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Physician Don’t Heal Thyself

By Genevieve Yates One reason why I chose to do medicine was that I didn’t always trust doctors – another being access to an endless supply of jelly beans. My mistrust stemmed from my family’s unfortunate collection of medical misadventures: Grandpa’s misdiagnosed and ultimately fatal cryptococcal meningitis, my brother’s missed L4/L5 fracture, Dad’s iatrogenic brachial plexus injury and the stuffing-up of my radius and ulna fractures, to name a few. I had this naïve idea that my becoming a doctor would allow me to be more in charge of the health of myself and my family. When I discovered that doctors were actively discouraged from treating themselves, their loved ones and their mothers-in-law, and that a medical degree did not come with a lifetime supply of free jelly beans, I felt cheated. I got over the jelly bean disappointment quickly – after all, the allure of artificially coloured and flavoured gelatinous sugar lumps was far less strong at age 25 than it was at age 5 – but the Medical Board’s position regarding self-treatment took a lot longer to swallow. Over the years I’ve come to understand why guidelines exist regarding treating oneself and one’s family, as well as close colleagues, staff and friends. Lack of objectivity is not the only problem. Often these types of consults occur in informal settings and do not involve adequate history taking, examination or note-making. They can start innocently enough but have the potential to run into serious ethical and legal minefields. I’ve come to realise that, like having an affair with your boss or lending your unreliable friend thousands of dollars to buy a car, treating family, friends and staff is a pitfall best avoided. Although we’ve all heard that “A physician who heals himself has an idiot for a doctor and a fool for a patient”, large numbers of us still self-treat. I recently conducted a self-care session with about thirty very experienced GP supervisors whose average age was around fifty. When asked for a show of hands as to how many had his/her own doctor, about half the group confidently raised their hands. I then asked these to lower their hands if their nominated doctor was a spouse, parent, practice partner or themselves. At least half the hands went down. When asked if they’d seek medical attention if they were significantly unwell, several of the remainder said, “I don’t get sick,” and one said, “Of course I’d see a doctor – I’d look in the mirror.” Us girls are a bit more likely to seek medical assistance than the blokes (after all, it is pretty difficult to do your own PAP smear – believe me, I’ve tried), but neither gender group can be held up as a shining example of responsible, compliant patients. It seems very much a case of “Do as I say, not do as I do”. I wonder how much of this is due to the rigorous “breed ’em tough” campaigns we’ve been endured from the earliest days of our medical careers. I recall when one of my fellow interns asked to finish her DEM shift twenty minutes early so that she could go to the doctor. Her supervising senior registrar refused her request and told her, “Routine appointments need to be made outside shift hours. If you are sick enough to be off work, you should be here as a patient.” My friend explained that this was neither routine, nor a life-threatening emergency, but that she thought she had a urinary tract infection. She was instructed to cancel her appointment, dipstick her own urine, take some antibiotics out of the DEM supply cupboard and get back to work. “You’re a doctor now; get your priorities right and start acting like one” was the parting message. Through my work in medical education, I’ve had the opportunity to talk to several groups of junior doctors about self-care issues and the reasons for imposing boundaries on whom they treat, hopefully encouraging to them to establish good habits while they are young and impressionable. I try to practise what I preach: I see my doctor semi-regularly and have a I’d-like-to-help-you-but-I’m-not-in-a-position-to-do-so mantra down pat. I’ve used this speech many times to my advantage, such as when I’ve been asked to look at great-aunt Betty’s ulcerated toe at the family Christmas get-together, and to write a medical certificate and antibiotic script for a whingey boyfriend with a man-cold. The message is usually understood but the reasons behind it aren’t always so. My niece once announced knowledgably, “Doctors don’t treat family because it’s too hard to make them pay the proper fee.” This young lady wants to be a doctor when she grows up, but must have different reasons than I did at her age. She doesn’t even like jelly beans! Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com/  
Dr Genevieve Yates
almost 7 years ago
