Information Overload

Today, for the first time, I was asked to dictate a letter. This came after a following clinic encounter with a patient who had been referred to hospital by her GP. Having never dictated a letter before, I asked my supervisor what to include. I was told that a useful way to structure a clinic letter is to have the patient's details, followed by three headings:

Diagnosis

Management

Follow-Up

The bulk of the text should then follow. The reason for this is that it means the GP can read the headings and get a summary of the outcome of the clinic appointment without spending a lot of time reading all of the text. The rest of the letter is available in the patient's notes, should the GP or a doctor need to refer to it in the future.

I realised that this approach is almost exactly the same as how many doctors must try to keep up with new guidelines and evidence. Work is busy and often there is rarely enough time to trawl through journal articles to try to keep up-to-date with all of the medical news. With evidence changing all of the time there are lots of ways to keep up. Guidelines produced by the SIGN or NICE are developed by researchers who collate all of the relevant research into easy to access guidance. These guidelines are now being made more widely and easily available through websites, apps and publications. The BMJ offers a useful summary of some of the most relevant articles. BBC News will pick up on major new studies as they break however will often present them in a way which is more suited to the lay public. Another way to keep up is through reading publications from more specialty specific organisations, such as the British Journal of General Practice. Lectures, talks and presentations from experts are also a useful way to learn new information.

In my opinion, the weekly BMJ offers one of the best ways to keep up with new developments. It summarises key evidence with a 'study question', 'summary answer' and 'what this paper adds'. Realistically this is a sensible way to condense a large amount of information into a more digestible amount. For example one of this weeks articles relates to the risk of pneumonia associated with the use of ACE inhibitors.

Study question: Do ACE inhibitors and ARBs decrease the risk of pneumonia?

Study answer: ACE inhibitors may be important in reducing the risk of pneumonia. This data could discourage the withdrawal of ACE inhibitors in some patients with cough who are at particularly high risk of pneumonia.

What is known and what this paper adds: ACE inhibitors have secondary effects on the respiratory system, which may protect against pneumonia. In pooled results from interventional and observational studies, ACE inhibitors had a significant protective role against pneumonia.

In an attempt to do my bit to reduce the amount of information overload which is often starting to occur in medicine, I'll try and keep my letters, presentations and discussions short, because the danger is that if there is too much information, the key points of most importance could be lost.

And of course this week wouldn't complete without mentioning some of the amazing successes of Team GB in the Olympics! Congratulations to all of the medal winners - so great to see all of the hard work pay off.

Keeping up with the NEWS

The London Olympics kicked off in dramatic style this weekend with a stunning opening ceremony. I've been hooked to the TV all weekend - hopefully some gold medals to come for Team GB! Apparently the GMC has granted temporary GMC registration for 849 doctors from 141 countries to help support the athletes. France has sent the most doctors (58 to support their 333 athletes). Compare this to the 18 doctors who are going to be supporting Britain's 542 athletes! We must be confident! It was good to see the NHS represented in the opening ceremony - the trampoline hospital beds for the kids was a fantastic idea.

Tomorrow is my last day as an FY1 doctor and I'm about to start at a new hospital at the dizzying new heights of FY2 (foundation doctor two). It's been a good year, ups and downs but overall enjoyable. Not long now until the serious matters of application to specialty training come into the fold. I'll probably put that off until AFTER the marathon (running 5 times a week and working full time doesn't leave much time for anything else!).

New Maggies Centre at Gartnavel, Glasgow

 <----This is the new Maggie's Centre which has been shortlisted for the Royal Institute of Architects' Stirling Prize. I visited the Maggie's centre in Dundee which I'd probably describe as a resource or meeting place for patients with cancer, offering a tranquil and relaxing environment away from the miserable hospital wards which can be depressing places to spend time, particularly I'd imagine for patients visiting regularly for chemo/radiotherapy. I think that these buildings are fantastic and looking at the photos of this new centre in the Glasgow's west end I think it will be equally successful. 

An article which I read in the BMJ News caught my attention this week. This was the proposal that a national early warning prediction score is adopted which is the same in all NHS hospitals. When I learnt about improving patient safety as a fifth year medical student, much emphasis was placed on the importance of reducing variation to improve patient safety. Currently in the Victoria Infirmary we use a "SEWS" (systemic early warning score) but in other parts of Scotland a "NEWS" (national early warning score) is being introduced. I think that this is a great idea. There must be more areas where we can reduce variations in our hospitals, such as with national agreements on evidence based best practice. With Wednesday being the big 'change-over' day, many doctors will move to new hospitals in new cities and health boards. If everything was standardised, less mistakes would be made and no doubt patients would benefit. I am a big believer in reducing variation to improve patient safety in our hospitals.

Sports Energy Drinks

Bradley Wiggins - Amazing Achievement!!

It was great on Sunday watching Bradley Wiggins cross the finish line of the 99th Tour de France as overall winner. What made the day even better for Team Sky was that Mark Cavendish won the sprint on the day, his 23rd stage win. While Bradley Wiggins took much of the attention, Team Sky showed that it really was a team effort in the end. Wiggins could have just let up in the last few laps of the Champs-Elysees, savouring the moment, waving to the crowd - but instead he was leading the peloton into the final sprint to help tee up Mark Cavendish to sprint to the finish for the win. It was an amazing achievement for British cycling and with Chris Froome finishing second overall, I don't think we'll ever see such a dominant performance from a British team in the Tour de France. It's incredible to think that some of these guys will be getting up, dusting themselves off and starting training for the Olympics, which starts in just four days time.

