a person who provides expert advice professionally:
he acted as campaign consultant to the president
[OFTEN AS MODIFIER] British a hospital doctor of senior rank within a specific field: a consultant paediatrician
forming names of inflammatory diseases: cystitis, hepatitis
(Origin - from Greek feminine form of adjectives ending in -it?s (combined with nosos 'disease' implied) )
You may not be surprised to hear that the way in which I recently heard the term 'consultantitis' used cannot be understood to mean 'inflammation of the senior hospital doctor'. Although, I wish it was.
Professionalism, compassion, transparency, teamwork and communication - all terms that appear to be used with an increasing regularity within the NHS. These are concepts that are not merely taught but preached to medical students today. Why? Well it is nit merely the work of a heavily publicised inquiry into a foundation trust, neither is it the upshot of the medical profession's own Voldemort - he who must not be named (except I will name him - Harold Shipman).
Is it then an attempt to heal the wounds within our national health service from within? I hope so. Yet, there are countless more 'isms' and other terms being muttered under the breath of healthcare professionals all over the country. 'Consultantitis' is one that fills me with sadness for one reason in particular: it suggests that those at the top are at the core of some of the problems.
Ponder over that for a while, I intend to explain myself further in my next blog post.
To be continued****.
This anecdote happened many years ago when I was a brand new (read: inexperienced) physician doing my stint in the Colonial Health Service of the former Belgian Congo. I was assigned to a small hospital in the interior of the Maniema province.
Soft tissue infections and abscesses were rather common in this tropical climate, but at one time there seemed to be virtual epidemic of abscesses on the buttocks or upper arms. It seemed that patients with these abscesses were all coming from one area of the territory. That seemed rather odd and we started investigating. By way of background let me say that the hospital was also serving several outlying clinics or dispensaries in the territory. Health aides were assigned to a specific dispensary on a periodic basis. Patients would know his schedule and come to the dispensary for their treatments. Now this was the era of “penicillin.”
The natives were convinced that this wonder drug would cure all their ailments, from malaria and dysentery, to headaches, infertility, and impotence. You name it and penicillin was thought to be the cure-all. No wonder they would like to get an injection of penicillin for whatever their ailment was.
As our investigation demonstrated, the particular health aide assigned to the dispensary from where most of the abscesses came, would swipe a vial of penicillin and a bottle of saline from the hospital’s pharmacy on his way out to his assigned dispensary. When he arrived at his dispensary there was usually already a long line of patients waiting with various ailments. He would get out his vial of the “magic” penicillin, show the label to the crowd and pour it in the liter bottle of saline; shake it up and then proceed to give anyone, who paid five Belgian Francs (at that time equivalent to .10 US $), which he pocketed, an injection of the penicillin, now much diluted in the large bottle of physiologic solution. To make matters worse, he used only one syringe and one needle. No wonder there were so many abscesses in the area of injection. Of course we quickly put a stop to that.
Anyone interested in reading more about my experience in Africa and many other areas can download a free e book via Smashwords at: http://www.smashwords.com/books/view/161522 . The title of the book is "Crosscultural Doctoring. On and Off the Beaten Path"
Fluoroscopy with Videography Showing Deployment of the Valve: The valve is deployed during rapid right ventricular pacing. The crimped valve and support frame are expanded with underlying balloon inflation. Also seen are the transesophageal echocardiography probe and the temporary right ventricular pacing lead.
Animation of the Complete Transfemoral Transcatheter Aortic-Valve Implantation (TAVI) Procedure: The procedure for transfemoral TAVI involves insertion of the sheath through the femoral artery, retrograde balloon aortic valvuloplasty, advancement of the TAVI system across the aortic valve, and subsequent deployment of the valve and support frame.
Last Wednesday (27/11/13) was Birmingham Medical Leadership Society’s second lecture in its autumn series on why healthcare professionals should become involved in management and leadership.