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461

I hate being on-call - I’m just not good at sleeping on the job

BOXING Day, 1.30am. “Are you the doctor on call?” I wrenched my reluctant brain from its REM state. “Yes.” “I’m worried about my wife. She’s 16 weeks pregnant and very gassy.” “Gassy?” “Burping and farting. Smells terrible! It’s keeping us both awake. I’m worried it could be serious.” By the time I ascertained that there were no sinister symptoms and that the likely culprit was the custard served with Christmas pudding (the patient was lactose intolerant), I was wide awake. My brain refused to power down for hours, as if out of spite for being so rudely aroused. I have a confession to make. When the Australian Federal Government announced that it was planning to abolish after-hours practice incentive payments, I was delighted. I know, I know, I should have been outraged along with the rest of you. After all, the RACGP predicted that after-hours care would be decimated if incentives were removed. Comparisons were made with the revamp of the UK system in 2004, which led to 90% of the profession opting out of after-hours work. Much as I sympathised, I was secretly rubbing my hands together with selfish glee. Surely this would mean that our semi-rural practice would stop doing all of our own on-call and free me from my after-hours responsibilities? I detest being on call. I loathe it with a passion completely out of proportion to the imposition it actually causes. I’m on call for the practice and our local hospital only once a week and the workload isn’t onerous. Middle-of-the-night calls aren’t all that frequent, but my sleep can be disturbed by their mere possibility, leaving me tired and cranky. If I’m forced suddenly into “brain on, work mode” by a phone call, I can kiss hours of precious slumber goodbye. I love to sleep, but, as with drawing and tennis, I’m not very good at it. I gaze with envy at those lucky devils who nap on public transport and fight malicious urges to disturb their peaceful repose. If I’m not supine, in a quiet, warm room, with loose-fitting clothing, a firm mattress and a pillow shaped just-so, I can forget any chance of sleep. Let’s just say I can relate to the Princess and the Pea story. I bet she wouldn’t have coped well with being phoned in the middle of the night either. If these nocturnal calls were all bona fide emergencies, I wouldn’t mind so much. It’s the crap that really riles me. I’ve received middle-of-the-night phone calls from patients who are constipated, patients with impacted cerumen (“Me ear’s blocked, Doc. I can’t sleep”) and patients with insomnia who want to know if it’s safe to take a second sedative. The call that took the on-call cake for me, though, was from a couple who woke me at 11.30 one night to settle an argument. “My husband says that bacteria are more dangerous than viruses but I reckon viruses are worse. After all, AIDS is a virus. Can you settle it for us so we can get some sleep? It would really help us out.” I kid you not. Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com  
Dr Genevieve Yates
over 6 years ago
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149

Imagine a world where procrastination became a productive pastime…

Imagine a world where procrastination became a productive pastime… Procrastination, as it stands, is a core feature of the ‘human condition’ and most would argue that it is here to stay. However, what if we could hijack the time we spend playing Candy Crush saga and trick ourselves into contributing towards something tangible. Today, I wish to explore this possibility with you. The phrase ‘gamification’ is not a new or made up word (I promise) although I agree it does sound jarring and I certainly wouldn’t recommend trying to use it in a game of scrabble (yet). The phrase itself refers to the process of applying game thinking and game mechanics to non-game contexts to engage users in solving problems. For our purposes and for the purposes of this blog ‘problems’ will equate to promoting healthy living for our patients and maintaining our own medical education. For one reason or another, most people show addictive behaviour towards games especially when they incorporate persistent elements of progression, achievement and competition with others. The underlying psychology won’t be discussed here; call it escapism, call it procrastination, call it whatever you will. What I want you to realise is that every day millions of people spend hours tending to virtual farms and cyber families whilst competing vigorously with ‘online’ friends. If we can take the addictive aspects of these popular games and incorporate them in to the non-game contexts I indicated to above, we could potentially trick ourselves, and even perhaps our patients, into a