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Three pipe chest pain…

14 Dec, 15 | by Toby Hillman


Medicine is no longer quite so full of time to ponder as it once seems to have been.  Rumination and consideration have taken a back seat to efficiency.  Protocols and pathways seem to be the order of the day, and once a patient is on a pathway, it can be very difficult to get them out of the diagnostic rut they have found themselves in, which more often than not is a medical cul de sac.

A paper in the PMJ on the clinical and diagnostic findings in patients with elevated CSF bilirubin set me off thinking about these dead-ends.

The paper takes a fine toothed comb to the cases of patients who underwent CSF bilirubin analysis as part of their assessment for headache over the course of a decade at two hospitals in Northern Ireland.  The paper explores some of the ins and outs of CSF analysis for possible aneurysmal SAH and gives some helpful insights.  One curiosity that stood out was the 13 patients in whom there was a complete lack of history of headache (not even simply not recorded as far as the presented data suggest) who underwent CSF bilirubin testing.  I suspect that this was over-eager requesting becuase CSF had been obtained, and all the boxes got ticked.  As far as this paper is concerned though, this practice diminishes the specificity of the test and as such erode the positive predictive value of the test.

However, my interest was piqued by the natural use of a term that will be well understood by medics who work in acute medical units, and seems to have become part of our everyday clinical language – the “CT negative headache.”  This terminology has cousins that are probably more often heard, but are just as beguiling in their simplicity and ease of use, but troubling in terms of their complete lack of detail.  These terms can be sprinkled liberally onto the discharge summary – neatly encapsulating the battery of tests that a patient was subjected to – resulting in normal findings (or non-significant ones at least) but sadly they entirely miss the point.

Pathways are designed with an end diagnosis in mind, and if a patient flows along the pathway, ticking the boxes as they go, or being forced to occupy them (the crime of procrustes) then they may usefully end up with the correct treatment, given in a standardised way with utmost efficiency.  However, there are few pathways with “diagnostic uncertainty” as the start point.  There are even fewer that allow one to consider all of the alternative diagnoses (the CSF paper above reminds us that there are over 100 causes of sudden and severe headache described) that might contribute to the clinical conundrum facing us.

As such – if your patient comes to hospital nowadays with chest pain, they may well go home with a diagnosis of chest pain (troponin negative).  This has not necessarily helped many of the players in this scene.  If the patient’s main concern was specifically that they were having a heart attack – this could be reassuring.  However, if I was the GP who had asked for the opinion of their local specialist service, I might feel a little short-changed.  Negative diagnoses do not contribute a great deal to a positive outcome.  Instead, it might be more helpful for the patient to go home with at least a list of possible or probable alternatives – costochondritis, or oesophageal spasm, or dyspepsia, or my personal favourite when I see it – the slipped rib syndrome

Negative diagnoses are undoubtedly here to stay – it is just too easy to be able to exclude the killer diagnoses, assure yourself and your patient that they are safe, and then send them on their way.  However, as educators, and as clinicians we must ensure that our adherence to guidelines, protocols and pathways do not allow our curiosity to atrophy, and through our own acceptance of the negative diagnosis, let this practice to be seen as the norm.

Sherlock Holmes used to rate problems by the number of bowls of tobacco required to think them through – in the world of multi-morbidity there are plenty of three pipe problems to be faced.  And whilst I don’t lament the passing of the ward smoking room, I think there is definitely something to be said for bringing back the art of the positive diagnosis, even if it requires a little rumination, and wandering from a well-marked pathway.


Aiming for ‘normal’

14 Nov, 15 | by Toby Hillman

Don Quixote via scriptingnews on

Normal ranges are papered to the door of almost every clinical medical student’s lavatory door or fridge, inside the cover of every notebook in the wards – accompanying every result on the EHR – everywhere we are told confidently what normal is. But as this paper studying the laboratory findings of several thousand inpatients at a hospital in North London highlights – ‘normal’ is not as clear cut as it may initially seem.

A paper from the hospitals looked at in this study was the subject of a previous blog  which highlighted the variation in practice and often poor implementation of ivestigations into the cause of low sodium values in patients acutely admitted to the three hospitals involved.