Firstly, a really big thank you to Mr Smart for travelling all the way to Birmingham for free (!) to speak to us. It was a brilliant event and certainly sparked some debate. A second big thank you to Michelle and Angie – the University of Birmingham Alumni and marketing team who helped organise this event and recorded it – a video will hopefully be available online soon.
Mr Tim Smart is the CEO of King’s NHS Foundation Trust and has been for the last few years – a period in which King’s has had some of the most successive hospital statistics in the UK. Is there a secret to managing such a successful hospital?
“It’s a people business. Patients are what we are here for and we must never forget that”
Mr Smart doesn’t enjoy giving lectures, so instead he had an “intimate chat” covering his personal philosophy of why we as medical students and junior doctors should consider a career in management at some point.
Good managers should be people persons. Doctors are selected for being good at talking to and listening to people – these are directly translatable skills.
Good managers should be team leaders. Medicine is becoming more and more a team occupation, we are all trained to work, think and act as a team and especially doctors are expected to know how to lead this team. Again, a directly transferable skill.
Good managers need to know how to make decisions based on incomplete knowledge and basic statistics. Doctors make life-altering clinical decisions every day based statistics and incomplete knowledge. A very important directly transferable skill.
Good managers get out of their offices, meet the staff and walk around their empires. Doctors, whether surgeons, GP’s or radiologists have to walk around the hospitals on their routine business and have to deal with a huge variety of staff from every level. To be a great doctor you need to know how to get the best out of the staff around you, to get the tasks done that your patients’ need. Directly transferable skills.
Good managers are quick on the up-take and are always looking for new ways to improve their departments. Doctors have to stay on top of the literature and are committed to a life-time of learning new and complex topics. Directly transferable.
Good managers are honest and put in place systems that try to prevent bad situations occurring again. Good doctors are honest and own up when they make a mistake, they then try to ensure that that mistake isn’t made again. Directly Transferable.
Even good managers sometimes have difficulties getting doctors to do what they want – because the managers are not doctors. Doctors that become managers still have the professional reputation of a doctor. A very transferable asset that can be used to encourage their colleagues to do what should be done.
A good manager values their staff – especially the nurses. A good doctor knows just how important the nurses, ODP, physio’s and other healthcare professionals and hospital staff are. This is one of the best reasons why doctors should get involved with management. We understand the front line. We know the troops. We know the problems. We are more than capable of thinking of some of the solutions!
“Project management isn’t magic”
“Everything done within a hospital should be to benefit patients – therefore everything in the hospital should be answerable to patients, including the hospital shop!”
“Reward excellence, otherwise you get mediocrity”
At the present The University of Birmingham Students Medical Leadership Society is in contact with the FMLM and other similar groups at the Universities of Bristol, Barts and Oxford. We are looking to get in contact with every other society in the country. If you are a new or old MLS then please do get in touch, we would love to hear from you and are happy to help your societies in any way we can – we would also love to attend your events so please do send us an invite.
Email us at firstname.lastname@example.org
Follow us on Twitter @UoBMedLeaders
Find us on Facebook @ https://www.facebook.com/groups/676838225676202/
Come along to our up coming events…
Thursday 5th December LT3 Medical School, 6pm
‘Why should doctors get involved in management’
By Dr Mark Newbold, CEO of BHH NHS Trust
Wednesday 22nd January 2014 LT3 Medical School, 6pm
‘Has the NHS lost the ability to care?’ – responding to the Mid Staffs inquiry’
By Prof Jon Glasby, Director of the Health Services Management Centre , UoB
Thursday 20th February LT3 Medical School, 6pm
‘Creating a Major Trauma Unit at the UHB Trust’
By Sir Prof Keith Porter, Professor of Traumatology, UHB
Saturday 8th March LT3 Medical School, 1pm
‘Applying the Theory of Constraints to Healthcare
By Mr A Dinham and J Nieboer ,QFI Consulting
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
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.
