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27
1008

Confidence Building During Medical Training

My fellow medical students, interns, residents and attendings: I am not a medical student but an emeritus professor of Obstetrics and Gynecology at the University of Miami Miller School of Medicine, and also a voluntary faculty member at the Florida International University Herbert Wertheim College of Medicine. I have a great deal of contact with medical students and residents. During training (as student or resident), gaining confidence in one's own abilities is a very important part of becoming a practitioner. This aspect of training does not always receive the necessary attention and emphasis. Below I describe one of the events of confidence building that has had an important and lasting influence on my career as an academic physician. I graduated from medical school in Belgium many years ago. I came to the US to do my internship in a small hospital in up state NY. I was as green as any intern could be, as medical school in Belgium at that time had very little hands on practice, as opposed to the US medical graduates. I had a lot of "book knowledge" but very little practical confidence in myself. The US graduates were way ahead of me. My fellow interns, residents and attendings were really understanding and did their best to build my confidence and never made me feel inferior. One such confidence-building episodes I remember vividly. Sometime in the middle part of the one-year internship, I was on call in the emergency room and was called to see a woman who was obviously in active labor. She was in her thirties and had already delivered several babies before. The problem was that she had had no prenatal care at all and there was no record of her in the hospital. I began by asking her some standard questions, like when her last menstrual period had been and when she thought her due date was. I did not get far with my questioning as she had one contraction after another and she was not interested in answering. Soon the bag of waters broke and she said that she had to push. The only obvious action for me at that point was to get ready for a delivery in the emergency room. There was no time to transport the woman to the labor and delivery room. There was an emergency delivery “pack” in the ER, which the nurses opened for me while I quickly washed my hands and put on gloves. Soon after, a healthy, screaming, but rather small baby was delivered and handed to the pediatric resident who had been called. At that point it became obvious that there was one more baby inside the uterus. Realizing that I was dealing with a twin pregnancy, I panicked, as in my limited experience during my obstetrical rotation some months earlier I had never performed or even seen a twin delivery. I asked the nurses to summon the chief resident, who promptly arrived to my great relief. I immediately started peeling off my gloves to make room for the resident to take my place and deliver this twin baby. However, after verifying that this baby was also a "vertex" without any obvious problem, he calmly stood by, and over my objections, bluntly told me “you can do it”, even though I kept telling him that this was a first for me. I delivered this healthy, screaming twin baby in front of a large number of nurses and doctors crowding the room, only to realize that this was not the end of it and that indeed there was a third baby. Now I was really ready to step aside and let the chief resident take over. However he remained calm and again, stood by and assured me that I could handle this situation. I am not even sure how many triplets he had delivered himself as they are not too common. Baby number three appeared quickly and also was healthy and vigorous. What a boost to my self-confidence that was! I only delivered one other set of triplets later in my career and that was by C-Section. All three babies came head first. If one of them had been a breech the situation might have been quite different. What I will never forget is the implied lesson in confidence building the chief resident gave me. I have always remembered that. In fact I have put this approach in practice numerous times when the roles were reversed later in my career as teacher. Often in a somewhat difficult situation at the bedside or in the operating room, a student or more junior doctor would refer to me to take over and finish a procedure he or she did not feel qualified to do. Many times I would reassure and encourage that person to continue while I talked him or her through it. Many of these junior doctors have told me afterwards how they appreciated this confidence building. Of course one has to be careful to balance this approach with patient safety and I have never delegated responsibility in critical situations and have often taken over when a junior doctor was having trouble. Those interested, can read more about my experiences in the US and a number of other countries, in a free e book, entitled "Crosscultural Doctoring. On and Off the Beaten Path" can be downloaded at this link. Enjoy!  
DR William LeMaire
over 5 years ago
Foo20151013 2023 e7fpn8?1444774293
3
339

The Importance Of Clinical Skills

In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees. Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this. In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment. In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room. What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it? Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important. Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.  
DR William LeMaire
over 5 years ago
Foo20151013 2023 xzilvf?1444774307
1
312

Why doesn’t the NHS make money?

