I have recently spent a few days following around registrars on military ward rounds. It has been a fantastic experience for learning about trauma care and rehab, but more importantly it has shown me just how vital team spirit is to modern health care! The military ward round is done once a week. It starts with a huge MDT of almost 40 people, including nurses, physios, registrars and consultants from all of the specialities involved in trauma and rehab. The main trauma ward round team then go to speak to all of the patients in the hospital. The team normally consists of at least one T+O consultant, one plastics, two physios, two nurses, 3 registrars and a few others. This ward round team is huge, unweildly and probably very costly, but those military patients receive a phenomenal level of care that is very quick and efficient. Having then compared this level of care with what I have experience on my 4th year speciality medicine placement, I now feel the NHS has a lot to learn about team work. I am sure that everyone working in healthcare can relate to situations where patients have been admitted under the care of one team, who don’t really know what to do with the patient but struggle on bravely until they are really lost and then look around to see who they can beg for help. The patient then gets ping-ponged around for a few days while management plans are made separately. All of the junior doctors are stressed because they keep having to contact multiple teams to ask what should be done next. The patient is left feeling that their care wasn’t handled very well and is probably less than happy with the delay to their definite treatment. The patient, thankfully, normally ends up getting the correct treatment eventually, but there is often a massive prolongation of their stay in hospital. These prolonged stays are not good for the patient due to increasing risks of complications, side effects, hospital acquired infections etc. They are not good for the health care staff, who get stressed that their patients aren’t receiving the optimum care. The delays are very bad for the NHS managers, who might miss targerts, lose funding and have to juggle beds even more than normal. Finally, it is not good for the NHS as a hole, which has to stump up the very expensive fees these delays cause (approximately £500 a night). There is a simple solution to this which would save a huge amount of time, energy and money. TEAM WORK! Every upper-GI ward round should be done with the consultant surgeon team and a gastroenterologist (even a trainee would probably do) and vice versa, every Gastroenterology ward round should have a surgeon attached. Every orthopaedic ward round should be done with an elderly care physician, physio/rehab specialist and a social worker. Every diabetic foot clinic should have a diabetologist, podiatrist, vascular surgeon and/or orthopaedic surgeon (even trainees). Etc. etc. etc. A more multi-disciplinary team approach will make patient care quicker, more appropriate and less stressful for everyone involved. It would benefit the patients, the staff and the NHS. To begin with it might not seem like an easy situation to arrange. Everyone is over worked, no one has free time, no one has much of a spare budget and everyone has an ego. But... Team work will be essential to improving the NHS. Many MDTs already exist as meetings. MDTs already exist as ED trauma teams, ED resus teams and Military trauma teams. There is no reason why lessons can’t be learnt from these examples and applied to every other field of medicine. I know that as medical students (and probably every other health care student) the theory of how MDTs should work is rammed down our throats time after time, but I personally still think the NHS has a long way to go to live up to the whole team work ethos and that we as the younger, idealist generation of future healthcare professionals should make this one of our key aims for our future careers. When we finally become senior health care professionals we should try our best to make all clinical encounters an MDT approach.
almost 8 years ago
British Medical Podcasts’ second podcast in the series. Created by Doctors for Doctors. We aim to give a comprehensive overview of each topic including need to know information. Content includes Definition, Aetiology, Epidemiology, Anatomy if relevant, Pathology, Clinical Presentation and Features, Treatment and Prognosis.
Dr Oliver Harvey & Dr Sam Thenabadu
almost 11 years ago
First in a series of Medical Podcasts created by two Doctors for Doctors. We aim to give a comprehensive overview of each topic. Content includes Definition, Aetiology, Epidemiology, Anatomy if relevant, Pathology, Clinical Presentation and Features, Treatment and Prognosis.
