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Archive for July, 2014

Summer BTS, Insidious Advertising, Le Grand Dèpart, The benefits of time off.

13 Jul, 14 | by tomfardon

I’m just back home from 2 weeks of annual leave. 2 whole weeks, with my whole family, without having to go to work. I think the last time my wife and I had 2 weeks off, together, back to back, was our honeymoon. In September 2000.

After one week off my e-mail inbox usually has about 600 unanswered messages, so it’s no surprise to find 1153 in there just now. But, despite me now answering them, and me not being at work, the hospital, and the medical school seem not to have fallen down, burnt down, ground to a halt, disappeared and reappeared on the moon. I suspect no-one has really noticed.

Two weeks off has allowed me to actually have a holiday – something I have to admit, I rarely manage. I think we underestimate the importance of taking a decent chunk of time off, as a single block, to unwind, chill out, and have a bit of fun with the family. I even took the kids to Alton Towers.

It looks like I have another few days of annual leave to take before the end of July, but I’ll have to spread them out, piecemeal throughout the next couple of weeks – I have a sneaking suspicion that I’ll spend at least one of those ‘days off’ catching up with e-mails, going into the office to do a bit of dictation, having a quick meeting over lunch. Perhaps I should just go back to Alton Towers.

The Summer BTS was in York in the middle of my two weeks off. So yes, I did do some work in the middle of my ‘2 week uninterrupted block’, but the Summer BTS, as previously discussed, is a highlight of the year for me, so I don’t consider it too arduous – and the racecourse is only one stop round the A64 from the designer outlet village, which is always worth a punt. A real highlight for me was Jon Britton’s hugely engaging presentation on smoking cessation. I was only one of the audience who posted a number of tweets during his presentation – you can follow the twitter discussion on #BTSSummer (Incidentally, BT Sport were using the #BTSSummer and #BTSWinter hashtags to hold a poll on whether the World Cup should be in Summer or Winter – our Summer BTS tweets provided an unexpected bias to the vote).

Something I’d really not thought about was the insidious advertising that is seemingly endemic on our TV programs in the UK. Coronation Street was used as an example: the beer served in the Rovers Return is fictional; when the residents want to search on the internet, they use Poogle (or some such), but all the cigarettes displayed in the corner shop are real, likewise any cigarette boxes on tables, or just lying around. The cigarette display counter in the corner shop is at 90 degrees to where it would naturally sit in a real shop, otherwise it wouldn’t be in camera shot.

The recent film Rush, based on the real life events of the F1 stars James Hunt and Nikki Lauder shows the era-accurate F1 McLaren cars, sponsored by Marlborough. Fair enough, you might say. SKY movies made the effort to remove the branding from the cars on a shot by shot basis, so avoid any inference of advertising. Not something I ever thought about.

The question of eCigarettes was obviously high on the agenda for Prof Britton. He showed evidence that the uptake of smoking has not increased in under 18 year olds since the introduction of eCigarettes, going against the suggestion that they ‘normalise’ smoking. The availability of smoking alternatives, such as Snüss in Sweden, have reduced smoking rates, and, Prof Britton suggests, eCigarettes are no different. He accepts that they are probably dangerous in their unlicensed form, but the next moving is licensing, not banning them. He makes a compelling argument. Great lecture.

Then I was a TourMaker at the Tour de France Grand Dèpart in Yorkshire. I’m a keen cyclist, and I’m from Yorkshire, so this was a dream come true. I marshalled in a sleepy village outside Aysgarth, which involved very little actual marshalling, but the sense of excitement in the whole of Yorkshire was something amazing to be part of. The real joy, though, was seeing so many people out on their bikes, all through Yorkshire. The roads were closed in front of the tour, but the cyclists of Yorkshire didn’t get the memo – on the bus to get to the marshalling point, we must have seen 2,000 people cycling up the road. People of all ages, sizes, seriousness, all cycling up the road to see the tour. We’re constantly being told how we’re an obese nation, who we’re a sedentary nation; the nation I saw that weekend were neither. It’s easy for me to be a cycling evangelist – I love being out on the bike – but it looks like I’m not alone. I was a standard spectator on Stage 3 in Cambridge; it wasn’t just Yorkshire folk totally enthralled with the Tour. There’s thousands of bikes in Cambridge every day of the year, but the excitement of the tour was palpable. I do hope the enthusiasm carries on through the post-tour excitement, the cardiovascular health of the country can only be positively affected.

My 2 weeks of actual holiday are over. Back to those 1000+ emails, and who knows what remains on my desk. I’m glad I went away, though.

How many beans make 5?

13 Jul, 14 | by tomfardon

More importantly, how many consultants make a department?

We interviewed for two new colleagues recently. 2 posts, 2 applicants, 2 shortlisted, 2 interviewed, 2 appointed. All smiles down at the DCA that night.

This brings us up to 6 consultants, but 5 Whole Time Equivalents, for our teaching hospital service. The Royal College of Physicians has a document to guide how many respiratory physicians are required for a typical DGH with a catchment of 250,000. It makes interesting reading.

Inpatient work
2 ward rounds a week, with the extra responsibilities of discharge planning, family meetings, etc, makes 3 PAs for inpatient work. Daily review of patients in MAU, add another 0.5PA. If the respiratory physician does some GiM – add another PA. And add in 0.5PA for each MDT.