This paper has taken a signal from a previous one and has now produced data that questions the validity of the 135-145 range for serum sodium.

The authors noted during their previous studies that many of the patients acutely admitted to the hospital had low sodium results, whilst a cohort of patients from care homes had higher values, and seemed to be dehydrated.  The mortality for patients being admitted rose with increaing sodium concentrations – but the break-point in the graph was within the normal range. So we have a population whose results don’t fit the ‘normal’ range, and a ‘normal’ range that seems associated with increasing mortality:


Locally estimated regression (locally weighted scatter plot smoother, LOWESS) plot of serum sodium against mortality for inpatients aged under 65 and 65 and older.


Clearly these retrospective observational studies shouldn’t have lab managers running around redefining normality and encourage us all to drive our patients’ sodium to the lower half of normal in an attempt to save lives…

BUT and it is a big but that deserves capital letters – we do need to work out who defined normality.  Thankfully Prof McKee and his colleagues have done a bit of digging for us and give a potted history of the normal range for sodium measurement. And it turns out that this range – embedded in millions of memories the world over is actually based on comparatively few data points – the first papers used about a hundred healthy volunteers using flame photometry – a technology that is largely superceded by more accurate methods.  The subsequent studies they refer to us up to a 1000 measurements (often in multiple sub-groups) from which they drew their conclusions.

How can this be? Surely we don’t just take decades old evidence and allow it to heavily influence our treatment plans, delay discharges and so on?

In this case the answer seems to be… yes.  However, this is not the only sphere of medicine where old data continues to heavily influence current practice.

Oxygen is one of the most commonly administered, but not prescribed, drugs in the formulary. In COPD it is one of the few drugs that has evidence for influencing mortality, rather than simply altering a trajectory of decline…

And the evidence for this? It is predominantly based on an MRC funded study from the late 1970s that included 87 patients.  That evidence was enough to change practice, and alter lives I am sure, but it probably would not stand up to scrutiny for the basis of a major shift in practice nowadays.  The linked paper on sodium measurements, for example looks at more than 100000 samples and trials of therapy in COPD looking to demonstrate a mortality benefit now need to have thousands of patients (the TORCH trial enrolled 6200)

So what is truly normal, are any of our favourite ‘common sense’ treatments justified in modern medicince, do we do anything right in our every day practice?

Clearly yes, there have been huge improvements in survival from many diseases over the decades, and common medical practices are clearly successful at identifying pathology, seeking out the underlying disease, and then targeting that.  However, when confidently stating that something is the correct strategy to pursue, we should also be mindful that our convictions might just be based on less than solid ground.  And this uncertainty is at the heart of a healtyh academic examination of our medical practice on a daily basis.

We should not be paralysed by doubt, but we should have a healthy degree of scepticism when appraising both existing practices (the PANTHER IPF trial is perhaps one of the most significant turnarounds of recommended practice triggered by high quality trial evidence) and when new technology comes along (see this blog on troponins in acute medicine.)

So next time you are on a ward round, and find yourself struggling to guide a patient towards ‘normal’ for a biochemical test, or some other finding that we all ‘know’ to be true – you should perhaps make a mental note and work out from the evidence if all we are doing is tilting at windmills, because that is what we have always done, or if there is a genuine reason to strive for that particular outcome.

Wait – did I just hear a zebra going past?

13 Oct, 15 | by Toby Hillman

‘Making a zebra’ by Jurvetson on Flickr (cc 2.0)

There is an often quoted medical witticism, that originated in 1940’s Maryland:

‘When you hear hoofbeats behind you, don’t expect to see a zebra’  

Suffice to say, there aren’t many zebras in Maryland…

In the rough and tumble of acute medical admissions, there are an increasing number of horses in the herd to contend with, and often they come in fairly sizeable herds – multimorbidity is now the norm, and single organ pathology increasingly rare.  Among the horses though, there are occasional zebras.

A paper in the PMJ published online recently explores the features of one of these zebras.  The paper looks at the current state of knowledge about non-convulsive status epilepticus (NCSE).

