The NHS provides care free at the point of us to British citizens and anyone who needs emergency care while in the UK. It tries to provide every kind of service and treatment that it can but obviously there are limits.
The NHS gets its money mainly from governments taxes, charities, research grants, some payment for services and from renting out retail space etc. Healthcare is a financial blackhole, any money put in the budget will get spent, efficiently and effectively or not.
The NHS is constantly being expected to provide a better, more efficient service and new treatments, without a comparable increase in government funding. So, why doesn’t the NHS set up services that could make it money?
Some money making suggestions
Gift shops and NHS clothing brand – The American hospital I went to for elective had quite a large shop near the entrance that sold hospital branded goods. People love the NHS and it could make itself a brand, “I love the NHS” t-shirts, “I was born here” ties, “I gave birth at Blah hospital” car stickers, hats, jackets, tracksuits, teddy bears in white coats and so many more things could be sold in this shops to raise money for the NHS.
Patients in a hospital are a captive market and their visitors are semi-captive. The captives get very bored! Why not provide opportunities for these people to spend their money and relieve the boredom while they are in hospital with some retail therapy? For instance, new hospitals should be built with a shopping mall in them and a cinema. A couple of clothes shops would give people something to do and raise money from rent.
While we are on the subject of new hospitals, they should be designed with the input of the clinical staff who know how to maximise the flow of patients through the "patient pathway". Hospitals should be built like industrial conveyor belts: patients enter through ED, get stabilised, get fixed in theatre, stabilised again in ITU, recover on the wards and out the exit to social services and the outpatient clinics.
New hospitals should be designed to sit on top of HUGE underground multi-story car parks. If shopping centres can do this then so can hospitals. Almost all hospitals are short of parking spaces and most car parks are eye sores. So, try to plan from the beginning to get as many car parking spaces as possible. Estimate how many are needed for staff and visitors - then double it! Also, design a park and ride system so additional parking is available off site.
If costa can make money from a coffee shop in an NHS hospital, why isn’t the NHS setting up its own brand of high quality coffee shops in the hospitals and cutting out Costa the middle man?
“NHS healthy eating” – NHS branded diet plans or ready meals could be produced in partnership with a supermarket brand. Mixing public heath, profit and the NHS brand. “Good for you and good for the NHS”
The NHS could set up hospitals abroad that are for profit institutions that use the NHS structures, or market our services to foreigners that they then pay for. Health tourism is a thing, why not make the most of it?
“NHS plus” – the NHS should be a two tier system. Hours of 8am til 6pm should be for elective procedures free at the point of use and free emergency care. Between 6pm and 11pm the hospitals currently only do emergency care, so there is loads of rooms and kit lying about unused. Why not allow hospitals to set up systems where patients can pay for an evening slot in the MRI scanner and cut the queue? Allow surgeons to pay to use the facilities for private procedures in the evenings. Allow physicians to pay to use the outpatients clinics for private work after hours.
An “NHS Journal” could publish research and audits conducted within and relevant to the NHS.
“NHS pharma” – the NHS buys a huge amount of off patent drugs, why not produce them itself? Set up a drug company that produces off patent medication, these can be given to the NHS at cost price and sold to other healthcare providers for profit. NHS pharma could also work with British universities and researchers to produce new drugs for the British market that would be cheaper than new Drug company drugs because they wouldn’t need huge advertising budgets.
There are so many ways the NHS could make more money for itself that could then be used to deliver newer and better treatments. Yes, it is a shift in ideology and culture, but I am sure it would have positive outcomes for the NHS and patients.
If you have any ideas on how the NHS could produce more money then please do leave a comment.
This anecdote happened many years ago when I was a brand new (read: inexperienced) physician doing my stint in the Colonial Health Service of the former Belgian Congo. I was assigned to a small hospital in the interior of the Maniema province.
Soft tissue infections and abscesses were rather common in this tropical climate, but at one time there seemed to be virtual epidemic of abscesses on the buttocks or upper arms. It seemed that patients with these abscesses were all coming from one area of the territory. That seemed rather odd and we started investigating. By way of background let me say that the hospital was also serving several outlying clinics or dispensaries in the territory. Health aides were assigned to a specific dispensary on a periodic basis. Patients would know his schedule and come to the dispensary for their treatments. Now this was the era of “penicillin.”
The natives were convinced that this wonder drug would cure all their ailments, from malaria and dysentery, to headaches, infertility, and impotence. You name it and penicillin was thought to be the cure-all. No wonder they would like to get an injection of penicillin for whatever their ailment was.
As our investigation demonstrated, the particular health aide assigned to the dispensary from where most of the abscesses came, would swipe a vial of penicillin and a bottle of saline from the hospital’s pharmacy on his way out to his assigned dispensary. When he arrived at his dispensary there was usually already a long line of patients waiting with various ailments. He would get out his vial of the “magic” penicillin, show the label to the crowd and pour it in the liter bottle of saline; shake it up and then proceed to give anyone, who paid five Belgian Francs (at that time equivalent to .10 US $), which he pocketed, an injection of the penicillin, now much diluted in the large bottle of physiologic solution. To make matters worse, he used only one syringe and one needle. No wonder there were so many abscesses in the area of injection. Of course we quickly put a stop to that.
Anyone interested in reading more about my experience in Africa and many other areas can download a free e book via Smashwords at: http://www.smashwords.com/books/view/161522 . The title of the book is "Crosscultural Doctoring. On and Off the Beaten Path"
It’s quick, it’s easy and we’ve all done it. Don’t blush, whether it’s at our leisure or behind the consultant’s back we can confess to having used the world’s sixth most popular website. You might have seen it, sitting pride of place on the podium of practically any Google result page. Of course, it’s the tell tale sign of one of Web 2.0’s speediest and most successful offspring, Wikipedia.
