Graduation and Summer Holiday

Graduation (24th June 2011) Caird Hall, with Heather

Garden Party - Outside the Union

Graduation Ball (4th June 2011) Aviemore

A few things that have been going on since last month - Grad Ball in Aviemore, Rockness, T in the Park, Graduation in Dundee and the University Grad Ball, Northern Ireland for MacFest and Banchory. Here's a couple of photos.

Start my shadowing at the end of the month so enjoying a final week off and getting organised before it all kicks off!

Updates from the BMJ

Preventing Stroke in Atrial Fibrillation

New guidelines have recently been published by the European Society of Cardiology on the management of patients with atrial fibrillation. They are summarised in the article New European Guidelines on Atrial Fibrillation BMJ 2011;342:d897. Two of the most important recommendations are the increased identification of patients at risk of stroke, and wider use of anticoagulants. The original CHADS2 score has now been replaced with the CHA2DS2-VASc system. Patients with each of the following demographics score a point (congestive heart failure, hypertension, diabetes, vascular disease, age >65 and female). Patients with each of the following score an additional 2 points: previous stroke or TIA, age >75. For a patient with a score of zero, no anticoagulant is required. For those with a score of 1 or greater, oral anticoagulants are recommended over aspirin 75mg. Although aspirin is still considered a reasonable option for patients with a risk score of zero to one following initial assessment, it is no longer the preferred option for most patients.

The new guidelines have been created following a wave of evidence of the benefits of oral anticoagulants over aspirin and new evidence has been released which shows that patients on warfarin or aspirin have a similar risk of bleeding. In addition, new oral anticoagulants are beginning to emerge which may replace warfarin in the future because they don't require therapeutic monitoring of levels. Dabigatran is a direct thrombin inhibitor that does not require therapeutic monitoring. Patients who are on warfarin presently and stable on the drug should not be changed to dabigatran but pending approval of the direct thrombin inhibitor, it may replace warfarin in the forthcoming years.

National Patient Safety Agency: NG Tube Placement

On a separate note but carrying on with the national patient safety agency theme, an article appeared in the BMJ this week on the topic of Checking placement of NG feeding tubes in adults. BMJ 2011;342:d2586. NG feeding tubes are frequently used for patients who develop dysphagia or those on ventilators in intensive care for short to medium term use as an alternative to longer term feeding via a PEG tube. Most NG tubes are inserted safely however there is potential for serious patient harm to occur should the tube become displaced from the stomach. Aspiration pneumonia following incorrect NG tube insertion can be potentially fatal. So how do we reduce the risk of this occurring? Testing acidity of stomach contents by using pH litmus paper is the gold standard first line check, with X-ray interpretation as second line. However, since 2005 in England there have been 21 reported deaths resulting from misplaced NG tubes with misinterpretation of xray images the leading contributary factor. This is a serious avoidable event, and in one audit, less than one third of junior doctors had received training on interpreting Xrays for misplaced tubes or were aware of existing guidelines. Ways to stop adverse events from occurring:

• Avoid placing NG tubes outside normal working hours wherever possible.
• Do not give NG tube feeding to patients at high risk of aspiration
• Do not place NG tubes without prior training including how to interpret the xrays
• Use the online website www.trainingngt.co.uk for guidance
• Do not flush the NG tube with anything until pH testing is completed
• pH level of between 1 and 5.5 is acceptable. No more.
• If no aspirate can be obtained or the pH level is >5.5, Xray request asking specifically for interpretation of NG tube placement. Ask a radiologist for interpretation advice if unsure.
• After radiography, clearly document decision and next steps for the patient eg. safe to use.
• Tubes should be checked once daily for correct placement and before giving feed or medication because they may have become displaced.

