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Foo20151013 2023 riytde?1444773947
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96

Reflection

Just as a bit of an intro, my name is Conrad Hayes, I'm a 4th year medical student studying in Staffordshire. My medical school are quite big on getting us into the habit of writing down reflections. It's something I feel I do subconsciously whilst I'm with patients or in teaching sessions, but frankly I suck at the written bit and I feel on the whole it's probably because there's nobody discussing this with us or telling me I'm an idiot for some of the things I may think/say! So I think if I'm going to attempt to complete a blog then I am going to do it in a reflective style and I do look forward to peoples feedback and discussions. I'll try to do it daily and see if that works out well, or weekly. But hopefully even if it doesn't get much response it can just be a store for me to look back on things! (Providing I keep up with it). So I'll start now, with a short reflection on my career aspirations which have been pretty much firmed up, but today I gave a presentation that I felt really galvanised me into this. So I want to do Emergency Medicine and Expedition Medicine (on the side more than as my main job). Emergency Medicine appeals to me as I love primary care and being the first to see patients, but I want to see them when they're ill and have a role in the puzzle solving, as it were, that is their issues. Possibly more to the point I want to do this in a high pressure environment where acutely ill individuals come in, and I feel (having done placements in A&E and GP and AMU) A&E is the place for me to be. Expedition Medicine on the other hand is something I accidentally stumbled upon really. In 2nd year I was part of a podcast group MedHeads that we tried to set up at my medical school. I interviewed Dr Amy Hughes of Expedition & Wilderness Medicine, a UK company, and I got really excited about the concepts she was talking about. Practicing medicine in the middle of nowhere, limited resources and sometimes only personal accumen and ingenuity to help you through. It sounded perfect! And since then I've wanted to do it, particularly being interested in Mountain Medicine and getting involved with some research groups. Today in front of my group I gave a presentation on the effects of altitude on the brain (I'm on Neurology at the moment and we had to pick a topic that interested us). I spoke for 15 minutes, a concept that usually terrifies me truth be told, and I thoroughly enjoyed myself. Now I've given a fair number of presentations but this was the first time I was actively excited and really happy about talking! It seems to me that if that isn't the definition of why you should go for a job, then I need to talk to a careers advisor. This experience has definitely ensured I pursue this course with every resource I have available to me! I would be interested in hearing how other people feel about their careers panning out and what got them into it so feel free to leave a comment!!  
Conrad Hayes
over 6 years ago
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Benchmarking Outpatient Referral Rates

Introduction GPs for a little while have been asked to compare each other’s outpatient referrals rates. The idea is that this peer to peer open review will help us understand each others referral patterns. For some reason and due to a natural competitive nature of human behaviour, I think we have these peer to peer figures put to us to try to get us to refer less into hospital outpatients. It’s always hard to benchmark GP surgeries but outpatient referral benchmarking is particularly poor for several reasons It's Very Difficult to Normalise Surgeries Surgeries have different mortalities morbidities ages and other confounding factors that it becomes very hard to create an algorithm to create a weighting factor to properly compare one surgery against another. There Are Several Reasons For The Referral I’ll go into more detail on this point later but there are several reasons why doctors refer patients into hospital which can range from: doctors knowing a lot about the condition and picking up subtle symptoms and signs lesser experienced doctors would have ignored; all the way to not knowing about the condition and needing some advice from an expert in the condition. We Need To Look At The Bigger Picture The biggest killer to our budget is non-elective admissions and it’s the one area where patient, commissioner and doctor converge. Patients want to keep out of hospital, it’s cheaper for the NHS and Doctors don’t like the lack of continuity when patients go in. For me I see every admission to hospital as a fail. Of course it’s more complex than this and it might be totally appropriate but if we work on this concept backwards, it will help us more. Likewise if we try to reduce outpatient referrals because we are pressurised to, they may end up in hospitalisation and cost the NHS £10,000s rather than £100s as an outpatient. We need to look at the bigger picture and refer especially if we believe that referrals will lead to less hospitalisation of patients further down the line. To put things into perspective 2 symptoms patients present which I take very seriously are palpitations in the elderly and breathlessness. Both symptoms are very real and normally lead to undiagnosed conditions which if we don’t tackle and diagnose early enough will cause patients to deteriorate and end up in hospital. Education, Education, Education When I first went into commissioning as a lead in 2006 I had this idea of getting to the bottom of why GPs refer patients to outpatients. The idea being if we knew why, we would know how to best tackle specialities. I asked my GPs to record which speciality to refer to and why they referred over a 7 month period. The reason for admission was complex but we divided them up into these categories: 2nd care input required for management of the condition. We know about the condition but have drawn the line with what we can do in primary care. An example of this is when we’ve done a 24 hour tape and found a patient has 2sec pauses and needs a pace maker. 2nd care input required for diagnosis. We think this patient has these symptoms which are related to this condition but don’t really know about the diagnosis and need help with this. An example of this is when a patient presents with diarrhoea to a gastroenterologist There could be several reasons for this and we need help from the gastroenterologist to confirm the diagnosis via a colonscopy and ogd etc. Management Advice. We know what the patient has but need help with managing the condition. For example uncontrolled heart failure or recurrent sinusitis. Consultant to Consultant Referral. As advised between consultants. Patient Choice. Sometimes the patient just wants to see the hospital doctor. The results are enclosed here in Excel and displayed below. Please click on the graph thumbnail below. Reasons For Referrals Firstly a few disclaimers and thoughts. These figures were before any GPSI ENT, Dermatology or Musculosketal services which probably would have made an impact on the figures. There are a few anomalies which may need further thought eg I’m surprised Rheumatology for 2nd input for diagnosis is so low, as frequently I have patients with high ESRs and CRPs which I need advise on diagnoses. Also audiology medicine doesn’t quite look right. The cardiology referral is probably high for management advise due to help on ECG interpretation although this is an assumption. This is just a 7 month period from a subset of 8-9 GPs. Although we were careful to explain each category and it’s meaning, more work might need to be done to clarify the findings further. In my opinion the one area where GPs need to get grips with is management advice as it’s an admission that I know what the patient has and need help on how to treat them. This graph is listed in order of management advice for this reason. So what do you do to respond to this? The most logical step is to education GPs on the left hand side of this graph and invest in your work force but more and more I see intermediary GPSI services which are the provider arm of a commissioning group led to help intercept referrals to hospital. In favour of the data most of the left hand side of the graph have been converted into a GPSI service at one point. In my area what has happened is that referrals rates have actually gone up into these services with no decline in the outgoing speciality as GPs become dis-empowered and just off load any symptoms which patients have which they would have probably had a higher threshold to refer on if these GPSI services were not available. Having said that GPSI services can have a role in the pathway and I’m not averse to their implementation, we just have to find a better way to use their services. 3 Step Plan As I’m not one to just give problems here are my 3 suggestions to help referrals. To have a more responsive Layered Outpatient Service. Setting up an 18 week target for all outpatients is strange, as symptoms and specialities need to be prioritised. For example I don’t mind waiting 20 weeks for a ENT referral on a condition which is bothering me but not life threatening but need to only have a 3 week turn over if I’m breathless with a sudden reduction in my exercise tolerance. This adds an extra layer of complexity but always in the back of my mind it’s about getting them seen sooner to prevent hospitalisation. Education, education, education It’s ironic that the first budget to be slashed in my area was education. We need to education our GPs to empower them to bring the management advice category down as this is the category which will make the biggest impact to improving health care. In essence we need to focus on working on the left hand side of this graph first. Diagnose Earlier and Refer Appropriately The worst case scenario is when GPs refer patients to the wrong speciality and it can happen frequently as symptoms blur between conditions. This leads to delayed diagnosis, delayed management and you guessed it, increased hospitalisation. The obvious example is whether patients with breathlessness is caused by heart or lung or is psychogenic. As GPs we need to work up patients appropriately and make a best choice based on the evidence in front of us. Peer to peer GP delayed referral letter analysis groups have a place in this process. Conclusion At the end of the day it's about appropriate referrals always, not just a reduction. Indeed for us to get a grip on the NHS Budgets as future Clinical Commissioners, I would expect outpatient referrals to go up at the expense of non-elective, as then you are looking at patients being seen and diagnosed earlier and kept out of hospital.  
Raza Toosy
over 6 years ago
Foo20151013 2023 113s0nw?1444773969
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378

The Medical Book Warzone... Which book is best?