Now for fear of patronizing a generation who have sucked on the teat of this resource since its fledgling years, the formalities will remain delightfully short. Wikipedia is the free, multilingual, online encyclopedia, which harnesses the collective intelligence of the world’s internet users to produce a collaboratively written and openly modifiable body of knowledge. The technology it runs on is a highly flexible web application called wiki. It is open-source software; hence the explosion of wiki sites all united under the banner of combined authorship. Anyone with internet access can edit the content and do so with relative anonymity. It would be unthinkable that a source, which does not prioritize the fidelity of its content, could possibly play a role in medical education. How ironic it seems that medical students can waste hours pondering which textbook to swear their allegiance for the forthcoming rotation, yet not spare a second thought typing their next medical query into Wikipedia. Evidently it has carved itself a niche and not just among medical students, but healthcare professionals as well. According to a small qualitative study published in the International Journal of Medical Informatics, 70% of their sample, which comprised of graduates from London medical schools currently at FY2 and ST1 level, used Wikipedia in a given week for ‘clinical purposes’. These ranged from general background reading to double checking a differential and looking up medications.
We are so ensnared by the allure of instantaneous enlightenment; it’s somewhat comparable to relieving an itch. "Just Google it..." is common parlance. We need that quick fix. When the consultant asks about his or her favourite eponymous syndrome or you’re a little short on ammunition before a tutorial, the breadth and ease-of-use offered by a service accessible from our phones is a clandestine escape.
The concept of Wikipedia, the idea that its articles are in a way living bodies because of the continual editing process, is its strength. Conversely textbooks are to a degree outmoded by the time they reach their publication date. While I commend the contributors of Wikipedia for at least trying to bolster their pages with references to high impact journals, it does not soften the fact that the authorship is unverifiable. Visitors, lay people, registered members under some less than flattering pseudonyms such as Epicgenius and Mean as custard, don’t impart the sense of credibility students (or for that matter patients)expect from an encyclopedia. Since the prestige of direct authorship if off the cards, it does beg the question of what is their motivation and I’m afraid ‘the pursuit of knowledge and improving humanity’s lot' is the quaint response. There is a distinct lack of transparency. It has become a playground where a contributor can impress his/her particular theory regarding a controversial subject unchallenged. Considering there is no direct ownership of the article, who then has the authority to curate the multiple theories on offer and portray a balanced view? Does an edit war ensue? It is not unheard of for drug representatives to tailor articles detailing their product and erase the less pleasant side-effects. Obviously Wikipedia is not unguarded, defences are in place and there is such a thing as quality control. Recent changes will come under the scrutiny of more established editors, pages that are particularly prone to vandalism are vetted and there are a special breed of editors called administrators, who uphold a custodial post, blocking and banishing rebellious editors. A study featured in the First Monday journal put Wikipedia to the test by deliberately slipping minor errors into the entries of past philosophers. Within 48 hours half of these errors had been addressed. Evidently, the service has the potential to improve over time; provided there is a pool of committed and qualified editors.
Wikiproject Medicine is such a group of trusted editors composed primarily of doctors, medical students, nurses, clinical scientists and patients. Since 2004, its two hundred or so participants have graded an excess of 25,000 health-related articles according to quality parameters not dissimilar to peer review. However, the vast majority of articles are in a state of intermediate quality, somewhere between a stub and featured article. Having some degree of professional input towards a service as far reaching as Wikipedia will no doubt have an impact on global health, particularly in developing countries where internet access is considered a luxury.
March this year saw the medical pages of the English Wikipedia reach a lofty 249,386,264 hits. Its ubiquity is enviable; it maintains a commanding lead over competing medical websites. The accessibility of this information has catapulted Wikipedia far beyond its scope as a humble encyclopedia and into a medical resource. Patients arrive to clinics armed with the printouts. As future doctors we will have to be just that one step ahead, to recognise the limitations of a source that does not put a premium on provenance but is nevertheless the current public health tool of choice.
Illustrator Edward Wong
This blog post is a reproduction of an article published in the Medical Student Newspaper, November 2013 issue.
The registrar's face was taking on a testy look. So enduring was the silence our furtive glances had developed a nystagmic quality. “Galactosaemia” came her peremptory reply. Right on queue the disjointed chorus of ahs and head nods did little to hide our mental whiteboard of differentials being wiped clean. At the time conjugated bilirubinaemia in children only meant one thing: biliary atresia. A fair assumption; we were sitting in one of three specialist centres in the country equipped to treat these patients. Ironically the condition has become the unwieldy yardstick I now measure the incidence of paediatric disease.
Biliary atresia is the most common surgical cause of neonatal jaundice with a reported incidence of 1 in 14-16ooo live births in the West. It is described as a progressive inflammatory obliteration of the extrahapatic bile duct. And Dr Charles West, the founder of Great Ormond Street Hospital, offers an eloquent description of the presenting triad of prolonged jaundice, pale acholic stools and dark yellow urine:
‘Case 18...It was born at full term, though small, apparently healthy. At 3 days however, it began to get yellow and at the end of 3 weeks was very yellow. Her motions at no time after the second day appeared natural on examination, but were white, like cream, and her urine was very high coloured.’
1855 was the year of Dr West's hospital note. An almost universally fatal diagnosis and it would remain so for the next 100 years. The time's primordial classification of biliary atresia afforded children with the 'noncorrectable' type, a complete absence of patent extrahepatic bile duct, an unfortunate label; they were beyond saving. Having discovered the extent of disease at laparatomy, the surgeons would normally close the wound. The venerable Harvardian surgeon, Robert E. Gross saved an enigmatic observation: “In most instances death followed a downhill course…”
K-A-S-A-I read the ward’s board. It was scrawled under half the children's names. I dismissed it as just another devilishly hard acronym to forget. The thought of an eponymous procedure had escaped me and in biliary atresia circles, it's the name everyone should know: Dr Morio Kasai.