The NHS provides care free at the point of us to British citizens and anyone who needs emergency care while in the UK. It tries to provide every kind of service and treatment that it can but obviously there are limits. The NHS gets its money mainly from governments taxes, charities, research grants, some payment for services and from renting out retail space etc. Healthcare is a financial blackhole, any money put in the budget will get spent, efficiently and effectively or not. The NHS is constantly being expected to provide a better, more efficient service and new treatments, without a comparable increase in government funding. So, why doesn’t the NHS set up services that could make it money? Some money making suggestions Gift shops and NHS clothing brand – The American hospital I went to for elective had quite a large shop near the entrance that sold hospital branded goods. People love the NHS and it could make itself a brand, “I love the NHS” t-shirts, “I was born here” ties, “I gave birth at Blah hospital” car stickers, hats, jackets, tracksuits, teddy bears in white coats and so many more things could be sold in this shops to raise money for the NHS. Patients in a hospital are a captive market and their visitors are semi-captive. The captives get very bored! Why not provide opportunities for these people to spend their money and relieve the boredom while they are in hospital with some retail therapy? For instance, new hospitals should be built with a shopping mall in them and a cinema. A couple of clothes shops would give people something to do and raise money from rent. While we are on the subject of new hospitals, they should be designed with the input of the clinical staff who know how to maximise the flow of patients through the "patient pathway". Hospitals should be built like industrial conveyor belts: patients enter through ED, get stabilised, get fixed in theatre, stabilised again in ITU, recover on the wards and out the exit to social services and the outpatient clinics. New hospitals should be designed to sit on top of HUGE underground multi-story car parks. If shopping centres can do this then so can hospitals. Almost all hospitals are short of parking spaces and most car parks are eye sores. So, try to plan from the beginning to get as many car parking spaces as possible. Estimate how many are needed for staff and visitors - then double it! Also, design a park and ride system so additional parking is available off site. If costa can make money from a coffee shop in an NHS hospital, why isn’t the NHS setting up its own brand of high quality coffee shops in the hospitals and cutting out Costa the middle man? “NHS healthy eating” – NHS branded diet plans or ready meals could be produced in partnership with a supermarket brand. Mixing public heath, profit and the NHS brand. “Good for you and good for the NHS” The NHS could set up hospitals abroad that are for profit institutions that use the NHS structures, or market our services to foreigners that they then pay for. Health tourism is a thing, why not make the most of it? “NHS plus” – the NHS should be a two tier system. Hours of 8am til 6pm should be for elective procedures free at the point of use and free emergency care. Between 6pm and 11pm the hospitals currently only do emergency care, so there is loads of rooms and kit lying about unused. Why not allow hospitals to set up systems where patients can pay for an evening slot in the MRI scanner and cut the queue? Allow surgeons to pay to use the facilities for private procedures in the evenings. Allow physicians to pay to use the outpatients clinics for private work after hours. An “NHS Journal” could publish research and audits conducted within and relevant to the NHS. “NHS pharma” – the NHS buys a huge amount of off patent drugs, why not produce them itself? Set up a drug company that produces off patent medication, these can be given to the NHS at cost price and sold to other healthcare providers for profit. NHS pharma could also work with British universities and researchers to produce new drugs for the British market that would be cheaper than new Drug company drugs because they wouldn’t need huge advertising budgets. There are so many ways the NHS could make more money for itself that could then be used to deliver newer and better treatments. Yes, it is a shift in ideology and culture, but I am sure it would have positive outcomes for the NHS and patients. If you have any ideas on how the NHS could produce more money then please do leave a comment.  
jacob matthews
about 5 years ago
141bd7ffe3b3ed512898cdd22d08791ee5e879ed4060425668804899
2
32

Radical Neck Dissection: (RND) Classification, Indication and Techniques

Crile in 1906 introduced RND and is followed by Martin as a the classical procedure for the management of cervical lymph node metastasis  
Souradeep Dutta
over 4 years ago
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1
29

The Truth About Medical Education: Corrupted Seeds with Far-Reaching Roots – in-Training, the online magazine for medical students

The continuation and progress of the human condition has been founded on the inheritance of knowledge. With each generation, the lessons learnt are passed on as another valuable brick in the pyramid towards the pinnacle of human success. However, just as progress necessitates the study of the phenomenon in question, the educational system itself has become a topic of scrutiny. Having been a student for most of my life and a mentor intermittently (whether as the fearless older sister or a tutor for other students), the architecture of the educational system is something that I have often pondered over. My dual citizenship in two very different cultures has provided me with two strains of the education system — one of Taiwanese, the other American — to juxtapose. No educational system is perfect, and I don’t believe it is possible to create a curriculum that can be “one size fits all.” That being said, as a current medical student, I often talk to past, current, and future medical students and wonder why medical school is so difficult? While the analogy of “drinking from a fire hose” parallels the insane amount of knowledge we must absorb within the given timeline and contributes to the difficulty of medical education, I find it hard to believe that time-pressed content is the sole reason. I believe that the attitudes and expectations already planted in our minds, the curriculum design, and the methods of student evaluation are crucial factors — just to mention a few — that contribute to the hefty weight that we carry as medical students.  
in-training.org
over 4 years ago
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0
18

Early methods of studying the brain

Visit us (http://www.khanacademy.org/science/healthcare-and-medicine) for health and medicine content or (http://www.khanacademy.org/test-prep/mcat) for MCAT...  
youtube.com
over 4 years ago
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0
0

Early methods of studying the brain - YouTube

Visit us (http://www.khanacademy.org/science/healthcare-and-medicine) for health and medicine content or (http://www.khanacademy.org/test-prep/mcat) for MCAT...  
youtube.com
over 4 years ago
Www.bmj
0
16

Endovascular therapy reduces disability from stroke, studies confirm

Endovascular therapy using minimally invasive procedures to remove blood clots from occluded brain vessels within the first few hours of ischaemic stroke significantly reduces disability when compared with medical therapy, two studies published in the New England Journal of Medicine have shown.1 2  
feeds.bmj.com
over 4 years ago
Www.bmj
0
11