As the days are slowly getting longer, and spring looms in the near future, it can only be the deep inhale of the medical student ready to embrace the months of revision that lies ahead. Books are dusted off the shelves and Gray's anatomy wrenched open with an immense sigh of distain. But which book should we be pulling off the shelves? If you're anything like me then you're a medical book hoarder. Now let me "Google define" this geeky lexis lingo - a person who collects medical books (lots of medical books) and believes by having the book they will automatically do better!... I wish with a deep sigh! So when I do actually open the page of one, as they are usually thrown across the bed-room floor always closed, it is important to know which one really is the best to choose?!? These are all the crazy thoughts of the medical book hoarder, however, there is some sanity amongst the madness. That is to say, when you find a really good medical book and get into the topic you start to learn stuff thick and fast, and before you know it you’ll be drawing out neuronal pathways and cardiac myocyte action potentials. Yet, the trick is not picking up the shiniest and most expensive book, oh no, otherwise we would all be walking around with the 130 something pounds gray’s anatomy atlas. The trick is to pick a book that speaks to you, and one in which you can get your head around – It’s as if the books each have their own personality. Here are a list of books that I would highly recommend: Tortora – Principles of anatomy and physiology Tortora is a fantastic book for year 1 medical students, it is the only book I found that truly bridges the gap between A levels and medical students without going off on a ridiculous and confusing tangent. While it lacks subtle detail, it is impressive in how simplified it can make topics appear, and really helps build a foundation to anatomy and physiology knowledge The whole book is easy to follow and numerous pretty pictures and diagrams, which make learning a whole lot easier. Tortora scores a whopping 8/10 by the medical book hoarder Sherwood – From cells to systems Sherwood is the marmite of the medical book field, you either love this book or your hate it. For me, Sherwood used to be my bible in year two. It goes into intricate physiological detail in every area of the body. It has great explanations and really pushes your learning to a greater level than tortora in year one. The book doesn’t just regurgitate facts it really explores concepts. However: I cannot be bias, and I must say that I know a number of people who hate this book in every sense of the word. A lot of people think there is too much block text without distractions such as pictures or tables. They think the text is very waffly, not getting straight to the point and sometimes discusses very advanced concepts that do not appear relevant The truth be told, if you want to study from Sherwood you need to a very good attention span and be prepared to put in the long-hours of work so it’s not for everyone. Nonetheless, if you manage to put the effort in, you will reap the rewards! Sherwood scores a fair 5-6/10 by the medical book hoarder Moore & Dalley – Clinical anatomy At first glance Moore & Dalley can be an absolute mindfield with an array of pastel colours that all amalgamate into one! It’s also full of table after table of muscle and blood vessels with complicated diagrams mixed throughout. This is not a medical book for the faint hearted, and if your foundation of anatomy is a little shakey you’ll fall further down the rabbit hole than Alice ever did. That being said, for those who have mastered the simplistic anatomy of tortora and spent hours pondering anatomy flash cards, this may be the book for you. Moore & Dalley does not skimp on the detail and thus if you’re willing to learn the ins and out of the muscles of the neck then look no further. Its sections are actually broken down nicely into superficial and deep structures and then into muscles, vessels, nerves and lymph, with big sections on organs. This is a book for any budding surgeon! Moore & Dalley scores a 6/10 by the medical book hoarder Macleod’s clinical examination Clinical examination is something that involves practical skills and seeing patients, using your hands to manipulate the body in ways you never realised you could. Many people will argue that the day of the examination book is over, and it’s all about learning while on the job and leaving the theory on the book shelf. I would like to oppose this theory, with claims that a little understanding of theory can hugely improve your clinical practice. Macleod’s takes you through basic history and examination skills within each of the main specialties, discussing examination sequences and giving detailed explanations surrounding examination findings. It is a book that you can truly relate to what you have seen or what you will see on the wards. My personal opinion is that preparation is the key, and macleod’s is the ultimate book to give you that added confidence become you tackle clinical medicine on the wards Macleod’s clinical examination scores a 7/10 by the medical book hoarder Oxford textbook of clinical pathology When it comes to learning pathology there are a whole host of medical books on the market from underwood to robbins. Each book has its own price range and delves into varying degrees of complexity. Robbins is expensive and a complex of mix of cellular biology and pathophysiological mechanisms. Underwood is cheap, but lacking in certain areas and quite difficult to understand certain topics. The Oxford textbook of clinical pathology trumps them all. The book is fantastic for any second year or third year attempting to learn pathology and classify disease. It is the only book that I have found that neatly categories diseases in a way in which you can follow, helping you to understand complications of certain diseases, while providing you with an insight into pathology. After reading this book you’ll be sure to be able to classify all the glomerulonephritis’s while having at least some hang of the pink and purples of the histological slide. Oxford textbook of clinical pathology scores a 8/10 by the medical book hoarder Medical Pharmacology at glance Pharmacology is the arch nemesis of the Peninsula student (well maybe if we discount anatomy!!), hours of time is spent avoiding the topic followed immediately by hours of complaining we are never taught any of it. Truth be told, we are taught pharmacology, it just comes in drips and drabs. By the time we’ve learnt the whole of the clotting cascade and the intrinsic mechanisms of the P450 pathway, were back on to ICE’ing the hell out of patients and forget what we learned in less than a day. Medical pharmacology at a glance however, is the saviour of the day. I am not usually a fan of the at a glance books. I find that they are just a book of facts in a completely random order that don’t really help unless you’re an expert in the subject. The pharmacology version is different: It goes into just the right amount of detail without throwing you off the cliff with discussion about bioavailability and complex half-life curves relating to titration and renal function. This book has the essential drugs, it has the essential facts, and it is the essential length, meaning you don’t have to spend ours reading just to learn a few facts! In my opinion, this is one of those books that deserves the mantel piece! Medical Pharmacology at a glance scores a whopping 9/10 by the medical book hoarder. Anatomy colouring book This is the last book in our discussion, but by far the greatest. After the passing comments about this book by my housemates, limited to the sluggish boy description of “it’s terrible” or “its S**t”, I feel I need to hold my own and defend this books corner. If your description of a good book is one which is engaging, interesting, fun, interaction, and actually useful to your medical learning then this book has it all. While it may be a colouring book and allows your autistic side to run wild, the book actually covers a lot of in depth anatomy with some superb pictures that would rival any of the big anatomical textbooks. There is knowledge I have gained from this book that I still reel off during the question time onslaught of surgery. Without a doubt my one piece of advice to all 1st and 2nd years would be BUY THIS BOOK and you will not regret it! Anatomy colouring book scores a tremendous 10/10 by the medical book hoarder Let the inner GEEK run free and get buying:)!!  
Benjamin Norton
over 6 years ago
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A review of 'Research Skills for Medical Students'.

This is a review of 'Research Skills for Medical Students' 1st Edition (Allen, AK – 2012 Sage: London ISBN 9780857256010) Themes – Research Skills, Critical Analysis Medical Students Thesis – Research and critical analysis are important skills as highlighted by Tomorrow’s Doctors Detailed Review Allen, drawing on many years’ experience as a researcher and lecturer in the Institute of Education, at Cardiff University has bridged the gap in Research methodology literature targeted at medical students. Pushing away from comparative texts somewhat dry and unengaging tones, this book encourages student interaction, empowering the student from start to finish. Not so much a book as a helpful hand guiding the student through the pitfalls and benefits of research and critical analysis from start to finish. Part of the Learning Matters Medical Education series, in which each book relates to an outcome of Tomorrow’s Doctors, this book is written from the a lecturers standpoint, guiding students through making sense of research, judging research quality, how to carry out research personally, writing research articles and how to get writings published. All of these are now imperative skills in what is a very competitive medical employment market. This concise book, through its clarity, forcefulness, correct and direct use of potentially new words to the reader, Allen manages to fully develop the books objectives, using expert narrative skills. With Allen’s interest in Global health, it is little wonder why this books exposition is clear and impartial, Allen consistently refers back to the Tomorrows doctors guidelines at the beginning of each chapter, enabling students to link the purpose of that chapter to the grander scheme. This enables Allen to argue the relevance of each chapter to the student before they have disregarded it. Openly declared as a book aimed at medical students (and Foundation trainees where appropriate) the authors style remains formal, but with parent like undertones. It is written to encapsulate and involve the student reader personally, with Allen frequently using ‘you’ as if directly speaking to the reader, and useful and appropriate activities that engage the reader in the research process, in an easy to use student friendly format. This book is an excellent guide for all undergraduate health students, not limited to medical students, and I thank Ann K Allen for imparting her knowledge in such a useful and interactive way.' This was original published on medical educator.  
Thomas Lemon
over 6 years ago
Foo20151013 2023 1ecatpw?1444774000
9
17920

My transition from medical student to patient

I started medical school in 2007 wanting to 'making people better'. I stopped medical school in 2010 facing the reality of not being able to get better myself, being ill and later to be diagnosed with several long term health conditions. This post is about my transition from being a medical student, to the other side - being a patient. There are many things I wish I knew about long-term health conditions and patients when I was a medical student. I hope that through this post, current medical students can become aware of some of theses things and put them into practice as doctors themselves. I went to medical school because I wanted to help people and make them better. I admired doctors up on their pedestals for their knowledge and skills and expertise to 'fix things'. The hardest thing for me was accepting that doctors can't always make people better - they couldn't make me better. Holding doctors so highly meant it was very difficult for me to accept their limitations when it came to incurable long-term conditions and then to accept that as a patient I had capacity myself to help my conditions and situation. Having studied medicine at a very academic university, I had a very strict perception of knowledge. Knowledge was hard and fast medical facts that were taught in a formal setting. I worked all day and night learning the anatomical names for all the muscles in the eye, the cranial nerves and citric acid cycle, not to mention the pharmacology in second year. Being immersed in that academic scientific environment, I correlated expertise with PhDs and papers. It was a real challenge to realise that knowledge doesn't always have to be acquired through a formal educational but that it can be acquired through experience. Importantly, knowledge acquired through experience is equally valid! This means the knowledge my clinicians have developed through studying and working is as valid as my knowledge of my conditions, symptoms and triggers, developed through experiencing it day in day out. I used to feel cross about 'expert patients' - I have spent all these hours in a library learning the biochemistry and pharmacology and 'Joe Bloggs' walks in and knows it all! That wasn't the right attitude, and wasn't fair on patients. As an expert patient myself now, I have come to understood that we are experts through different means, and in different fields. My clinicians remain experts in the biological aspects on disease, but that's not the full picture. I am an expert in the psychological and social impact of my conditions. All aspects need to be taken into account if I am going to have holistic integrated care - the biopsychosocial model in practice - and that's where shared-decision making comes in. The other concept which is has been shattered since making the transition from medical student to patient is that of routine. In my first rotation, orthopaedics and rheumatology, I lost track within the first week of how many outpatient appointments I sat in on. I didn't really think anything of them - they are just another 15 minute slot of time filled with learning in a very busy day. As a patient, my perspective couldn't be more different. I have one appointment with my consultant a year, and spend weeks planning and preparing, then a month recovering emotionally. Earlier this year I wrote a whole post just about this - The Anatomy of an Appointment. Appointments are routine for you - they are not for us! The concept of routine applies to symptoms too. After my first relapse, I had an emergency appointment with my consultant, and presented with very blurred vision and almost total loss of movement in my hands. That very fact I had requested an urgent appointment suggest how worried I was. My consultants response in the appointment was "there is nothing alarming about your symptoms". I fully appreciate that my symptoms may not have meant I was going to drop dead there and then, and that in comparison to his patients in ICU, I was not as serious. But loosing vision and all use of ones hands at the age of 23 (or any age for that matter) is alarming in my books! I guess he was trying to reassure me, but it didn't come across like that! I have a Chiari malformation (in addition to Postural Orthostatic Tachycardia Syndrome and Elhers-Danlos Syndrome) and have been referred to a neurosurgeon to discuss the possibility of neurosurgery. It is stating the obvious to say that for a neurosurgeon, brain surgery is routine - it's their job! For me, the prospect of even being referred to a neurosurgeon was terrifying, before I even got to the stage of discussing the operation. It is not a routine experience at all! At the moment, surgery is not needed (phew!) but the initial experience of this contact with neurosurgeons illustrates the concept of routines and how much our perspectives differ. As someone with three quite rare and complex conditions, I am invariable met in A&E with comments like "you are so interesting!". I remember sitting in the hospital cafeteria at lunch as a student and literally feasting on the 'fascinating' cases we had seen on upstairs on the wards that morning. "oh you must go and see that really interesting patient with X, Y and Z!" I am so thankful that you all find medicine so interesting - you need that passion and fascination to help you with the ongoing learning and drive to be a doctor. I found it fascinating too! But I no longer find neurology that interesting - it is too close to home. Nothing is "interesting" if you live with it day in day out. No matter what funky things my autonomic nervous may be doing, there is nothing interesting or fascinating about temporary paralysis, headaches and the day to day grind of my symptoms. This post was inspired by NHS Change Day (13th March 2013) - as a patient, I wanted to share these few things with medical students, what I wish I knew when I was where you are now, to help the next generation of doctors become the very best doctors they can. I wish you all the very best for the rest of your studies, and thank you very much for reading! Anya de Iongh www.thepatientpatient2011.blogspot.co.uk @anyadei  
Anya de Iongh
over 6 years ago
Foo20151013 2023 1vfzxkt?1444774033
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529