Originating from Aomori prefecture, Honshu, Japan, Dr Kasai graduated from the National Tohoku University School of Medicine in 1947. His ascension was rapid, having joined the 2nd department of Surgery as a general surgeon, he would assume the role of Assistant Professor in 1953. The department, under the tenure of Professor Shigetsugu Katsura, shared a healthy interest in research.
1955 was the landmark year. Katsura and Kasai operated on their first case: a 72 day old infant. Due to bleeding at the incised porta hepatis, Katsura is said to have 'placed' the duodenum over the site in order to staunch the flow. She made a spectacular postoperative recovery, the jaundice had faded and there was bile pigment in her stool. During the second case, Katsura elected to join the unopened duodenum to the porta hepatis. Sadly the patient's jaundice did not recover, but the post-mortem conducted by Kasai confirmed the development of a spontaneous internal biliary fistula connecting the internal hepatic ducts to the duodenum. Histological inspection of removed extrahepatic duct showed the existence of microscopic biliary channels, hundreds of microns in diameter. Kasai made a pivotal assertion: the transection of the fibrous cord of the obliterated duct must contain these channels before anastomosis with the jejunal limb Roux-en-Y loop. This would ensure communication between the porta hepatis and the intrahepatic biliary system. The operation, entitled hepatic portoenterostomy, was first performed as a planned procedure for the third case at Tohoku. Bile flow was restored and Kasai published the details of the new technique in the Japanese journal Shujutsu in 1959. However, news of this development did not dawn on the West until 1968 in the Journal of Pediatric Surgery. The success of the operation and its refined iterations were eventually recognized and adopted in the 1970s. The operation was and is not without its dangers. Cholangitis, portal hypertension, malnutrition and hepatopulmonary syndrome are the cardinal complications. While diagnosing and operating early (<8 weeks) are essential to the outcome, antibiotic prophylaxis and nutritional support are invaluable prognostic factors.
Post operatively, the early clearance of jaundice (within 3 months) and absence of liver cirrhosis on biopsy, are promising signs. At UK centres the survival after a successful procedure is 80%. The concurrent development of liver transplantation boosts this percentage to 90%. Among children, biliary atresia is the commonest indication for transplantation; by five years post-Kasai, 45% will have undergone the procedure.
On the 6th December 2008, Dr Kasai passed away. He was 86 years old and had been battling the complications of a stroke he suffered in 1999. His contemporaries and disciples paint a humble and colourful character. A keen skier and mountaineer, Dr Kasai lead the Tohoku University mountain-climbing team to the top of the Nyainquntanglha Mountains, the highest peaks of the Tibetan highlands. It was the first successful expedition of its kind in the world. He carried through this pioneering spirit into his professional life. Paediatric surgery was not a recognized specialty in Japan. By founding and chairing multiple associations including the Japanese Society of Pediatric Surgeons, Dr Kasai gave his specialty and biliary atresia, the attention it deserved.
Despite numerous accolades of international acclaim for his contributions to paediatric surgery, Dr Kasai insisted his department refer to his operation as the hepatic portoenterostomy; the rest of the world paid its originator the respect of calling it the ‘Kasia’. Upon completion of their training, he would give each of his surgeons a hand-written form of the word ‘Soshin’ [simple mind], as he believed a modest surgeon was a good one.
At 5 foot 2, Kasai cut a more diminutive figure one might expect for an Emeritus Professor and Hospital Director of a university hospital. During the course of his lifetime he had developed the procedure and lived to see its fruition. The Kasia remains the gold standard treatment for biliary atresia; it has been the shinning light for what Willis J. Potts called the darkest chapter in paediatric surgery. It earned Dr Kasai an affectionate but apt name among his peers, the small giant.
Miyano T. Morio Kasai, MD, 1922–2008. Pediatr Surg Int. 2009;25(4):307–308.
Garcia A V, Cowles RA, Kato T, Hardy MA. Morio Kasai: a remarkable impact beyond the Kasai procedure. J Pediatr Surg. 2012;47(5):1023–1027.
Mowat AP. Biliary atresia into the 21st century: A historical perspective. Hepatology. 1996;23(6):1693–1695.
Ohi R. A history of the Kasai operation: Hepatic portoenterostomy for biliary atresia. World J Surg. 1988;12(6):871–874.
Ohi R. Morio Kasai, MD 1922-2008. J Pediatr Surg. 2009;44(3):481–482.
Lewis N, Millar A. Biliary atresia. Surg. 2007;25(7):291–294.
This blog post is a reproduction of an article published in the Medical Student Newspaper, April 2014 issue.
So you're sitting in a bus when you see a baby smile sunnily and gurgle at his mother. Your automatic response? You smile too. You're jogging in the park, when you see a guy trip over his shoelaces and fall while running. Your knee jerk reaction? You wince. Even though you're completely fine and unscathed yourself. Or, to give a more dramatic example; you're watching Titanic for the umpteenth time and as you witness Jack and Rose's final moments together, you automatically reach for a tissue and wipe your tears in whole hearted sympathy ( and maybe blow your nose loudly, if you're an unattractive crier like yours truly).
And here the question arises- why? Why do we experience the above mentioned responses to situations that have nothing to do with us directly? As mere passive observers, what makes us respond at gut level to someone else's happiness or pain, delight or excitement, disgust or fear? In other words, where is this instinctive response to other people's feelings and actions that we call empathy coming from?
Science believes it may have discovered the answer- mirror neurons.
In the early 1990s, a group of scientists (I won't bore you with the details of who, when and where) were performing experiments on a bunch of macaque monkeys, using electrodes attached to their brains. Quite by accident, it was discovered that when the monkey saw a scientist holding up a peanut, it fired off the same motor neurons in its brain that would fire when the monkey held up a peanut itself. And that wasn't all. Interestingly, they also found that these motor neurons were very specific in their actions. A mirror neuron that fired when the monkey grasped a peanut would also fire only when the experimenter grasped a peanut, while a neuron that fired when the monkey put a peanut in its mouth would also fire only when the experimenter put a peanut in his own mouth. These motor neurons came to be dubbed as 'mirror neurons'.
