Con-Dems

So far, then, the new government has done or tried to:
(1) Sell off all the publically-owned forest to private companies
(2) Declare the failure of multiculturalism
(3) Stealth-privatise the NHS
(4) Close public libraries
(5) Cut tax for top-rate tax-payers

I want to live somewhere less shit.

On producing rabbits from hats, and being a medical student

Several things of late have made me think back to medical school, and try to pin down a vague sense of unease I had there. I think everyone at times finds medical school both fascinating and terrifying in equal measures, albeit to varying extents, but in terms of time most of it, quite correctly, is spent learning about disease. In practice this means a lot of book-learning, and then when you're released fresh-faced and nervous onto the wards (yes, even after nights like the Daily Fail has recently reported), you talk to patients, take histories to a template in your head, and then try to elicit the excitable beats of the heart, the telltale falling away of the pulse, the kicks and wriggles of pathology, and you learn where to tap and press to make sickness unmask itself on the body.

It is undoubtedly necessary; you cannot presume to treat someone without as firm a grasp as you can muster of what is making them sick, and that means taking advantage of the astonishing, often incomprehensibly brilliant advances made in science which allow us to understand exactly why Aunt Mabel has been getting fat, forgetful, and short on hair, or rather why she has Hashimoto's thyroiditis: humoral antibodies to one or both of thyroid peroxidase and thyroglobulin cause a type II hypersensitivity reaction which destroys follicles in the thyroid. That is the sort of thing you learn at medical school, and as I say it is necessary: a better question is perhaps the extent to which it is an evil.

The problem I have with it is that the process of taking a history and of eliciting signs distracts you from the person sat in front of you. A group of us saw a man at medical school as part of a teaching session, and took turns examining his neurology: I think he had motor neurone disease, so that he had no strength in his arms or legs, and his muscles were a mass of tiny writhings. We tapped and pushed him, scored his weaknesses and assessed and noted him down, and it was only when a pair of us went back later that we talked about how he was missing his dog at home, a dog he will never have walked again.

The phrasing was intentionally emotive: medical school does divorce you from the person in front of you in favour of breaking them down into a series of manageable, interpretable bits. You learn to produce rabbits from hats, and this is a wonderful skill to gain - but there needs, also, to be an awe in what you are doing, at the repercussions of these signs on the man before you.

This blog was prompted partly by reading about an ambulance technician who didn't respond to a 999 call as he was on a tea break; the 36-year old involved had a fatal myocardial infarction. Laying aside the obvious questions (what if he was on the loo?), it was the response of the family to the note that the man would be sent for training before restarting work that set me thinking: "Surely they can't teach compassion, so what are they going to give him lessons in?".

I'm not sure that's correct. To some extent the exposure to patients, even through the filter of the structured history and the rigorous examination, obliges you to feel some compassion, and attendance at clinics certainly does. There's a nod to teaching it at university, but my experience of these sessions was that they tended to be smug and pious, that they treated you all like potential Shipmanesque serial killers, and that at their core they reduced compassion to exactly the sort of structured, tick-box exercise which at least serves a purpose in making a diagnosis (the same malaise afflicts junior doctors in the form of the Case-based Discussion or CbD, but that's one for another time).

Exposure is perhaps the key. At the risk of over-reminiscing, probably the single most memorable clinical encounter I had was when a consultant neurosurgeon took us to see a boy who had I think had a tumour of some sort - the purpose of the exercise was to show us what brain-death looked like. He took us in to see the patient with mum at the bedside, obviously in pieces, and asked her permission to examine her son "because it's important they learn". This is the sort of thing that the Medical Educators would regard as appalling, as a terrible invasion of a grieving mother's privacy; in reality she didn't hesitate. It taught me what brain-death looks like, certainly, but it taught me about that in a human context, with mum weeping quietly by the bedside, permitting our presence there because she knew her son would not mind any more and because she trusted the surgeon who had tried to treat him. You can teach these things, perhaps, through exposure not just to signs, but to signs in the context of grief, trust, emotion.