Non-convulsive status epilepticus is one of those pathologies that sets the mind to thinking – the very name seems a little contradictory.  However, it is a very real pathology and can be incredibly disabling.  As the authors point out, this is a disease that is tricky for many reasons – not least that there is no accepted definition of what constitutes NCSE, and to make a confident diagnosis, one probably requires access to EEG monitoring and a specialist neurological opinion.  So not easy then, for the layman to identify and manage. The incidence of NCSE though, means that those dealing with acutely unwell patients on the medical take ought to be aware of NCSE as a differential diagnosis, and when it would be appropriate to take a second look at the source of all those hoofbeats.

Risk factors for NCSE in the elderly include being female, having a history of epilepsy, neurological injury ( eg stroke), recent withdrawal of long-term benzodiazepines, and having some characteristic clinical signs.  The suggested investigation at this point is then a thorough drug history, review of metabolic derangement, and then to progress to an EEG if one is available in a timely fashion.  The interpretation of the EEG is somewhat beset by pitfalls, but remains the most objective way to reach a conclusion in a tricky situation.

All this is very well, but the ‘half empty’ reader may feel that the paper suggests that this problem, that could affect up to 43 patients per 100,000 is bound to go unrecognised, and therefore untreated as it is poorly defined, and difficult to diagnose.  To assume that because a condition is a challenge to diagnose and manage, the generalist can simply file under ‘too difficult’ would be a shame, and a failing.

The authors use a fantastic phrase that I hope will resonate with jobbing clinicians – ultimately clinical judgement rather than exact criteria is key.

Clinical judgement is one of those qualities one is asked to assess in trainees – a quality that has been lauded and viewed with suspicion over the years, but remains central to clinical practice.  To me, clinical judgement is the synthesis of knowledge about both the patient being considered, their symptoms, signs, and preferences, along with knowledge of up-to-date evidence of therapeutic strategies to formulate a management plan that provides the best outcome – as defined by the needs of the patient.

In the world of multi-morbidity, clinical judgement and one’s ability to interpret available evidence in the context of the patient in front of you is the key clinical skill that can be lost by slavish adherence to criteria, scoring systems, and guidelines.  As the practice of medicine develops, the nuances of how to apply clinical judgement will change, but ultimately this quality continues to be a defining feature of the medical profession.  To maintain a high standard of clinical judgement, one must continue learning – especially about zebras – it would be a shame not to recognise one when it gallops up behind you.


Fashionable inequality?

13 Sep, 15 | by Toby Hillman

Gluten free- fashion or fundamental?

Modern life in developed societies is a world away from the lives our recent ancestors lived. Better sanitation, advances in farming and food supply, the cumulative effects of public health interventions over the years, and huge advances in medical knowledge and technology have also shifted the landscape of disease.

As a society, our preoccupation is now with controlling potential illness, improving wellbeing, managing risk factors, and trying to improve our health through individual actions.  Pick up any newspaper on a weekend, and you will find sections discussing the latest discovery of a link between a foodstuff and cancer, another reason to do this, or that.  The open availability of medical information is a great advance, that allows patients a greater degree of control over their illnesses, and a greater degree of autonomy in the management of long term conditions.  Shared decision making must be the future model of the medical consultation.

However, alongside the valid, sensible information, there are many health concerns that achieve wide publicity that can generate anxiety amongst the worried well, and can lead to profound changes in the way people live their lives.  Often the roots of these fears are in the translation of medical advice about well described pathologies into lifestyle choices to address concerns that are less well established, but popularised through mainstream media.

The impact of these choices is mainly on the individual, but a recent paper in the PMJ about the availability and cost of gluten free (GF) food in supermarkets, and shops in Sheffield provoked the thought that these choices may have a wider impact in our modern, marketised society.

The paper from explores the availability and pricing of gluten free products in the city of Sheffield.  The authors examined  a number of variables, and examined deprivation as part of their analyses.

On the price and availability of gluten free food – there were striking findings.  The price difference between ‘normal’ and GF foods were large – with GF foods costing, on average 4.1 times more. In the case of bread, the cost was ~7.6 times higher per 100g for GF than a non-GF alternative.  Combined with cost was the issue of availability – where budget supermarkets and corner shops did not stock any GF foods at all – the greatest choice being within regular, large supermarkets.