My Top 5 Tips to Use Social Media to Improve your Medical Education

Introduction Hello and welcome! I am finally back to blogging after having a brief hiatus in order to take my final exams. Whilst the trauma is still fresh in my mind, I would like to share with you the top 5 social media tips that helped me through the dark days of undergraduate medicine. Some of you may have already read my old essay on 'How Medical Students should interact with Social Media Networking Sites' and this document deals with some of the problems with professionalism surrounding the use of social media. This blog will not cover such issues, but will instead focus on how you can use social media to benefit your learning/ revision processes. Top Tip 1: YouTube For those of you who are unaware, YouTube is a video-sharing website. Sometimes the site is overlooked as a 'social media' resource but if you consider the simple definition of Social Networking Sites as 'those with user led content,' you can quickly see how YouTube definitely falls into the social media category. It wasn't until I got to University that I realised the potency of YouTube as an educational tool. It has a use at every stage of medical education and it is FREE. If you are still in your pre-clinical training then there are a wealth of videos that depict cellular processes and 3D anatomy - very useful content for the visual learner. For the clinical student, there are a number of OSCE demonstration videos that may be useful in honing your examination skills. There are also a number of presentations on clinical topics that have been uploaded, however, YouTube has no quality control measures for these videos (to my knowledge) so it may be best to subscribe to a more official source if you like to use podcasts/ uploaded presentations for your revision. Another reason YouTube comes in as my number 1 top tip is because I find it difficult to procrastinate whilst using the site. Sure, you can start looking up music and videos that have nothing to do with medicine but personally I find that having a little bit of music on in the background helps me work for longer periods, which is a definite bonus during the revision period. On the other hand, there are many that find YouTube difficult to harness due to the draw of funny videos and favourite Vloggers (Video Bloggers) that can distract the unwary from revision for hours on end. At the end of the day, YouTube was created for funny videos (predominantly of cats it seems) and not for medical education, and this should be kept in mind if you choose to use it as a tool for your learning. Top Tip 2: Facebook Yes, the dreaded Facebook comes in at number two for me. Facebook is by far and away my largest source of procrastination when it comes to writing / working / revising or learning. It is a true devil in disguise, however, there are some very useful features for those who like to work in groups during their revision... For example, during the last six months I have organised a small revision group through Facebook. We set up a 'private page' and each week I would post what topics would be covered in the weeks session. Due to the nature of Facebook, people were obviously able to reply to my posts with suggestions for future topics etc. We were also able to upload photos of useful resources that one or more of us had seen in a tutorial in which the other students hadn't been able to attend. And most importantly, we were able to upload revision notes for each other via the Facebook 'files' tab. This last feature was invaluable for sharing basic notes between a few close colleagues. However, for proper file sharing I strongly recommend the file sharing service 'Dropbox,' which provides free storage for your documents and the ability to access files from any computer or device with internet. Coming back to Facebook, my final thoughts are: if you don't like group work or seeing what your colleagues are doing via their statuses or private messages then it probably isn't a useful resource for you. If you have the motivation (unlike myself) to freeze your Facebook account I can imagine you would end up procrastinating far less (or you'll start procrastinating on something else entirely!). Top Tip 3: Twitter Twitter is a microblogging site. This means that users upload microblogs or 'Tweets' containing useful information they have found on the internet or read in other people's tweets. Twitter's utility as an educational resource is directly related to the 'type' of people you follow. For example, I use Twitter primarily to connect with other people interested in social media, art & medicine and medical education. This means my home screen on twitter is full of people posting about these topics, which I find useful. Alternatively, I could have used my Twitter account to 'follow' all the same friends I 'follow' on Facebook. This would have meant my Twitter home page would have felt like a fast-paced, less detailed version of my Facebook feed just with more hashtags and acronyms - not very useful for finding educational resources. With this in mind, consider setting up two twitter accounts to tease apart the useful tweets about the latest clinical podcast from the useless tweets about what your second cousin once removed just had for lunch. A friend suggested to me that if you really get into twitter it is also possible to use one account and 'group' your followers so that you can see different 'types' of tweets at different times. This seems like a good way to filter the information you are reading, as long as you can figure out how to set up the filters in the first place. Like all Social Media Sites, Twitter gets its fair share of bad press re. online professionalism and its tendency to lure users into hours of procrastination. So again, use with caution. Top Tip 4: Meducation It would not be right to write this blog and not include Meducation in the line-up. Meducation is the first website that I have personally come across where users (students, doctors etc) upload and share information (i.e. the very soul of what social networking is about) that is principally about medicine and nothing else. I'm sure there may be other similar sites out there, but the execution of this site is marvellous and that is what has set it apart from its competitors and lead to its rapid growth (especially over the last two years, whilst i've been aware of the site). When I say 'execution,' I mean the user interface (which is clean and simple), the free resources (giving a taste of the quality of material) and the premium resources (which lecture on a variety of interesting clinical topics rather than sticking to the bread and butter topics 24/7). One of my favourite features of Meducation is the ability to ask 'Questions' to other users. These questions are usually asked by people wishing to improve niche knowledge and so being able to answer a question always feels like a great achievement. Both the questions and answers are mostly always interesting, however the odd question does slip through the net where it appears the person asking the question might have skipped the 'quick google search' phase of working through a tough topic. Meducation harnesses social networking in an environment almost free from professionalism and procrastination issues. Therefore, I cannot critique the site from this angle. Instead, I have decided to highlight the 'Exam Room' feature of the website. The 'Exam Room' lets the user take a 'mock exam' using what I can only assume is a database of questions crafted by the Meducation team themselves (+/- submissions from their user base). However, it is in my opinion that this feature is not up to scratch with the level and volume of questions provided by the competitors in this niche market. I feel wrong making this criticism whilst blogging on Meducation and therefore I will not list or link the competitors I am thinking of here, but they will be available via my unaffiliated blog (Occipital Designs). I hope the Meducation team realise that I make this observation because I feel that with a little work their question database could be improved to the point where it is even better than other sites AND there would also be all the other resources Meducation has to offer. This would make Meducation a truly phenomenal resource. Top Tip 5: Blogging Blogging itself is very useful. Perhaps not necessarily for the learning / revision process but for honing the reflective process. Reflective writing is a large component of undergrad medical education and is disliked by many students for a number of reasons, not least of which is because many find some difficulty in putting their thoughts and feelings on to paper and would much prefer to write with the stiffness and stasis of academic prose. Blogging is great practice for breaking away from essay-writing mode and if you write about something you enjoy you will quickly find you are easily incorporating your own personal thoughts and feelings into your writing (as I have done throughout this blog). This is a very organic form of reflection and I believe it can greatly improve your writing when you come to write those inevitable reflective reports. Conclusion Thanks for reading this blog. I hope I have at least highlighted some yet unharnessed aspects of the sites and resources people already commonly use. Please stay tuned in the next week or two for more on social media in medicine. I am working together with a colleague to produce 'Guidelines for Social Media in Medicine,' in light of the recent material on the subject by the General Medical Council. Please feel free to comment below if you feel you have a Top Tip that I haven't included! LARF Twitter Occipital Designs My Blog As always, any views expressed here are mine alone and are not representative of any organisation. A Worthy Cause... Also, on a separate note: check out Anatomy For Life - a charity medical art auction raising money for organ donation. Main Site Facebook Twitter  
Dr. Luke Farmery
over 6 years ago
Foo20151013 2023 xc9z4h?1444774045
2
3767

Undergraduate Co-Ordinators: Help or hindrance?

Thanks to those who read my last post. I was encouraged to hear from my colleagues at Med school that the post sounded very positive and hopefully. A few of them queried whether I had actually written it because there was a noticeable lack of sarcasm or criticism. So... the following posts may be a bit different. A little warning - some of what I post may be me playing "Devil's advocate" because I believe that everything should be questioned and sparking debate is a good way of making us all evaluate what we truly think on a subject. With no further a do, let's get on to the subject of today's post .... An Introduction to Clinical Medicine The previous year was my first as a clinical med student. Before we started I naively thought that we would be placed in helpful, encouraging environments that would support us in our learning, so that we were able to maximize our clinical experience. My hope was that there would be lots of enthusiastic doctors willing to teach, a well organised teaching schedule and admin staff that would be able to help us with any difficulties. I hoped these would all be in place so that WE medical students could be turned from a bunch of confused, under-grad science students into the best junior doctors we could possibly be. It seems that medical school and the NHS have a very different opinion of what clinical medical teaching should be like. What they seem to want us to do is 1) listen to the same old health and safety lecture at least twice a term, 2) re-learn how to wash our hands every 4 weeks, 3) Practicing signing our name on a register - even when this is completely pointless because there are no staff at the hospital anyway because the roads are shut with 10 inches of snow most of the time, 4) Master the art of filling in forms that no one will ever look at or use in anyway that is productive, 5) STAY OUT OF THE WAY OF THE BUSY STAFF because we are useless nuisances who spread MRSA and C.Dif where ever we go! How we all learn medicine and pass our exams is any ones guess! Undergraduate Co-Ordinators - Why won't you make life easier for us? While at my last placement I was elected as the 3rd year student representative for that hospital. While I was fulfilling that role it got me wondering what it is that Under-grad Co-Ordinators actually do? I thought this may be an interesting topic of debate. 1) Who are they and how qualified are they? 2) what is their job description and what are they supposed to be doing? 3) Are they a universal phenomena? or have they just evolved within the West Midlands? 4) Does anyone know an under-grad Co-Ordinator (UC - not ulcerative colitis) who has actually been more benefit than nuisance? 1) UC's as a species are generally female, middle aged, motherly types who like to colonize obscure offices in far flung corners of NHS training hospitals. They can normally be found in packs or as they are locally known "A Confusion of co-ordinators". How are they qualified? I have absolutely no idea, but I am guessing not degrees in Human Resource Development. 2)I am fairly certain what their job should involve: 1) be a friendly supportive face for the poor medical students; 2) organise a series of lectures; 3) organise the medical students into teaching firms with enthusiastic consultants who are happy to give them regular teaching; 4) ensure the students are taught clinical skills so that they can progress to being competent juniors; 5) be a point of contact for when any students are experiencing difficulties in their hospital and hopefully help them to rectify those problems to aid their learning. What do they actually do? It seems to be a mystery. I quite regularly receive emails that say that I wasn't in hospital on a certain day, when I was in fact at another hospital that they specifically sent me to on that day. I often receive emails saying that my lectures are cancelled just as I have driven for over an hour through rush hour traffic to attend. I sometimes receive emails saying that I, specifically, am the cause of the whole hospitals MRSA infection because I once wore a tie. I never receive emails saying that such and such a doctor is happy to teach me. I never receive emails with lecture slides attached to them so that I can revise said lectures in time for an exam. I NEVER receive any emails with anything useful in them that has been sent by a UC! Questions 3 and 4, I have no idea what the answers are but would be genuinely pleased to hear people's responses. The reason I have written this blog is that, these people have frustrated my colleagues and I all year. I am sure they are integral to our learning in some way and I am sure that they could be very useful to us, but at the moment I just cannot say that they are as useful as they should be. To any NHS manager/ medical educator out their I make this plea I am more than happy to give up 2 weeks of my life to shadow some UC to see what it is they do. In essence I want to audit what it is they do on a day to day basis and work out if they are a cost-effective use of the NHS budget? I want to investigate what it is they spend their time on and how many students they help during a day? I would like someone with a fresh pair of eyes to go into those obscure offices and see if they can find any way of improving the systems so that future generations of medical students do not have to relive the inefficiencies that we have lived through. I want the system to be improved for everyone's sake. OR if you won't let a medical student audit the process, could you manager's at least send your UC's to learn from other hospitals where things are done better! If we (potential future) doctors have to live by the rule of EVIDENCED BASED MEDICINE, why shouldn't the admin staff live by a similar rule of EVIDENCED BASED ADMINISTRATION? Share good ideas, learn from the best, always look for improvements rather than keep the same old inefficient, pointless systems year after year. My final point on the subject - at the end of every term we have to fill in long feedback forms on what we thought of the hospital and the teaching. I know for a fact that most of those forms contain huge amounts of criticism - a lot of which was written exactly the same the year before! So, they are collecting all of this feedback and yet nothing seems to change in some hospitals. It all just seems such a pointless waste. Take away thought for the day. By auditing and improving the efficiency, of the admin side of an undergraduate medical education, I would hope the system as a whole would be improved and hence better, more knowledgeable, less cynical, less bitter, less stressed junior doctors would be produced as a result. Surely, that is something that everyone involved in medical education should be aiming for. Who is watching (and assessing) the watchers!  
jacob matthews
over 6 years ago
Foo20151013 2023 y4lule?1444774066
1
2591

