Medical Ethics in Everyday Clinical Practice

It's interesting to read that medical ethics and law can be studied at a post-graduate level in the form of a masters degree. Ethical situations are encountered frequently in everyday practice however the demands of busy hospital workloads mean that often ethical situations are overlooked. I remember in 5th year when we were choosing a topic for our ethics essays, people would often email the professor in medical ethics at Dundee, saying that they couldn't find an ethical dilemma which they had encountered which would be suitable for an essay. She emailed all of the 5th year students to say that this was 'nonsense' and that ethical dilemmas are encountered everyday. Courses in medical ethics tend to focus around big moral questions, such as euthanasia, but an example of everyday ethics would include, for example, responding to competing demands by prioritising, and speaking to families who are frightened or angry. It is important to recognise that, the same way confidence and expertise in other aspects of medicine develops with practice and experience, so does ethical awareness. The University of Edinburgh offers a distance learning course in medical ethics which looks interesting.

Other articles in the BMJ which I've been reading this week:

Illegally produced alcohol - In the UK there are increasing amounts of illegally produced alcohol entering the market. In a society which consumes alcohol as heavily as our own in Scotland, it is hard to know how much could be produced illegally. The potential health hazards are very serious. The different categories include counterfeit alcohol designed to look like 'the real thing'. There is also homemade spirits imported from Europe, and then there is the consumption of other industrially produced chemicals, such as ethanol (which can lead to blindness).

How can we treat multiple chronic conditions? - An article written by the associate editor of the BMJ relating to the difficulty of treating multiple chronic conditions. Chronic illnesses are much more common now that acute illnesses and with people living for many years, there are often multiple co-morbidities. In fact it is rare these days to see a medical admission without something in the 'past-medical-history' section. But how do we treat patients with multiple co-morbidities? Guidelines for practitioners on this topic is thin on the ground but apparently it is a rapidly expanding area of research.

After the annual leave....

I can't believe we're into March already - this year's flying in. Less than four months until the wedding now and summer's just round the corner so lots to look forward to after a great week off. Feeling re-energised and ready to go. 

Some interesting articles which I've been reading over the past week or so:

1) The BMA council is going to ballot it's members on industrial strike action for the first time in almost 40 years. This relates to the government's new offer on pensions for public sector workers which will see an increase in contributions for a lower final pension for doctors.

2) Sudden death in epilepsy: Patients with epilepsy are more likely to die pre-maturely than the rest of the population. SUDEP stands for 'sudden, unexpected, non-traumatic and non-drowning death in patients with epilepsy'. The profile of patients most likely to be affected are young age of onset, male and a longer duration of epilepsy with frequency of seizures one of the most important risk factors identified. This adds further evidence to support the need for good compliance with treatment amongst patients with epilepsy. One of the major drives in the place I work in is the medicines reconciliation process - ie. ensuring that patients admitted to hospital as an emergency have an up-to-date prescription made for their regular medications. Missing doses such as anti-epileptic treatments in this case or prescribing the wrong dose could have a potentially catastrophic impact.

3) Air pollution is associated with a higher risk of myocardial infarction within just one week of exposure to a high concentration. The associations for this are most highly linked to 'traffic' pollution. The same meta-analysis study also recognised that higher levels of air pollution are also associated with faster rate of cognitive decline. So in other words, avoiding pollution will lead to all-round health benefits, not restricted to the incidence of respiratory conditions.

4) In the BMJ careers section last week there were some interesting articles about the career progression of FY2s entering specialty training. In less than 12 months I'll be applying for specialty training so these issues are particularly relevant to me. Last year a third of UK foundation doctors did not directly enter specialty training. Reasons for the third who didn't include taking a career break, experiencing medicine abroad and just locum working. At the moment the plan is to apply for GP training and Core Medical Training but that could change over FY2 depending on how things go.

Finally, my parents are off to Grenada (my favourite place) for a holiday and I'm just a little bit jealous that I didn't get invited so I thought I'd put a picture from my elective up to help things. I'll have the last laugh when I'm in the Maldives on the honeymoon in four months time anyway!