Scottish election - SNP win an overall majority

The major news in Scotland this week was the Scottish election. The map on the left shows the SNP (yellow) dominance and the Scottish National Party have won an overall majority in the Scottish parliament (Scottish election: SNP majority for second term). Like it or not, the SNP are going to be at the centre of any decision making processes in Scotland over the next five years, but what does this mean for healthcare and the NHS in Scotland? The SNP outlined in their manifesto that they would "ring-fence" NHS spending in their budget, but is this enough? Over the next five years the NHS in Scotland is going to need significant amounts of investment in order to carry on providing a high-quality service to its patients. Continuing with the current level of spending may not be enough. Scotland is facing an ageing population and the government is going to be expected to foot the bill of the countries increasing health burden. But where is this money going to come from? The SNP have said that they will freeze council tax for five years, so not from there. Prescription charges, they were abolished as well. Perhaps the SNP's proposal for minimum-pricing on alcohol will make a return to the forum after it was rejected last year. What will Scotland's reaction be to any proposed NHS reforms in England, will Scotland follow suit? Even the government in Westminster cannot seem to agree on the correct course of action (Clegg fights back with NHS pledge - BBC News). It has been quite widely commented that the SNP defeated Labour in the election due to Labour's 'negative' tactics in contrast to the SNP's 'positive' visions. I just hope that behind the promises and pledges which won the SNP the election there is a sustainable vision for the future of Scotland's economy. And what about the independence referendum? Surely that is something that the country can ill afford at this point in time and could turn out to be a costly waste of time. On the other hand, with the SNP winning such a large majority of seats in the government, perhaps Scotland will become an independent country within my lifetime. I never thought I'd see the day but all of a sudden it becomes quite a realistic, albeit concerning prospect. On one hand, the next five years could either be one of many successes and improvements for Scotland, but on the other it could be a very difficult one if the correct decisions are not made.

Patient Safety in the Undergraduate Curriculum

Furnace, near Inveraray

First photos from the rural GP placement here, one from Furnace with a view of Loch Fyne on the background, and another of Inveraray castle. Don't think it has rained a single day since I got here 3 weeks ago, maybe a first for the west coast of Scotland.

Inveraray Castle, home of the Duke of Argyll

I read the following editorial in the BMJ this week with interest: Paterson-Brown S. Improving patient safety through education. BMJ 2011;342:d214. According to the author "a window of opportunity exists to include training in human factors in undergraduate and postgraduate training". I thought that what we'd done over the past four months was pretty relevant, so submitted this to the BMJ as a 'rapid response'...

" Teaching undergraduate students about human factors and how to investigate adverse events should become part of the curriculum. In some places, teaching on this subject is already attracting the attention it deserves. Here, a small group of medical students undertook a selected study module in patient safety in their final undergraduate year. Clinical supervisors identified areas where patient safety was at risk, including shift handover, venous thromboembolism prophylaxis and oxygen prescribing. Using guidance from the Institute for Health Improvent, the students spent four weeks carrying out improvement projects using ‘plan, do, study, act’ (PDSA) cycles. The “bundles of care” or changes otherwise introduced resulted in improvements in patient outcomes by the end of the project period. The efforts resulted in benefit for the students who learnt about patient safety, and the patients who received better care. One way of teaching this subject is by investigating either incidents where errors have occurred or areas where improvement is required. Patient safety is not currently as high up the educational agenda as it should be. An opportunity exists now to introduce this into the undergraduate curriculum for the benefit of the next generation of doctors and patients."

I'm lucky to have had teaching on this already as an undergraduate but I don't think everyone is being given the opportunity at the moment. It seems to me that this is pretty important for all future doctors to know so I think the emphasis should be placed on teaching students, rather than postgraduates, in order to make improvements from the bottom upwards.

Better: A Surgeon's Notes on Performance

Just finished reading this book and I'd highly recommend it to anyone who has anything to do with healthcare and improvement. Atul Gawande is a surgeon who lives in Boston and works as an assistant professor at Harvard Medical School. This is his second book (after 'Complications' several years ago). The book is basically a series of short stories of success within medicine where resources are stretched and tasks seemingly impossible. Examples include the WHO's worldwide polio vaccination programme, treating polytrauma casualties in Iraq and the medicine's constant battle against hospital acquired infections. His stories all revolve around a common theme of improvement in face of adversity. He makes his point in the final part of the book where he talks about the 'young science of improvement'. His argument is that not enough is being done to make the most of what we already have and changing the systems we work in.