Keeping on the subject of sport, the BBC's Panorama ran an episode last week in conjunction with the BMJ about "The Truth Behind Sports Drinks" (it'll still be available on BBC iPlayer for a week or so). Sports marketing is big business, praying on the needs of sportsmen and women seeking to improve their performance, or just as a "fashion accessory" to be seen using whilst taking part in sport. Energy drinks such as Lucozade and Powerade make claims on the adverts and packaging about "boosting performance" and are becoming an "essential piece of sporting equipment". They advise people to drink before they feel thirsty. This is all a new concept. In the 1970s, runners were discouraged from drinking too much for the fear that it would slow them down. When the evidence is carefully scrutinised, it doesn't hold up. A lot of the studies cited are sponsored by the companies wishing to promote their products and the evidence is weak. What the promotion of these products has achieved is to undermine the importance of thirst. This is the basis that the only symptom of dehydration is thirst. Drinking too much can lead to exercise associated hyponatraemia, with 16 marathon deaths recorded due to a drop in sodium levels. The most effective way to prevent hyponatraemia during marathin running is said to be to prevent having a positive fluid balance. When the BMJ asked the major manufacturers of sports drinks to supply evidence, only GSK (who make Lucozade), supplied evidence. Other problems arising from sports drinks are the risks of obesity (people drinking too much - one in four American parents believe sports drinks are healthy for their children), and increasing numbers of patients with diabetes. So in conclusion, the evidence is not all there - sports drinks are not all that they are cracked up to be, and only drink water when you're thirsty. Plus it'll save you a lot of money!

The Challenges Facing New Doctors

Only one more week until the changeover and the new FY1s step up and take over. The media seem to take of advantage of this, by coming up with 'shocking' headlines and describing August as "the killing season" in NHS hospitals. This doesn't really help the confidence of the new doctors who will already be nervous at the prospect of taking on massive responsibility. A column in the BMJ this week written by an inter-calating medical student talks about exactly this. What people often seem to forget is that we've been at medical school for 5, 6 even 7 years sometimes working up to this point, and the new FY1s will be much more prepared than they realise. Studies have shown that the care given by new doctors in training is comparable with that of their senior colleagues. I'm giving a talk to the new FY1s next week to give some advice on how to work as a save, effective FY1 doctor and I'll try and remember how I felt when I was in their shoes only a year ago. I'll be moving on to a new hospital on the 1st August and no doubt I'll have plenty of new challenges to get my head around. 

I presented the gentamicin audit which I talked about in the last post before the wedding to the department in June and it seems as if it was good timing to do an audit on gentamicin because the new prescribing form is being rolled out across NHS Greater Glasgow and Clyde next week. No doubt there will be a few speed-bumps initially as doctors and nurses get used to it but hopefully it'll lead to safer prescribing and closer monitoring of IV gentamicin in the long run. I'll try and recruit some of the new doctors in the hospital next year to repeat the audit next January to see if there really is an improvement with the new prescribing form.

The president of the Royal College of General Practitioners (Dr Iona Heath) this week spoke out in praise of young doctors. In a letter to the BMJ she wrote that too much emphasis from an early stage of training new doctors is on science and understanding. However science is never enough in a profession which seeks to try to alleviate human suffering. Students and doctors are not being encourgaed enough to think and question assumptions about the nature of science and medicine. She continues in the letter to talk about the erosion of continuity of care, and the lack of a 'team based' attitude to practicing medicine (only this week we had to our FY1 end of year ball due to a lack of interest from our senior colleagues). She highlights that with shift patterns and the European Working Time Directive, it is difficult to learn from our actions (I used to see patients on night shift and then wonder what had happened to them the following day - I would sometimes go and check out patients at the start of my next shift to see what had happened but often time wouldn't allow). 

She also argues that there is a rapidly changing culture in medicine of 'protocol and guideline medicine'. Many doctors are now afraid not to follow the guidelines and although I've only had one years experience, I am already starting to feel that there is a great deal of "over-treatment" and "over-diagnosis" in the NHS at times such as end-of-life care which can be dangerous and un-necessary. According to Dr Heath this is "destroying the confidence of many young doctors, so that they no longer feel able to make the courageous professional judgements necessary to tailor treatment to the needs, aspirations, value and context of individual patients". Finally she says "as I grow old and frail, I want a doctor who thinks and questions, not one who feels obliged to blindly follow protocols".

Wedding and Honeymoon Photos!

It came and went in a flash - the wedding was an amazing day. Great to see so many family and friends on the day, it seemed like all of the guests enjoyed themselves as much as we did!
 

Brig O'Doon, Ayr, Scotland - Saturday 23rd June 2012

Reethi Beach Resort - The Maldives

Gentamicin Pescribing Audit Project

 Last week I presented the results of the audit project I've been working on in the hospital where I work as part of the monthly medical division clinical governance meeting. Audit is an important process whereby everyday practice is compared to the ideal standards and practice. I wanted to audit prescribing of gentamicin in the hospital. It is an antibiotic which has nephrotoxic and ototoxic effects if given in high concentrations. Monitoring of blood levels is very important to ensure safe prescribing and levels should ideally be documented on a monitoring chart, with the dose calculated based on the patient's weight and renal function. Duration of treatment should not exceed 72 hours except in exceptional circumstances. I audited this process and found that in more than half of cases at least one of my outcome measures were not being completed correctly. In these patients, it was more likely that renal function would be affected, leading to my suggestion that patients will directly benefit form improved compliance with these monitoring protocols. The plan is for a new gentamicin prescribing and monitoring chart to be introduced in the hospital in August 2012 which will hopefully improve compliance. There's a lot coming up over the next couple of months (the wedding, portfolio hand-in etc) so I'd imagine that posts on here are going to be a bit more sparse over the next while. More to follow...