Monday, 27 February 2012

Mistakes. I've made a few.


I got to get very involved in a  number of clinics this week, which I really enjoyed. Unfortunately, because I am being so involved, I have plenty of opportunity room to make mistakes. Fortunately neither of the mistakes I made this week were severe, but both are definitely things I can learn from, and one was something that could turn out quite seriously in different circumstances.

Studying or practising medicine is all about learning what to do and what not to do (pretty much like anything else). The easiest way to learn seems to be by making a mistake or saying something stupid yourself, then being so embarrassed by what you have done or said that you will forever remember that moment, and thus forever remember the correct answer. Medical education used to be based a lot more around the 'make them feel stupid' school of teaching, and most universities and consultants have moved on from this now, seeing it as cruel! Despite the fact that this ritual humiliation is no longer used as a method of teaching (by most people), making mistakes is always going to happen. While mistakes are going to be unavoidable, I think the hope is that you are taught enough to avoid serious mistakes, and the minor mistakes you do make, you either make early enough to have someone senior be able to cover for you, or are so minor that they don't endanger patients.

Missing something serious, such as a sign of cancer may end up killing someone...

The first mistake involved a confusion over names. When calling out the next patient to come and see me in the waiting room, I called out "Gladys Burr". An elderly lady stood up, and I walked her and her husband to the consultation room, where I then proceeded to chat away with them about the problem she had come in with. She was talking about a changing mole she wanted to be looked at, so I asked all the standard questions (is it changing, what other symptoms, history of sun exposure and so on) and then examined it. To my surprise the mole looked different to how the GP had described it, as he had described it as being small, irregular and being darkly pigmented (fear of melanoma) whereas to me it looked brownish, large and pearly, possibly being a basal-cell-carcinoma. Whilst looking in the notes I noticed that this sprightly lady who enjoyed hill walking had a DNAR (do not attempt resuscitation) form filled in in the front. I was surprised by this as she seemed very healthy, but didn't mention it. When presenting this patient to the registrar he decided he wanted the consultant to look at the changing mole, so went to get her. The consultant knew the patient as she had seen her before, and chatted away with her, before telling us she wanted to see the notes. Ignoring the ones I held out, she whisked outside, got a different set and came back. After flicking through them briefly she told us it was something she would want to have biopsied and left. Confused, I looked at the notes the consultant had taken, which were for a patient called "Gladys Furr". Here the referral letter from the GP explained the legion as we saw it, and there was no DNAR form in the front. I had been writing in the wrong set of notes the whole time! Here, there was little damage done as I could transcribe what I had written across and rip out the wrong page. I can imagine that getting patients mixed up at other times could be much more serious though, such as before operations. This is why we should always ask about birth dates! Fortunately the registrar I was working with just found it funny that there were two so similarly named people and while the earlier one had not yet arrived, the later one had and had heard what she thought was her name for the consultation. I know I will be careful in the future with this now!

The second mistake was more of a waste of a time than a mistake. Before consulting one patient I flicked through the notes, but couldn't find the letter from the GP that is always sent with each patient, explaining why the patient has been sent to the dermatology clinic. Not wanting to waste more time, as we were running behind, I decided to just see the patient anyway and get them to tell me their story. Unfortunately this was a bit of a mistake. The lady was 99 years old and appeared very spry for her age, joking and flirting away on the way to the consultation room. However, when I asked her what the matter was she told me she had a lump on her foot, taking her shoe off to show me hallux valgus (a bunion). I asked her if this was what she had been sent to us with, and she said that it must be, as she didn't have any problems, but she doesn't really see her GP at all. She reported no medical problems and told me she wasn't taking any drugs, so I just took a history of her bunion, though the consultation seemed to be going around in circles, giving me the feeling that she was not quite thinking straight. This took some time, and as I was wrapping up, the dermatologist came in to see me and the patient (normally I would go to them, present the patient and then bring them back to see the patient, but I had taken far too much time here). I explained the situation, so he flopped open the notes, and they immediately opened on the referral letter from the GP which had been stuffed into the middle of them. What luck... It turns out she had what looked like a malignant melanoma on her back, which the GP had seen while treating her for a problem with her stomach. All things that she hadn't mentioned bit when the consultant ran over them, agreed with "oh yes, that's right". I looked like a real fool! Next time, I don't think I will want to see the patient without the referral letter!