There are roughly 7000 medical students graduating each year from 33 medical schools in the UK. Medical degrees take either 4, 5 or 6 years depending on the route you take.
The government via the Student Finance Company will pay for your tuition fees for the first 4 years of any undergraduate degree. After this the NHS will pay for the last year or 2 years of the undergraduate medical tuition fees.
The maintenance loan depends on family income. The figures aren’t easy to find for the background of most UK medical students but a ‘guestimate’ based on my medical school is that 50% went to a private school, 30% went to selective state schools and 20% went to a comprehensive. Of the private school kids probably about half had a scholarship or bursary. So, a rough guess would be that 70% of med students come from a “middle class” family who have a decent income but not huge wealth and are therefore eligible for a ‘maintenance loan’ above the minimum. This majority therefore rely on there loan to get through the year.
An average student income is between £1000 and £1500/term (£1200 average-ish). Most university terms are 10 weeks, hence average income is about £120/week. As a preclinical medical student this is fine and we are on par with everyone else. As soon as we become clinical med students the game changes!
Clinical years are far longer, more like 40 weeks a year rather than 30. Students are on placement, have to dress professionally and travel to placement daily. This adds additional costs and requires the money to stretch further. Doubly bad!
Once, the NHS starts paying the tuition fees, the Student Loans Company starts reducing the maintenance loan, by half! Why?
A final year student or a 4th year who has intercalated now has to survive at University for one of their course’s longest years with half the money they had previously. >40 weeks on a loan of roughly £1500/year. This situation is pretty much unique to medical students.
Some students are lucky enough to have parents who can afford the extra couple of thousand pounds required for the year. Some students get selected into the military and get a salary. A greater proportion find part time jobs to help cover the cost and the rest have to resort to saving money where they can and taking out loans.
When I was a member of the BMA medical student committee I did a project as part of the finance sub-committee investigating the loans available for medical students. Many banks used to “professional development loans” which allowed medical and law students to borrow money for a year before they had to start repaying the loan. Hardly any banks now offer this service, so the only loan available is an overdraft or a standard loan that requires you to have a regular income.
This means that final year medical students with limited family support may have to live for a year on less than £2000. Does this seem fair? Does this seem sensible government policy?
Medical students are 99% guaranteed to be earning over £25 thousand pounds within a year. We will be able to repay any loans. So why isn’t the Student Loan Company allowing us to continue having a ‘normal’ maintenance loan? And why aren’t banks giving us the benefit of the doubt and helping us out in our time of need?
When I was on the BMA MSC there was talk of having a campaign to lobby government and the banks to rectify this situation but I can’t say I’ve been aware of any such campaign. Are the NUS, BMA, UKMSA or anyone else doing anything about this?
Please do leave a comment if you do know if there has been a progress and if there hasn’t why don’t we start making a fuss about this!
Worst experience ever? - this is pretty difficult as I've worked in some of the poorest countries in the world and seen some things that should never happen like children dying of dehydration and malaria. But this recent experience was definitely the worst.
It was midnight and I was trying to get my 16 month old to sleep having woken up after vomiting in his cot. Despite paracetamol, ibuprofen, stripping to nappy, damp sponging and having the window open he went rigid and started fitting. It only lasted a minute or two yet felt like an eternity as he was unable to breathe and became progressively blue as my mind raced ahead to brain damage or some other horrible sequalae.
The fitting stopped and my mind turned to whether I was going to have to start CPR. I lay him on the floor and put my ear to his chest and was glad to hear a strong heartbeat but he was floppy with a compromised airway so I quickly got him in the recovery position. The ambulance arrived in 8 minutes and after some oxygen and some observations he was strapped in and ready to go. He had been unconscious for about 15 minutes but was starting to come round, much to my relief.
The ambulance crew were great and their quick response made all the difference but then they took nearly half an hour to get to A&E in the middle of the night because they took the most awkward route imaginable. I don't know if it was a deliberate delaying tactic or just a lack of local knowledge but even without a blue light I could have done it in half the time! Why do ambulances not have GPS - ideally with local traffic info built in?