Early Cancer Detection and Investigation of Focal Liver Lesions

After reading an article about the GP who ran from Scotland to the Sahara (see 06/02/12), I've been inspired and entered my first marathon in September, the Loch Ness Marathon. It feels like a suitable step up from the Great North Run last September and a good target to aim for. I can already feel the pain though! Thought I'd also share this picture which a friend posted on Facebook recently - a lot of truths there!

I was forwarded an interesting letter this week from the Scottish Medical Officer about a new ambitious 'Detecting Cancer Early' programme which aims to improve survival for patients with cancer. There is of course very strong evidence to show that early detection of cancer results in more effective treatment, however sometimes early presentations are missed. There are several different ways to approach this topic, for example one way of achieving this goal is by educating patients about worrying symptoms ('red-flag' symptoms as doctors would call them) and stressing the importance of seeking help from a GP. Another way to improve early detection is by promoting GPs to refer patients early for investigations where there are symptoms suspicious of cancer. In my role in hospital, I would be expected to have a high index of suspicion for cancer in patients presenting with non-specific symptoms and where there is diagnostic uncertainty. Improved participation of the public in screening programmes is another technique. In Scotland there is going to be a high profile campaign to tackle negative attitudes about cancer, followed by a public campaign to promote awareness of specific types of cancer, starting with breast cancer.

Rational use of imaging in extremely important for many reasons, not least reducing the risk of harm caused by excessive imaging of patients in hospital. In the BMJ this week there is an interesting article about investigating focal liver lesions. I did not know this, but the vast majority of incidental liver lesions found on imaging are benign, not metastatic as I'd previously thought. The differential diagnosis for a focal liver lesion is actually quite extensive and includes simple hepatic cysts, focal nodular hyperplasia, heamangiomas, focal fatty infiltration, primary and secondary malignant tumours. Most benign lesions can be characterised using non-invasive imaging alone without having to resort to liver biopsy. Ultrasound is usually the first line investigation, whislt MRI has a higher sensitivity and specificity than CT. Contrast enhanced ultrasonography is a newer imaging modality becoming more popular and able to perform as effectively as CT or MRI. Liver biopsy is typically only considered when imaging fails to characterise an abnormality with certainty. Approximately 2% of image guided liver biopsies result in complications and therefore they should not be carried out on every patient found to have a focal liver lesion.

Finally, in the news section of the 'Careers' section of the BMJ this week there is an article which warns that the NHS is set to train 60% more consultants than needed by 2020. If this is the case then there is going to be huge competition for consultant posts at the end of specialty training. Strategic changes could involve making training longer, recruiting more consultants who are on-site at all hours to offer more senior expertise out-of-hours, or the introduction of a new tier eg. 'pre-consultant' and 'full consultant'. Controversial I think!

Hands only CPR - No kissing!

Vinnie Jones is here to teach us a lesson. This is brilliant! Watch it if you haven't already seen it! Although it seems that the public are getting a bit of a mixed message about CPR. Since 2005 we've gone from:
2 breaths, then 15 chest compressions to 2 breaths,
to
30 compressions then 2 breaths
to
Just compressions.
Is this evidence based or is simplification the best way to improve outcomes? Only criticism is not enough emphasis on calling for HELP - I think that is THE most important thing to do in an arrest situation!!

Hip Fractures and Falls in Older Patients

What's going on this week... a news article in the BMJ follows on from an earlier post I had on here about hospital at weekend. Apparently the new 'evidence' of worse outcomes for patients at the weekend is re-igniting calls for more out-of-hours cover to allow hospitals to offer a full service at weekends. Sounds great in principle and would no doubt lead to better outcomes for patients but how's it going to be funded, and where are the added staff going to come from? Interestingly the Royal College of Physicians have issued a call for any hospital that admits acutely ill patients to have a consultant physician on site for at least 12 hours a day, seven days a week, who should have no other duties during this time.

An article was published this week about the use of anti-hypertensives in patients with gout or symptomatic uricaemia. This caught my eye because last week one of the doctors I work with was telling me about a patient on her ward who developed gout but had acute kidney injury. The acute management of gout mainly comprises non-steroidal anti-inflammatories eg. ibuprofen, however these are contra-indicated in renal impairment. It's long been known that hyperuricaemia and untreated hypertension commonly co-exist. High uric acid levels in the blood can predict development of hypertension, diabetes and chronic kidney disease. A recent study however shows that amongst UK GPs, the use of calcium channel blockers and losartan in patients with hypertension was associated with a significantly reduced risk of incident gout. Diuretics, beta-blockers and ACE inhibitors were associated with increased risk of gout. As well as preventing gout, losartan in particular is believed to protective renal effect.