Other than these two mistakes I made, I had a pretty productive week. I was very involved in the clinics, hence why I was able to make these mistakes, effectively seeing patients and planning management myself, consulting with the consultant during, obviously, to make sure my diagnosis and management plans were correct. For example, one patient who came in had a strange rash all over his legs, which looked a little like the picture below:

A picture showing a similar rash to the one the patient I saw had

I talked to this patient and took a good history, mainly asking about changes in the environment at home, changes in medication and whether he had had a sore throat in the past. This was because the rash looks like a vasculitis, a ash caused by the inflammation of blood vessels. This can be caused by a number of things, such as an allergic reaction to  something (such as drugs or an insect sting); or a streptococcal infection where the toxins released inflame the blood vessels. Here, working out the cause of the rash is important as that way it can be avoided or treated. After talking to him and excluding obvious causes from the history, I then make a plan as to what to do next and talk to the dermatologist, who agrees with everything I have planned to do, and tells me to get on with it. Get on with it I do, and I take a throat swab for streptococcal infection and bloods to look at the immune system and look for viruses (which I get first time, which is fortunate as the poor man nearly faints when the needle goes in [then again, who does like needles!]) The dermatologist also wants a skin biopsy to send for histology, which I help them take whilst explaining the process to him. I then help talk him through all the possibilities and what will be done next. Its as though I have my own patients! I really enjoy this interactive way of learning - it reminds me of my elective in Tanzania where I had to run the outpatients, but at least this time I have the safety net of the consultant peering over my shoulder so everything (hopefully) gets done right!

Monday, 20 February 2012

Out of hours GP work


This week, despite being on my dermatology rotation still, I spend a lot of time with GPs, attending both the regular bi-weekly session which I have on rotation throughout this year, and a one off session with the out of hours GP service as well. This service is linked to GPs across the county, meaning after the surgeries close the calls are forwarded on to here, where the patients can then talk to GPs, or have GPs visit them at home if they are poorly enough. The patients I see in both surgeries, one in the day time one in the night time, seem to come in clumps by illness, which is strange. Perhaps this is the same phenomenon which causes buses to come in groups of three.

With the on call GP, the GP sits in a room in a hospital with a phone and a computer. Patients who are put through to the 'out of hours GP service', either by a forwarded call from a closed GP surgery or they can call the number directly after being given it by a service such as NHS direct. The calls are dealt with by some poor call-handler, who then puts them on the computer with information about the patient for the GP to call. This way the GP's time isn't wasted collecting address info and the such, and he perform a quick triage, calling the most important looking patients first. After calling and talking to them, the GP can either just reassure them, send a prescription to a nearby pharmacy by fax for them to collect, ask them to come into the hospital to see him (if they need to be examined) or (if they are really sick) arrange an immediate home visit. There are two GPs running this service, both carrying out this role, but one also has to go out in the car and visit the patients who need to be seen. I am not with this doctor, so don't see many home visits, but as the vast majority of calls ended up with the patient being asked to come into the hospital, I think I had the better deal.