Outpatient Work
For a population of 250,000 people, 900 new referrals will be generated per year, requiring 11 – 12 PAs per week to cover the clinics – not including the cancer workload. And there will be general medicine follow up appointments added to this, in some centres. 30 mins per New, and 15 mins per Return mean in 4 hours we should see 4 New and 8 Returns – this ignores the need for CXRs and PFTs, of course.

Bronchoscopy
Everyone likes to keep their skills up – so most physicians undertake one PA of bronchoscopy a week, with no more than 6 patents per list.

Thoracoscopy
More excitement for the chest physician, but it is demanding, so requires a PA for every 2 patients per session.

Sleep Disordered Breathing
2-4 PAs of consultant staff, 2 WTE nurses, 0.5 WTE secretarial staff.

NIV
Ideally one consultant should supervise the service, requiring 1 or 2 PAs.

Lung Cancer
0.5 PAs for everyone who goes to MDT, and 0.5 PA for the the local clinical lead. A DGH of 250,000 population generally requires 10 PAs of consultant time to run the lung cancer service.

TB
Generally requires 2 consultant, with a lead taking 0.5 PAs for each 25 annual cases.

Specialist Clinics
Difficult asthma, bronchiectasis, ILD, transition clinic – all require another PA for the consultant carrying out the work.

CF
0.75 PAs for every 50 patients

And there’s some more, less common, more esoteric things that we might like to do too.

This adds up to a lot of clinicians. I don’t think we’re any different in respiratory medicine; I’m sure every speciality feels they are under-staffed, overworked, etc, and they’re probably right. I’ve written previously on the increasing number of junior doctor roles we have to cover when on call, and the lonely figure of the on call consultant, writing in notes, rewriting drug charts, fluid charts et al at the weekend – it’s not just the chest physicians.

But, reading through the list of things chest physicians get to play with, I’m sure we should be inundated with applications for ST3 numbers in our speciality. We’ve filled all our permanent, and LAT posts here in Sunny Dundee, but the national picture is not as rosy – many centres have unfilled LAT positions, meaning consultants will be ‘acting down’ more and more.

How many consultants does a respiratory service need? How many registrars? If you had the choice, would you want a consultant, or 2 registrars?

How many beans make 5? 2 consultants, 2 ST3s and 2 LATs, seemingly.

Summer BTS – Day 1 in the BTS House

3 Jul, 14 | by tomfardon

I like the Summer BTS. It’s not as well attended as the Winter meeting in London, there’s a smaller choice of talks, it’s doesn’t have a pub right opposite into which to retire post conference, there’s a far smaller number of posters, talks, and it’s shorter, out there’s something relaxed about the Summer meeting that I like. It’s certainly nice to run into old friends and colleagues at these meetings.

The program is necessarily limited, as there’s not many rooms, but the organisers have sorted out a very interesting and diverse meeting.

I skipped this morning’s year in review, instead going to “Sarcoid”. It’s pleasing to hear that essentially everyone has the same problematic patients labelled with “Sarcoid”, who continue to have symptoms, deteriorating lung function, and more, despite having this seemingly straightforward, steroid responsive disease. Evidence not in abundance, but opinion valuable. PET scanning, gadolinium enhancing cardiac MRI, leflunomide, methotrexate at rheumatologically laughable doses. A great session.

I stayed in the exact same seat for the PE session, chaired by my old classmate Rachel Davies, now one of the pulmonary hypertension consultants at the Hammersmith – she’ll not thank me for mentioning that she was in the year above me at med schl, but she did teach me how to do ophthalmoscopy in the medical school bar.

What is a massive PE, what is a submissive PE? Who should we thrombolyse, who should we sit tight and watch? Luke Howard: “[vs tPA] placebo wins hands down”. How to set up a PE follow up service, but no clear decision on who to give life-long anticoagulation to – Patient preference was proposed as the first step… If we can’t decide, how can we expect the patients to decide??? A whistlestop tour of the novel oral anticoagulants wrapped up the morning session.

There might not be a pub round the corner at the Knavesmire, but the food onsite is always pretty good. Menu (with local Yorkshire translation from my step father): Tagine Lamb (lamb stew with an apricot in it); Salmon Mornay (fish in white sauce); mushroom risotto (something veggie).

Non-Tuberculous Mycobacterial Infection in the afternoon. Charles Howarth, Andreas Floto, Michael Loebinger, Rob Wilson – the usual top notch presentations, with gems of wisdom from Rob Wilson. The interactive voting system was out in force – nice to see the experts in the room and the audience completely disagree on management of complex NTM infection…

The Tour de France starts on Saturday in Leeds, stage 2 starts on Sunday in York city centre. The whole of Yorkshire has gone cycling crazy – it’s great to see. Usually when I visit God’s Own County I see a couple of folk out on their bikes; this year I’ve seen hundreds. Every shop has a bike in the window. Every village has a yellow bike on the village green. I cycled up Buttertubs pass on Monday – it’s pretty brutal, 1 in 4 for long stretches, and 1 in 3 for a short stretch. It might not be as long a climb as the Col de la Croix de Fer, but it’s steep enough!

Tomorrow, day 2 in the BTS house. Bronchiectasis, Lung Cancer Survivorship, Occupational Lung Disease, Interventional Procedures, Quandries in TB, and commissioning (not for the Scots and the Welsh). And what will be for lunch?

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