Stage III pancreatic cancer and the role of irreversible electroporation

About a third of patients with pancreatic cancer present with locally advanced disease that is not amenable to resection. Because these patients have localized disease, conventional ablative therapies (thermal ablation and cryoablation) have the potential to be beneficial, but their use is inherently limited in the pancreas. These limitations could be overcome by irreversible electroporation—a novel, non-thermal ablative method that is gaining popularity for the treatment of many soft tissue tumors, including those of the pancreas. This review summarizes the status of this technique in the treatment of locally advanced pancreatic cancer. Most of the evidence on efficacy and safety is based on non-randomized prospective series, which show that irreversible electroporation may improve overall survival and pain control in locally advanced pancreatic cancer. As experience with this procedure increases, randomized controlled trials are needed to document its efficacy in locally advanced pancreatic cancer more precisely.  
feeds.bmj.com
over 4 years ago
Www.bmj
0
9

Minimising bleeding during percutaneous coronary intervention

In 2013 more than 92 500 percutaneous coronary intervention (PCI) procedures were performed in the United Kingdom alone.1 Bleeding events are among the most common complications; reported incidences vary between 2.2% and 14%.2 Peri-procedural bleeding has a negative effect on patients’ outcomes—as indicated by higher mortality and morbidity and diminished quality of life—and on metrics of healthcare provision such as length of stay and associated costs.3 Large registries of US patients undergoing PCI have shown that 12.1% of in-hospital mortality is attributable to post-procedural bleeding and suggest a significant association between major bleeding and in-hospital mortality across all strata of bleeding risk.4 The 2011 American Heart Association guidelines state that all patients should be evaluated for risk of bleeding before PCI (class of recommendation 1, level of evidence C).5  
feeds.bmj.com
over 4 years ago
Www.bmj
0
11

Orthopaedic surgery can transform the lives of adults with spasticity

Surgery has a role in managing spasticity in adults.1 We run a monthly clinic for adult patients with spasticity after stroke, multiple sclerosis, brain injury, and cerebral palsy. Several surgical procedures improve the quality of such patients’ lives, including wrist fusions, …  
feeds.bmj.com
over 4 years ago
Www.bmj
0
26

Endovascular therapy reduces disability from stroke, studies confirm

Endovascular therapy using minimally invasive procedures to remove blood clots from occluded brain vessels within the first few hours of ischaemic stroke significantly reduces disability when compared with medical therapy, two studies published in the New England Journal of Medicine have shown.1 2  
feeds.bmj.com
over 4 years ago
Www.bmj
0
13

Minimally invasive surgery for lumbar spinal stenosis

Recent trends in spine surgery, such as endoscopic and other “micro” techniques, promised less invasive procedures and better outcomes compared with conventional open techniques for decompressing nerves. Minimally invasive techniques are popular with patients, promoted by industry, and increasingly used by surgeons.1 However, recent studies have failed to report any clear benefits for patients.2 Is our hunger for new techniques based on little more than a gut feeling that new and smaller is always better and, if so, is it ethically justifiable to “test” these new techniques on patients? In a linked paper (doi:10.1136/bmj.h1603) Nerland and colleagues provide some hard evidence to help inform these important debates.3  
feeds.bmj.com
over 4 years ago
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0
22

Using sedation for shoulder dislocation muscle spasm

This video shows a shoulder reduction being attempted, using non-sedating methods. However, it is unsuccessful, and eventually a touch of sedation is used to...  
youtube.com
over 4 years ago
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0
22

Shoulder Relocation using Cunningham technique positioning

This video shows a dislocated shoulder being reduced by the Cunningham Technique. Make careful note of the positioning of the patient during the procedure, w...  
youtube.com
over 4 years ago
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0
0

Shoulder Relocation using Cunningham technique positioning - YouTube

This video shows a dislocated shoulder being reduced by the Cunningham Technique. Make careful note of the positioning of the patient during the procedure, w...  
youtube.com
over 4 years ago
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0
10

Published data demonstrates superiority of TIF procedure over PPI

EndoGastric Solutions (EGS) announces that Gastroenterology, the official journal of the American Gastroenterological Association (AGA) Institute and the most prominent journal in the...  
medicalnewstoday.com
over 4 years ago
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0
11

EndoGastric solutions reports two-year durability data from TIF Registry for GERD patients choosing Transoral Incisionless Fundoplication

EndoGastric Solutions® (EGS) has announced publication of US registry data showing that long-term gastroesophageal reflux disease (GERD) sufferers who underwent an incisionless procedure...  
medicalnewstoday.com
over 4 years ago
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0
8

Treatment with MUSE™ system keeps patients off daily PPI therapy, three-year follow up study results

Medigus Ltd., a medical device company developing minimally-invasive, endosurgical tools and procedures, announced recently that two presentations involving the use of its MUSE™ System...  
medicalnewstoday.com
over 4 years ago
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0
4

Improved screening methods likely following new insights into Barrett's esophagus, cancer evolution

A new appreciation of how cancer cells evolve could help scientists design better screening methods to catch cancer before it advances.  
medicalnewstoday.com
over 4 years ago