better way of life. The first time I heard the phrase ‘gamification’ was only last year. I was in Paris attending the Doctors 2.0 conference listening to talks on how cutting edge technologies and the Internet had been (or were going to be) incorporated into healthcare. One example that stood out to me was a gaming app that intended to engage people with diabetes to record their blood sugars more regularly and also compete with themselves to achieve better sugar control. People who have the condition of Diabetes Mellitus are continuously reminded of their diet and their blood sugar levels. I am not diabetic myself, but it is not hard to realise that diet and sugar control is going to be an absolute nightmare for people with diabetes both from a practical and psychological standpoint. Cue the mySugr Compainion, an FDA approved mobile application that was created to incorporate the achievement and progression aspects of game design to help encourage people with diabetes to achieve better sugar control. The app was a novel concept that struck a chord with me due to its potential to appeal to the part in everyone’s brain that makes them sit down and play ‘just one more level’ of their favorite game or app. There are several other apps on the market that are games designed to encourage self testing of blood sugar levels in people with diabetes. There is even a paediatric example titled; “Monster Manor,” which was launched by the popular Sanofi UK (who previously released the FDA / CE approved iBGStar iPhone blood glucose monitor). So applying aspects of game design into disease management apps has anecdotally been shown to benefit young people with Diabetes. However, disease management is just one area where game-health apps have emerged. We are taught throughout medical school and beyond that disease prevention is obviously beneficial to both our patients and the health economy. Unsurprisingly, one of the best ways to prevent disease is to maintain health (either through exercise and / or healthy eating). A prominent example of an app that helps to engage users in exercising is ‘RunKeeper,’ a mobile app that enables people to track and publish their latest jog-around-the-park. The elements of game design are a little more subtle in this example but the ability to track your own progress and compete with others via social media share buttons certainly reminds me of similar features seen in most of today’s online games. Other examples of ‘healthy living apps’ are rife amongst the respective ‘app stores,’ and there seems to be ample opportunity for the appliance of gamification in this field. An example might be to incorporate aspects of game design into a smoking cessation app or weight loss helper. Perhaps the addictive quality of a well designed game-app could overpower the urge for confectionary or that ‘last cigarette’… The last area where I think ‘gamification’ could have a huge benefit is in (medical) education. Learning and revising are particularly susceptible to the rot of procrastination, so it goes without saying that many educational vendors have already attempted to incorporate fresh ways in which they can engage their users to put down the TV remote and pick up some knowledge for the exams. Meducation itself already has an area on its website entitled ‘Exam Room,’ where you can test yourself, track your progress and provide feedback on the questions you are given. I have always found this a far more addictive way to revise than sitting down with pen and paper to revise from a book. However, I feel there could be a far greater incorporation of game design in the field of medical education. Perhaps the absolute dream for like-minded gamers out there would be a super-gritty medical simulator that exposes you to common medical emergencies from the comfort of your own computer screen. I mean, my shiny new gaming console lets me pretend to be an elite solider deep behind enemy lines so why not let me pretend and practice to be a doctor too? You could even have feedback functionality to indicate where your management might have deviated from the optimum. Perhaps more sensibly, the potential also exists to build on the existing banks of online medical questions to incorporate further aspects of social media interaction, achievement unlocks and inter-player competition (because in case you hadn’t noticed, medics are a competitive breed). I have given a couple of very basic examples on how aspects of game design have emerged in recent health-related apps. I feel this phenomenon is in its infancy. The technology exists for so much more than the above, we just need to use our imagination… and learn how to code.  
Dr. Luke Farmery
over 6 years ago
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612

Hello World, I've been to London's Air Ambulance for a bit...