Pathology does not seem to accommodate these things. Certainly, slides of blood cells with things swimming around them which you have to be able to prepare, examine, and interpret do not feel, are not linked to a person despite the paragraph of text describing a notional person they are hung upon. The beautiful, mechanistic intricacies of cell signalling and division, the astonishing techniques parasites use to get into us, and the perpetual arms-race between antibiotic and bacteria do not accommodate feeling. It is only when you put them together and learn to talk of clinical courses as "indolent", "florid", "insidious" that these terms lead you away from the cells to the person in front of you, and you're reminded that these things have a human impact which was of course your reason for doing it all in the first place.

I don't know if there are better ways of doing it; I know there are already numerous bad ones, but all in all medical school seems to work and to produce capable, caring people. Let's hope it stays that way, shall we?

Bronchiolitis season = silly season

Dr Daedalus saw a child in hospital recently with quite severe bronchiolitis - she hadn't been eating for about a day and a half, sounded and looked terrible, and a chest X-ray showed she had one entire lung full of muck. So far, so easy - secondary bacterial infection on top of bronchiolitis. Treatment - iv antibiotics.

So we told mum this was what we needed to do - this mother who'd obviously noticed her child was sick, struggling for breath, and getting dehydrated, and had been worried enough to bring her to A&E. Her response? She wanted to talk to her homeopath instead.

Difficult situation, in that you don't want to terrify the parents but at the same time you can't let the child go home to take water - so you mention the severity of the illness, the possibility of lasting damage if it's not treated, and the fact that children do die from this sort of infection.

Outcome? We treated her with high-dose broad-spectrum antibiotics, and she got better.

I was reminded of the Australian homeopaths convicted of manslaughter for their (admittedly much more chronic) neglect of working treatments for their daughter in favour of the woo of homeopathy.

And of Andrew Lansley's comments on his healthcare reform:
"It is time to put patients in charge of their own healthcare. While that may lead initially to some catastrophic misdiagnoses and thousands of easily preventable deaths, it is surely better than some top down, centralised bureaucracy where ordinary patients are constantly told what to do by qualified medical professionals who see them as nothing more than a human being that is displaying a set of symptoms of which they have a high degree of expert knowledge."

When do these things become child protection issues? If you honestly believe the child is at risk of imminent death if they go home untreated, do you treat against the parents' wishes? If so, do you get sued afterwards?

I know what I'd do. But it's a tough call, all the same.

Laboratory jobsworths

Reading the superlative Jobbing Doctor's recent experience with a private contractor who refused to do the job they are being paid to reminded me of a current bête noire of mine at work: the labs.

I mean, all they have to do is take the bottles of blood I send them and put them into a machine, right? In exchange for this, they can make me do whatever they want. I'm obliged to include something like seventeen different patient identifiers on bottles for cross-match, for instance, and given that I'm working with newborn babies at the moment the bottles are about the diameter of a biro, and not nearly as long. In addition, they're frequently covered in blood, and to cap it all off the affluent population of the area I'm working in love double-barreled names.

I do understand the need to avoid putting results on the system under the wrong name, incidentally - but we have to include little sticky-labels in the "BIOHAZARD" plastic bags the bottles go in which have all this information on. Again.

All this microscopic calligraphy would be fine if the labs actually ran the samples - but no. One bottle I sent off recently came back - on the computer - with the comment "patient details illegible. Please ask the patient to state their name and date of birth." My immediate reaction, bizarrely, was to think:

But how would that help you read it?

followed closely by:

Can you still run the sample in two or three years when the baby has learned to speak?

The weird and wonderful world of baby checks

My recent inactivity is largely due to being insanely busy at work. On the upside, I regularly do baby checks, which for some reason get a bad rep among many doctors I work with. Several of the paediatrics trainees I work with currently find them boring and repetitive - which I can understand, as you do end up battling with dozens of intractable newborns every day to get them to (a) open their eyes and (b) not urinate on you.

There are lots of fun bits, though - the parents are normally in that fug of post-delivery hormones/relief and enjoy having baby MOTed. Some of them, though, do come out with some really extraordinary things.

One part of the check, for instance, involves putting a finger into baby's mouth to check the palate feels intact, and to assess baby's suck. Generally they are unsurprisingly good at this as it's how they feed, and I normally say something like "the palate feels fine and he/she's got a good strong suck". This often prompts mum to wince and say "I know". On one memorable occasion, however, dad piped up instead:

"Just like mummy!"

...and then sniggered. Mum took a playful swing at him and, feeling it best not to probe, I carried on with the examination.