As a slight aside, I found it interesting that shops in Sheffield do not seem to follow the ‘rules’ of deprivation – in that ‘quality’ shops had no significant difference in deprivation score when compared with ‘budget’ shops.  This point may be a quirk of the analysis used (postcodes rather than wards), or that in Sheffield as in many other cities, areas of deprivation and affluence co-exist in close proximity, rather than in geographically discrete ghettoes.

The authors have noted a number of factors that could contribute to their findings regarding the maintenance of hight prices for gluten free foodstuffs, and how this might negatively impact on patients with coeliac disease who are from lower socioeconomic groups.  However,  their paper made me think about the additional impact of consumer choice, and market forces within the system they examined.  Wheat free, and gluten free diets are often advocated to improve general wellbeing, and food intolerances in general are commonly held to be responsible for a number of non-specific symptoms.

Gluten free diets are both fashionable, and medically necessary.  My feeling is that the increasing availability of gluten free foods in supermarkets is testament to the wider popularity of gluten free food rather than the exploitation of an increasingly prevalent medical condition to create a market.  The reported incidence of coeliac disease is around 1% – although it is predicted that only a quarter of patients with the disease have been formally diagnosed.  Such a small segment of the population is unlikely to be able to sustain a £0.5 billion market in the UK alone.

The popularity of a (costly) gluten free diet amongst people who have not been diagnosed with coeliac disease is therefore likely to be both expanding the selection of available GF foodstuffs, but also keeping prices high. When GF foods are also restricted by market forces to shops where patients with coeliac disease and a lower disposable income are unlikely to frequent – we see that the popularisation of health concerns, and a widespread adoption of a dietary choice by those privileged to afford it may have negative consequences for patients with a pathology which demands the very same diet.

This is, of course, all speculation, and further examination of the provision, availability and consumption of GF foods would be welcome.  In particular, my knowledge of what prescribed gluten free foods are available is minimal – so I’m not sure how this plays into my argument.

However, as our society seems to be ever more obsessed with avoiding risks to health (although strangely resistant to simple, effective measures like increased physical activity) I wonder how many more areas it may be possible to observe where a lifestyle choice appears to exacerbate a health inequality for those with a formally diagnosed condition.

A disease by any other name…

17 Aug, 15 | by Toby Hillman

Single Rose by Thor


As a UK medical graduate, working in a London Hospital, it is fair to say that my CV doesn’t contain a huge diversity of workplaces, or populations served.  However, it is striking how many different levels of health literacy I encounter within the working week.

I have had conversations with patients to correct the perception that oxygen delivered by face mask was being introduced directly into a vein, and also had conversations with patients about the finer points of pulmonary vascular autoregulation, as applied to their own illness.

Given the range of knowledge and experience of patients is so wide, it is essential to be able to evaluate this as part of a consultation.  There is little point launching into an explanation of why a certain treatment is being recommended or discussed if my patient remains completely mystified by what I think might be wrong with them.  However, my getting to meet a patient might well rely on their ability to interpret their own symptoms, and seek help for them.

A paper in the current issue of the PMJ explores this in a setting so far removed from my own that I thought I might not find a great deal relevant to my own practice.  I was pleasantly surprised to be proved wrong on a few counts.

The study is a qualitative exploration of glaucoma awareness and access to healthcare at a clinic in Northern Tanzania (Open access).

The first lesson I took was that qualitative research of this sort is hugely valid, and absolutely required, even in situations where one might think that discovering the opinions, and feelings of patients may be lower down on the research priorities than achieving wider ranging public health successes.  The paper reveals some of the reasons why patients have presented late to the clinic with symptoms that, one feels, could have been noted a little sooner…

“sometimes my wife asked why are you going to off the road”

The paper is rich with the difficulties encountered in accessing healthcare for glaucoma, and the late presentations start to become clear.  There are the expected problems of cost, distances to travel (151.5km on average!) and knowledge of the disease process itself, but the interviews revealed a wealth of other information that point to ways in which this service could improve – through improved health education, changes to operational policies to smooth the running of clinics for those who had travelled furthest, and utilising patients to spread information about a modifiable cause of blindness (a massive economic burden on family and community, especially in poor, rural areas)

The other key point I took from this, that has resonance in all healthcare settings was the use of language, and it’s impact on health literacy and efficacy.  Swahili is the main language of Tanzania, and there is no direct translation of ‘glaucoma’ into swahili.  The word is translated in different forms – contributing to the confusion of patients.