Hi. Or rather, #HelloMyNameIs Adam. I like trauma, emergency medicine, PHEC, #FOAMed, twitter and scuba diving (but only when there's sunshine involved afterwards). I also like teaching and education, and I'm one of the final year medical students here in Edinburgh. But for 2 months I wasn't. I was one of the London's Air Ambulance elective students down in Whitechapel at the Royal London Hospital. So as an opening gambit, and by some way of an introduction I thought you might want to hear about that. After all, they're much more interesting than I am, and I can't host you for your elective… I managed to swindle my way into a 2 month elective with LAA just before Christmas 2014 and in a word it was pretty great. For those of you thinking of doing it, just go, now, and apply. Then you can come back and read the rest of my ramblings. For the rest of you, here’s what happened. LAA electives are a bit different, unsurprisingly. To cover its 1800-odd missions a year, LAA runs both their trauma service in two flavours: a helicopter (G-EHMS, aka “Mike Sierra” or MEDIC 1) by day and a car (DA “Delta Alpha” 77 or MEDIC 1 NIGHT) by night, (because apparently, whilst sporting and enjoyable for the pilots, landing in metropolitan areas in the dark is too risky, especially with comparatively empty roads). Alongside the trauma service, there is also a Physician Response Unit (PRU) which responds locally to cardiac arrests to provide quality CPR (along with some advanced post-arrest care like cooling and delivery to a cath lab), but for the most part does jobs for the London Ambulance Service which have been deemed probably not to require hospital, but might benefit from a doctor. There’s a 5 year waiting list for day-time flying shifts, and not much less for the rest of their work, so you’re not going to spend 4, 6 or 8 weeks in a helicopter flying round London taking names and saving lives, in fact the helicopter schedule is totally off-limits to students. Instead you’ll start off scheduled for a couple of night shifts each month and there will be opportunities to see a lot of London Ambulance Service, from the “control” at the Emergency Operations Centre (EOC), to time spent with road crews, and, off the back of some of the folk you’ll meet, a route in to observing with some more specialist units too. (More on that in the future if I run out of other ideas!) As well as the “live” experience there are 5 very experienced senior registrars from a variety of backgrounds as well as the 4 full-time LAA consultants, and opportunities to learn both practical skills and theoretical knowledge from them abound. As it turned out, the PRU was probably my favourite part of the elective. You can read about all the trauma that LAA goes to elsewhere, its splashed all over their shiny new website for a start, and many things have been written about their work (I might even write some more later on!) and there’s even a (not great) telly program on Channel 5. But the PRU is just really cool. I hate that word but it is. It fits into a strange, but now expanding niche in emergency care. That is, it serves to lighten the load both on the ambulance service and on the Emergency Departments of London by going out to people who have called 999 and asked for an ambulance but might in fact be better managed in the community. The work is incredibly varied, you can see older folk with a nasty UTI who couldn’t get to see their GP, you can go to a school and glue the head of a kid who’s taken a nasty fall in the playground, or you can end up in some sheltered housing talking to a lady who’s having the roughest of times and trying to deal with borderline personality disorder to boot. The PRU is crewed about half the time by a small group of GPs and EM docs who have been doing it for a while, usually about once a week or so, and quite often in their own time (in between the rota is made up with the LAA docs who usually work the trauma service). They’re kept firmly in line by an experienced LAS paramedic who is seconded over to run this unit, 9-5, 5 days a week, usually for about a year. As a team, they have perfected their ability to assess a patient using the minimal resources available to them, and as we are so often reminded, quite rightly, it turns out to be all in the history. Some interventions are available to them that aren’t available to paramedics, prescribing antibiotics or other drugs to leave with the patient, bypassing the ED for referral straight to specialists, and doing urine dipsticks being the most used among them; but mostly it is the team’s experience and advanced clinical judgement which makes this unit tick, and empowers them to safely leave so many of their patients at home, with care delivered, advice given, and a plan arranged should anything deteriorate. This wasn’t my first rodeo, I’ve been lucky enough to spend some time with the Scottish Ambulance Service up here in Edinburgh, and have spent more than my fair share of time in our Emergency Department, but it was still impressive to see how these guys dealt with the delicate balance of who to leave at home and who might need a further investigation in hospital. Firstly, this is something that anyone who aspires to work in an emergency department should aspire to be comfortable to do. There are going to be a huge number of people who don’t need to be admitted coming through it every day, wherever it is. The faster and more confidently you can identify their problems, treat them, and crucially, reassure them with appropriate advice, good follow up and a safety net, the better experience they will have. Of course much of this comes with experience and training, but tagging along with teams like this is a fine way to start getting some. Secondly, and this is a bit of a stab in the dark, but I think this idea really might take off. The media is almost swamped with stories of A&E departments being overwhelmed, ambulance services are operating at or near capacity, and we’re struggling to work out how we get the public to access the right care provider for their problem at that time. So maybe this is a solution. Maybe doctors, have a new role to play in assessing people earlier rather than people going through so many steps down a potentially unsuitable line of care. We’re starting to see consultants running triage at A&Es, we’re starting to see doctors out in cars like this. Get in on the ground floor guys and girls, I think we’re going to start being “first on scene” a little more often than we might be used to, even if you never leave the hospital.  