Staying Active with Diabetes

Many know that engaging in regular physical activity and exercise will tremendously improve one’s health and overall well-being. This goes the same, if not tenfold, for individuals suffering with diabetes. However, before rushing in a high intensity or physically straining physical régime, consult with your diabetes care provider. Make sure to discuss your plans take note of any precautions that may be needed to be made prior or during these activities. It will be interesting to know that individuals with type 2 diabetes who do participate in some exercise (even at work) reduce their risk for heart disease. Remember that a physical examination that focuses on the signs and symptoms of diseases affecting the heart and blood vessels, eyes, feet, nervous system, and kidneys must be made in advance before any extensive work out plan takes into action. Any strenuous strength training or high-impact exercise is generally not recommended for people with uncontrolled diabetes. Such strain caused by these exercises can weaken blood vessels in the eyes of patients who suffer from the common diabetic complication known as retinopathy. High-impact exercise can also injure blood vessels in the feet. In fact, diabetes can contribute to foot problems in several ways: diabetic neuropathy; which is a nerve disorder that causes numbing and pain in the hands, legs and feet as well as damage to internal organs; also poor circulation to the feet is another problem that can be associated due to diabetes. Keeping this in mind it is imperative to keeping your feet healthy, investing in some great therapeutic footwear like these can be a great step in moving toward healthy feet! One thing is for sure, physical activity can increase the health in anyone’s life. Always make sure to take care of your body and take the extra precautions needed in order to maintain proper health.  
Camille Mitchell
over 6 years ago
Foo20151013 2023 w5wmg1?1444774074
16
720

Exam Survival Guide

1. Sleep (I realize I’m posting this at 12:30 am…) (http://www.helpguide.org/life/sleep_tips.htm) I know there’s a popular perception of sleep deprivation going hand in hand with working hard or succeeding academically. However, that is only true if you’re working very last minute, and don’t care about retaining the information–you basically just want to get through your upcoming test/assignment. I would like to clarify that, although learning about 10 months of material in 2 weeks is overwhelming, it is NOT last minute because whatever you’re working on right now, you’ll have to remember in 2 weeks for your exam. Besides the exam, if you’re studying medicine, you need to remember most of these things for the rest of your life. In order to retain that information, you need to stay alert, well rested and motivated. Prolonged sleep deprivation can make you feel very ‘CBA’ very fast. 2. Stay Energized Sleep is only one factor in staying motivated and alert; another is staying energized¬–in a healthy way. Simply put: if you feel well, you’ll work well. Eat well: difficult, I know, when you’ve got so little time to spare; but as much as you can, try to eat more whole foods (aka things that don’t come in wrappers or have their own commercial) and keep a balanced diet (too much of anything is usually not good). Everyone snacks while they’re doing exams, but try to find a vice that won’t put you in a sugar coma (some good examples include berries and other fruits, nuts, carrots with hummus to dip in, granola bars, etc). Note: drinking tea is also an excellent way to stay energized! Stay active: Again, I know something like this is difficult to keep up in normal everyday life, let alone during exam stress. Even if it is just for 15-20 minutes, some cardio (note: the more strenuous the workout in a short period of time, the more benefit you’ll get) is a fantastic ‘eye-opener’ (I learned that phrase while learning how to take an alcohol history and now I really like it)! No one wants to go for a run in the morning, but after you get past the first 2-3 minutes of wanting to collapse, your body starts to feel really grateful. This is the BEST way to stimulate your senses and wake yourself up. I promise it’s better than any energy drink or cup of coffee you could have. Take small breaks: SMALL breaks!!! About 10 minutes. Every once in a while, you need to get up and walk around to give yourself a break, have some fresh air, grab a snack, but try not to get carried away; try to avoid having a short attention span. 3. Make Lists I cannot stress enough how counterproductive it is to overwhelm yourself with the amount of work you have. Whether you think about it or not, that pile is not going anywhere. Thinking about it won’t wish it away. Stop psyching yourself out and just get on with it– step by step. Making a list of objectives you need to accomplish that day or week is a great way to start; then, cross them out as you go along (such a satisfying feeling). Being able to visualize your progress will be a great motivator. Remember: it is important to be systematic with your studying approach; if you jump around between modules because they’re boring you’re just going to confuse yourself and make it hard to remember things when that exam comes Note: I have a white board in my room where I write my objectives for the week. Some days it motivates, some days it I want to throw it out the window (but I can't reach the latch)… 4. Practice Questions Practice questions are excellent for monitoring your progress; they’re also excellent at scaring you. Do not fear! This is a good thing, because now you know what you’re missing, go back and read up on what you forgot to take a look at, and come back and do the questions later. Then give yourself a sticker for getting it right ? Practice questions are also great for last minute studying too because they can help you do what I call “backwards studying”–which is what I just described: figuring out what you need to learn based on what the questions look like. 5. Be realistic Set realistic goals for yourself; most importantly, set realistic daily goals for yourself so that when you get all or most or even some of them done you can go to sleep with a level of satisfaction. Also, you need to pick your battles. Example: if you suck at neuro, then one module’s loss is another’s gain. Don’t spend too much time trying to get through one thing, just keep moving forward, and come back to it later 6. ‘Do not disturb’ Facebook, twitter, instagram, youtube, whatsapp, texting, pinterest, meme websites, so many fantastic ways to kill your time… Do yourself a favor, save them for your breaks. If someone is dying or on fire, they will most likely call you, not text you or write on your wall; you do not need to check your phone that often unless you're expecting something time sensitive. 7.Don’t Compare Everyone studying in your program is going to be stressed about things; do NOT let it rub off on you. You know those moments when you hear a peer or a prof/tutor describing something you have never even heard of, then you start panicking? Yeah, don’t do that. It happens to everyone. Instead of worrying so much, just go read about it! Simple solution right? What else are you going to do? Plus, a lot of the time other students seem to know more than they need to about certain things (which I can tell you right now, doesn’t always mean they’re doing better than you; knowing random, very specific factoids doesn’t mean they can bring it in clinic. Everyone can pull a Hermione and know a book inside out, but this is not necessarily the hallmark of a good doctor), what’s it to you? Worry about yourself, be confident in your abilities, and don’t trouble yourself with comparing to other people 8.Practice for Practicals Everyone is afraid of practical exams, like the OSCE (at any rest station you're likely to find me with my head in my hands trying to stabilize my breathing pattern and trying not to cry). The best way to be ready is to practice and practice and practice and practice. It’s like learning to drive a car. At first you’re too aware of your foot on the gas, the position of your hand on the wheel, etc; but, after driving for a little while, these things become subconscious. In the same way, when you walk into a station, you could be so worried about how you’ll do your introduction and gain consent, and remembering to wash your hands, and getting equipment and and and and and; the anxiety affects your confidence and your competence. If you practice enough, then no matter what they throw at you, you will get most of the points because the process will be second nature to you. Practice on your roommates, friends, family members, patients with a doctor's help...when appropriate... Even your stuffed animals if you're really desperate. DO NOT leave practicing for these practicals to the last minute; and if you do, make sure you go through every thing over and over again until you’re explaining examinations in your sleep. NOTE: When I'm practicing for OSCE alone, I record myself over and over again and play it back to myself and criticize it, and then practice againn. 9.Consistency You don’t necessarily have to study in the same place every day; however, it is always good to have some level of routine. Some examples include: waking up/sleeping at the same time everyday, going for a run at the same time every day, having the same study routine, etc. Repetition is a good way to keep your brain focused on new activities because, like I said before, the more you repeat things, the more they become second nature to you. Hope these tips are of some use to you; if not, feel free to sound off in the comments some alternate ways to get through exams. Remember that while exams are stressful, this is the time where you build your character and find out what you’re truly capable of. When you drop your pen after that final exam, you want to feel satisfied and relieved, not regretful. Happy Studying ?  
Mary
over 6 years ago
Foo20151013 2023 159552n?1444774079
3
105