This is not a problem unique to non-English speakers though.  ‘Medicalese’ is a language we all use – it is often a matter of shame amongst the medical profession to admit that one doesn’t know the precise meaning of a medical term, and as such, we can use language as a tool to exclude others (intentionally or otherwise) from our conversations.  We do the same with patients – the art of the medical synonym is well practiced on the wards… ‘malignant, neoplastic, mitotic…’ and when we simplify into ‘lay terms’ we can cause just as much confusion:  ‘water on the lungs’  – pulmonary oedema? pleural effusion?

The use of language is to me one of the key aspects of communication that can influence the ability of patients to hear about, understand, process the implications of, and work with the possible solutions to their problems.  There are definitely times when my choice of words has been below par, and a less favourable outcome has been the same.  Language used in consultations is also key to establishing and maintaining the relationship between physician and patient.

The linked paper shows just why the appropriate use of a clear and unambiguous explanation of medical terms is so important.  There are wide-ranging effects of good and poor language, from the initial access to healthcare, understanding and using treatments appropriately, and thereafter in informal health promotion and education within a community.

Whilst I am lucky not to have to tackle consultations in swahili myself, I think it is right that we remind ourselves regularly of how foreign ‘medicalese’ is from the vernacular, and conciously tackle the use of sloppy terms that often only increase the confusion they attempt to disspate.



If a job’s worth doing…

13 Jul, 15 | by Toby Hillman

Cryptic clothing label

Image via WM Jas on Flickr

Competency based curricula have largely replaced purely knowledge-based curricula in medical education.  As assessment of competency has become a seemingly endless task, the participants in medical education have often complained that learning and development has been reduced to a series of hoops to jump through or, even worse, a series of boxes to tick.

The development of clinical governance frameworks in the late 1990s formalised the involvement of trainee physicians in the process of clinical audit.  Audit became mandated, and as such, became a box to tick.  If one could not demonstrate an audit of some description (any really) then one could not progress.

As such, clinical audit is one of the more reviled duties undertaken by trainees (in their own time) as very often the information ‘uncovered’ is simply an explicit statement of an open secret.  The time taken to prove an acknowledged reality is usually resented by the auditor, and the recipients of the news that their practice falls below expected standards aren’t usually overjoyed.  The result of such projects commonly a list of recommendations, presented on the last week of an attachment, by a junior member of the team, that will be agreed by all, but actioned by no-one. (Only around 5% of audits ever make any difference to practice)

Quality Improvement projects have been lauded by many (me included) as an answer to the problems with clinical audit:  the burden of data required to make changes is less, the measurements and standards can be set by the instigators, and can be flexible enough to actually be achieved, and the change process is embedded as a primary aim within the most common methodologies employed.

Having been adopted into many curricula, quality improvement is now suffering many of the same problems as clinical audit. The projects are usually carried out in trainee’s own time, but are a mandated part of training – leading to resentment. The subjects tackled tend to be huge (‘We need a new IT system – the current one is not fit for purpose’) or focused on another team’s practice (‘The radiology department need to be quicker at doing the tests we ask for…’)  The doctors participating in a QI project often come with a solution in mind (‘We will just get a bit of data – do what they did at my last hospital – and then we’ll show an improvement’) without really understanding the problem in its current context.

Sadly the result is that some of the most powerful tools for driving change within organisations have been reduced to a ‘tick’ on an assessment sheet, and are done as last-minute efforts, to scrape through the next annual progression check.