The range of patients the GP had to deal with was pretty diverse, as you would expect from someone who works in primary care. The patients ranged from suspected breaks in bones and musculoskeletal injuries to sick children. The pace of the work was really nice. At times, working in the day at a GP surgery can feel very rushed as you have dozens of patients to see in one morning, meaning there is a very real time limitation on each consultation. Here it was very different. Patients were called up and talked to as much as needed, and then once they were bought in they coul talk with the doctor for as much time as the doctor wanted. I was there for more than 6 hours, and we only talked to about 12 patients, seeing most of them afterwards. At about 30 minutes a patient that is fantastic, and with the much smaller waiting times (basically none) I have no idea why people were bothering to attend the busy 3 hour wait A&E next door to us in the hospital! Its a shame the services aren't merged, though, as I am sure the GP could have seen many of the patients who come into A&E, giving him a little more work but taking a lot of pressure off of the A&E department. I suppose it wouldn't have been as much fun then, though!

The GP who I was working with was a fantastic man. 70 odd years old, he had retired from working as a partner in a GP practice, and now just did locum work, and the occasional out of hours shift for interest. He had been a bus driver in his youth, but had decided to work as a doctor and gone to medical school. As well as being a GP after graduating, he had done many other jobs, including setting up and running a small railway, running for parliament and competing in the world championships of a popular sport! Fantastic to see that its possible to combine medicine with a healthy life outside.

Being a GP is a little like running a one man band, but when you have all these things going on in your life outside medicine as well... !!

As I said before, the patients seemed to come in clumps of disease while I was working with this GP. First, there were a few children who had developed fevers, followed by a couple of people with labyrinthitis. This is inflammation of the inner ear, often caused by a viral infection, and can make people cripplingly dizzy. I don't know if there were a number of them because there is some kind of contagious virus going around, but I hope I don't get it. Being unable to get out of your bed without being sick from the vertigo does not sound much fun at all! Strangely, after that there were two patients (with one seen in between them) who had both come in having found a strange lump below their sternum. One had been prodding around his upper abdomen after a diagnosis of gastro-oesophageal reflux disease, the other had just found it while 'poking himself' (odd man). The diagnoses in both of these cases were that the 'lump' that was being felt was nothing other than the 'xiphisternum' a small jutting-out-bit below your sternum that everyone has, which can be hard or a bit gristly. I thought that the odds of one person deciding this normal part of anatomy was some disease and coming in were low, so the odds of two people on the same night deciding this independently was unbelievable. The GP tells me that this is quite a common mistake, and he has seen many people coming in with these 'strange lumps' in his time as a GP. Obviously they all do need to be examined (can't just tell them its fine over the phone in this case) as there are many other causes for lumps in the upper abdomen! Towards the end of the shift, there was a call from a paramedic, who had been called to someone's house who was very ill and had put them on oxygen (increasing saturations from 75% [very low] to 90% [still low]). The family of the person had decided that a DNR should be filled in, as this person seemed to be dying. A doctor needs to fill in one of these forms, so the car doctor was dispatched to the house in order to fill out the form, meaning that later, when the patient stopped breathing, he could just be left to die in peace. This is clearly a good idea, as if you die from something like cancer, resuscitation will not get rid of the cancer, and you will just die again, but it just seemed so businesslike and cold to me. Perhaps that is the way doctors try and conduct this sort of business, to try and remove themselves from the reality a little bit.

On the way home, I had to take the last train back, as my car is being fixed up. I hadn't had dinner as I had been on the shift over dinner time, so had grabbed some chips to eat on the train on my way to the station. I was in quite a poor area, and there were a couple of youngsters in Burberry wear on the platform drinking their Stella waiting to get the last train home as well. One started talking to me, saw my badge and then started goin on about how respectable it was that I worked in the NHS, and that his 'old ma' also worked in the hospital. He pulled the other over and started going on about how I, while their age, was going around saving lives all day. Very embarrassing and all far too fast. I don't go around saving lives all day at all - I am a medical student and just follow doctors around wasting their time. Unfortunately this praise had gone on too long for me to deny it now, so I just buried my head in my chips. The chap who had been pulled over was not impressed at all though, and slurred 

"He doesn't work for the NHS, don't be a prat. Look. He's eating a kebab"

