· Resting pulse and blood pressure
· Exercise induced pulse and blood pressure variability
· Fasting blood sugar
· Health literacy
“You ask hard questions.”
“No I don’t. I ask easy factual questions: you know the answer or you don’t; no thinking involved.”
Facts are easy; deductions are harder and inductions are hardest. I would so appreciate it if people were taught to think much earlier in life deliberately rather than by some undisclosed process of osmosis.
Developing expertise is said to take about ten thousand hours: at 4 hours per day, 5 days per week, 45 weeks per year that is about 11 years. It cannot be hurried or circumvented.
The medical students and doctors who come through the department cannot be much better than they are because they have not had enough time to be better. They cannot be expected to learn A&E medicine in their short stints. They can learn an approach, a perspective, and a process and they can calibrate their knowing and their not-knowing.
In conducting research we need to begin with what is known, then what needs to be known and finally what can be known. We need too to allocate resources to answering the questions that would provide the greatest gains.
The larger proportion of clinical research is without clinical utility and the clinically useful tends to be actuarially so rather than allowing clinicians to answer specific questions related to specific patients at the bedside. The few nuggets to be found lie in a morass of the unintelligible and the useless.
There is very little evidence for anything and a great deal of research simply ends with a defined need for a well designed blinded randomised control trial. We do not have the resources for well designed blinded randomised control trials; we need to find some other way to answer the questions that need answering.
The police brought a young man who had self-harmed and threatened suicide to the ED for assessment and treatment late at night. They had tasered and handcuffed him in order to do so. He had cut himself 21 times, none of them serious and the worst of them the instant he was shocked because “he lost control”. Only two lacerations were sutured. And he had never cut himself before.
He had acted impulsively after breaking up with his girlfriend of 6 months.
He was an angry young man professing depression with an energy and animation uncharacteristic of depression. He had also cooled down and although still upset about the break-up had decided to speak to his girlfriend rather than kill himself or otherwise harm himself. My assessment, credible as he was, was that he was not at immediate or high risk of self harm and that he could be assessed by a member of the mental health team in the morning (normal business hours).
The offsite supervising officer in charge was not happy with my assessment and instructed her officers to arrest my patient and take him to a psychiatrist to assess him which would involve taking him to the psychiatric hospital where they would be directed to return him to the ED where a psychiatric SHO would come to assess him. It seemed to make no difference to her that a second assessment several hours later would be by a junior doctor with considerably less experience of self harm and dangerousness.
Assessments of dangerousness are probabilistic, difficult, inexact and often no better than chance. The variables that contribute are numerous and unstable and like predicting the weather become meaningless beyond the immediate future. Some things make prediction easier: a history of violence; acute psychosis; drugs and alcohol; and severe antisocial personality disorders.
Most cases like this one do not have obvious predictors and so the assessment is made on the basis of the lack of predictors, the patient’s stated intent, observed impulsivity and self-regulation, level of emotional arousal and my own improvised provocations over a relatively long period of time: hours rather than minutes. Prolonged exposure to many dangerous people over many years also helps build a tacit model of the dangerous.
The role of the doctor is four–fold:
The nature of medicine is changing much faster than the practice of medicine: we are human and as such the older we get, the less flexible, the less malleable. The role of the doctor cannot be tied up in specifics because life is complex, uncertain and – at the individual level – entirely probabilistic.
After-action reflection means learning something everyday, but not all learning is noteworthy on short timescales. Perspective is important and time offers better perspectives.
Looking back at my day I find my emotionality an issue: part of that is fatigue and part is the nature of the work and part is that all those who interact with us do so with imperfect and incomplete information. Life is complex.
Many profound truths sound asinine stated baldly: they are too obvious. They get their meaning, their depth and breadth from the hearer’s interpretation: the mouths of babes yield only the words of babes; no more. Meaning is tenuous and personal.
And generosity is always welcome; as is compassion.
What if life could be understood forwards? What if you could see the shape of your life now, well before its end?
I walked this path and left a legacy….
Sculptors often say that they do no more than liberate the sculpture rather than create. Can a life be sculpted in the same way? The means can be varied infinitely towards the same end.
What tools, whose hands and how long?
My question, essentially, is how early in life can you know or discover your purpose? If you know that your life’s work cannot begin until you know what it is, how can you go about discovering it sooner?
A doctor remarked that had she known that a patient was a consultant she would have spoken differently: he had broken his femur and she would have said that he had a femoral fracture and needed some pain killers and an x-ray. She didn’t say what she said instead or would say and found my request for clarification “annoying”.
If I broke my hip, I would have no feelings about the use of the word “hip” instead of “neck of femur”. I would not consider the word itself condescending. I do not believe myself atypical in this.