This does not mean that audits are inherently useless, or that QI projects should be abandoned as a tool for engaging junior doctors in understanding how to improve clinical practice.  What it means is that, if a job is worth doing, it is worth doing it properly…

To do a job properly, one must know what is required, and what the best tools for the job are.  Not everything can be part of a QI project, and not everything needs auditing.  A paper republished in this month’s PMJ is an excellent exploration of the different ways in which changes can be evaluated, and this can be reverse-engineered, allowing potential change agents to know if they are setting off down the wrong road.  It also reminds us that there are more options for change efforts available than the simple ‘before and after’ audit, or the use of multiple PDSA cycles.

Audit and QI are not the only area where the adage of ‘doing a job properly’ applies – as I discussed recently, all of the assessments we use to monitor competency are well intended, and when used enthusiastically and correctly, can uncover unexpected learning from even the most mundane of clinical encounters.  It is probably true that if something has been ‘reduced to a tick-box’ then someone thought that box was worth ticking at one point.  By taking the time to understand the theory and background to where the box came from, we might find ourselves using the tools available to us properly, and learning something in the process.


I am conflicted…are you?

12 Jun, 15 | by Toby Hillman

via Tambako on Flickr

via Tambako on Flickr


I am conflicted… and it is down to a couple of papers in this May’s PMJ that look at the development of a new tool for assessing the performance of trainees in a key medical task.

Most nights – or at least 2 a week – I spend a portion of my evening logging into the e-portfolio system for medical trainees, and try to fill in several online forms to reflect the practice and learning of doctors that I have worked with over the past few weeks.

There is an array of choices to make, and choosing the right assessment for each task can be a bit difficult – you must know your SLE from your WPBA, your Mini-CEX (pronounced ‘kehks’ to avoid worrying conversations) from your DOPS, and woe betide anyone who mistakes their MCR for an MSF, or a CBD for an ACAT.  By the way, none of these is made up.

I find it difficult to make time in the day to fill these forms in with the subject of them sitting alongside me, but I do try to make an effort to build at least one or two learning points into each form to make them more useful than just a tick in a box on a virtual piece of paper.

The conflict I have is that these forms often feel like soul-less, mechanistic hoops that trainees simply have to plough through to enable progression to the next level in the platform game that is a training career in medicine in the UK. Some days I would like nothing more than to ditch the whole enterprise, and head back to the good old days where apprentice medics would work alongside me, learn by osmosis and through trial and error.

However, there are other days when the format of an assessment, or the very fact that a trainee has demanded one provides the opportunity to frame a discussion around an event, an experience, or an interaction that requires more attention – where real learning can take place during a discourse about what went well, less than ideally and what could be improved for the future in someone’s practice.  At these times, I am grateful that I don’t have to make up an assessment on the spot, but there is a framework to formulate my feedback, provide a breakdown of areas to concentrate on, and direction for where to find help and resource to improve.

The papers that have provoked my feelings of conflict look at a project in the West Midlands to develop a tool for assessing trainee’s performance in conducting ward rounds in the paediatric department. One describes the creation of the tool, and the other looks at the reliability and practical use of the tool

The end product is a multi-source feedback tool that does what it says on the tin, and reliably so.  It has similarities to other assessments already in use, but crucially focusses on a narrow, but important and ubiquitous part of medical practice – the ward round.

The development of the tool started in response to a reaslisation that ward rounding is an essential skill, and yet is not usually assessed formally in training.  It is one of those tasks or set-piece rituals that is learned by osmosis.  I think there are other areas that are similarly neglected too… responding to conflict within the MDT, responding to angry patients or complaints, effective handover between shifts, debriefing after significant events – or even after every shift, chairing meetings, reporting to a committee and so on…

Should we, therefore have tools for each of these areas, with specific numbers required by trainees in each post, to demonstrate competence?  I can imagine the response if this suggestion were taken up wholeheartedly for each vital part of a consultant job that is not at present explicitly covered in a WPBA (workplace based assessment)

So no, if we don’t want to be over-burdened by assessments, and end up with a fully tick-boxed CV, we should therefore rely on the education methods of old… in those halcyon days of yore when registrars still knew everything, and would fledge into consultant form without having had to get anything ‘signed off’ on an e-portfolio, but would be vouched for in references and conversations over sherry.