I wasn't really sure what to say to this, are healthcare workers not allowed to eat unhealthy food? And it was chips, not a kebab! I decided that laughing and shrugging was the least confrontational thing to do, but the first wasn't having any of it. He kept trying to get me to show his friend my badge to prove I worked in the NHS, but I didn't want them to look at it too closely as they would see I was only a medical student, and didn't actually work at all! Some cat and mouse ensued where I was flashing my badge to them (it was hidden under my coat, i bet this looked weird to the others on the platform), hopefully a little to fast for them to read it with their hazy vision. The friend was still unconvinced, due to my 'kebab cravings'. After ten minutes or so, the train arrived and I escaped to another carriage politely. The first guy still full of compliments, the second getting ready to start a fight with me or his friend. The fun times you have on trains!

You don't work for the NHS. You are eating a kebab!

The rest of my week was much calmer than this, with some time in dermatology again and the regular GP placement (hellish to get to without a car!). Here I got a lot of practice at orthopaedic examinations as a number of people came in with damaged shoulders (that grouping of illness presentations again. Odd). A couple of people had arthritis in their shoulder, one person had damaged the rotator cuff muscle doing sport, and the final patient had fallen during his work in a factory and was seeking compensation against the company. Once litigation is involved, the whole process becomes very careful, as GPs are well aware that lawyers may well want to read their notes. The man appeared healthy and seemed to be playing up a little during the examination, giving a mixed picture of pain. He wanted to be signed off from work for another two weeks as he said he was still too injured to work. The GP wasn't really sure if this was the case, and thought that perhaps he may be malingering. A hard call to make for a GP, who doesn't want to damage the relationship they build up with patients, but doesn't want to lie either.  Perhaps this is where the government's "Work capability" assessment comes in useful, letting people be seen by healthcare professionals who are not their own, though I know there is opposition to it. In the end the GP decided to give him one more week of time off work and an urgent referral to the physiotherapist. The plan was that the next decision would be based on the physiotherapist's report, meaning that someone with much more expert knowledge than the GP could take a look, and in a small way, the GP would have more people backing up their decision to sent the patient back to work. This is important as well, as the GP tells me of patients who have gone back to work after arguments with their doctor and carried out tasks they know will injure them further, so they can try to sue the doctor as well. So cheeky! 

Monday, 13 February 2012

Getting 'hands on'


Last week was relatively quiet again, something I am getting dangerously used to on this rotation. I spend a couple of the days this week in dermatology clinics, where I got to get my hands surprisingly 'dirty' for someone with a week of dermatological experience, and one day in lectures. The other days I mostly had off. Working three and a half to four days out of seven is wonderful, don't get me wrong, but I think it is something I could quickly get used to, all these lovely lie ins and time to spend with friends. I think, after 6 weeks to get used to this, come a harder rotation, or my final year, I could get quite a serious shock to the system!

The clinics that I was placed in this week were both with the same dermatological consultant. They were much more interesting than the theatre list which I was in last week, and I was given a lot more to do.  The idea was that of the patients waiting, myself or the other medical student would pick the next to be seen, and take them from the waiting room to one of the examination/consultation rooms to take their history and examine the problem with their skin. We would then go back to the doctor, present what we had learnt about the patient and give our differential diagnoses for the condition and what we think should be done to manage the condition, then she would go to see the patient. She would look at the problem with the skin, exchange a few words with the patient to confirm the important things we had told her, and then decide on the course of treatment. This could be leaving it, putting a cream on it or cutting out out (which could be done then and there for most of the minor skin problems)

Because we two medical students were seeing different patients and doing much of the time consuming work (the history) this meant that the clinic could take place twice as fast, as she could just review the patients, carry out procedures such as cutting out parts of the skin, and do her paperwork as we talked to the patients. This made me feel useful, and was a great chance for me to practice taking a dermatological history. All aspects of medicine need different questions asked, and dermatology is no different, needing questions asked about things such as sun exposure which wouldn't factor into 'normal' histories. Because of being kept so busy at both of these clinics, the time flew by. This was a very different experience to the times I have spent in clinics in other rotations so far this year. The neurology and oncology clinics were very specialised, so the doctor would lead most of the discussion and I would sit passively in the corner for most of it trying my best to pay attention, learn something and not fall asleep. 

