You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Archive for February, 2014

How to mend a broken heart…

13 Feb, 14 | by Toby Hillman


photo credit: Mrs Magic via photopin cc

“Doctoring her seemed to her as absurd as putting together the pieces of a broken vase. Her heart was broken. Why would they try to cure her with pills and powders?”


So, it is Valentine’s day – and what better than a bit of medical education about broken hearts.  As it happens, Leo Tolstoy may have been onto something when he wrote Anna Karenina.  Why would one try to cure a patient with a broken heart?

Well, helpfully, this paper examines the question of what non-pharmacological treatments are available for end stage heart failure.

The paper explores the major recent advances in devices for heart failure, and is a great primer for the general physician, or generally interested on the recent advances in medical technology available for those with end stage heart failure.

The devices which grab my attention are those which have the potential to inform patients, and their treating physicians even before symptoms of an exacerbation of their condition occur.

This paper describes three existing systems which can allow patients to monitor their own condition.  The devices use surrogates for fluid overload, or impaired LV function (intrathoracic impedance, left atrial pressure, or right ventricular pressure) and can be used to provide feedback to decision makers to allow adjustment of therapy, pre-emptively arrange admission, or intervene in other ways to avoid an exacerbation.

These advances may represent something of a watershed in the management of this particular long term condition, and in the involvement of patients in management of their own diseases.

For years patients have sought help, relief, and advice from their physicians. The traditional model is that patients attend clinic with their physician, have an assessment which lasts a few minutes, and then a plan is made to last for the next few weeks / months or years.  This doesn’t, however, reflect the lived experience of long-term conditions when seen from the patient perspective.

Patients with LTCs actually live with the condition impacting on their every day life.  Indeed, the condition ultimately can become part of their personal identity.

Recognising that patients live with a particular condition, and yet, are often subject to the decisions made by physicians, and live with the consequences of these decisions until their next visit is vital if we are to understand how to assist patients in taking back control of their disease, developing greater health literacy.

Technology can provide the answers in some cases, but only if we trust patients by giving them back some control.  In the case of heart failure, it seems that providing patients with the ability to monitor various indices can lead to improvement in symptoms, and even lead to an overall reduction in drug treatments.  People with diabetes have been entrusted to control their own blood sugars through self-administration of insulins for many years now, and the provision of action plans for patients with respiratory conditions like asthma, bronchiectasis and COPD have resulted in improvements in overall symptom and disease management.  The blending of technology and self-management is gathering pace, and the opening up of clinical information to patients through systems like Renal PatientView are transforming the way some clinicians and patients approach long-term condition management.

So, on this feast of St Valentine, why not take a look at the options for patients of yours who may have broken hearts, but also think about how utilising advances in technology can help to transform not only disease management, but also change the relationships we have with our patients, and they have with their diseases.






Help! – I need somebody…

1 Feb, 14 | by Toby Hillman

One of the best school mottos I have encountered is that which introduces the General Knowledge Quiz of King William’s College on the Isle of Man.  The motto is:  Scire ubi aliquid invenire possis, ea demum maxima pars eruditionis est.  It  essentially translates as, ‘ to know where you can find anything is, after all, the greatest part of erudition’

I sometimes feel that this should be a touchstone for healthcare professionals nowadays.  Often we encounter situations where we don’t know the answer, and yet, that doesn’t really have such an impact now that we can access focused, accurate and useful information readily – if we know how to use the tools available.

But what is it that makes us recognise our knowledge deficit and press the HELP button?

A paper published in the PMJ has studied what makes emergency physicians consult an emergency poisons advice service. This study found that rates is consultation to the poisons service were significantly lower than in previous studies (only 11.4% of cases were referred), and there were some important differences between those whose cases were discussed with the poison centre, and those whose cases weren’t.

However, female sex, multiple substances, and suicidal intent did result in a higher rate of consultation with the poison service. The day of the week that the case presented to hospital had an influence on referral (more often consulted on Mondays and Tuesdays) and the severity of the incident had a fascinating influence in that if the poisoning severity score was zero (low) or three (severe) then consultation was more likely, but mild and moderate cases prompted consultation less often.

The authors of the paper offer some reasons why they feel the results were returned, but can’t offer explanations for all of the observed associations.

So, for the emergency physicians studied – does a case of poisoning with no symptoms offer few clues as to the required management, or what to suspect – hence the call for help, and is it that odd poisons are ingested on Mondays and Tuesdays, whereas on Fridays and Saturdays it is just the familiar alcohol / heroin which is sadly routine in many EDs in this country too?

The low rate of referrals reported in this paper made me consider my own decision making. What is it that makes me reach for the phone to check on my decision making, and in which situations am I more confident?

Cognitive bias can be defined as a pattern of deviation in judgement, which can lead to illogical decision making.  This paper in the NEJM highlights the importance of being aware of cognitive bias, and advises physicians to undertake regular surveillance of one’s intuitive behaviour.

Many biases can come to bear on the diagnostic thinking of physicians within the ED, and other wards:

Triage cueing – the difficulty of leaving the initial judgements of the triage assessment behind, even when new evidence comes to light.

Anchoring – the attribution of greater importance to a key feature that is heard early in the history.

Ascertainment bias – when stereotyping and prior expectations exert undue influence on a supposedly rational process.

There is also the cultural context to be considered.  This paper on the culture of medicine offers some additional food for thought about why and when we ask for help…

It may not be that cognitive bias and cultural context can fully explain why physicians don’t consult dedicated poison centres when confronted with cases of poisoning, but this paper does provide an opportunity for us to reflect on our own practice – how often do we stop to question our own intuitive behaviour, and consider when and why we ask for help?

Next time you find yourself holding back from asking for help to solve a bit of a diagnostic conundrum, or feeling that you ‘really should know the answer to this one’ just consider if it is your cognitive biases trying to persuade you down a particular route, or that your intuitive behaviour is taking over your analytical thinking – and if in doubt, really do ask for help… especially if it involves poisons.

Latest from Postgraduate Medical Journal

Latest from PMJ