Clearly neither of these scenarios could be considered perfect, but where do we draw the line.  As with targets in all industries – what gets measured gets done, but what gets measured is not always what ought to be measured.

As we become slightly more reductionist in our thinking about medical education, we risk hitting the target but missing the point as we try to encompass all that is important about being a senior clinician in formalised assessments – but I am also convinced that training in the good old days probably wouldn’t be up to the job of training senior physicians and surgeons for the modern world of healthcare – so I remain conflicted…

The tool the authors have developed looks promising, and I intend to use it to help registrars start thinking more objectively about how they conduct their ward rounds – and for myself to improve my practice, but I can’t help thinking that I might just miss something else if I only stick to the tools available to me in the eportfolio.

Service, safety and training – a tricky trio.

16 May, 15 | by Toby Hillman

The National Health Service is more than a health service, is is perhaps one of the biggest postgraduate universities in the world.  Within the corridors, operating theatres, and wards of the hospitals in the UK, healthcare professionals are learning.

They are taught by example every day, and increasingly are allocated time out of the service to learn at dedicated teaching days / seminars and courses.

This key role of the state-funded health service in the UK can sometimes be forgotten, or hidden away under the demands to provide a service to the sick and needy that are entering hospitals in ever-increasing numbers.  But ask patients who are in any of the teaching hospitals in the UK, and I am sure that they will be familiar with the request for a student to practice taking a history, or performing a clinical examination.   Alongside students, there are many more trainees of different levels of seniority who also ask permission to learn from patients: patients consent to procedures where a trainee will be carrying out the procedure, under the supervision of a colleague who is fully qualified.

This type of learning is essential to ensure that the next generation of doctors is suitably skilled and qualified to deal with the problems they are to encounter during their careers.  These procedures might be simple – like inserting a cannula, or a urinary catheter, or far more complex.

Recently there have been pressures on this style of training.  Opinions differ on the relative impact of each development, but the European Working Time Directive, competency based curricula, formalised workplace-based assessments and streamlining of the training career ladder have all affected how we train teh next generation of Consultants.

The increasing concern for patient safety, and the increasing awareness of patients about potential complications have resulted in less invasive procedures being carried out by general teams, but instead by specialists in more controlled environments – conferring undoubted benefits to the individual patient receiving the treatment.

This situation leaves us with a tension – trainees need to train, patients require a service, and patients need to be safe.  To train safely, trainees require willing patients, supervision, and opportunities to learn techniques in a safe, supervised environment. Increasing pressures on services have led to a situation where taking time off the ward to attend such opportunities seems beyond reach, and negatively impacts on the care of other patients within the same service.

BUT – emergencies happen, our trainees are usually the first on the scene, and will need skills usually developed in elective procedures to deal with the emergency confronting them.

So, in the modern world, are we balancing this tension – are we giving trainees the chances to develop the skills we expect of them, whilst ensuring the patients who kindly offer the opportunity to trainees to learn are safe – both electively and in the emergency setting?

A paper published recently online in the PMJ takes a look at this question in one area that sits right in the middle of this conundrum – the insertion of intercostal chest drains.

This core skill for general physicians is increasingly becoming the preserve of respiratory specialists, and even then, is becoming the preserve of sub-specialists.

The paper looked at attitudes, experience, and training in chest drain insertion.  The results are interesting, and pose very important questions for those who train general physicians, or any trainees where procedures are considered a core skill.

Overall, there was consensus that general medical registrars (general physicians) should be able to place chest drains, and that the procedure should not become a specialist only activity.

So – general medical trainees should be trained… but how much did they think was required?

Overall, trainees and consultants agreed that to be considered competent, an individual must place at least 5-10 chest drains, and to maintain this competency, must place 5-10 per year thereafter.

And… how did they do compared with their own standards?

Higher trainees (senior residents) who are most likely to be the ones called on to perform these procedures urgently had, in the main acquired the suggested number of drains to be called competent.

But only 5% of those who weren’t Respiratory trainees had been able to maintain their competency – as defined by their own standards.

So – as the authors conclude, chest drain insertion is a vital procedure for a service to be able to provide, but those we rely to provide this service – by their own admission, cannot maintain the necessary competence.