It was a small leap from monkeys to humans. And with the discovery of a similar, if not identical mirror neuron system in humans, the studies, hypotheses and theories continue to build. The strange thing is that mirror neurons seem specially designed to respond to actions with clear goals- whether these actions reach us through sight, sound, smell etc, it doesn't matter. A quick example- the same mirror neurons will fire when we hop on one leg, see someone hopping, hear someone hopping or hear or read the word 'hop'. But they will NOT respond to meaningless gestures, random or pointless sounds etc. Instead they may well be understanding the intentions behind the related action. This has led to a very important hypothesis- the 'action understanding' ability of mirror neurons.
Before the discovery of mirror neurons, scientists believed our ability to understand each other, to interpret and respond to another's feeling or actions was the result of a logical thought process and deduction. However, if this 'action understanding' hypothesis is proved right, then it would mean that we respond to each other by feeling, instead of thinking. For instance, if someone smiles at you, it automatically fires up your mirror neurons for smiling. They 'understand the action' and induce the same sensation within you that is associated with smiling. You don't have to think about what the other person intends by this gesture. Your smile flows thoughtlessly and effortlessly in return.
Which brings us to yet another important curve- if mirror neurons are helping us to decode facial expressions and actions, then it stands to reason that those gifted people who are better at such complex social interpretations must be having a more active mirror neuron system.(Imagine your mom's strained smile coupled with the glint in her eye after you've just thrown a temper tantrum in front of a roomful of people...it promises dire retribution my friends. Trust me.)
Then does this mean that people suffering from disorders such as autism (where social interactions are difficult) have a dysfunctional or less than perfect mirror neuron system in some way?
Some scientists believe it to be so. They call it the 'broken mirror hypothesis', where they claim that malfunctioning mirror neurons may be responsible for an autistic individual's inability to understand the intention behind other people's gestures or expressions. Such people may be able to correctly identify an emotion on someone's face, but they wouldn't understand it's significance. From observing other people, they don't know what it feels like to be sad, angry, surprised or scared.
However, the jury is still out on this one folks. The broken mirror hypothesis has been questioned by others who are still skeptical about the very existence of these wonder neurons, or just how it is that these neurons alone suffered such a developmental hit when the rest of the autistic brain is working just dandy? Other scientists argue that while mirror neurons may help your brain to understand a concept, they may not necessarily ENCODE that concept. For instance, babies understand the meaning behind many actions without having the motor ability to perform them. If this is true, then an autistic person's mirror neurons are perfectly fine...they were just never responsible for his lack of empathy in the first place.
Slightly confused? Curious to find out more about these wunderkinds of the human brain? Join the club. Whether you're an passionate believer in these little fellas with their seemingly magical properties or still skeptical, let me add to your growing interest with one parting shot- since imitation appears to be the primary function of mirror neurons, they might well be partly responsible for our cultural evolution! How, you ask? Well, since culture is passed down from one generation to another through sharing, observation followed by imitation, these neurons are at the forefront of our lifelong learning from those around us. Research has found that mirror neurons kick in at birth, with infants just a few minutes old sticking their tongues out at adults doing the same thing.
So do these mirror neurons embody our humanity? Are they responsible for our ability to put ourselves in another person's shoes, to empathize and communicate our fellow human beings? That has yet to be determined. But after decades of research, one thing is for sure-these strange cells haven't yet ceased to amaze and we definitely haven't seen the last of them. To quote Alice in Wonderland, the tale keeps getting "curiouser and curiouser"!
The use of smartphones amongst health care professionals is now estimated to be in excess of 85%, with Apple's iPhone currently being the most popular platform. There is a wealth of information (from popular blogs, to formal journals) that demonstrate the potential of smartphone apps (and technology in general) to improve healthcare. However, despite widespread use of smartphones, proper application of the software at our disposal has been arguably poor. The latest mobile Apple operating system 'iOS 8', may be the start of a long-awaited overhaul of the current health apps available.
The App Store - as it stands
The Apple app store boasts many hundreds of what it describes as 'medical' apps. A review of the 'Top 200' medical apps conducted in 2012 by this author revealed that 49% were in fact general health or lifestyle applications aimed at the general public. The same process was repeated this year (2014) and demonstrated that this percentage has increased to 54%. This increase in apps aimed at the general public suggests that Apple do not differentiate between 'medical apps' and 'health and lifestyle' apps. This could negatively affect health care professionals' perception of the otherwise high-quality medical apps that are available. In addition, of the remaining percentage of apps aimed at healthcare professionals, only 5.56% were deemed to be of clinical benefit (an increased from 3% in 2012). The overwhelming majority of 'medical' apps aimed at medical professionals are actually educational in content and usually focus on the learning of anatomy.
Current health apps
Much like the 'medical' apps, only a limited selection of the health apps that are aimed at the public/patient are deemed to be high-quality. Prominent examples include the blood glucose monitors that record data in to a smartphone and similarly, the blood pressure and pain diaries. These examples focus on people with medical conditions, but it is important to note the potential of apps in preventative medicine too (i.e. promoting general health). Typical high-quality apps in this category include RunKeeper and Map My Ride. These apps allow everyone to become their own personal trainer and keep an accurate record of their physical activity. Smartphones will even send reminders to the user that a workout is due, and the option is present to share your stats and 'compete' with friends/family via social media. These features highlight the absolute vanguard of what could potentially come in terms of technology influencing healthy living.
A current criticism of health apps is that most (if not all) are individual enterprises with very little information shared between them. The metaphor of 'silos' is used to represent these large vessels of information that sit adjacent to one another whilst never benefiting from the contents of one another. The iOS 8 operating system hopes to ameliorate this current issue with its new Health app and HealthKit, which will enable developers and their apps to pull data from several health related apps into one streamlined app. It is envisaged that this app will be able to feed (with the appropriate permissions of course) health related information to your family physician for health monitoring purposes. This could have impressive effects in community blood pressure management and blood glucose management (just to name the obvious ones).