Teaching this week was on the topic of falls, one of the 'geriatric giants' that's talked about at medical school. Every night shift - it's the same story. Request comes in to the FY1, please review patient - fall. The frequency that this happens at night in a hospital where there are nursing staff keeping a close eye on patients makes it alarming to think how many 'falls' happen in the community on a day to day basis. In particular, older patients suffering from hip fractures have poor outcomes (see dramatic photo). The main points I took from this teaching was that the diagnosis is all in the history. 'Dizzy' is not a good descriptive turn because it means something different for so many people, ask the patient 'what does dizziness mean to you?'. The examination should include balance tests eg. the sit to stand test, assessment of gait and the push test. All too often patients admitted with falls are assessed by having an ECG with a 24 hour cardiac monitor and lying / standing blood pressures. However cardiology is only one group of causes. Look for neurological signs in older people, such as nystagmus. Think about otological causes eg. inner ear diseases. Don't miss hip fractures and of course mechanical is a major cause of falls so it's worth remembering that simple prevention can be much better than a cure. Having an occupational therapist go out to see a patient's home and suggest ways to make it safer could prevent a hip fracture and save a life.

Blood Tests - Why Do We Do Them?

Raised Inflammatory Markers - Yesterday when I was on-call I was reviewing the blood results from a patient and noticed that CRP (C-reactive protein, a commonly tested inflammatory marker in the hospital setting) was suddenly elevated. Why was this? Why do we do a CRP test on so many patients in hospital on a near daily basis? I then saw this article which answered a few questions:

Normal levels of inflammatory markers are useful for ruling out a few specific conditions, such as giant cell arteritis. They are also useful for monitoring treatment to disease. So what to do with a suddenly elevated CRP? CRP is particularly useful in identifying bacterial infection. According to this article, if the history and examination yeild no clue as to cause, it would be sensible to do nothing and wait to see if symptoms develop. Incidental abnormalities can lead to unnecessary and potentially harmful investigations. This is supported by follow-up studies in asymptomatic patients with incidental findings of raised inflammatory markers over a six year period.

Hand-Washing Compliance - I was sent an email with a copy of a letter from the Scottish Health Secretary Nicola Sturgeon this week with an update on hand-hygeine compliance. Apparently doctors have a consistently lower hand hygiene compliance rate than other staff groups in the hospital settings. The question I wondered about this was why? Is there a reason for this and what can be done about it?

Disappointing for Scotland this weekend!

The Running GP - This was an article on the BBC News website which was also printed in this week's BMA News. A GP based in Edinburgh with a passion for long-distance running ran from John O'Groats to the Sahara desert in 77 days and has been appointed by the Scottish Government to promote physical exercise. He states that according to research having a low physical activity level is equivalent in risk to health to smoking, having diabetes and being obese all combined. I don't think we give patients enough advice on physical activity and it certainly doesn't feature on routine hospital 'clerk-ins' whereas alcohol, smoking and BMI do. Perhaps we should be asking all physically able patients on admission to hospital what their levels of physical activity are. I fear that in Glasgow the standard is pretty low.

Vital Signs + Abbreviations - I read a letter to the BMJ this week from a GP who complains about the use of abbreviatons in discharge summaries sent to GPs. One particular script had the abbreviation 'MIRO'. The GP phoned the consultant, who had no idea. The consultant then asked the FY1, who said it stood for 'myocardial infarction ruled out'. Embarrasing for the FY1 and a fair reminder about the dangers of using abbreviations which can widen the communication gap between primary and secondary care.

Consultant Feedback - Finally, a junior doctor in London writes in about the '360 feedback' which doctors are required to fill out every 4 months, where at least 2 respondents must be consultants. At first I thought this was going to be a moan about feedback but actually he makes the point - when do the juniors get the opportunity to feed back to the consultants? Perhaps junior doctors should become involved in feedback about consultants from time to time - I think this sounds reasonable!