Current Social Media Guidance

Hello & Welcome! You may have already read my blog on 'My Top 5 Tips to use Social Media to Improve your Medical Education' and if so you will have an idea of what 'Social Media' is and how it can be harnessed to improve medical education. There are also features that could improve health promotion and communication but today I would like to focus on where we have to be careful with these resources. In my last blog I circumnavigated the drawbacks of social media in medicine so that I could give them the full attention they deserve in their own blog today. But its not all doom and gloom! I also hope to give you a brief overview of the current social media guidance that is available to doctors and medical students and how we can minimise the risks associated with representing ourselves online. But firstly, what actually is social media and why do i keep blogging about it? If you are new here I recommend giving 'Social Media' a quick google, but the phrase basically includes any website where the user (i.e. you) can upload information and interact with other users. Thats a definition of the top of my head, so don't hold me to it, but most people would agree that this definition includes the classic examples of Facebook, Twitter, YouTube, Linkedin etc, but there are many many more. These sites are important to us as (future) health professionals because they can be both used and unfortunately abused. However, several medical bodies including the General Medical Council and the Royal College of General Practitioners agree that these resources are here to stay and they shouldn't (and probably couldn't) be excommunicated. With this in mind, there has been much guidance on the topic, but as you are about to find out a lot of it is common sense and your own personal discretion. Before you read on, I'd like to forewarn you that I try and keep things lighthearted with this topic. I'll hope you can excuse my levity of the situation, especially if any of the original authors of these guidelines end up reading this post. But as I am sure you are aware, this is a dry topic and hard to digest without the odd joke or two... British Medical Association - Using Social Media: practical and ethical guidance for doctors and medical 2011 The BMA guidance is the earliest guidance originating from a major medical body that i've come across. That said, I have not done a proper literature review of the subject. This is a blog, not a dissertation. But still, the BMA gives an early and brief summary of the problems facing health professionals using social media. Key points such as patient confidentiality, personal privacy, defamation, copyright and online professionalism are covered and therefore it is a nice starting point. It is also quite a short document, which may appeal to those who are less feverent on the subject. On the other hand, I personally feel that the BMA guidance does social media an injustice by not going into the great benefits these resources can yield. There are also no really practical tips or solutions for the drawbacks they've highlighted to students. Read it for yourself here or just google 'BMA Guidance Social Media' Royal College of General Practitioners - Social Media Highway Code Feb 2013 The RCGP guidelines are my favourite. After a cheesy introduction likening the social media surge with the dawn of the automobile they then take a turn for the worse by trying to continue the metaphor further by sharing a 'Social Media Highway Code'. Their Top 10 Tips that form the majority of the code don't look to be much more than common sense. However, each chapter there after dissects each of their recommendations in great detail and provides practical tips on how to make the most from social media whilst protecting yourself from the issues raised above. As I mentioned earlier, the RCGP recognise the inevitability of social media and they acknowledge this in the better part of their introduction. They make a great point that older doctors have a responsibility to become technologically savvy, whereas younger doctors who have grown up engrossed in social networking probably have to develop their professionalism skills more than their older colleagues (I'm aware this is a generalising statement). Either way, the RCGP highlight that everyone has something to take away from this set of guidelines. Read it for yourself here or google; 'RCGP Social Media Guidance,' but be warned, this is one of the more lengthy documents available on the topic. General Medical Council - Doctor's Use of Social Media April 2013 The GMC guidance kicks off with a little summary of the relevant bits of 'Good Medical Practice.' Again, nothing much that isn't common sense. That being said, they then go on to write that 'Serious or persistent failure to follow this guidance will put your registration at risk,' which sounds ominous and probably warrants a quick flick through (do it now! - the PDF is at the bottom of their page). Reassuringly, the GMC does not try and place a blanket ban on social media. They give a 'tip of the hat' to the benefits of social media and then go on to outline all the drawbacks as many of the guidance already has. Asides from the issue of anonymity there is really nothing new covered and the GMC actually gives a lot of autonomy to doctors and medical students. However, the GMC are, in many ways, who we ultimately answer to and so you would be a fool not to revisit the issues they cover in their version of the guidance. As I mentioned, the GMC brought online anonymity to the forefront of our minds. Should we, shouldn't we? A lot of health professionals believe that the human right to a private life extends to the right to have anonymity online. However, before we go into this any further lets take a closer look at what the GMC actually says... If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the view of the profession more widely. As you can see, the use of the phrase 'Should also identify yourself by name' gives some room for manoeuvre and is a world apart from what could have been written (i.e. you must). To those who believe their human rights are being infringed, perhaps a solution is to stop identifying yourself as a doctor online, although I appreciate this can be difficult if you are tagged in certain things. There are a number of good points why doctors shouldn't be anonymous online and it is certainly a must if you are in the trade of offering health promotion via the world wide web. However, I can see the point of those who want to remain anonymous for comical or satirical purposes. A quick google of the topic will reveal that the GMC has said that they do not envisage fitness to practice issues arising from doctors remaining anonymous online, but from the temptations that arise from running an anonymous profile such as cyber-bullying and misinformation. Read the GMC guidance yourself here. National Health Service (Health Education) - Social Media in Education May 2013 The NHS-HE guidelines are high quality and cover the entire scope of what social media means to medicine. There are several key issues that I haven't encountered elsewhere. This set of guidance is written from a managerial, technical perspective. It doesn't really feel aimed at doctors or medical students but it gives such an overview of the subject that I thought it was worth including. If you feel brave enough, read it for yourself here. Conclusion To my knowledge, these are the current key guidelines for the use of social media in medicine. I hope you have found this blog useful in providing a quick summary of a topic that is becoming increasingly swamped with lengthy guidelines. In the future we need to see material produced or delivered that educates health professionals in how to use social media, rather than regurgitating the pros and cons every couple of months. I think webicina is a good example of a social media 'training course,' . There should be more material like this. Perhaps this is where I'm headed with my next project... As always, if you have anything to add to this blog, please feel free to add to the comments below. I will be able to take difficult queries forwards with me to the Doctors 2.0 conference next week! If you are a student and interested in coming to the conference in Paris next week you should get in contact with me directly (@LFarmery on twitter). Also, it would be a great help if you could fill out my very quick pilot survey to help me understand how doctors and medical students currently use social media. Also see my website Occipital Designs LARF Disclaimer The thoughts and feelings expressed here are those produced by my own being and are not representative in part or whole of any organisation or company. Occipital Designs is a rather clunky, thinly veiled, pseudonym. If you would like to contact me please do so on Twitter...  
Dr. Luke Farmery
over 6 years ago
Foo20151013 2023 2hilgx?1444774083
4
1052

So you want to be a medical student: READ THIS!

There are so many sources for advice out there for potential medical students. So many books, so many forums, so many careers advice people, and so many confusing and scary myths, that I thought it might be useful to just put up some simple guidelines on what is required to become a medical student and a short book list to get your started. I am now in my 5th year at university and my 4th year of actual medicine. Since getting into Medical School in 2009 I have gone back to my 6th form college in South Wales at least once a year to talk to the students who wanted to become medical or dental students, to offer some advice, answer any queries that I could. This year, I tried to to do the same sort of thing for high achieving pupils at my old comprehensive, because if you don't get the right advice young enough then you won't be able to do everything that is required of you to get into Medical school straight after your A-levels. Unfortunately, due to some new rules I wasn't allowed to. So, since I couldn't give any advice in person I thought that a blog might be the easiest alternative way to give young comprehensive students a guide in the right direction. So here goes... How to get into medical school: You must show that you have the academic capacity to cope with the huge volume of information that will try to teach you and that you have the determination/tenacity to achieve what you need to. To show this you must get good grades: a. >8A*s at GCSE + separate science modules if possible = you have to be able to do science. b. >3A’s at A-Level = Chemistry + Biology + anything else you want, as long as you can get an A. 2. You must have an understanding of what Medicine really involves: a. Work experience with a doctor – local GP, hospital work experience day, family connections, school connections – you should try to get as much as you can but don’t worry if you can’t because you can make up for it in other areas. b. Work experience with any health care professional – ask to see what a nurse/ physio/ health care assistant/ phlebotomist/ ward secretary does. Any exposure to the clinical environment will give you an insight into what happens and gives you something to talk about during personal statements and interviews. c. Caring experience – apply to help out in local care homes, in disabled people’s homes, at charities, look after younger pupils at school. All these sorts of things help to show that you are dedicated, motivated and that you want to help people. 3. Be a fully rounded human being: a. Medical schools do not want robots! They want students who are smart but who are also able to engage with the common man. So hobbies and interests are a good way of showing that you are more than just a learner. b. Playing on sports teams allows you to write about how you have developed as a person and helps you develop essential characteristics like team work, fair play, learning to follow commands, learning to think for yourself, hand-eye co-ordination etc. etc. All valuable for a career in medicine. c. Playing an instrument again shows an ability to learn and the will power to sit and perfect a skill. It also provides you with useful skills that you can use to be sociable and make friends, such as joining student choirs, orchestras and bands or just playing some tunes at a party. d. Do fun things! Medicine is hard work so you need to be able to do something that will help you relax and allow you to blow off some stress. All work and no play, makes a burnt out wreck! 4. Have a basic knowledge of: a. The news, especially the health news – Daily Telegraph health section on a Monday, BBC news etc. b. The career of a doctor – how does it work? How many years of training? What roles would you do? What exams do you need to pass? How many years at medical school? c. The GMC – know about the “Tomorrow’s Doctor” Document – search google. d. The BMA e. The Department of Health and NHS structure – know the basics! GP commissioning bodies, strategic health authorities. f. What the Medical School you are applying to specialises in, does it do lots of cancer research? Does it do dissection? Does it pride itself on the number of GPs it produces? Does it require extra entry exams or what is the interview process? These 4 points are very basic and are just a very rough guide to consider for anyone applying to become a medical student. There are many more things you can do and loads of useful little tips that you will pick up along the way. If anyone has any great tips they would like to share then please do leave them as a comment below! My final thought for this blog is; READ, READ and READ some more. I am sure that the reason I got into medical school was because I had read so many inspiring and thought provoking books, I had something to say in interviews and I had already had ideas planted in my head by the books that I could then bring up for discussion with the interview panel when asked about ethical dilemmas or where medicine is going. Plus reading books about medicine can be so inspiring that they really can push your life in a whole new direction or just give you something to chat about with friends and family. Everyone loves to chat people – how they work, why they are ill, what shapes peoples' personalities etc and these are all a part of medicine that you can read into! Book Recommendations Must reads: http://www.amazon.co.uk/Trust-Me-Im-Junior-Doctor/dp/0340962054/ref=sr_1_1?s=books&ie=UTF8&qid=1374240729&sr=1-1&keywords=trust+me+i%27m+a+junior+doctor http://www.amazon.co.uk/Rise-Fall-Modern-Medicine/dp/0349123756/ref=sr_1_1?s=books&ie=UTF8&qid=1374240763&sr=1-1&keywords=the+rise+and+fall+of+modern+medicine http://www.amazon.co.uk/Selfish-Gene-30th-Anniversary/dp/0199291152/ref=sr_1_1?s=books&ie=UTF8&qid=1374240793&sr=1-1&keywords=the+selfish+gene http://student.bmj.com/student/student-bmj.html http://www.newscientist.com/subs/offer?pg=bdlecpyhvyhuk1306&prom=1234&gclid=CLT0tZ3Wu7gCFfLHtAodWwUAyA http://www.amazon.co.uk/Man-Who-Mistook-His-Wife/dp/B005M1NBYY/ref=sr_1_3?s=books&ie=UTF8&qid=1374240909&sr=1-3&keywords=the+man+who+mistook+his+wife+for+a+hat http://www.amazon.co.uk/Better-Surgeons-Performance-Atul-Gawande/dp/1861976577/ref=sr_1_1?s=books&ie=UTF8&qid=1374240987&sr=1-1&keywords=better+atul+gawande http://www.amazon.co.uk/House-Black-Swan-Samuel-Shem/dp/0552991228/ref=sr_1_1?s=books&ie=UTF8&qid=1374241124&sr=1-1&keywords=the+house+of+god+samuel+shem http://www.amazon.co.uk/Bad-Science-Ben-Goldacre/dp/000728487X/ref=sr_1_1?s=books&ie=UTF8&qid=1374241298&sr=1-1&keywords=bad+science+ben+goldacre Thought provokers: http://www.amazon.co.uk/Complications-Surgeons-Notes-Imperfect-Science/dp/1846681324/ref=sr_1_1?s=books&ie=UTF8&qid=1374241026&sr=1-1&keywords=atul+gawande+complications http://www.amazon.co.uk/Checklist-Manifesto-How-Things-Right/dp/1846683149/ref=sr_1_1?s=books&ie=UTF8&qid=1374241049&sr=1-1&keywords=atul+gawande+checklist http://www.amazon.co.uk/Brave-New-World-Aldous-Huxley/dp/0099518473/ref=sr_1_1?s=books&ie=UTF8&qid=1374241067&sr=1-1&keywords=aldous+huxley http://www.amazon.co.uk/Island-Aldous-Huxley/dp/0099477777/ref=sr_1_1?s=books&ie=UTF8&qid=1374241093&sr=1-1&keywords=aldous+huxley+island http://www.amazon.co.uk/Mount-Misery-Samuel-Shem/dp/055277622X/ref=pd_sim_b_4 http://www.amazon.co.uk/Psychopath-Test-Jon-Ronson/dp/0330492276/ref=sr_1_1?s=books&ie=UTF8&qid=1374241180&sr=1-1&keywords=the+psychopath+test http://www.amazon.co.uk/Drugs-Without-Minimising-Harms-Illegal/dp/1906860165/ref=sr_1_1?s=books&ie=UTF8&qid=1374241197&sr=1-1&keywords=drugs+without+the+hot+air http://www.amazon.co.uk/How-Win-Friends-Influence-People/dp/0091906814/ref=sr_1_1?s=books&ie=UTF8&qid=1374241222&sr=1-1&keywords=how+to+win+friends+and+influence+people http://www.amazon.co.uk/Bad-Pharma-companies-mislead-patients/dp/0007350740/ref=pd_bxgy_b_img_y Final Final Thought: Just go into your local book shop or library and go to the pop-science section and read the first thing that takes your interest! It will almost always give you something to talk about.  
jacob matthews
over 6 years ago
Foo20151013 2023 1fhdw5v?1444774091
0
92