Adam Collins
over 6 years ago
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300

Gin & Tonic Anyone?

It was a Saturday, about tea-time in the quaint village of Athelstaneford, East Lothian. Mrs Alexandria Agutter sat in her cottage, enjoying the delights of the late-summer evening with a glass of gin and tonic. She listlessly sipped from the rather generous pick-me up, no doubt chewing over the happenings of the day. Blast! The taste was much too bitter to her liking. She stood up. And promptly crumpled to the floor in a dizzied heap. It had not been five minutes when a fiery pain gripped her parched throat and in her frenzied turn she watched the bleary room become draped in a gossamery silk. How Dame Agatha would approve. But this is no crime novel, on that fateful day, 24th August 1994, poor Mrs Agutter immortalised herself in the history books of forensic medicine; she was the victim of a revered toxin and a vintage one it was too. She had unwittingly imbibed a G&T laced with a classic poison of antiquity. A clue from the 21st century: do you recall the first Hunger Games film adaption? Those inviting purple-black berries or as Suzanne Collins coined them ‘Nightlock’; a portmanteau of hemlock and Deadly Nightshade. True to the laters’ real life appearance those onscreen fictional fruits played a recurring cameo role. Deadly Nightshade is a perennial shrub of the family Solanaceae and a relative of the humble potato (a member of the Solanus genus). It is a resident of our native woodland and may be found as far afield as Europe, Africa and Western Asia. The 18th century taxonomist, Carl Linnaeus gave the plant an intriguing name in his great Species Plantarum. The genus Atropa is aptly named after one of the three Greek Fates, Atropos. She is portrayed shearing the thread of a mortal’s life so determining the time and manner of its inevitable end. The Italian species name belladona (beautiful woman) refers to the striking mydriatic effect of the plant on the eye. The name pays homage to Pietro Andre Mattioli, a 16th century physician from Sienna, who was allegedly the first to describe the plant’s use among the Venetian glitterati - ladies of fashion favoured the seductive, doe-eyed look. Belladona is poisonous in its entirety. It was from the plant’s roots in 1831, the German apothecary Heinrich F. G. Mein isolated a white, odourless, crystalline powder: it was (surprise, surprise) atropine. Atropine is a chiral molecule. From its natural plant source it exists as a single stereoisomer L-atropine, which also happens to display a chiral potency 50-100 times that of its D-enantiomer. As with many other anaesthetic agents it is administered as a racemic mixture. How strange that atropine now sits among the anaesthetist’s armamentarium, its action as a competitive antimuscarinic to counter vagal stimulation belies its dark history. It was a favourite of Roman housewives seeking retribution against their less than faithful husbands and a staple of the witch’s potion cupboard. Little wonder how belladona became known as the Devil’s plant. Curiouser still it’s also the antidote for other poisons, most notably the organophosphates or nerve gases. On account of its non-selective antagonism, atropine produces a constellation of effects: the inhibition of salivary, lacrimal and sweat glands occurs at low doses; dry mouth and skin are early markers. Pyrexia is a central effect exacerbated by the inability to sweat. Flushing of the face due to skin vessel vasodilatation. Low parasympathetic tone causes a moderate sinus tachycardia. Vision is blurred as the eye becomes dilated, unresponsive to light and accommodation is impaired. Mental disorientation, agitation and ataxia give the impression of drunkedness or a delirium tremens like syndrome. Visual hallucinations, often of butterflies or silk blowing in the wind, are a late feature. It was then that Mr Agutter, seemingly untroubled by the sight of his wife’s problematic situation, proceeded to leave a message with the local practitioner. How fortunate they were to have the vigilant locum check the answering machine and come round to the Agutter’s lodge accompanied by an ambulance crew. The attending paramedic had the presence of mind to pour the remainder of Mrs Agutter’s beverage into a nearby jam jar, while Mr Agutter handed over what he suspected to be the offending ingredient: the bottle of Indian tonic water. As it soon transpired there were seven other casualties