kamath
Assistant Professor
Manipal University, India

As young doctors being trained in hospital and health administration, we had a class in Organisational behaviour where the professor began saying that caste was a very important factor in any organisation. It was important for the caste to be right, the professor pontificated. If attention wasn’t paid to caste, then no matter how good the organisation was, it wouldn’t last. Organisations that didn’t pay any attention to caste became uncompetitive. Caste was all important. Several of my classmates couldn’t believe their ears. We were in an educational institution that prided itself on its principles of equality, equity, social justice and welfare of the underprivileged. Casteism was anathema. This was among India’s foremost institutes of social sciences. Exactly half the class came from underprivileged backgrounds or from castes that had been classified by the government for, among other purposes, affirmative action, as historically disadvantaged. There was an air of disbelief at what was happening. How could someone say that the caste had to be right?

Healthcare was caste intensive, he continued. Maybe it wasn’t apparent now, but we only had to start working and we would realise the importance of caste. Top management is always concerned about caste. Your bosses will be concerned about caste. In no time, you will also become attuned to the all pervasive importance of caste! One of the students could take this no longer. Sir!, his hand shot up, I do not agree with you. How can you say these things about caste?! The professor seemed perplexed. If the caste is high, he continued, can the common man afford healthcare?

Afford? Caste? It then slowly dawned on us that what the professor with the Tamilian (Tamil Nadu is a state in southern India) accent meant was “Cost”, but his accent made it “Caste” to our non-Tamil ears. With this realisation came relieved laughter. The tension vanished. Caste didn’t matter, thankfully.

Competing interest statement : We declare that we have no competing interests.

Contributorship statement : Both the authors have conceptualised, drafted and proof – read the contribution.

A collection of thoughts from Colorado Springs to mind

8 Aug, 17 | by jbanning

Philip D Welsby
Retired Consultant in Infectious Diseases,
University Teaching Fellow, University of Edinburgh

Two events of medical interest occurred during a recent visit to the Rocky Mountains and Colorado Springs. I developed gout in my left little toe within one week of arrival in Denver, the “mile high” city (5,280 feet) above sea level. Denver is technically a semi desert, having only 15.8 inches of rain a year, and has the third lowest humidity of all American cities. I had had an exactly similar attack of gout when I had previously visited the Rocky Mountains. Almost certainly the gout was precipitated by unappreciated dehydration, with water loss via increased ventilation (related to relative hypoxaemia at altitude and increased sweating). Why the little toe? I had severely dislocated this during a judo related incident as a medical student.

My 12-year-old grandson, who lives in Illinois (583 feet above sea level), developed central cramping abdominal pain a few days after arrival, later localising to the right iliac fossa. There was tenderness, rebound tenderness, and a positive psoas stretch test. He was however afebrile and, although having marked discomfort, was not systemically unwell. His urine was dark but not cloudy. Appendicitis was obviously a possibility. I thought, correctly, that he ought to be seen by a proper doctor who, to my slight embarrassment, diagnosed constipation (although my grandson had never had constipation before), and this was supported by a predominantly right sided loaded colon on X-ray. Apparently doctors practicing locally at high altitude see more severe forms of constipation, again because of unappreciated dehydration.

The learning point from these two episodes is that altitude-related dehydration can be more significant than superficial assessment might suggest, can cause significant problem, and local “high-altitude doctors” see a different spectrum of dehydration in recently arrived visitors than do “sea-level” doctors.

Collusion, illusion, or delusion?

22 Nov, 16 | by Toby Hillman

Fending Off Death 1 by wiebkefesch on DeviantArt

Doctors are – in the main – trained to prevent death.  Modern medicine has made huge advances, and life expectancies continue to rise.  However, there remains only one certainty in this life – that we are all going to die.

Patients in the last year of life are common in hospital.  Data from a 2014 study showed that nearly 30% of patients in hospital are actually in the last 12 months of their lives.  However, identifying these patients, and appropriately managing their last few months of life is notoriously difficult in those patients with chronic diseases like COPD, and in patients where multi-morbidity makes such predictions even more complex.

Patients receiving palliative chemotherapy for lung or colorectal carcinomas have been found to have an overly optimistic view of what their palliative treatments will achieve.  A 2012 study published in the NEJM showed that patients with stage IV disease overwhelmingly (93.6%) opted for chemotherapy treatments.  And of those that received chemotherapy, 69% of those with lung, and 81% of those with colorectal cancers wrongly felt that the treatment might offer a chance of a cure.

A study published recently in the PMJ from Dr Jeba and colleagues in Tamil Nadu looked at the prevalence of collusion during consultations with patients being seen in their palliative care clinic.  The authors defined collusion as consultations where information was withheld from the patient primarily at the request of family members.  There was surprising number of patients who made it to the palliative care clinic without knowing their diagnosis at all (18%), and collusion regarding diagnosis or prognosis was present in 40% of cases referred.  Of these, within a month 58% had had this collusion addressed.  The remaining cases were thought to be those where the family request for information to be withheld was very strong and persistent.

The study looked at factors which might be associated with collusion and found that collusion was more prevalent where female patients were affected, and was more prevalent amongst patients whose occupation involved manual labour.  It was felt that cultural norms will have led to a bias against women being fully involved in decision making.  Manual labour may have been a surrogate for educational attainment – and it is well described that less educated patients often have less information needs.