We arrived in A&E and were ushered to a miserable receptionist who took our details and told us to have a seat. I noticed above her head that the wait time was 3.5 hours, though we did see a junior nurse who took his observations again. Not long after the screen changed to a 5 hour wait and a bit later to a 6 hour wait! I am glad to say that by about 3 hours my little man was back to his usual self (as evidenced by his attempts at destroying the department) and so after getting the nurse to repeat his obs (all normal) we decided to take him home, knowing we had a few more hours to wait for the doctor, and that the doctor was now unlikely to do anything as he was now well.
I tell the story in such detail in part for catharsis, in part to share my brief insight into being on the other side of the consultation, but also because it illustrated a number of system failures. It was a horrible experience but made a lot worse by those system failures. And I couldn't help but feel even more sorry for those around me who didn't have the medical experience that I had to contextualise it all. Sickness, in ourselves or our loved ones, is bad enough without the system making it worse.
I had 3 hours of walking around the department with my son in my arms which gave me plenty of time to observe what was going on around me and consider whether it could be improved. I did of course not have access to all areas and so couldn't see what was happening behind the scenes so things may have been busier than I was aware of. Also it was only one evening so not necessarily representative.
There were about 15 children in the department and for the 3 hours we were there only a handful of new patients that arrived so no obvious reason for the increasing delay. As I walked around it was clear to me that at least half of the children didn't need to be there. Some were fast asleep on the benches, arguably suggesting they didn't need emergency treatment. One lad had a minor head injury that just needed a clean and some advice. Whilst I didn't ask anyone what was wrong with people talk and so you hear what some of the problems were. Some were definately far more appropriate for general practice.
So how could things have been improved and could technology have helped as well?
One thing that struck me is that the 'triage' nurse would have been much better as a senior doctor. Not necessarily a consultant but certainly someone with the experience to make decisions. Had this been the case I think a good number could have been sent home very quickly, maybe with some basic treatment or maybe just with advice. Even if it was more complex it may have been that an urgent outpatient in a few days time would have been a much more satisfactory way of dealing with the problem. Even in our case where immediate discharge wouldn't have been appropriate a senior doctor could have made a quick assessment and said "let's observe him for a couple of hours and then repeat is obs - if he is well, the obs are normal and you are happy then you can go home". This would have made the world of difference to us.
So where does the technology come in? I've already mentioned Sat Nav for the ambulance but there are a number of other points where technology could have played a part in improving patient experience. Starting with the ambulance if they had access to real time data on hospital A&E waiting times they may have been able to divert us to a hospital with a much shorter time. This is even more important for adult hospitals were the turnover of patients is much higher. Such information could help staff and patients make more informed decisions.
The ambulance took us to hospital which was probably appropriate for us but not for everyone. Unfortunately many of the other services like GP out of hours are not always prepared to accept such patients and again the ambulance crews need to know where is available and what access and waiting times they have. Walk-in patients are often also totally inappropriate and an easy method of redirection would be beneficial for all concerned. But this requires change and may even require such radical ideas as paying for transport to take patients to alternative locations if they are more appropraite.
The reasons patient's choose A&E when other services would be far more appropriate are many and complex. It can be about transport and convenience and past experiences and many other things. It is likely that at least some of it is that patients often struggle to get an appointment to see their own GP within a reasonable time frame or just that their impression is that it will be difficult to get an appointment so they don't even try. But imagine a system where the waiting times for appointments for all GPs and out of hours services were readily available to hospitals, ambulances, NHS direct etc. Even better imagine that authorised people could book appointments directly, even when the practice was closed. How many patients would be happy to avoid a long wait in A&E if they had the reassurance of a GP appointment the next day? And the technology already exists to do some of this and it wouldn't be that hard to adapt current technology to provide this functionality. Yet it still doesn't happen. I have my theories as to why but this is enough for one post.