“The meaning of the message is the response you get.” Even a professor of orthopaedics would not take exception to “hip”, he would simply ask to see the x-rays: a picture is worth a thousand words.
Simple, clear, unambiguous language is not exceptionable. If your language can be understood by a six year old, it can unexceptionably be understood by an adult. Being simple, clear and direct is no mean feat.
I am to do a case presentation in two weeks. In choosing my case I was reminded of another patient – somewhat like my sentinel case because the entire time I was assessing the patient I am going to present, I was thinking about the other patient.
My sentinel was a middle aged woman who did not know why she had been brought to the hospital. She had no complaints and her examination was unremarkable except that she was disengaged and avolitional. She was not psychotic or depressed and this affect was entirely new.
She recovered whilst in the ED before her admission to the medical ward and we spoke again before her admission. She said to me that she knew earlier that something was wrong, but that she could not be bothered. I would tell you my diagnosis, but that would be a spoiler for my next presentation and it is not my diagnosis that is the point of this post; rather that medicine is an education in observation.
There is an old joke in medicine about the student who failed an OSCE for a simple lack: he did not ask the patient his name. The patient had no somatic complaints and his physical examination revealed nothing abnormal. The student’s diagnosis was “Normal” and the patient’s actual diagnosis was “Psychosis”: he believed himself to be Napoleon.
An acute observation can tell by a woman’s walk whether she is ovulating or menstruating; by a child’s resting expression how well he slept the night before; and by an old man’s signature how good a day he is having. We are all unconscious broadcasters of our fundamental states.
“What are you? A house office, SHO or what?” I find the question intensely irritating; rather than apropos the questioner finds it fundamental. I understand that experience is relevant to evaluations, but I do not see it equally relevant to observations.
I can see that this will be a problem in 5-10 years time with registrars and new consultants who see a job title as proxy for knowledge, experience and effectiveness. And I do not have a solution other than to become a consultant myself or learn a deeper patience. Given that NHS powers recognise that job titles cost more without truly being proxies as above, they are hoping to give people cheaper job titles and still benefit from their expertise, so becoming a consultant might be a little more difficult going forward.
I am not too keen either on the training rigmarole.
Rand observed that patience is not a virtue; it is a necessity. I agree.
The world will be a very different place in 10 years time, but medicine will still be more art than science and people will be as human as ever.
In populations where people self-select for cover for health insurance and it is not mandatory no degree of insurance is affordable for anyone: those who are healthy and who would subsidise those who are not would tend to leave, raising the risk profile and costs leading to a new marginal group who would leave. Until the worst risk members would be clustered and they would not be able to afford the premiums as a class. In populations where people have mandatory health cover and where risk / morbidity is normally distributed, 2/3 would be much better off than without such mandatory cover and 1/6 would be very badly off with such mandatory cover. The remaining 1/6 could live with it, if unhappily. However, risk / morbidity is not normally distributed, nor is it binary. Those with the worst risks are least able and least inclined to deal with them.
This means that mandatory health insurance is unfair to those who take care of themselves - however large a minority they are. How responsible people are depends also on their level of development. (This is also why HIV prevention efforts are doomed to fail: those most at risk, <25, are not able to adopt the behaviours necessary to make a difference. And preventing MTCT simply delays infection by a median of 15 years – not accounting for child rape.)
So, insurance that is not mandatory and non-profit has to discriminate against a large proportion of any population. It also has to rely on imperfect information, non-rational choices, and high transaction costs.
What do you insure against? Why?
As an intern I thought that ill patients took precedence over everything: meetings, eating, sleep… because what could be more important? I mean ill patients, not dying patients. Most patients in hospital don’t die and those who do are usually not unexpected or avoidable deaths. Some may argue this as a self-esteem issue, but I think it was no more than a wrong-priority issue.
As a first year SHO I learnt that my learning took precedence and I wasn’t entirely comfortable with that. I understood that doing the wrong things was worse than not doing anything, but not-doing just did not feel right.
Now I know and understand that Hazards-Hello-Help is the right and necessary order, but I don’t always remember or apply it: and my failure is not machismo.
I know that balance is important and that First Principles are FIRST: first things first: only a fool insists on tying his shoelaces in a fiercely burning building. Having said that, stress narrows our cognitive focus acutely so that we cannot remember things we know very well.
This post is because of the reason I left work late this morning, at 0h35, and walked home in the rain. It was quite pretty.
My intention to post frequently has come up against the unwilled and unpredictable vagary of illness.
Disease is aptly named: dis-ease = the absence of ease; misery. A hiatus; meanness; prayer; mercy – a little free association.
Several times, at night, I actually considered going to A&E – my A&E – for…. I didn’t go: I don’t relish being prodded and stabbed and fussed over.
This was going to be a long, rambling post, but I find that I must stop now.