Dr Oliver Harvey & Dr Sam Thenabadu
almost 11 years ago
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
over 7 years ago
This field of medicine requires much more physiological and pathophysiological knowledge than most people give it credit for. Psychiatric illness DO have physical manifestations of symptoms; in fact those symptoms help form the main criteria for differential diagnoses. For example, key physical symptoms of depression, besides having a low mood for more than two weeks (yes, two weeks is all it takes to be classified as 'depressed'), include fatigue, change in appetite, unexplained aches/pains, changes in menstrual cycle if you're a female, altered bowel habits, abnormal sleep, etc. Aside from this, studies suggest that psychiatric illnesses put you at higher risk for physical conditions including heart disease, osteoarthritis, etc. (the list really does go on) Although some mental health conditions, like cognitive impairments, still do not have very effective treatment options; most psychiatric medications work very well, and are necessary for treating the patient. The stigma surrounding them by the public causes a huge problem for doctors. Many patients are reluctant to comply with medications because they are not as widely accepted as the ones for non-mental health conditions. A psychiatrist holds a huge responsibility for patient education. It can be tough to teach your patients about their medication, when many of them refuse to belief there is anything wrong with them (this is also because of stigma). Contrary to my previous beliefs, psychiatrists DO NOT sit around talking about feelings all day. The stereotypical image of someone lying down on a couch talking about their thoughts/feelings while the doctor holds up ink blots, is done more in 'cognitive behavioural therapy.' While this is a vital healthcare service, it's not really what a psychiatrist does. Taking a psychiatric history is just like taking a regular, structured medical history; except you have to ask further questions about their personal history (their relationships, professional life, significant life events, etc), forensic history, substance misuse history (if applicable), and childhood/developmental history. Taking a psychiatric history for a new patient usually takes at least an hour. The interesting thing about about treating a psychiatric patient is that the best guidelines you have for making them healthy is their personality before the symptoms started (this is called 'pre-morbid personality'). This can be difficult to establish, and can often be an ambiguous goal for a doctor to reach. Of course, there is structure/protocol for each illness, but each patient will be unique. This is a challenge because personalities constantly evolve, healthy or not, and the human mind is perpetual. On top of this, whether mental or physical, a serious illness usually significally impacts a person's personality. Most psychiatric conditions, while being very treatable, will affect the patient will struggle with for their whole life. This leaves the psychiatrist with a large portion of the responsibility for the patient's quality of life and well-being; this can be vey rewarding and challenging. The state of a person's mind is a perpetual thing, choosing the right medication is not enough. Before I had done this rotation, I was quite sure that this was a field I was not interested in. I still don't know if it is something I would pursue, but I'm definitely more open-minded to it now! PS: It has also taught me some valuable life lessons; most of the patients I met were just ordinary people who were pushed a little too far by the unfortunate combination/sequence of circumstances in their life. Even the ones who have committed crimes or were capable of doing awful things.. It could happen to anyone, and just because I have been lucky enough to not experience the things those people have, does not mean I am a better person for not behaving the same way as them.
over 7 years ago
This was a presentation of an SSC essay I did wrote on Barrett's Oesophagus. Aims to summarise current management of Barrett's and promote the efficacy of endoscopic over surgical, management which is commonplace in Gloucester Hospital (where I was placed with a Gastro firm at the time)
over 10 years ago
Venepuncture performed following official University Hospitals of Leicester (UHL) Guidelines Stage 1 - Consent 0:39 Stage 2 - Equipment 1:54 Stage 3 - Procedure; Treatment Room 2:48 Patient Area 5:35 Stage 4 - After Care 8:59 http://leicesterclinicalskills.weebly.com/
Leicester Clinical Skills
over 7 years ago
I'm an SHO, but I don't have your typical ward based job. In the last four years I have treated in jungles, underwater (in scuba gear), 5m from a gorilla, up a volcano, on a beach, at altitude, on safari, in a bog and on a boat. Expedition medicine is a great way to travel the world, take time out whist expanding your CV, and be physically and mentally challenged and develop your skill and knowledge base. As a doctor, you can undertake expeditions during your 'spare time' but it is more common for doctors to go on expeditions between F2 and specialty training. This is the ideal time either because you have been working for the last 7 years and either you need a break, the NHS has broken you, or you don't know what you want to do with your career and need time to think. At this point I would recommend using your F2 course/study budget on an Expedition Medicine course. They are expensive, but the knowledge and skill base you gain makes you more prepared and competitive for expedition jobs. There are many types of Expedition Medicine jobs ranging from endurance sports races to scientific expeditions. Although the jobs differ, there are many ailments common to all. You should expect to treat diarrhoea and vomiting, insect bites, blisters, cuts, injuries, and GP complaints such headaches and exacerbations of chronic illnesses. More serious injuries and illnesses can occur so it is good to be prepared as possible. To help, ensure your medical kit is labelled and organised e.g. labelled cannulation kit, emergency kit is always accessible and you are familiar with the casevac plan. Your role as an Expedition Medic involves more that the treatment of clients. A typical job also includes client selection and education, risk assessment, updating casevac plans, stock-checking kit, health promotion, project management and writing debriefs. What's Right For You? If you're keen to do Expedition Medicine, first think about where you want to go and then for how long. Think hard about these choices. A 6 month expedition through the jungle sounds exciting, but if you don't like spiders, creepy-crawlies and leaches, and the furthest you have travelled is an all-inclusive to Mallorca, then it might be best to start with a 4 week expedition in France. When you have an idea of what you want to do there are many organisations that you can apply to, including: Operation Wallacea Raleigh Across the Divide World Challenge Floating Doctors Doctors Without Borders Royal Geographical Society Action Challenge GapForce Each organisation will have different aims, clients, resources and responsibilities so pick one that suits you. Have fun and feel free to post any question below.
Dr Rachel Saunders
over 8 years ago
Osteoarthritis is the most common form of arthritis that affects the knee. In this condition, the slippery cartilage that covers the ends of bones in knee joint wears down. This video also explores a treatment option called a fixed knee replacement.
about 5 years ago
3rd year iSSC project
over 11 years ago