The Arterial Highway

Metaphors and analogies have long been used to turn complex medical concepts into everyday ones, albeit with fancy terminology. Having been involved with many 3D animations on the topics of Blood Pressure, arteriosclerosis, cholesterol and the like, we find that often a metaphor goes a long way to building understanding, credibility and even compliance with patients. One of my favorite analogies is what we call the arterial highway. Much like their tarmacked counterparts, arteries act as conduits for all the parts that make your body go. A city typically uses highways, gas lines, water pipes, railways and other infrastructure to distribute important materials to its people. Your body is much the same, except that it does it all in one system, the cardiovascular system. This is used to deliver nutrients, extract waste, transport and deliver oxygen and even to maintain the temperature! The arteries can do all these things because of their smart three-layered structure. Our arteries consist of a muscular tube lined by smooth tissue. They have three layers named – the Adventitia, Media and Intima. Each is designed with a specific function and through the magic of evolution has developed to perform its function perfectly. The first is the Tunica Adventitia, or just adventitia. It is a strong outer covering over the arteries and veins. It has special tissues that are fibrous. The fibers let the arteries flex, expanding and contracting to accommodate changes in blood pressure as the blood flows past it. Unlike a steel pipe, arteries pulsate and so must be at once be flexible, and strong. Tunica Media - the middle layer of the walls of arteries and veins is made up of a smooth muscle with some elasticity built in. This layer expands and contracts in a rhythmic fashion, much like a Wave at a baseball game, as blood moves along it. The media layer is thicker in arteries than in veins, and importantly so, as arteries carry blood at a higher pressure than veins. The innermost layer of arteries and veins is the Tunica Intima. In arteries, this layer is composed of an elastic lining and smooth endothelium - a thin sheet of cells that form a type of skin over the surface. The elastic tissue present in the artery can stretch and return, allowing the arteries to adapt to changes in flow and blood pressure. The intima is also a very smoothe, slick layer so that blood can easily flow past it. Every layer of the artery has developed evolutionary traits that help your arterial system to maintain flexibility, strength and promote blood flow. Diseases and conditions like high cholesterol or high blood pressure, diabetes and others prevent the arteries from doing their function well by creating blockages or increasing the stress on one or more of the layers. For example, high blood pressure causes rips in the smooth lining of the Intima. Anybody who has experienced a pipe burst in a house knows that the damage can be extreme and can never fully be restored. Understanding the delicate functions of the arterial structure gives good incentive to treat them better. Conditions like high blood pressure, high cholesterol and lifestyle diseases such as diabetes create tears, holes, blockages, and can disrupt the functions of one or more layers. Getting patients to visualize the effect of bad eating habits on their anatomy helps to increase patient compliance. In modern society, the concept of highways goes hand in hand with the concept of traffic jams. Patients understand that the arterial highway is one that can never be jammed.  
Mr. Rohit Singh
about 6 years ago
%3fr=0
7
178

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
about 6 years ago
Foo20151013 2023 m4u3lk?1444774141
13
715

I can't get my head around pharmacology

Maybe it’s just me, but I cannot get my head around pharmacology and antibiotics are certainly doing their best to finish me off! My group at uni decided that this was one area that we needed to revise, and the task fell on my hands to provide the material for a revision session. So, the night before the session I began to panic about how to come up with any useful tips for my group, or indeed anyone at all, to try to remember anything useful about antibiotics at all. If only Paracetamoxyfrusebendroneomycin was a real drug, it would make our lives so much easier. Come on Adam Kay and Suman Biswas, get the trials started and create your wonderful super drug. For the mean time I guess I will just have to keep blissfully singing along to your song. However, that is not going to help me with my task in hand. After a lot of research that even took me beyond the realms of Wikipedia (something I do not often like to do), I found various sources suggesting remembering these Top 10 Rules (and their exceptions) All cell wall inhibitors are ?-lactams (except vancomycin) All penicillins are water soluble (nafcillin) All protein synthesis inhibitors are bacteriostatic (aminoglycosides) All cocci are Gram positive (Neisseria spp.) All bacilli are Gram negative (anthrax, tetanus, botulism, diptheria) All spirochetes are Gram negative Tetracyclines and macrolides are used for intracellular bacteria Pregnant women should not take tetracyclines, aminoglycosides, fluroquinolones, or sulfonamides Antibiotics beginning with a ‘C’ are particularly associated with pseudomembranous colitis While the penicillins are the most famous for causing allergies, people may also react to cephalosporins If those work for you, then I guess you can stop reading now… If they don’t, I can’t promise that I have anything better, but give these other tips that I found a whirl… Alternatively, I have created a Page on my own blog called Rang and Dale’s answer to Antibiotics, which summarises their information, so please take a look at that. Most people will suggest that you can categorise antibiotics in three ways, and it’s best to pick one and learn examples of them. Mode of action: bactericidal (kill) bacteriostatic (stop multiplying) 2 mnemonics to potentially help you remember examples: We’re ECSTaTiC about bacteriostatics? Erythromycin Clindamycin Sulphonamides Tetracyclines Trimethoprim Chloramphenicol Very Finely Proficient At Cell Murder (bactericidal) - Vancomycin Fluroquinolones Penicillins Aminoglycosides Cephalosporins Metranidazole Spectrum of activity: broad-spectrum (gram positive AND negative) narrow (gram positive OR negative) Mechanism of action Inhibit cell wall synthesis Inhibit nucleic acid synthesis Inhibit protein synthesis Inhibit cell membrane synthesis If you have any more weird and wonderful ways to remember antibiotics, let me know and I will add them! As always, thank you for reading.  
Mrs Malaika Smith
almost 6 years ago
Foo20151013 2023 ud040l?1444774156
2
457

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
almost 6 years ago
Foo20151013 2023 a5gegv?1444774173
5
174