There are scattered anecdotal reports of users being wary of centralised health information and as always Data Protection is a major concern (whether it is warranted or not).
In addition, whilst a large percentage of the population may have a smartphone many may still opt not to use health related apps. Poor uptake will obviously limit the perception of this medium as a method of health monitoring.
Smartphone usage is high and many healthcare related apps are already available either to serve as medical tools to healthcare professionals or health monitoring devices for the public. Currently, Apple does not seem to differentiate between medical and lifestyle apps on its app store and many lower quality apps seem to appear in 'medical' searches. Also, Current apps do not share information. However, with iOS 8 it seems that Apple seems to be addressing several key issues surrounding the use of the iPhone as a health monitoring device. For the moment it seems that healthcare professionals will have to harness this patient-held approach. Perhaps direct improvements to the medical aspect of the Apple app store and the quality and originality of apps aimed at doctors is still a little way off.
Commencing the first clinical year is a milestone. Things will now be different as your student career steers straight into the unchartered waters of clinical medicine. New challenges and responsibilities lie ahead and not just in an academic sense. After all this is the awaited moment, the start of the apprenticeship you have so desired and laboured for. It won’t be long before these clinical years like the preclinical years before them, will seem just as distant and insular, so why not make the most of it?
The first days hold so much excitation and promise and for many they deliver, however, it would be wise not to be too optimistic. I am afraid your firm head standing abreast the doors in a prophetic splaying of arms is an unlikely sight. In this new clinical environment, it is natural to be a little flummoxed. The quizzical looks of doctors and nurses as you first walk in, a sure sign of your unexpected arrival, is a recurring theme. If the wards are going to be your new hunting ground, proper introductions with the medical team are in order. This might seem like a task of Herculean proportions, particularly in large teaching hospitals. Everyone is busy. Junior doctors scuttling around the ward desks job lists in hand, the registrar probably won’t have noticed you and as luck would have it your consultant firm head is away at a conference. Perseverance during these periods of frustration is a rewarding quality. Winning over the junior doctors with some keenness will help you no end. What I mean to say is that their role in our learning as students extends further than the security of sign-off signatures a week before the end of the rotation. They will give you opportunities. Take them! Although it never feels like it at the time, being a medical student does afford some privileges. The student badge clipped to your new clinic clothes is a license to learn: to embark on undying streaks of false answers, to fail as many skills and clerkings as is required and to do so unabashed.
Unfortunately, the junior doctors are not there purely for your benefit, they cannot always spare the time to directly observe a history taking or an examination, instead you must report back. With practice this becomes more of a tick box exercise: gleaning as much information and then reconfiguring it into a structured presentation. However, the performance goes unseen and unheard. I do not need to iterate the inherent dangers of this practice. Possible solutions? Well receiving immediate feedback is more obtainable on GP visits or at outpatient clinics. They provide many opportunities to test your questioning style and bedside manner. Performing under scrutiny recreates OSCE conditions. Due to time pressure and no doubt the diagnostic cogs running overtime, it is fatefully easy to miss emotional cues or derail a conversation in a way which would be deemed insensitive. Often it occurs subconsciously so take full advantage of a GP or a fellow firm mate’s presence when taking a history.
Self-directed learning will take on new meaning. The expanse of clinical knowledge has a vertiginous effect. No longer is there a structured timetable of lectures as a guide; for the most part you are alone. Teaching will become a valued commodity, so no matter how sincere the promises, do not rest until the calendars are out and a mutually agreed time is settled. I would not encourage ambuscaded attacks on staff but taking the initiative to arrange dedicated tutorial time with your superiors is best started early. Consigning oneself to the library and ploughing through books might appear the obvious remedy, it has proven effective for the last 2-3 years after all. But unfortunately it can not all be learnt with bookwork. Whether it is taking a psychiatric history, venipuncture or reading a chest X-ray, these are perishable skills and only repeated and refined practice will make them become second nature. Balancing studying with time on the wards is a challenge. Unsurprisingly, after a day spent on your feet, there is wavering incentive to merely open a book. Keeping it varied will prevent staleness taking hold. Attending a different clinic, brushing up on some pathology at a post-mortem or group study sessions adds flavour to the daily routine. During the heated weeks before OSCEs, group study becomes very attractive. While it does cement clinical skills, do not be fooled. Your colleagues tend not to share the same examination findings you would encounter on an oncology ward nor the measured responses of professional patient actors.
So ward time is important but little exposure to all this clinical information will be gained by assuming a watchful presence. Attending every ward round, while a laudable achievement, will not secure the knowledge. Senior members of the team operate on another plane. It is a dazzling display of speed whenever a monster list of patients comes gushing out the printer. Before you have even registered each patient’s problem(s), the management plan has been dictated and written down. There is little else to do but feed off scraps of information drawn from the junior doctors on the journey to the next bed. Of course there will be lulls, when the pace falls off and there is ample time to digest a history. Although it is comforting to have the medical notes to check your findings once the round is over, it does diminish any element of mystery. The moment a patient enters the hospital is the best time to cross paths. At this point all the work is before the medical team, your initial guesses might be as good as anyone else’s. Visiting A&E of your own accord or as part of your medical team’s on call rota is well worth the effort. Being handed the initial A&E clerking and gingerly drawing back the curtain incur a chilling sense of responsibility. Embrace it, it will solidify not only clerking skills but also put into practice the explaining of investigations or results as well as treatment options. If you are feeling keen you could present to the consultant on post-take.
Experiences like this become etched in your memory because of their proactive approach. You begin to remember conditions associated with patient cases you have seen before rather than their corresponding pages in the Oxford handbook. And there is something about the small thank you by the F1 or perhaps finding your name alongside theirs on the new patient list the following morning, which rekindles your enthusiasm. To be considered part of the medical team is the ideal position and a comforting thought. Good luck.