in the surrounding countryside of East Lothian – all involving an encounter with tonic water. In fact by some ironic twist of fate, two of the victims were the wife and son of Dr Geoffry Sharwood-Smith, a consultant aneasthetist. Obviously very familiar with the typical toxidrome of anticholinergic agents, he was quick to suspect atropine poisoning. Although for a man of his position with daily access to a sweetshop of drugs, it was not something to draw attention to. Through no small amount of cunning had the poisoner(s) devised the plan. It was elegant; atropine is very bitter. So much so that it can be detected at concentrations of 100 parts per million (0.001%). Those foolish enough to try the berries of belladonna during walks in the woods are often saved by the berry’s sour taste. They are soon spat out. But the quinine in the tonic water was a worthy disguise. The lethal dose for an adult is approximately 90-130mg, however atropine sensitivity is highy variable. In its salt form, atropine sulfate, it is many times more soluble: >100g can be dissolved in 100ml of water. So 1ml may contain roughly tenfold the lethal dose. There ensued a nationwide scare; 50 000 bottles of Safeway branded Indian tonic water were sacrificed. Only six bottles had been contaminated. They had all been purchased, tops unsealed, from the local Safeway in Hunter’s Tryst. Superficially this looked like the handiwork of a psychopath with a certain distaste for the supermarket brand, and amidst the media furore, it did have some verisimilitude: one of the local papers received a letter from 25 year old, Wayne Smith admitting himself as the sole perpetrator. The forensic scientist, Dr Howard Oakley analysed the contents of the bottles. They all contained a non-lethal dose, 11-74mg/litre of atropine except for the Agutter’s, it contained 103mg/litre. The jam jar holding Mrs Agutter’s drink bore even more sinister results, the atropine concentration was 292mg/L. It would appear Mrs Agutter had in some way outstayed her welcome. But she lived. A miscalculation on the part of the person who had added an extra seasoning of atropine to her drink. According to the numbers she would have had to swallow a can’s worth (330ml) to reach the lethal dose. Thankfully she had taken no more than 50mg. The spotlight suddenly fell on Dr Paul Agutter. He was a lecturer of biochemistry at the nearby University of Napier, which housed a research syndicate specialising in toxicology. CCTV footage had revealed his presence at the Safeway in Hunter’s Tryst and there was eye witness evidence of him having placed bottles onto the shelves. Atropine was also detected by the forensic investigators on a cassete case in his car. Within a matter of two weeks he would be arrested for the attempted murder of his wife. Despite the calculated scheme to delay emergency services and to pass the blame onto a non-existent mass poisoner, he had not accomplished the perfect murder. Was there a motive? Allegedly his best laid plans were for the sake of a mistress, a mature student from Napier. He served seven years of a twelve year sentence. Astonishingly, upon his release from Glenochil prison in 2002, he contacted his then former wife proclaiming his innocence and desire to rejoin her in their Scottish home. A proposition she was not very keen on. Dr Agutter was employed by Manchester University as a lecturer of philosophy and medical ethics. He is currently an associate editor of the online journal Theoretical Biology and Medical Modelling. We will never know the true modus operandi as Dr Agutter never confessed to the crime. Perhaps all this story can afford is weak recompense for the brave followers of the Dry January Campaign. Oddly these sort of incidents never appear in their motivational testimonials. Acknowledgements Emsley J. Molecules of Murder. 2008, Cambridge, RSC Publishing, p.46-67. Lee MR. Solanaceae IV: Atropa belladona, deadly nightshade. J R Coll Physicians Edinb. March 2007; 37: 77-84. Illustrator Edward Wong This blog post is a reproduction of an article published in the The Medical Student Newspaper January issue, 2014 http://www.themedicalstudent.co.uk/  
James Wong
over 6 years ago
Foo20151013 2023 gvoh9v?1444774222
2
313

Socks, Kiwis and Surgical Removal

