Wednesday, September 26, 2007

BMJ Rapid Response: Workforce planning a wicked problem

There seem to be several peculiar assumptions underlying the arguments made:


  • Workforce planning is a science
  • The future will be like the past
  • Change is easy
  • Equity matters
  • Cost is not a consideration
  • Consequences can be accurately vectored


People make decisions that serve their own perceived interests; governments do the same.


Should UK graduates be preferred? Yes, that is fair. Should foreign graduates be locked out? No, but the rules should be stated clearly and commitments already made should be honoured.



Tuesday, September 25, 2007

Context and Parsimony

My ignorance is monumental and my proportion of know:All_Knowledge continues to shrink. Until such time as consilience is a reality and subliminal learning is confirmed and routine I have no hope of the trend reversing. I can confine myself to a shrinking domain but doing so is intrinsically unsatisfying and reduces me to technician rather than professional.


I work in emergency medicine and most of what I see is not emergent. The context, however, teaches parsimony and requires an action orientation. Usually, those who are unwell need admission under the care of some other speciality. It is my sad and often frustrating experience that those working in the receiving specialities have no appreciation of context: of the administrative, cognitive and emotional milieu of an emergency department. I suspect that I am perceived as stupid rather than ignorant with some regularity (von Schiller notwithstanding).


I console myself: “When I was 20 I was amazed and disappointed by how ignorant my father was. At 25 I was astonished at how much he had learned in a mere 5 years.”


This little rant – if such – was occasioned by the almost obligatory quiz I enter daily with my referrals. More information is not necessarily better: I’d refer them to Gigerenzer, but I suspect they do not have the time.

Competence Is a Habit

Competence Is a Habit

David C. Leach, MD

JAMA. 2002;287:243-244.


Monday, September 24, 2007

Booker's Law

An ounce of application is worth a ton of abstraction.


Booker's Law

Sunday, September 23, 2007

T.H. Huxley

“The great end of life is not knowledge but action.”

T.H. Huxley

Sunday, September 16, 2007

Canaries and Zebras

Common things occur commonly, but as a group uncommon things are also frequent. Exactly how frequent they are we do not know. We do know that our estimates are biased under-estimates. Similarly, randomised control trials are not as unbiased as we would hope….


“How complex or simple a structure is depends critically on the way in which we describe it”


Herbert Simon

Friday, September 14, 2007


We are always getting ready to live but never living. 


Ralph Waldo Emerson


Man's main task in life
is to give birth
to himself,
to become what he
potentially is.



Monday, September 10, 2007

Type 3 Error?

It is better to solve the right problem the wrong way than to solve the wrong problem the right way.

Richard Hamming

Haiku: Self

The first work of art

is always Self: bridge between

Appetite and ACT.

Thursday, September 06, 2007


I had an 83 year old female who presented with a large, rapidly progressive, intracerebral and intraventricular bleed. She was on warfarin and presented an hour after a sudden collapse already persistently comatose. The extent of the bleed made it inoperable.


In situations where an attempt at resuscitation would be futile we decide and document that when cardiac or respiratory arrest occurs, it won’t be treated. Such decisions preserve resources, emotions and patients’ dignity. Making such decisions can be extremely difficult especially considering that family and caregiver sentiments are not medico-legally relevant. We like to get agreement from those close to the dying patient but initiating or terminating treatment is not a democratic process. Wide agreement helps share the emotional burden.


DNAR orders are, however, not binary: there are many interventions between doing nothing and providing pressor support with IPPV. Bodies need fluids, electrolytes, calories, vitamins, trace elements, oxygen and movement. They also need to get rid of wastes. Medication related side effects and adverse reactions need to be managed and disease complications need to be anticipated and prevented or mitigated.


The medical registrar to whom I referred agreed that death was imminent and inevitable; he nevertheless prescribed vitamin k as anti-coumadin. I asked why and he said that she may have been continuing to bleed and that the treatment would stop the bleeding. He felt morally or ethically obliged to close the gate after the horse had bolted. If the treatment would make any difference, it would serve only to delay death; it would not reverse the coma, relieve pain or in any other way make dying easier.


I pointed out that not giving vitamin k could – not definitely would – hasten death and that it was an acceptable omission similar in essence to treating cancer pain with high dose opiates that ultimately hastened death. In both cases, death was not an aim, but the end of an inevitable process. He remained unconvinced.


As humans we are inconsistent. For the most part it does not matter. In matters such as these, I believe it does.

Via Minerva

NHS Direct, the UK's 24 hour healthcare telephone service, has reported a big rise in the number of callers reporting mosquito bites over the past three months. Since the country has not enjoyed much hot weather recently, the mosquito explosion is more likely to be caused by warm and humid conditions, as well as the lakes of standing water left by severe rainstorms. Calls in August about bites are 28% up on the same time last year (