This blog post is a reproduction of an article published in the Medical Student Newspaper, Freshers 2013 issue.
I’m sure there are times when all us GPs feel under-appreciated — by our patients, staff, specialist colleagues or society in general. You can’t blame them for sometimes taking us for granted — it’s part of the human condition. People don’t value what they have until they lose it, whether “it” is the ability to walk or a domestic fairy who makes sure there’s always spare toilet paper.
It’s a common lament that we can’t be at our own funerals to hear how much we’re loved. Mind you, eulogies are rarely objective and balanced. Nonetheless, it’s a pity we’re not around to hear the praise — deserved or otherwise — that is expressed once we’re gone.
The long-serving, somewhat-taken-for-granted GP has a non-fatal way of bringing out the appreciation in his or her patients and staff: moving on.
After 10 years of GP-ing in the Noosa hinterland and a lifetime of living in south-east Queensland, I headed south of the border: to northern NSW. The hardest part of the move for me — harder than selling my house in a depressed market, harder than dealing with banks, builders, real estate agents, solicitors and Australia Post, harder even than trying to get rational answers out of my telecommunications company after they cut off my internet and phone prematurely — was telling my patients that I was leaving.
I knew many of my patients were very attached. I knew they’d come to me expecting to receive a loyal, life-long partner kind of doctoring, rather than the one-night-stand variety. But I had no idea how difficult it would be to break the “I’m leaving you” news again and again and again.
Hard as breaking up a relationship may be, at least you only have to do it once when you leave a romantic partnership. For me, telling patients I was leaving felt a bit like breaking up with hundreds of boyfriends, one after the other after the other.
You may interpret this as my being too close to my patients or not close enough to my boyfriends, but the fact is I found the protracted process exhausting, emotionally draining and just plain horrible. The “it’s not you, it’s me” part goes without saying and
I know I am far from irreplaceable, but seeing the tears well up in countless eyes because of the words I’ve uttered was enough to break my tender heart.
Looking on the bright side, as I am wont to do, if I’d ever felt under-appreciated, I sure don’t now. I received more expressions of gratitude in those last three months than I did in the previous decade. To hear how influential I was in some of my patients’ lives put a warm glow in my battered heart. And as much as it hurt me to see my patients upset, it probably would’ve hurt me more if they’d been completely indifferent to my leaving.
However, I did please someone. Mrs L had been trying for years to get her husband to agree to move interstate to be near family. His last remaining excuse was that his multiple complex medical problems meant that he couldn’t possibly leave me, his long-term GP. A grateful Mrs L rang me within hours of my informing them of my impending departure to say:
“He’s finally come around. Thank you so much for deciding to leave us.”
It’s nice to be appreciated!
(This blog post has been adapted from a column first published in Australian Doctor www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-moving-on- )
Dr Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com/
Being Black in America is dangerous. We hear about the deaths by police shooting or white supremacist - and by gun violence generally, which disproportionately plagues Black communities. But we hardly ever discuss the persistent discrepancy in life expectancy between white and black. There are many ways to attack the latter through healthcare policy and practice -- if we are willing. That remains the question for America 48 years after King was killed.
Storylines on popular TV dramas are a great way of raising the public's awareness of a disease. They're almost as effective as a celebrity contracting an illness.
For example, when Wiggles member Greg Page quit the group because of postural orthostatic tachycardia syndrome, I had a spate of patients, mostly young and female, coming in with self-diagnosed "Wiggles Disease". A 30% increase in the number of mammograms in the under-40s was attributed to Kylie Minogue's breast cancer diagnosis. The list goes on.
Thanks to a storyline on the TV drama Desperate Housewives, I received questions about male postnatal depression from local housewives desperate for information:
"Does it really exist?"
"I thought postnatal depression was to do with hormones, so how can males get it?"
"First it's male menopause, now it's male postnatal depression. Why can't they keep their grubby mitts off our conditions?"
"It's like that politically correct crap about a 'couple' being pregnant. 'We' weren't pregnant, 'I' was. His contribution was five seconds of ecstasy and I was landed with nine months of morning sickness, tiredness, stretch marks and sore boobs!"
One of my patients, a retired hospital matron now in her 90s, had quite a few words to say on the subject.
"Male postnatal depression -- what rot! The women's liberation movement started insisting on equality and now the men are getting their revenge. You know, dear, it all began going downhill for women when they started letting fathers into the labour wards. How can a man look at his wife in the same way if he has seen a blood-and-muck-covered baby come out of her … you know? Men don't really want to be there. They just think they should -- it's a modern expectation. Poor things have no real choice."
Before I had the chance to express my paucity of empathy she continued to pontificate.
"Modern women just don't understand men. They are going about it the wrong way. Take young couples who live with each other out of wedlock and share all kind of intimacies. I'm not talking about sex; no, things more intimate than that, like bathroom activities, make-up removal, shaving, and so on."
Her voice dropped to a horrified whisper. "And I'm told that some young women don't even shut the door when they're toileting. No wonder they can't get their de facto boyfriends to marry them. Foolish girls.
Men need some mystery. Even when you're married, toileting should definitely be kept private."
I have mixed feelings about male postnatal depression. I have no doubt that males can develop depression after the arrival of a newborn into the household; however, labelling it "postnatal depression" doesn't sit all that comfortably with me. I'm all for equality, but the simple fact of the matter is that males and females are biologically different, especially in the reproductive arena, and no amount of political correctness or male sharing-and-caring can alter that. Depressed fathers need to be identified, supported and treated, that goes without saying, but how about we leave the "postnatal" tag to the ladies?
As one of my female patients said: "We are the ones who go through the 'natal'. When the boys start giving birth, then they can be prenatal, postnatal or any kind of natal they want!"