This is a worrying admission to make, and should ring alarm bells for those managing acute medical services, and those charged with the education of doctors within the university that is the NHS.

The solution will not be a quick fix, but it seems that the relationship between training, service and safety has changed in recent years.

This tripod is a tricky one to balance, but if one leg grows out of proportion to the others, something is bound to fall over…

Picture by RetSamys

The beauty of the written word?

21 Apr, 15 | by Toby Hillman

New Font "Doctor's Handwriting"

Of the essential skills for doctors, writing has to be up there as one of the most important.  Doctors writing has been the butt of many jokes ove the years – justifiably, and written prescriptions remain a significant source of error in hospitals up and down the land.

The medical notes are another area where the handwriting of doctors is often held up to scrutiny.  In days gone by, the registrar would be the doctor who registered the opinion of the consulting physician, and before that notes were kept mainly for the interest and records of the physician themselves – helping in the discovery of syndromes and new disease entities through meticulous observation, and synthesis of the salient features of cases over time.

And now – what are the medical notes now?  The medical notes are now no longer the preserve of physicians, with entries from the whole MDT contributing to the story of admission, recovery, discharge planning, and plans for the future.  But the written history remains a key part of the journey of every patient.  It is often in those initial observations, descriptions of symptoms and signs that they keys to a diagnosis can be found.

The changes in medical training models, staffing models, and working conditions have also increased the importance of the initial history, and the medical notes as a tool for communicating the key aspects of a case to the team that follows after.  Given that a patient may be cared for by a different doctor almost every day of their admission, written notes are more than ever the most reliable repository of clinical information.

For such a key part of the medical system, one might expect that there is a rigorous training scheme, with competencies, certificates, seminars and reflective practice to ensure that all the appropriate details are recorded, communicated and understood by those who come along afterwards to care for the patient and understand the complexities that make up every patient and their story. Unfortunately there is little work in the literature that supports the training of medical students in written communication.

A study published online for the PMJ looked at the development and evaluation of a scheme that aimed to tackle the lack of formal training in constructing written histories, and support trainers in the evaluation of medical students efforts at a ‘clerking’.

They developed a study with three arms – one of standard practice, one with additional training for students in communication, and a final arm with training in communication, combined with training for residents on how to give feedback using the RIME tool.  The combined intervention showed positive results with statistically significant improvement in clerking scores between the start and the end of the study.  There was also a correlation between good handwriting, and overall quality of the histories – a correlation that could have been one of the key messages of the paper.

In addition the approach that the authors took of not simply ‘educating’ students, but in fact, working to create an environment where useful feedback, using a consistent and routinely applied tool is a good lesson for anyone trying to improve educational interventions, and is an important lesson from this paper.

However, I think we need to look a little more critically at what we as a profession are trying to achieve with the education we offer our students.

I often think that we are training the doctors of the future for the hospitals of yesterday – and we know that a significant proportion of what we teach our students will be wrong by the time they enter the workplace

So when we look at the direction of movement in the medical world when it comes to written notes, perhaps we need to take a leap forwards in terms of what we are teaching our students.

A few years ago patients were hardly ever copied into their clinic letters – now it is accepted as the norm. This increasing access to medical records is gathering pace in a far more profound way in the US through the open notes movement, where physicians and patients share near equal access to the medical notes, changing the balance of consultations, and written records, and ensuring that patients can play a far more active role in the management of their illnesses.

The other transformation is from handwriting to typing, and in the near future, to voice recognition. Electronic health records are also transforming the skills required to be a physician.  No longer is a trusty fountain pen, and a good dictation speed the mark of a skilled communicator in the written form.  Now we shall have to be proficient at forms of communication that are more immediate, direct, and perhaps more open to misinterpretation (tone is notoriously difficult to convey in quick electronic communiqés.)

Training medical students in how to construct and communicate a history is vital, but we must keep in mind how our workplaces are changing, and how our communication is no longer necessarily directed to other medical professionals, but in fact towards the subject of the note.  This will require not only the skills encapsulated in Reporter, Interpreter, Manager, and Educator framework, but all of those that ensure a doctor can also be a partner in managing a chronic disease.


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.



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