I’m a klutz. Always have been. Probably always will be. I blame my clumsiness on the fact that I didn’t crawl. Apparently I was sitting around one day and toddling on two feet the next. Whatever the cause, it’s a well-tested fact that I’m not good on icy footpaths. Various parts of my anatomy have gotten up close and personal with frozen ground on many an occasion. Not usually an issue for a born-and-bred Australian, except when said Australian goes to visit her Canadian family during the northern winter. During one such visit, I found myself unceremoniously plopped onto slick ice while my two-year-old niece frolicked around me with sure-footed abandon. I thought, “There has to be an easier way.” As freezing water seeped through my jeans, providing a useful cold pack for my screaming coccyx, my memory was jogged. I recalled that a lateral-thinking group of New Zealand researchers had won the Ignoble Prize for Physics for demonstrating that wearing socks on the outsides of shoes reduces the incidence of falls on icy footpaths. To the amusement of my niece, I tried out the theory for myself on the walk home. I don’t know if I had a more secure foothold or not, but I did manage to get blisters from wearing sneakers without socks. I love socks. They cover my large, ungainly clod-hoppers and keep my toes toasty warm almost all year round. You know the song ‘You can leave your hat on.’? Well for me, it is more a case of ‘You can leave your socks on, especially in winter. There’s nothing unromantic about that… is there? I’m not, however, as attached to my socks as a patient I once treated. As an intern doing a psychiatry rotation, one of my tasks was to do physical examinations on all admissions. Being a dot-the-i’s kinda girl, when an old homeless man declined to remove his socks so that I could examine his feet, I didn’t let it slide. “I haven’t taken off my socks for thirty years,” he pronounced. “It can’t be that long. Your socks aren’t thirty years old. In fact, they look quite new,” I countered. “When the old ones wear out, I just slip a new pair over the top.” I didn’t believe him. From his odour, I would have believed that he hadn’t showered in thirty years, but the sock story didn’t add up. He eventually agreed to let me take them off. The top two sock layers weren’t a problem but then I ran into trouble. Black remains of what used to be socks clung firmly to his feet, and my gentle attempts at their removal resulted in screams of agony. I tried soaking his feet. Still no luck. His skin had grown up into the fibres, and it was impossible to extract the old sock remnants without ripping off skin. In retrospect I probably should have left the old man alone, but instead got the psych registrar to have a peek, who then involved the emergency registrar, who called the surgeon and soon enough the patient and his socks were off to theatre. The ‘surgical removal of socks’ was not a commonly performed procedure, and it provided much staff amusement. It wasn’t so funny for Mr. Sock Man, who required several skin grafts! From my perspective here in Canada, while I thoroughly commend the Kiwis for their ground-breaking sock research, I think I’ll stick to the more traditional socks-in-shoes approach, change my socks regularly and work a bit on my coordination skills. References: PHYSICS PRIZE: Lianne Parkin, Sheila Williams, and Patricia Priest of the University of Otago, New Zealand, for demonstrating that, on icy footpaths in wintertime, people slip and fall less often if they wear socks on the outside of their shoes. "Preventing Winter Falls: A Randomised Controlled Trial of a Novel Intervention," Lianne Parkin, Sheila Williams, and Patricia Priest, New Zealand Medical Journal. vol. 122, no, 1298, July 3, 2009, pp. 31-8. (This blog post has been adapted from a column first published in Australian Doctor http://www.australiandoctor.com.au/articles/58/0c06f058.asp) 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/  
Dr Genevieve Yates
over 6 years ago
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1008

Confidence Building During Medical Training