In case you were wondering my son appears to have made a full recovery with no obvious ongoing problems. I think I have recovered and then he makes the same breathing noises he made just before the fit and I am transported back to that fateful night. I think it will take time for the feelings to fade.
Our University is embarking on a Project of web-based education for General Physicians in Pakistan and the whole region in the form of recorded videos. The videos shall cover a pertinent area of interest or knowledge considered important to a GP.
The recorded lectures shall be presented as groups of class-room lectures put together as modules. Each module shall carry weightage of certain CME credithours when the required percentage of a pass are achieved by answering the post-test questionnaires. Some thirty to forty
such modules are in plan to cover all the essential clinical areas and core competencies required in a GP for safe, evidence based practice in the community. This is the level I activity and forms a mandatory course or review material for all grades of General practitioners.The lectures
are being delivered by local expertise and expected to include international ones in due course of time. More and more are being contacted and those,who agree to join and participate in the programme are welcome regardless of their speciality and parent institution and location and free from any obligation.
A second level entry and access shall be provided to the successful participants to get trained for professional membership and fellowship programmes either developed locally or in collaboration with international institutions. Will it be successful in attracting and enrolling enough FPs and GPs locally and internationally? If so how?
Dr.Syed Shakeel Ahmad
Coordinator e-CME Programme
and Pakistan College for General Practitioners Pakistan
This is an excerpt from "Fluids and Electrolytes Made Incredibly Easy! 1st UK Edition" by William N. Scott. For more information, or to purchase your copy, visit: http://tiny.cc/Fande. Save 15% (and get free P&P) on this, and a whole host of other LWW titles at lww.co.uk when you use the code MEDUCATION when you check out!
The chemical reactions that sustain life depend on a delicate balance – or homeostasis – between acids and bases in the body. Even a slight imbalance can profoundly affect metabolism and essential body functions. Several conditions, such as infection or trauma, and certain medications can affect acid-base balance. However, to understand this balance, you need to understand some basic chemistry.
Understanding acids and bases requires an understanding of pH, a calculation based on the concentration of hydrogen ions in a solution. It may also be defi ned as the amount of acid or base within a solution.
Acids consist of molecules that can give up, or donate, hydrogen ions to other molecules. Carbonic acid is an acid that occurs naturally in the body. Bases consist of molecules that can accept hydrogen ions; bicarbonate is one example of a base.
A solution that contains more base than acid has fewer hydrogen ions, so it has a higher pH. A solution with a pH above 7 is a base, or alkaline.
A solution that contains more acid than base has more hydrogen ions, so it has a lower pH. A solution with a pH below 7 is an acid, or acidotic.
Getting your PhD in pH
A patient’s acid-base balance can be assessed if the pH of their blood is known. Because arterial blood is usually used to measure pH, this discussion focuses on arterial samples.
Arterial blood is normally slightly alkaline, ranging from 7.35 to 7.45. A pH level within that range represents a balance between the concentration of hydrogen ions and bicarbonate ions. The pH of blood is generally maintained in a ratio of 20 parts bicarbonate to 1 part carbonic acid. A pH below 6.8 or above 7.8 is usually fatal.
Under certain conditions, the pH of arterial blood may deviate significantly from its normal narrow range. If the blood’s hydrogen ion concentration increases or bicarbonate level decreases, pH may decrease. In either case, a decrease in pH below 7.35 signals acidosis.
If the blood’s bicarbonate level increases or hydrogen ion concentration decreases, pH may rise. In either case, an increase in pH above 7.45 signals alkalosis.
Regulating acids and bases
A person’s well-being depends on their ability to maintain a normal pH. A deviation in pH can compromise essential body processes, including electrolyte balance, activity of critical enzymes, muscle contraction and basic cellular function. The body normally maintains pH within a narrow range by carefully balancing acidic and alkaline elements. When one aspect of that balancing act breaks down, the body can’t maintain a healthy pH as easily, and problems arise.
“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.