(This blog post has been adapted from a column first published in Australian Doctor http://bit.ly/1aKdvMM)
This field of medicine requires much more physiological and pathophysiological knowledge than most people give it credit for. Psychiatric illness DO have physical manifestations of symptoms; in fact those symptoms help form the main criteria for differential diagnoses. For example, key physical symptoms of depression, besides having a low mood for more than two weeks (yes, two weeks is all it takes to be classified as 'depressed'), include fatigue, change in appetite, unexplained aches/pains, changes in menstrual cycle if you're a female, altered bowel habits, abnormal sleep, etc. Aside from this, studies suggest that psychiatric illnesses put you at higher risk for physical conditions including heart disease, osteoarthritis, etc. (the list really does go on)
Although some mental health conditions, like cognitive impairments, still do not have very effective treatment options; most psychiatric medications work very well, and are necessary for treating the patient. The stigma surrounding them by the public causes a huge problem for doctors. Many patients are reluctant to comply with medications because they are not as widely accepted as the ones for non-mental health conditions. A psychiatrist holds a huge responsibility for patient education. It can be tough to teach your patients about their medication, when many of them refuse to belief there is anything wrong with them (this is also because of stigma).
Contrary to my previous beliefs, psychiatrists DO NOT sit around talking about feelings all day. The stereotypical image of someone lying down on a couch talking about their thoughts/feelings while the doctor holds up ink blots, is done more in 'cognitive behavioural therapy.' While this is a vital healthcare service, it's not really what a psychiatrist does. Taking a psychiatric history is just like taking a regular, structured medical history; except you have to ask further questions about their personal history (their relationships, professional life, significant life events, etc), forensic history, substance misuse history (if applicable), and childhood/developmental history. Taking a psychiatric history for a new patient usually takes at least an hour.
The interesting thing about about treating a psychiatric patient is that the best guidelines you have for making them healthy is their personality before the symptoms started (this is called 'pre-morbid personality'). This can be difficult to establish, and can often be an ambiguous goal for a doctor to reach. Of course, there is structure/protocol for each illness, but each patient will be unique. This is a challenge because personalities constantly evolve, healthy or not, and the human mind is perpetual.
On top of this, whether mental or physical, a serious illness usually significally impacts a person's personality.
Most psychiatric conditions, while being very treatable, will affect the patient will struggle with for their whole life. This leaves the psychiatrist with a large portion of the responsibility for the patient's quality of life and well-being; this can be vey rewarding and challenging. The state of a person's mind is a perpetual thing, choosing the right medication is not enough.
Before I had done this rotation, I was quite sure that this was a field I was not interested in. I still don't know if it is something I would pursue, but I'm definitely more open-minded to it now!
PS: It has also taught me some valuable life lessons; most of the patients I met were just ordinary people who were pushed a little too far by the unfortunate combination/sequence of circumstances in their life. Even the ones who have committed crimes or were capable of doing awful things.. It could happen to anyone, and just because I have been lucky enough to not experience the things those people have, does not mean I am a better person for not behaving the same way as them.
There are roughly 7000 medical students graduating each year from 33 medical schools in the UK. Medical degrees take either 4, 5 or 6 years depending on the route you take.
The government via the Student Finance Company will pay for your tuition fees for the first 4 years of any undergraduate degree. After this the NHS will pay for the last year or 2 years of the undergraduate medical tuition fees.
The maintenance loan depends on family income. The figures aren’t easy to find for the background of most UK medical students but a ‘guestimate’ based on my medical school is that 50% went to a private school, 30% went to selective state schools and 20% went to a comprehensive. Of the private school kids probably about half had a scholarship or bursary. So, a rough guess would be that 70% of med students come from a “middle class” family who have a decent income but not huge wealth and are therefore eligible for a ‘maintenance loan’ above the minimum. This majority therefore rely on there loan to get through the year.
An average student income is between £1000 and £1500/term (£1200 average-ish). Most university terms are 10 weeks, hence average income is about £120/week. As a preclinical medical student this is fine and we are on par with everyone else. As soon as we become clinical med students the game changes!
Clinical years are far longer, more like 40 weeks a year rather than 30. Students are on placement, have to dress professionally and travel to placement daily. This adds additional costs and requires the money to stretch further. Doubly bad!
Once, the NHS starts paying the tuition fees, the Student Loans Company starts reducing the maintenance loan, by half! Why?
A final year student or a 4th year who has intercalated now has to survive at University for one of their course’s longest years with half the money they had previously. >40 weeks on a loan of roughly £1500/year. This situation is pretty much unique to medical students.
Some students are lucky enough to have parents who can afford the extra couple of thousand pounds required for the year. Some students get selected into the military and get a salary. A greater proportion find part time jobs to help cover the cost and the rest have to resort to saving money where they can and taking out loans.
When I was a member of the BMA medical student committee I did a project as part of the finance sub-committee investigating the loans available for medical students. Many banks used to “professional development loans” which allowed medical and law students to borrow money for a year before they had to start repaying the loan. Hardly any banks now offer this service, so the only loan available is an overdraft or a standard loan that requires you to have a regular income.
This means that final year medical students with limited family support may have to live for a year on less than £2000. Does this seem fair? Does this seem sensible government policy?
Medical students are 99% guaranteed to be earning over £25 thousand pounds within a year. We will be able to repay any loans. So why isn’t the Student Loan Company allowing us to continue having a ‘normal’ maintenance loan? And why aren’t banks giving us the benefit of the doubt and helping us out in our time of need?
When I was on the BMA MSC there was talk of having a campaign to lobby government and the banks to rectify this situation but I can’t say I’ve been aware of any such campaign. Are the NUS, BMA, UKMSA or anyone else doing anything about this?
Please do leave a comment if you do know if there has been a progress and if there hasn’t why don’t we start making a fuss about this!
In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees.
Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this.
In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment.
In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room.