One of the clinics was for people who had been referred to the dermatologist under the two week wait rune, meaning that the GP who had referred them thought that the changes to their skin could have been cancerous, the other was just a general clinic for skin conditions. In both of these clinics I saw some pretty horrific looking skin problems, showing how important a cure is for a lot of these patients. Patients like those with psoriasis (picture below) can have their lives turned around if it is treated properly. Unfortunately the dermatology clinic encourages us not to use gloves unless the wound is obviously infected and oozing, as using gloves gives patients the  impression that they are dirty and unclean, an idea that we are trying to dispel. While this may be good for the patient, it certainly isn't good for the medical student as you try and rummage through peeling skin to look at the sore underneath to see if it has a 'pearly looking edge' to differentiate a basal cell carcinoma from an area of actinic keratosis.

Psoriasis across a ladies back. This is an auto-immune condition where the skin becomes thick, scaly and peels

In summery, while the week was pretty relaxed, the time I did spend in the hospital was very productive. I now feel a lot more confident taking a dermatologically skewed history and examining damaged skin to try and spot cancers. While I still don't think that this is the speciality for me, the fact that I have only seen about 5 conditions so far makes it easy for the medical student to clerk the patient in and guess at the problem. I am enjoying this rotation a lot more than I was last week, and I hope that this continues!

Sunday, 5 February 2012



This week, seeing as I have finished my neurology rotation, I move onto dermatology. This has never really been a subject that has interested me all that much, and what I have seen so far this week really just re-affirms this  feeling. While dermatology is clearly a valuable subject, with skin conditions being one of the more obvious illnesses, (what with your skin being on the outside of your body, meaning that people can be very upset by such visible problems), it just seems overly complicated to me. Most conditions seem to be treated by either emollients (moisturisers); topical steroids or by cutting bits of skin off. Don't get me wrong, there are other, more complex treatments, but these seem to be in the minority. Dermatologists seem to have made up for this dearth of treatments by creating lots of complicated names for different skin rashes or spots; names which are derived from dead languages. This sounds like I am being scathing of dermatologists, but this isn't the case. Some skin conditions can be very disfiguring, changing peoples lives completely (such as psoriasis), and can be treated effectively, putting peoples lives back to normal. It is a valuable speciality (obviously, just like all the others), but just not a speciality that seems to appeal to me. People don't tend to have emergencies with their skin, meaning you rarely need to treat them immediately for fear of death (quite an exciting idea in medicine for me), though for some people this aspect of dermatology would probably be a real plus (sociable hours!)

All hospital specialities are just as important as one another.

Anyway, perhaps I am judging dermatology too fast, and based on too little information given it is only my first week of the rotation. This week the highlight, if it can be called that, of my time in dermatology was spending a day in the theatre. I went to the dermatology theatres with another medical student, and as there were two lists running we ended up splitting up. One was run by a dermatologist, while the other was being run my a maxillofacial surgeon. Maxfax surgeons need to have both a medical and a dentistry degree (so much time in uni!), and concentrate on the head area of the patient. Neither of us had seen any of this sort of surgery before, whereas we have both seen some dermatology-based-surgery before from placements in first and second years. They only wanted one medical student to be in each theatre, and as surgery and dermatology don't really interest me all that much, I let the other student go in with the Maxfax surgeon, and took the dermatology list.