Commitment Issues

I recently read a question on meducation posted around a year ago, the jist of which was “as a medical student, is it too early to start developing commitment to a specialty?” I.e. “even though I haven’t graduated yet, should I start building a portfolio of experience and evidence to show that specialty X is what I really want to do?” MMC revolutionised (for better or worse) the medical career structure forcing new graduates to decide on a career path much earlier. Many have appreciated the clear delineation of their career pathway. Others have found the 15 month period between leaving university and applying for specialty training too short to make an informed decision (just ask the 10% of FY2s that took a career break last year (i)). Whether right or wrong, there is now less time to rotate round ‘SHO’ jobs, decide on a career and build a CV capable of winning over an interview panel. You’ll probably find you’re in one of 2 camps at university: Those who are absolutely 110% certain there is nothing they want to do, ever, other than specialty X, or Those who really like specialty X, but also like specialties W, Y and Z and haven't made up their minds (A few people find themselves feeling they don’t want to be part of any medical career, but that’s for another post.) Students identifying with the first statement are usually concerned they will not get enough general experience, or that they will be stuck with their decision if they change their minds later on. Those who are leaning more towards statement 2 may not build as strong a body of evidence for any one specialty; however it’s possible to get involved in activities either relevant to a few career options, or several specialty-specific activities and subsequently edit the CV for a specific interview. The key message is that whether you think you have your career mapped out or not, medical school is the perfect time to start collecting evidence that you’re interested in a career in a particular specialty: time for extra-curricular activities only becomes scarcer when you have a full time job complete with working long days, nights and weekends. Your experiences at medical school can then be supplemented with taster weeks, teaching and judicious use of your study budget for training days and conferences; bear in mind that all specialties allow at least 3 years* following FY2 before starting specialty training which can be used for gaining further experience (but be prepared to justify and defend your actions). It’s also important to consider the manner in which individual specialties require such a commitment to be demonstrated: In general terms, the more niche and/or competitive the specialty, the more they will want you to demonstrate that you a) really know what the job entails and b) have made a concerted effort to further your knowledge of the subject. To get a job in neurosurgery for example, which is not only niche but had a completion ratio of 4.9 in 2013(ii) you’ll need to have gone to courses relevant to neurosurgery and have achievements related to the specialty such as a neurosurgical elective, attachment or taster experience(iii). Some specialties assess commitment in a variety of situations e.g. the radiology interview this year had stations on the general overview and future of radiology as a career, a CV based demonstration of commitment to specialty as well as a station requiring the interpretation of images. General Practice on the other hand which in its very nature is very broad, at no point allocates marks specifically for commitment to specialty (or anything else on a CV for that matter) as it is entirely dependent on an exam (SJTs and clinical questions) and skill-based stations at a selection centre. The person specification* details what is expected and desirable as demonstration of commitment in each specialty. So, how do you actually show you’re committed to a specialty? It may be pretty obvious but try to get a consistent and well-rounded CV. Consider: • Joining a student committee or group for your specialty. If there isn't one at your university, find some like-minded people and start one • Asking the firms you work for if you can help with an audit/research even if data collection doesn’t sound very interesting • Finding a research project (e.g. as part of a related intercalated or higher degree) • Prizes and examinations relevant to the specialty • Developing a relevant teaching programme • Selecting your selected study modules/components, elective and dissertation with your chosen specialty in mind • Going to teaching or study days aimed at students at the relevant Royal College Remember it’s not just what you’ve done but also what you’ve learnt from it; get into a habit of reflecting on what each activity has helped you achieve or understand. This is where most people who appear to have the perfect CV come unstuck: There will always be someone who has more presentations and publications etc. etc. but don’t be put off that it means they are a dead cert for the job. Whatever you do, make sure you have EVIDENCE that you’ve done it. Become a bit obsessive. Trust me, you forget a lot and nothing counts if you can’t prove it. Assessing commitment to specialty aims to highlight who really understands and wants a career in that specialty. From my own recent experience however, just identifying experiences explicitly related to a specific specialty ignores the transferable and clinically/professionally/personally important skills one has that would make them a successful trainee. I’d be very interested in your views on ‘commitment to specialty’: for example do you think the fact someone has 20 papers in a given specialty means they are necessarily the best for the job? Or are you planning to take a year out post-FY2 to build on your CV to gain more experience? Let us know! References *See person specifications for specialty-specific details at http://specialtytraining.hee.nhs.uk/specialty-recruitment/person-specifications-2013/ i. http://www.foundationprogramme.nhs.uk/download.asp?file=F2_career_destination_report_November_2013.pdf ii. http://specialtytraining.hee.nhs.uk/wp-content/uploads/sites/475/2013/03/Specialty-Training-2013.pdf iii. http://specialtytraining.hee.nhs.uk/wp-content/uploads/sites/475/2013/03/2014-PS-NEUROSURGERY-ST1-1.02.pdf  
Dr Lydia Spurr
almost 6 years ago
Foo20151013 2023 13vodzp?1444774194
9
164

Is ADHD a difficult diagnosis?

In a recent article in the BMJ the author wonders about the reasons beyond the rising trend diagnosing Attention Deficit Hyperactivity Disorder (ADHD). The article attempts to infer reasons for this. One possible reason was that the diagnostic criteria especially DSM may seem for some to be more inclusive than ICD-10. The speculation may explain the rise of the diagnosis where DSM is used officially or have an influence. In a rather constructive way, an alternative to rushing to diagnosis is offered and discussed in some details. The tentative deduction that the Diagnostic Statistical Manual (DSM) may be one of the causes of rising diagnosis, due to raising the cut-off of age, and widening the inclusion criteria, as opposed to International Classification of Diseases, 10th revision (ICD-10), captured my attention. On reading the ICD-10 diagnostic criteria for research (DCR) and DSM-5 diagnostic criteria, I found them quite similar in most aspects, even the phraseology that starts with 'Often' in many diagnostic criteria, they seem to differ a bit in age. In a way both classification, are attempting to describe the disorder, however, it sounds as if someone is trying to explain a person's behaviour to you, however, this is not a substitute to direct clinical learning, and observing the behaviour, as if the missing sentence is 'when you see the person, it will be clearer'. El-Islam agrees with the notion that DSM-5 seems to be a bit more inclusive than ICD-10. A colleague of mine who is a child psychiatrist and she is doing her MSc. thesis in ADHD told me, that DSM-5 seems to be a substantial improvement as compared to its predecessor. The criteria - to her - though apparently are more inclusive, they are more descriptive with many examples, and she infers that this will payback in the reliability of the diagnosis. She hopes gene research can yield in biological tests for implicated genes and neurotransmitters in ADHD e.g. DRD4, DAT, gene 5,6,11 etc. One child psychiatrist, regretted the fact that misdiagnosis and under-diagnoses, deprive the patient from one of the most effective treatments in psychiatry. It is hoped the nearest forthcoming diagnostic classification (ICD-11), will address the issue of the diagnosis from a different perspective, or else converge with DSM-5 to provide coherence and a generalised newer standard of practice. The grading of ADHD into mild, moderate, and severe seem to blur the border between disorder and non-disorder, however, this quasi-dimensional approach seems realistic, it does not translate yet directly in differences in treatment approaches as with the case of mild, moderate, severe, and severe depression with psychotic symptoms, or intellectual disability. The author states that one counter argument could be that child psychiatrists are better at diagnosing the disorder. I wonder if this is a reflection of a rising trend of a disorder. If ADHD is compared to catatonia, it is generally agreed that catatonia is less diagnosed now, may be the epidemiology of ADHD is not artefact, and that we may need to look beyond the diagnosis to learn for example from environmental factors. Another issue is that there seems to be significant epidemiological differences in the rates of diagnosis across cultures. This may give rise to whether ADHD can be classified as a culture-bound syndrome, or whether it is influenced by culture like anorexia nervosa, or it may be just because of the raising awareness to such disorders. Historically, it is difficult to attempt to pinpoint what would be the closest predecessor to ADHD. For schizophrenia and mania, older terms may have included insanity, for depression it was probably melancholia, there are other terms that still reside in contemporary culture e.g. hypochondriasis, hysteria, paranoia etc. Though, it would be too simplistic to believe that what is meant by these terms was exactly what ancient cultures meant by them, but, they are not too far. ADHD seems to lack such historical underpinning. Crichton described a disorder he refers to as 'mental restlessness'. Still who is most often credited with the first description of ADHD, in his 1902 address to the Royal College of Physicians. Still describes a number of patients with problems in self-regulation or, as he then termed it, 'moral control' (De Zeeuw et al, 2011). The costs and the risks related to over-diagnosis, ring a warning bell, to enhance scrutiny in the diagnosis, due to subsequent stigma, costs, and lowered societal expectations. They all seem to stem from the consequences of the methodology of diagnosis. The article touches in an important part in the psychiatric diagnosis, and classifications, which is the subjective nature of disorders. The enormous effort done in DSM-5 & ICD-10 reflect the best available evidence, but in order to eliminate the subjective nature of illness, a biological test seems to be the only definitive answer, to ADHD in particular and psychiatry in general. Given that ADHD is an illness and that it is a homogeneous thing; developments in gene studies would seem to hold the key to understanding our current status of diagnosis. The suggested approach for using psychosocial interventions and then administering treatment after making sure that it is a must, seems quite reasonable. El-Islam, agrees that in ADHD caution prior to giving treatment is a recommended course of action. Another consultant child psychiatrist mentioned that one hour might not be enough to reach a comfortable diagnosis of ADHD. It may take up to 90 minutes, to become confident in a clinical diagnosis, in addition to commonly used rating scales. Though on the other hand, families and carers may hypothetically raise the issue of time urgency due to scholastic pressure. In a discussion with Dr Hend Badawy, a colleague child psychiatrist; she stated the following with regards to her own experience, and her opinion about the article. The following is written with her consent. 'ADHD is a clinically based diagnosis that has three core symptoms, inattention, hyperactivity and impulsivity in - at least - two settings. The risk of over-diagnosis in ADHD is one of the potentially problematic, however, the risk of over-diagnosis is not confined to ADHD, it can be present in other psychiatric diagnoses, as they rely on subjective experience of the patient and doctor's interviewing skills. In ADHD in particular the risk of under-diagnosis is even more problematic. An undiagnosed child who has ADHD may suffer various complications as moral stigma of 'lack of conduct' due to impuslivity and hyperactivity, poor scholastic achievement, potential alienation, ostracization and even exclusion by peer due to perceived 'difference', consequent feelings of low self esteem and potential revengeful attitude on the side of the child. An end result, would be development of substance use disorders, or involvement in dissocial behaviours. The answer to the problem of over-diagnosis/under-diagnosis can be helped by an initial step of raising public awareness of people about ADHD, including campaigns to families, carers, teachers and general practitioners. These campaigns would help people identify children with possible ADHD. The only risk is that child psychiatrists may be met with children who their parents believe they might have the disorder while they do not. In a way, raising awareness can serve as a sensitive laboratory investigation. The next step is that the child psychiatrist should scrutinise children carefully. The risk of over-diagnosis can be limited via routine using of checklists, to make sure that the practice is standardised and that every child was diagnosed properly according to the diagnostic criteria. The use of proper scales as Strengths and Difficulties Questionnaire (SDQ) in its two forms (for parents SDQ-P and for teachers SDQ-T) which enables the assessor to learn about the behaviour of the child in two different settings. Conner's scale can help give better understanding of the magnitude of the problem. Though some people may voice criticism as they are mainly filled out by parents and teachers, they are the best tools available at hands. Training on diagnosis, regular auditing and restricting doctors to a standard practice of ensuring that the child and carer have been interviewed thoroughly can help minimise the risk of over-diagnosis. The issue does not stop by diagnosis, follow-up can give a clue whether the child is improving on the management plan or not. The effects and side effects of treatments as methylphenidate should be monitored regularly, including regular measurement height and weight, paying attention to nausea, poor appetite, and even the rare side effects which are usually missed. More restrictions and supervision on the medication may have an indirect effect on enhancing the diagnostic assessment. To summarise, the public advocacy does not increase the risk of over-diagnosis, as asking about suicidal ideas does not increase its risk. The awareness may help people learn more and empower them and will lead to more acceptance of the diagnosed child in the community. Even the potential risk of having more case loads for doctors to assess for ADHD may help give more exposure of cases, and reaching more meaningful epidemiological finding. From my experience, it is quite unlikely to have marked over-representation of children who the families suspect ADHD without sufficient evidence. ADHD remains a clinical diagnosis, and it is unlikely that it will be replaced by a biological marker or an imaging test in the near future. After all, even if there will be objective diagnostic tests, without clinical diagnostic interviewing their value will be doubtful. It is ironic that the two most effective treatments in psychiatry methylphenidate and Electroconvulsive Therapy (ECT) are the two most controversial treatments. May be because both were used prior to having a full understanding of their mechanism of action, may be because, on the outset both seem unusual, electricity through the head, and a stimulant for hyperactive children. Authored by E. Sidhom, H. Badawy DISCLAIMER The original post is on The BMJ doc2doc website at http://doc2doc.bmj.com/blogs/clinicalblog/#plckblogpage=BlogPost&plckpostid=Blog%3A15d27772-5908-4452-9411-8eef67833d66Post%3Acb6e5828-8280-4989-9128-d41789ed76ee BMJ Article: (http://www.bmj.com/content/347/bmj.f6172). Bibliography Badawy, H., personal communication, 2013 El-Islam, M.F., personal communication, 2013 Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347) De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011) Diagnostic Statistical Manual 5, American Psychiatric Association, 2013 Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994 International Classification of Diseases, World Health Organization, 1992  
Dr Emad Sidhom
almost 6 years ago
Foo20151013 2023 e9tc1t?1444774226
5
236