What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it?
Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important.
Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.
So, I think its about time I posted another blog post!
A few weeks ago I received the results from my most recent scan. I was both nervous and excited to find out my results, after months of tests and being misdiagnosed several times I just wanted to know what was wrong with me. However, as I read through the letter from my consultant I realised that my journey was just beginning. I was diagnosed with a rare stomach condition.
Gastroparesis. A chronic illness. There is no known cure, just various treatments with limited success. I didn’t really know how to react to this news. Shouldn’t I be happy that I finally knew what was wrong?
I had convinced myself for months that as soon as the doctors found out what was wrong, they could fix it and I’d be better in no time, but this wasn’t to be. I couldn’t understand how this could happen. Slowly the reality began to sink in, I’ll probably be fighting this battle for the rest of my life.
I think the mental aspect of chronic conditions is so commonly overlooked. I’ve sat through endless lectures about the pathophysiology of illnesses but I’ve never once stopped to think what it must be like to actually have it. The way it can limit your life, from not being able to go for a drink with friends because you’re in too much pain to the countless hospital appointments that your life seems to revolve around. The thing that hit me the most is the amount of medications I have to take on a daily basis just to make my symptoms bearable. I no longer have full control of my life and that's the worst part.
This experience has given me an invaluable insight into how patients with chronic illness feel. It affects almost every aspect of your life and you can never escape. It scares me to think of the future, I never know when I’m going to get my next flare up or how long its going to last. I just have to take one day at a time and hope that when I wake up tomorrow I won’t be too nauseous.
After spending a few weeks feeling down about it all, I’ve realised that I just have to enjoy life when I can and be grateful that I can still live a normal-ish life. It doesn’t matter how much I complain, it's not going to go away, and I think I’ve finally accepted that fact.
If anything, this experience has made me more determined to achieve my dream of becoming a doctor. I’ve been a lot more motivated to work harder so that one day I can help others like me through some of their toughest times, hopefully bringing them some comfort and relief.
This is my first blog on Meducation. I decided to tell the reader a bit about myself, so that future blogs will make sense.
At age 48 and in an active and successful academic practice of OB & GYN, my best friend died from a complication of cardiac surgery. This tragic event made my wife's and me consider other things in life than just work, thus at age 55, I decided to retire from my academic position and to start working as a locum in many different cultural settings. The plan was to work somewhere in an area of need for six months and alternate this with travel for six months. It did not quite work out exactly that way, but close enough.
I worked in Japan, then Pakistan, Tasmania, Australia, New Zealand, Alaska, St Lucia, and Chiapas in Mexico. Much earlier I had had a two year experience in Africa.
It was a very satisfying experience and my wife and I have never looked back. Many of my friends and colleagues kept urging me to write a book about our experiences and how we accomplished them. For a long time I kept resisting, probably because I felt that no one might be interested, and because I might have been lazy, and most likely for both of these reasons. I finally gave in, started writing and published an e book.
The title is "Crosscultural Doctoring. On and Off the Beaten Path." the book can be down loaded for free from Smashwords at: http://www.smashwords.com/books/view/161522
The book is meant for medical as well as non medical people. It is written as a series of loosely connected anecdotes, some medical, some non medical, some funny, some not so funny. The book describes the immense satisfaction my wife and I experienced from our decision and I hope that reading the book might inspire others, medical or non medical people, who might be thinking about a career change or early retirement to jump of the beaten path. The book might also inspire other with similar experiences to write about them.
I would love to receive some comments.
William J. LeMaire
Learn more about me please visit my website at: http://www.freewebs.com/wimsbook
A doctor is nothing without patients. But, unless they make themselves known in the community, and make themselves available, they are not going to be able to attract a lot of patients. One of the most important thing for many people is that doctors have convenient hours. This is no longer a nine to five world, and people often need to have appointments that will fit in with their schedules. One way that doctors can gain a good reputation in the community and increase their caseloads is to be accessible. This means offering things like early or late hours. When doctors increase their availability, it means fewer trips to the emergency room for patients when they need to see doctors after hours.
In addition to having better hours, there are other ways that doctors can attract new patients. These include:
Electronic Health Records
One of the things people hate the most about visiting a medical office is having to fill out a bunch of forms each time they visit. When you have electronic health records, they will only have to fill out one form. All of their information will be recorded and easy to access, so you will always have the information you need, when you need it. You can even use the system to send out prescriptions to pharmacies.
Better Telephone Hours
Many people don’t have time to call for a medical appointment when they are working, and prefer to call during their lunch hour or even after work. If your office closes for lunch, you are going to miss getting calls from patients who need to call at this time. Have a member of your staff on hand to answer the phones during the lunch hour. That way, patients will be able to get through, and you won’t be missing any calls. If there is no one to answer the phone, most people are likely to call another doctor, and will never call you back again. You may also want to consider extending your telephone hours, so patients can call after 5 pm.
You need to get your name out there, and one way to do it is to be up front with pricing. Often, patients will want to know what procedures cost before having them done. You can use Yempl.com to inform potential patients about your rates. They compare your information to that of other doctors in order to make the best decisions.
No matter how organized your office is, there are still bound to be patients waiting in the office for appointments. They are not getting anything done while they are just sitting around, but they can be more productive when they are able to connect to the Internet. You can provide free Wi-Fi services so your patients can use their mobile devices to connect to the Internet and check emails, shop, chat with friends, get work done, and more. With so many people carrying mobile devices these days, it makes little sense not to offer this service.
Create a Web Portal
When you have a web portal that is easy to use, patients can schedule appointments, reschedule appointments, access and print out forms before their visits, and more. You can use the portal to easily update things like contact, insurance, and personal information about your patients. This is a great way for patients to be able to make payments, get prescription refills, get results from tests, and get messages from doctors to avoid missed phone calls. Be sure to include a smartphone app so patients can contact you from anywhere.
Image Source: Seaside Medical Practice