Fascinatingly, the study also revealed that if the family member attending the clinic was the spouse of the patient, collusion was very much less likely.  Perhaps the presence of one who knows the other so well simply means there are less opportunities to hide feelings and knowledge.  Other than trying to ensure that the spouse was present when a diagnosis was being discussed, no firm conclusions were made.

These three scenarios – doctors chasing an illusion of wellbeing – patients believing in a treatment will do what it emphatically cannot  – and finally collusion between treating doctors and relatives – are all important reminders that doctors hold a vital position of power, and how we wield this power has a significant impact on the patients we consult with, treat and comfort.

The delusions, illusions and collusions we all engage in as physicians are well-intentioned, but as the internet democratises information, and patients are no longer so willing to be advised directly on a course of action or of treatment – doctors must change.

We must truly reflect on our interactions with patients – and work out if we are peddling a myth, and if we are, why? Is it our own biases, experiences or fears?  And if we are acting in the best interests of the patients – have we actually given them an opportunity to express their opinion?

I suspect that if we do each of these things – we might find that the ones who have been a little deluded – chasing an illusion – are ourselves.

All in a day’s work

20 Oct, 16 | by Toby Hillman


Becoming a doctor is a long and arduous process.  It involves many years of study and more of practice.  It is inconceivable that this process leaves those who go through it untouched.  This process is called professional socialisation.  It confers values, and behaviours on the participants, and these help to mark our profession out from other groups in society.

The following reflection is from Dr Ciara Deall, a trainee plastic surgeon, recalling events which took place on a flight to North America, and in which her training allowed her to offer a stranger comfort, despite being off duty – a state that perhaps is never truly realised by those whose vocation is the practice of medicine.

We had cleared the west coast of Ireland and I was beginning to relax on flight AA365 heading for New York and a weeklong, intensive microsurgery course. Just time to let go of a non-stop week of on-call mayhem and enjoy some inflight entertainment to help wind down.

The intercom interrupted abruptly: “Hi, this is the chief steward, will any medically trained passengers please make themselves known to the crew; we have an emergency.” Almost without thinking I found myself standing up and telling a stewardess I was a doctor, before wondering what I might be letting myself in for – a stroke, anaphylaxis, heart attack, choking? Was I the only one?

The 19-year old girl was doubled up in agony, clutching her stomach, clearly very frightened and panicky. “Hi, I’m a doctor.” She was French and couldn’t understand much English. However, her GCS was 15, pulse and respiratory rate were raised but in range, she was not breathless and on eyeballing her from the aisle, she was in pain, but not acutely deteriorating.

The stewardess asked if there was anything I needed. “An interpreter please.” Not quite what she had been expecting, but after another intercom request, the perfect match was found and I made rapid progress in establishing my patient wasn’t pregnant, had no fevers, no urinary symptoms or diarrhoea, but had been out the night before eating too many different foods and drinking too much alcohol with subsequent vomiting episodes. Her pain was 4-5/10, crampy in nature and relieved by lying down. On abdominal examination she had very mild generalised tenderness, but a completely soft abdomen with no guarding or rigidity; bowel sounds present.

Her panic was subsiding fast with my apparent calmness as I completed the full history and examination. I was offered an astonishing state-of- the-art medical kit and pointing to an endless array of emergency drugs, including adrenaline, atropine and morphine, the stewardess invited me to help myself to whatever I wanted! I almost felt guilty in only using the sphygmomanometer and some mild pain relief, explaining the other drugs could severely harm or even kill her!

My patient settled to rest lying down, with water to hand for her dehydration. I promised to be back in 15 minutes. The crew were effusive in their gratitude and what it meant to them to have an ‘expert’ on hand. They recounted some past horror stories where no one had volunteered. Unwittingly I had calmed their nerves as well.

Back in my seat I reflected for a while on my encounter and realised the potential vulnerability of tens of thousands of long haul travellers daily and their attending cabin crew. Crossing immense oceans a truly sick person could be many hours away from trained medical staff and properly equipped facilities, unless there happened to be a willing, qualified passenger on board; clearly a gamble that is a daily occurrence. I was glad of my ATLS training, recognising it could be called on at anytime, anywhere, even at altitude.

Furthermore, it was a reminder of the unique (and privileged) position that doctors have, where particularly in emergency situations, complete strangers are willing to put their absolute trust in us. Even when we least expect it, the way we conduct ourselves and the skills we deploy can have a profound effect on those around us, for both patient and onlookers. No one cared whether I was a junior doctor or not. At 38000 feet I was valued for my willingness to offer and use my expertise. It was a sobering, almost humbling thought and without overstating it, I reminded myself that we are never completely ‘off duty’.

My patient slept. On waking she smiled feeling much improved and couldn’t thank me enough. Approaching New York, the stewardess asked if I had space in my carry-on for a bottle of their best champagne. I did!

At the end of the flight I accompanied my French charge off the plane. Another fascinating day in the life of a junior doctor.

The art of medicine.

14 Sep, 16 | by Toby Hillman



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.

In the land of the blind…

13 Jun, 16 | by Toby Hillman


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


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.



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