My fellow medical students, interns, residents and attendings: I am not a medical student but an emeritus professor of Obstetrics and Gynecology at the University of Miami Miller School of Medicine, and also a voluntary faculty member at the Florida International University Herbert Wertheim College of Medicine. I have a great deal of contact with medical students and residents. During training (as student or resident), gaining confidence in one's own abilities is a very important part of becoming a practitioner. This aspect of training does not always receive the necessary attention and emphasis. Below I describe one of the events of confidence building that has had an important and lasting influence on my career as an academic physician. I graduated from medical school in Belgium many years ago. I came to the US to do my internship in a small hospital in up state NY. I was as green as any intern could be, as medical school in Belgium at that time had very little hands on practice, as opposed to the US medical graduates. I had a lot of "book knowledge" but very little practical confidence in myself. The US graduates were way ahead of me. My fellow interns, residents and attendings were really understanding and did their best to build my confidence and never made me feel inferior. One such confidence-building episodes I remember vividly. Sometime in the middle part of the one-year internship, I was on call in the emergency room and was called to see a woman who was obviously in active labor. She was in her thirties and had already delivered several babies before. The problem was that she had had no prenatal care at all and there was no record of her in the hospital. I began by asking her some standard questions, like when her last menstrual period had been and when she thought her due date was. I did not get far with my questioning as she had one contraction after another and she was not interested in answering. Soon the bag of waters broke and she said that she had to push. The only obvious action for me at that point was to get ready for a delivery in the emergency room. There was no time to transport the woman to the labor and delivery room. There was an emergency delivery “pack” in the ER, which the nurses opened for me while I quickly washed my hands and put on gloves. Soon after, a healthy, screaming, but rather small baby was delivered and handed to the pediatric resident who had been called. At that point it became obvious that there was one more baby inside the uterus. Realizing that I was dealing with a twin pregnancy, I panicked, as in my limited experience during my obstetrical rotation some months earlier I had never performed or even seen a twin delivery. I asked the nurses to summon the chief resident, who promptly arrived to my great relief. I immediately started peeling off my gloves to make room for the resident to take my place and deliver this twin baby. However, after verifying that this baby was also a "vertex" without any obvious problem, he calmly stood by, and over my objections, bluntly told me “you can do it”, even though I kept telling him that this was a first for me. I delivered this healthy, screaming twin baby in front of a large number of nurses and doctors crowding the room, only to realize that this was not the end of it and that indeed there was a third baby. Now I was really ready to step aside and let the chief resident take over. However he remained calm and again, stood by and assured me that I could handle this situation. I am not even sure how many triplets he had delivered himself as they are not too common. Baby number three appeared quickly and also was healthy and vigorous. What a boost to my self-confidence that was! I only delivered one other set of triplets later in my career and that was by C-Section. All three babies came head first. If one of them had been a breech the situation might have been quite different. What I will never forget is the implied lesson in confidence building the chief resident gave me. I have always remembered that. In fact I have put this approach in practice numerous times when the roles were reversed later in my career as teacher. Often in a somewhat difficult situation at the bedside or in the operating room, a student or more junior doctor would refer to me to take over and finish a procedure he or she did not feel qualified to do. Many times I would reassure and encourage that person to continue while I talked him or her through it. Many of these junior doctors have told me afterwards how they appreciated this confidence building. Of course one has to be careful to balance this approach with patient safety and I have never delegated responsibility in critical situations and have often taken over when a junior doctor was having trouble. Those interested, can read more about my experiences in the US and a number of other countries, in a free e book, entitled "Crosscultural Doctoring. On and Off the Beaten Path" can be downloaded at this link. Enjoy!  
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