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Archive for March, 2015

Observe, record, tabulate, communicate…

31 Mar, 15 | by Toby Hillman

Observe, record, tabulate, communicate.

© CEphoto, Uwe Aranas / , via Wikimedia Commons

When I was knee high to a grasshopper, I had a teacher that used to be incredibly irritating.  Instead of getting away with a lucky guess, or a grasp at a faded memory, we had to be able to ‘show our workings.’  This meant we had to understand where our answers came from, from first principles, and learning by rote wasn’t going to cut it.  At the time this was infuriating, and led to a whole load of extra work. However, now I realise that she had started me on a learning journey that continues on a daily basis.

This insistence on understanding the basis for an argument or fact has been a common feature amongst a number of my most inspiring tutors over the years since.

One particular tutor was Dr Alan Stevens. He was a pathologist at my medical school and was assigned to me in my first year as my tutor. Pathology made up quite a significant portion of the syllabus in our first years, and what a bore – hundreds of blobs of pink, blue, and occasionally fluorescent green or yellow. And all of these colours were swimming before my eyes in a lab that seemed a million miles from the wards where the ‘real’ work of a hospital was under way.

So when Dr Stevens took us out for a meal in the week before our yearly finals (another insistence that good wine and good company made for better performance than late nights cramming in an airless library – I still nearly believe this one) and he started to explain how pathology is the basis of knowledge of all disease, I was a little upset.  As with most medical students I was sure I knew best and knew what I wanted to learn so pathology remained one of those subjects that was somewhat neglected in my revision schedules.

However, once I hit the wards, I rued the day I forgot to ‘show my workings’.  As I encountered diseases I knew the names, and symptoms of, but had a sketchy understanding of the pathology or pathophysiology, I struggled from time to time with working out why a specific treatment might help, and how treatment decisions were being made.

A paper in this month’s PMJ may appear to be one of those that a casual reader would skip entirely owing to the title, or the description. A clinicopathological paper on fulminant amoebic colitis may not have immediate relevance to my work, but the paper is an example of how medical knowledge has expanded over the years;  a clinical question, borne out of experience is subjected to scientific examination and analysis, in an effort to move beyond the empirical approach to disease.

The paper looks at the clinical featues, pathological findings and outcomes of patients admitted to an 1800 bed tertiary care centre in Western India who underwent colectomy, and were diagnosed with amoebic colitis.  30 patients were included in the study, and the mortality rate was 57%.

Various features are explored – with some information flying in the face of traditional teaching.  For example, the the form of necrosis encountered in the study was not that traditionally associated with the disease – and could lead to a change in practice in the path lab – potentially allowing a more rapid diagnosis.(In the study the authors found basophilic dirty necrosis with neutrophil rich inflammatory exudate in the study population vs eosinophilic necrosis with little inflammation usually reported in textbooks)

The authors also pose some interesting questions in their conclusion regarding their observed increase in disease incidence – relating to many of the current woes in clinical medicine.

Overuse of medication is suggested as a contributing factor to the increased incidence of amoebic colitis. The authors postulate that indiscriminate use of antacid medications may be promoting the increased incidence of amoebic colitis by allowing ameobic cysts to survive transit through the stomach.  This mirrors some of the concerns about the (over)use of PPIs promoting c. diff infections in the UK.  In addition, lifestyle factors are suggested as contributory – a reduction in dietary fibre can increase colonic transit time, increasing opportunities for the amoebae to adhere to the bowel wall – and the organism itself may be changing in virulence.

So whilst I may not have learned a great deal that I will employ next time I am in clinic, this paper is a great example of the value of close observation over time of the population one serves, maintaining an enquiring mind about the pattern of disease encountered, and then subjecting such notions to scientific scrutiny – eliciting new knowledge, new questions for research, and returning this information to the clinical field to improve practice, and hopefully change outcomes for patients of the future. Osler would be proud.



Our caring profession

16 Mar, 15 | by Toby Hillman

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Anatomy of a Junior Doctor – Eoin Kelleher


The rigours of life as a junior doctor are well described, both in popular modern classics like House of God by Samuel Shem and the television series Scrubs, but also in lesser known works, like A Country Doctor’s Notebook by Mikhail Bulgakov.

There are common themes – imposter syndrome, fear of killing patients, bullying seniors, long hours, mental and physical exhaustion.

There is no doubt that working conditions have improved somewhat from those experienced by Bulgakov in revolutionary Russia, but the first months and years of clinical practice remain a difficult time.

A paper in the current issue of the PMJ looks at a group of junior doctors who face additional challenges, and examines their coping strategies.

Dyslexia is considered to have a global prevalence of around 6% and in the medical profession, the rates of declaration of dyslexia amongst medical students are around 2%, and rising.  The paper highlights the difficulties that people with dyslexia face, and the potential impacts these would have on doctors who have just entered into their professional roles.

All of the FY1 grade doctors in Scotland were asked if they would take part in the study, and 9 agreed.  This could represent about 40% of the junior doctors in Scotland who have dyslexia, so the study provides quite an insight into their experiences.

One question that interested me was if the subjects had disclosed their dyslexia to colleagues.  The report states that only a few had discolsed their dyslexia to colleagues.  The reasons for this were varied.

Some felt that to disclose a problem like dyslexia might be considered by others as ‘help-seeking’ or as an excuse for poor performance, that would mark them out as different from the ‘neuro-typical’ house officers, with the attendant problems this might produce.  Shame was a factor in some decisions not to disclose, and there was anxiety amongst the subjects about the impact of dyslexia on their future careers – owing to the difficulties with written exams, and subjects were aware that dyslexia could become a reason for bullying.

Only the minority had actually disclosed their dyslexia to others, and had seemed to have benefited – with a wider range of coping strategies available, particularly in troublesome settings like ward rounds, or presenting cases in MDTs. One subject had made use of a ‘buddy’ system for writing on ward rounds.

The issues that this paper highlights around disclosure of dyslexia throw up questions to us all about how we as a profession treat our colleagues – not only those with dyslexia, but anyone in our profession that might be suffering with an illness that is not immediately obvious.

My most recent blog tried to highlight that doctors remain humans, despite their attempts to control physiology, master illness and manipulate tissue. As such, we are at the mercy of the cognitive biases that have been discovered in other professional groups, but we also need to realise that we are at the mercy of our own biology just as much as those patients we try to help. And yet, as a profession we still take pride in being robust, if not indestructible, and the prevailing opinion is generally that admitting to an illness, or struggle is beyond the pale.  This is reflected in ubiquitous anecdotes about ‘never having had a day off sick in x years’ or ‘the only reason I got any treatment was because I clerked myself in.’

However, when studied objectively, residents in the US reported the feeling that there would be both empathy for colleagues who missed work through illness, and a concurrent risk of being ostracized from their peer group.  This tension reflects the both the caring nature of our profession, but also the seemingly excessive expectations we place on ourselves and our colleagues when it comes to stamina, and resilience.

I would not advocate moving to a world where the slightest hiccough sends us running for the duvet, but equally, if colleagues in one of the most stressful periods of their careers cannot turn to peers and supervisors for help for fear of being ostracised, then the hidden curriculum has swung the wrong way.

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