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Archive for July, 2014

Too much information?

15 Jul, 14 | by Toby Hillman

Information overload – by BigCBigC at deviantart.com

 

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

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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.

 

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