There's a very good chapter near the end of the book about how the practice of obstetrics has dramatically improved outcomes for mothers and children over the past 100 years. He tells us that most of the changes did not come down to randomised controlled trials, double-blinded studies etc, but rather keen observations of outcomes and comparisons. The practice, he writes, was changed forever with the introduction of the Apgar score. This gave a score of the outcome of new born babies immediately after birth. This score allowed for comparisons between outcomes (outcome measures). In the next chapter about cystic fibrosis, he tells us about how all CF specialist centers make their outcomes and patient results (ie. average life expectancy of their patients) known to each other. Apparently in medicine, most outcomes form a 'bell-curve' distribution, so there are always some poor performers and some exceptionally good performers. Although comparison of outcomes increases competition, it drives improvement and change.

In the final afterword, Atul Gawande sets out his five suggestions on how to become a positive deviant (part of a lecture he gives medical students each year):

1. Ask an unscripted question. Medicine can feel at times like a machine with the doctor and patient small cogs in the process. Asking a patient (or indeed a colleague) a simple question, such as 'what do you do for a living?', 'did you watch the game last night?' makes a human connection.

2. Don't complain. Nothing is more dispiriting than hearing doctors complain. I agree with this point. Resist it it because it is boring, be prepared to have other things to discuss, such as something interesting which you saw, or even the weather if nothing else.

3. Count something. If you count something interesting, you will find something interesting.

4. Write something. Whether it is a few paragraphs in a blog, a paper for a journal or even a piece of creative writing. Make your reflections available to a wider audience, because an audience is a community and the published word is a declaration of membership of this community, as well as a willingness to contribute to it.

5. Change. The final suggestion for a successful life in medicine. Become an early adopter. Some of the best ideas and revolutionary concepts in medicine initially met large resistance. Be willing to recognise inadequacies of what you do and try to find solutions.

So always try to be better. Find something new to try, count how often it fails, or succeeds, and write about it. I think these sound like good words of advice. To anyone who finds these ideas interesting, I'd highly recommend this book.

Inveraray Rural GP, Exams and Management of Hypertension

I don't think I could have been much luckier than being sent to Inveraray for my GP placement! I'm actually living in a B&B in a small village called Furnace about 7 or 8 miles south west of Inveraray. Here's a link to the website. www.maggiesbedandbreakfast.com

My tutor asked me to identify an area of general practice which I wanted to investigate / look into in a bit more detail. When I was looking out for ideas, I found this article in the BMJ this week titled 'Angiotensin converting enzyme inhibitors and angiotensin receptor blockers in hypertension'. The ABCD management of hypertension has changed since I was in first year in 2005 (beta blockers are no longer preferred as a routine first line initial treatment for adults with hypertension), meaning it's now more of the A-CD rule of treating hypertension. I thought that I would take a look at patients with hypertension under the age of 55 and the treatments which they were on. NICE guidelines recommend that white patients <55 years old are started on an ACE inhibitor. The target systolic blood pressure for these patients should be <140mmHg (<130mmHg for patients with higher cardiovascular risk). The guidelines (NICE Clinical Guideline 34) recommend that if the target blood pressure is not achieved, a second agent should be introduced. According the BMJ, 4-30% of long term users of ACE inhibitors have a dry cough and if this is intolerable, an ARB, such as losartan should be introduced. Treatment with an ACE inhibitor and an ARB together was shown to worsen decline in renal function and the two together are contraindicated. So the questions I want to try and answer as agreed with my tutor are:

1. Are there any patients on ACE inhibitors and ARBs?
2. Are patients <55 years old being started on ACE inhibitors?
3. If target BP is not reached, are patient's being offered a second drug?

On another note, I'm spending quite a lot of time at the moment getting my portfolio organised and preparing for my fifth year exams which are looming ever closer. I did however read this blog, and realise that exams are something I'm going to have to deal with beyond medical school! In this post on the BMA website, Ben Molyneux writes that sometimes it seems as if medical recruitment is a merry-go-round of problems and that an average trainee can expect to fail his MRCP exams 1.5 times before passing at an average cost of £2,399! Whats more, there doesn't seem to be agreement between different stages of postgraduate training as to when MRCP exams should ideally be sat. The College suggests that exams be taken during the foundation years, while the Foundation Programme advise that no exams should be taken during the foundation years. Fantastic.