At the time, this seemed a bit of a mistake, as the dermatologist's list turned out to be super boring. I saw about 8 patients, all of whom had a Basal-cell carcinoma (BCC) or two being removed from their skin. A boring operation, where the cancer is cut out of the skin using an ellipse shape and local anaesthetic, then the skin is stitched up again. BCCs are a common skin cancer, but rarely spread out of the skin, and rarely kill people. It should still be removed though, to stop it growing further, and that was what was being done here. I had already seen this operation in my first year, and all the operations I saw today looked pretty much the same as the operation I saw then. Watching this go on all day was really quite boring, though I am sure that doing the surgeries would be just as boring as well. Another reason not to be a dermatologist! The only real interesting thing which happened during this day of surgeries was meeting a man who used to work in nuclear testing with the British government, and who had kept developing a large number of BCCs all over his body for the last 30 years or so. He had been having 5-10 removed from his body every year for these last 30 years, and it was thought that this was due to the high levels of radiation he may have been exposed to earlier in his life. Developing this large number of BCCs is certainly unusual, and as they are often caused by sun exposure, I don't see why radiation from another source wouldn't cause them as well. Despite this obviously occupational injury, and the inconvenience he has having to go to hospital several times a year to have them cut out, he has no interest in trying to seek compensation at all. He thinks the money is much better off with the government than with him, and he is probably right, though it is a shame more people don't share this sort of mentality. Fortunately (or perhaps, unfortunately) it transpired that the maxfax surgeon's list was exactly the same as the one I sat in on, just removing BCCs from the face, so I didn't really miss anything by my misguided act of kindness.

An image of a basal cell carcinoma from the internet, characterised by its 'pearly coloured' appearance, and raised rounded edges.

Like the previous rotation, dermatology also includes a large number of seminars and lecture-like teaching. More time that I would prefer to spend in clinical teaching, but also more time where I get spoon-fed information, which is always nice. This weeks most notable was a lecture on topical therapies for skin care. The subject material wasn't that exceptional, mostly teaching about emollients and steroid creams, but the nurse leading the seminar had bought along 20-30 different creams for us to try out. Fantastic! I wanted a bit of all of them, so now, if I did actually have any possible infections / autoimmune disorders or any other conceivable dermatological disorder I am now hopefully cured. Cured problems or not, my arms are now certainly highly moisturised! 

I also spent some more time on my GP placement again this week, and saw more adults and children with physical and mental illnesses (GPs do see a wide range of problems!). All the time I have been spending with this GP has attracted me more towards being a GP... It still doesn't appeal that much, and I still think I want to follow a different career path into hospital medicine, but my time with the GP has shown me that it really can be fun as well. Before, I just saw it as time which was spent looking after people with snivels and colds, like I found the outpatient department to be like during my time in Tanzania, but there is so much more to it than that. The GP has to make some quite hard calls without any specialist knowledge. For example, a mother came in to see us concerned about her child, who she didn't bring with her as he was at school. She had been concerned about him for some time, and at 4 he still couldn't pick up things like a pen or a knife and fork, and still had no concept of potty training at all. Despite these problems, he can still talk in huge detail about several of his toys, down to the date that he got it. This lack of fine motor skill and problems in learning what the potty was for had worried the mother slightly, as they were very different to her previous child, but she came to the doctor after the teachers at school had told her that they had noticed obsessive traits in his dealings with other children and toys in the class room. Hopefully this is nothing, but these sort of traits could well be suggestive of a problem such as autism. The GP's problem is what to say to the mum, and what plans to make next. She could tell the mum that is was possible that the child had a learning difficulty, and refer them onto a specialist to help the mum cope and investigate the girls behaviour better. This may help the child get help (which they may need), but would this end up putting a label on a child who could otherwise be fine? Or does the GP leave it, and risk the child falling behind in school because they are finding the work much more difficult than the other children? Being a GP seems to involve a lot of 'grey area' sort of decisions that you need to make on your own in a 5 minute space. In this case the possibility of a condition causing this behaviour was discussed with the woman, which was something she already suspected (hence the attendance at the doctor's) and the GP and mother decided together to leave it for now, and see if the difficulties continued; if they did then they could look into getting some extra help for the child. This was pretty much exactly the outcome we are taught towards in medical school - one that is patient choice directed!