This was noticeably better than the parents who were worried about baby jerking his arms in his sleep. They described a completely normal twitching of the arms during sleep which baby then proceeded to demonstrate to me, so I told them it was nothing to worry about.

Dad: "Can I tie his hands together to stop him doing it?"
Me: "Well, you can certainly swaddle him and keep his arms in that way, yes."
Dad: "And can I tie his hands together?"
Me: "No. No - don't tie his hands together. Just let him wave his arms around a bit. It won't hurt him."

I refrained from going on: "whereas your tying his hands together will", but am now slightly concerned this was a mistake.

Choose and re-refer

Today I received a letter in the surgery post from our local hospital, telling me that we'd asked for a choose and book referral for Mrs. Jones (I know), but that unfortunately at the time there were no appointments available and so her details had been forwarded to the "Central Booking Service" at the hospital. It went on to explain that:

"When we receive a patient's details in this manner, we are unable to access their referral on the Choose and Book software, this is a national issue, rather than a [local hospital] one. We subsequently requested, on three occasions, for your practice to fax us a copy of your patient's referral letter but we had no success."

They had therefore discharged the patient, because without the referral (which we sent through Choose and Book and they couldn't access) they couldn't make an appointment.

I checked the system. We had never had a request from them for the original referral letter. So we had sent them a referral they knew they had but couldn't see, and they had made three requests of us which we didn't have and couldn't see.

I called the hospital. Much confusion: she had an outpatient appointment booked, despite the letter saying exactly the opposite. The reason I couldn't find their requests for faxes is that "normally we telephone with them".

I know our reception very well indeed, and they invariably answer phones quickly and pass on messages efficiently. With this sort of thing they wouldn't even do that - the referral would just have been reprinted and refaxed.

All a bit suspicious - although at least my patient has an appointment. Despite the system.

Rules for seeing your General Practitioner

Just a few guidelines.

(1) Courtesy
(1a) You are well advised to be polite to the reception staff. This is chiefly because they run the place, but also because they invariably tell me if you've been rude to them, and you will get short shrift from the doctors if you then come in and are all deferential sweetness and light to us.
(1b) Despite (1a), I am a polite person. Honestly I am. But if you've just spent six minutes telling me about your diarrhoea and vomiting, and then watched me carefully wash my hands after prodding your belly, don't offer me your hand to shake on your way out.

(2) Children
(2a) For some reason, every child that enters my office tries - and succeeds - to dismantle the scales. They unscrew the lid, and then try to pull the needle off which tells me how much they weigh. I don't like to ask you to rein them in, but they
(2a) Amoxicillin is not the answer.

(3) Sick notes
(3a) Do not ask for a reissue of a sick note you've lost. If you are sick enough to need one, you are sick enough to look after it properly.
(3b) Do not ask for a backdated sick note. If you were sick enough to have needed one three months ago last thursday, you were sick enough to have mentioned it at the time -and if you haven't been working for the intervening period, you've had plenty of time on your hands to come in and see the doctor.
(3c) Do not ask for a sick note if you are also claiming carer's allowance. You cannot simultaneously be so unwell that you can't work, and well enough to claim an allowance for looking after someone full-time.
(3d) You will not get a sick note "because I've always had them". I am interested in how you are right now, not in how you were seven years ago when you had your car crash / breakdown / stabbing / overdose.
(3e) I appreciate that your having not attended court / gone to a job interview / made it to your wedding / attended the birth of your child is inconvenient. It does not, however, mean I'm obliged to write you a sick note to "cover it" if I don't think you were so unwell that you couldn't make it.

(4) Hay fever: if you haven't tried an established hay fever medication, you will be trying that before I give you an identical one the drug companies have churned out to keep the patent alive (see also: gaviscon advance). There is nothing 'neo' about neoclarityn, and desloratadine is the same as loratadine. Yes, I know there are some people who respond to one but not the other - I blame regression to the mean.

(5) Contraception: yasmin is really expensive. If you haven't tried older pills we know more about, you will be. Please don't try to bully me into giving you it by saying you won't take another pill if I give it to you - if you want to get pregnant because you'd rather throw a hissy fit about your pill than try another one, that's entirely your choice, and similarly a convenient recollection of every pill side-effect you can remember from the packet just makes me think you're not telling the truth.

More to follow. Maybe.