Grand Round: Dos and Don’ts

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” The words of Sir William Osler, the acclaimed father of modern medicine, are still no less profound. They hark from an age when medicine still retained a sense of ceremony: an amphitheatre filled to the rafters, the clinicians poised in their white coats and ties, all eyes convergent on their quarry or rather the patient seated before them. Any memory of such scenes live out a vestigial existence in black&white photos or histrionic depictions recalling the rise of modern medicine. To think this is how the tradition of grand rounds proceeded in the not so distant past. Today grand rounds have a more tuitional flavour to them. The Socratic dialogue which reportedly took place has been superseded by the much less appetising PowerPoint presentation. It’s a weekly event marked in the calendar. For the ever-busy junior doctor it at least offers the prospect of a free lunch. I gest, they serve a social as well as an educational function. On the other hand medical student grand rounds are purely a learning exercise. They are most importantly not a race to find and present the most ‘interesting’ case in the trust because this is usually interpretted as a vanishingly rare condition, which even your ejudicating consultant has never encountered in a lifetime of experience. It falls short of the primary aim: to learn about the patients who you will be seeing as a junior doctor and as the addage goes - common things are common. What will make your grand round interesting, is not the patient you choose but how you choose to present that patient. Unfortunately, as fair a point Sir Osler makes, the old practice of patient participation in grand rounds has long since faded. You will have to call upon your thespian talents to retell the story to your fellow students. Of course not everyone’s a natural showman, however fortune favours the prepared and in my experience there are only a handful of things to worry about. Structure. This is the back bone of your presentation. Obviously a solid introductory line about the patient with all the salient points goes without saying, it’s no different to presenting to the consultant on ward rounds or in the clinic. Always set the scene. If you clerked your patient on a hectic night oncall down in majors, then say so. It makes the case less one dimensional. The history is your chance to show off - to consider the presenting complaint expressed in the patient’s own words and to form a working differential, which you can encourage your colleagues to reel off at the outset. The quality of the history should guide your audience to the right diagnosis. Equip them with all the information they need, so not just the positive findings. Showing that you have ruled out important red flag symptoms or signs will illustrate good detective work on your part. However you wish to order the relevant past medical/family history, medications, social impact etc is up to you. It’s a subjective thing, you just have to play the game and cater to the consultant’s likes. You can only gage these after a few cases so do the honourable thing and let your colleagues present first. Performance. Never read your slides in front of an audience. Their attention will rapidly wane (especially if they’re postprandial). The slides are an aide-memoire and to treat them as a script is to admit your presence adds nothing more to your presentation. Communicating with the audience requires you to present uncluttered slides, expanding on short headings and obliging your colleagues to listen for the little nuggets of clinical knowledge you have so generously lain in store. Insight. When the consultant asks you the significance of an investigation, always know on what grounds it was ordered and the limitations of the results. The astute student will be aware of its diagnostic or prognostic potential.The same may be said of imaging. Perusing the radiologists report and using it to guide the audience through (anoynmised) CXRs, CTs, US etc is a feather in your cap. Literature reviews of your choosing constitute a mandatory part of the presentation. They are demonstrative of not only your wider reading but your initiative to find the relevant evidence base e.g. the research underlying the management plan of a condition or perhaps its future treatments. Timing. Waffling is only detrimental to the performance. Rehearsing the presentation with a firm mate is a sure way to keep to time constraints. Memorability, for the right reasons, relies on a concise and interactive presentation. A splash of imagination will not go unnoticed. The consultant marking you has seen it all before; surprising titbits of knowledge or amusing quirks in your presentation will hopefully appeal to their curious and humorous side. If anything it might break the tedium grand rounds are renown for. Oratory is a universal skill and is responsible for so much (undue) anxiety. The more timid can take comfort grand rounds aren’t quite the grand occasions they used to be. Illustrator Edward Wong This blog post is a reproduction of an article published in the Medical Student Newspaper, December 2013 issue.  
James Wong
over 5 years ago
Foo20151013 2023 1u6up6r?1444774235
4
132

Keep on Truckin’

Shattered. Third consecutive day of on-calls at the birth centre. I’m afraid I have little to show for it. The logbook hangs limply at my side, the pages where my name is printed await signatures; surrogate markers of new found skills. Half asleep I slump against the wall and cast my mind back to the peripheral attachment from which I have not long returned. The old-school consultant’s mutterings are still fresh: “Medical education was different back then you see....you are dealt a tough hand nowadays.” I quite agree, it is Saturday. Might it be said the clinical apprenticeship we know today is a shadow of its former self? Medical school was more a way of life, students lived in the hospital, they even had their laundry done for them. Incredulous, I could scarcely restrain a chuckle at the consultant’s stories of delivering babies while merely a student and how the dishing out of “character building” grillings by their seniors was de rigeur. Seldom am I plied with any such questions. Teaching is a rare commodity at times. Hours on a busy ward can bear little return. Frequently do I hear students barely a rotation into their clinical years, bemoan a woeful lack of attention. All recollection of the starry-eyed second year, romanced by anything remotely clinical, has evaporated like the morning dew. “Make way, make way!...” cries a thin voice from the far reaches of the centre. A squeal of bed wheels. The newly crowned obs & gynae reg drives past the midwife station executing an impressive Tokyo drift into the corridor where I stand. Through the theatre doors opposite me he vanishes. I follow. Major postpartum haemorrhage. A bevy of scrubs flit across the room in a live performance of the RCOG guidelines for obstetric haemorrhage. They resuscitate the women on the table, her clammy body flat across the carmine blotched sheets. ABC, intravenous access and a rapid two litres of Hartmann’s later, the bleeding can not be arrested by rubbing up contraction. Pharmacological measures: syntocinon and ergometrine preparations do not staunch the flow. Blood pressure still falling, I watch the consciousness slowly ebb from the woman’s eyes. Then in a tone of voice, seemingly beyond his years, the reversely gowned anaesthetist clocks my badge and says, “Fetch me the carboprost.” I could feel an exercise in futility sprout as I gave an empty but ingratiating nod. “It’s hemabate....in the fridge” he continues. In the anaesthetic room I find the fridge and rummage blindly through. Thirty seconds later having discovered nothing but my general inadequacy, I crawl back into theatre. I was as good as useless though to my surprise the anaesthetist disappeared and returned with a vial. Handing me both it and a prepped syringe, he instructs me to inject intramuscularly into the woman’s thigh. The most common cause of postpartum haemorrhage is uterine atony. Prostaglandin analogues like carboprost promote coordinated contractions of the body of the pregnant uterus. Constriction of the vessels by myometrial fibres within the uterine walls achieves postpartum haemostasis. This textbook definition does not quite echo my thoughts as I gingerly approach the operating table. Alarmingly I am unaware that aside from the usual side effects of the drug in my syringe; the nausea and vomiting, should the needle stray into a nearby vessel and its contents escape into the circulation, cardiovascular collapse might be the unfortunate result. Suddenly the anaesthetist’s dour expression as I inject now assumes some meaning. What a relief to see the woman’s vitals begin to stabilise. As we wheel her into the recovery bay, the anaesthetist unleashes an onslaught of questions. Keen to redeem some lost pride, I can to varying degrees, resurrect long buried preclinical knowledge: basic pharmacology, transfusion-related complications, the importance of fresh frozen plasma. Although, the final threat of drawing the clotting cascade from memory is a challenge too far. Before long I am already being demonstrated the techniques of regional analgesia, why you should always aspirate before injecting lidocaine and thrust headlong into managing the most common adverse effects of epidurals. To have thought I had been ready to retire home early on this Saturday morning had serendipity not played its part. A little persistence would have been just as effective. It’s the quality so easily overlooked in these apparently austere times of medical education. And not a single logbook signature gained. Oh the shame! This blog post is a reproduction of an article published in the Medical Student Newspaper, February 2014 issue.  
James Wong
over 5 years ago
Foo20151013 2023 3cqojv?1444774240
3
98

Goodbye fear and ego, hello better patient care

The best doctors in the world still have bad consultation. Sometimes you just start off on the wrong foot. The patient leaving in a floor of tears is usually an indication that this has just occurred. On one of my medical placements I witnessed one such consultation. A young woman in the early stages of her pregnancy had a per vaginal bleed and wanted a scan to see if the pregnancy was still ok. Medically speaking, a scan wasn’t indicated as the pregnancy was too early on to detect any changes. The doctors noted the “agenda” as they later remarked, and was not going to “play the game” and send the young woman for a scan. She was not happy about this. The doctor felt that he couldn’t have done more. Medically there was nothing he could offer to the woman other than advice to go home and wait a little while before repeating a pregnancy test. To me, there was lots that could have been done. This woman was scared and worried and a sympathetic ear and a tissue would have gone some way to making her feel better. The doctor I was with couldn’t see this. They were blind sighted by the repeated requests for a scan and slightly frustrated that the unhelpfulness of this was not being understood. When the young woman began to cry I was waiting for the doctor to hand over a tissue. “Any second now...” I thought, but it never happened. I wanted to give the woman a tissue and put my arm around her but that would have meant physically placing myself between the doctor and the patients and interrupting a consultation I wasn’t really a part of. But the truth is. I was a part of that consultation. I might not have been the doctor in charge but I was another person in that room who could have made that situation easier for that patient and I didn’t. Hours later, on my way home, I was still thinking about this. I felt I had let that woman down. I could see what she needed and I sat there and did nothing. After the consultation I immediately told the doctor what I thought. I felt that the patient had been let down. They took on what I said and mostly agreed with it. All egos were put aside in that frank conversation and the doctor genuinely reflected on how they could have done better in that situation. It wasn’t about me or the doctor. It was about the patient. As a medical student it is easy to feel in the way in the hospital environment or in a busy clinic. When the consultant is running behind, it takes a lot to ask the patients something or butt in and add something you think is relevant that in the end may turn out to be a very trivial thing. But at the end of the day, it is worth it if it means that there is a better out come for the patient because when all is said and done they are the ones we are doing this all for. I regret not handing that patient a tissue and it’s a mistake I hope never to repeat again.  
Salma Aslam
over 5 years ago