slightlymoving

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i spend a fair bit of time on twitter. not quite a power user, but enough that it’s my regular social media platform of choice.

i’m also interested in the use of social media in healthcare, and participate in a weekly chat (when i’m not working!) on Sunday evenings that uses the #hcsmanz tag. join in if you’re interested.

i just stumbled - actually i think it was via Quora - onto a recent live tweeting of a surgery via a blog post from the friend of the son of the patient involved in the surgery. you can read the post here. it gives a secondhand, yet very direct, account of the reasons why a patient would allow such access to a private medical matter. to put it simply, they were: 1) supporting the hospital, who has supported them. 2) wanting realtime updates about progress for family members. 3) because it made them feel less concerned (you wouldn’t tweet something that had a high risk of going wrong)

and i just keep thinking about what the tweets would have looked like if things had gone wrong. scary.

you can read the all the tweets from the surgery on slideshare.

now reportedly the impetus behind tweeting the event was in the interest of raising health awareness - March being National Kidney Month in the US. i guess this does allow more people access to information - and raise the issue of renal health. it also allows people some insight into the process involved in removing part of a kidney. and it was all done with the consent of the patient, of course.

at the same time though, it’s clearly cross promotional. the Da Vinci robot gets a gurnsey, as does the hospital and the surgeon involved. i’m not particularly concerned about promoting services on social media, but i do wonder about the approach to making this happen (consent and transparency - did it make the surgery free? was there coercion?) and the impact on future patients. not all patients are good candidates for surgery, yet here a successful operation using a particular device is given wide promotion. does this create a demand for unwarranted surgery? or increased expectation about outcomes?

i actually really like the approach, and recall a TV show where a cardiac surgeon was taking questions live - people could tweet in and he would answer their questions.

i wonder if anyone is tracking/analysing/recording data around these sort of twitter events and their impact as health interventions? would be very difficult to measure.

make sure you check out the photo of the surgeon with his twitter handle embroidered onto his scrubs. there’s a market there… or maybe QR codes on scrubs would be easier. :)

seesaw

last year i had an interview in Panacea, the Australian Medical Students’ Association magazine, it was for being awarded the inaugural National Student Award.

they emailed me a set of questions and i wrote answers then they sent me an edit for final corrections. very nice really. but some of it didn’t get in - probably because i waffle too much.

i thought i’d post some of the questions and answers here. then people (the 3 people who actually read this - hi mum) can accuse me of blowing my own trumpet. which i do, given i’m a trumpet player. or was, during my first degree.

anyway, after that rambling intro, here’s what i had about the whole work life balance issue which people harp on about a lot.

AMSA: As a person with very diverse interests what advice would you offer to junior medical students to help them maintain a good work life balance?

David: The phrase “work life balance” gets used a lot, but I feel like the focus should actually be on “life balance”. I think balance in our lives is predicated on finding sustenance in what we do. Work and study can be sustaining, as can family, sport, art and many other hobbies. Each aspect of our lives can feed into and support the others, and giving our many interests, including work, some attention or space can recharge us and help to maintain our energy levels.

I strongly believe that getting involved – in student groups, in sports groups, in research, in tutoring, in medical forums - and contributing to something that interests you provides sustenance in the long run. I think a quote from Sir William Osler sums things up nicely, “We are here to add what we can to life, not to get what we can from life.”

i sound serious don’t i.

keep on learning

I’m not sure I’ve written here before about Life in the Fast Lane.

But I should have.

Such a great resource for junior doctors. And not so junior doctors as well.

Tonight, while on night shift, I’ve been reading a post about the 6 true emergencies, which is gold for new docs. Of course we get taught about approaches to MET calls and following the ACLS guidelines in an arrest - and i’m sure everyone has a way of remembering the Hs and Ts to find reversible causes of arrest - but this post makes it even more straightforward for determining emergency treatment.

1. Is the airway obstructed?
2. Is there a tension pneumothorax?
3. Do they have a ventricular dysrhythmia?
4. Are they bleeding out?
5. Do they have a pericardial tamponade?
6. Are they hypoglycaemic?

These 6 things all require immediate treatment/management - everything else can be a little more leisurely. What is great about the post though is that for each condition they’ve given a guide to prevalence (how likely is it going to be this), the basic problem and solution, how long it takes to address, and the difficulty. Like I said, gold for the new doctor.

The one thing it doesn’t mention, and I think it’d always worth remembering, is that in any emergency situation you’re never alone. Always ask for help, and always work with the other healthcare professionals who are there. Particularly as a junior doctor.

Book Review: The Pen & the Stethoscope

Edited by Leah Kaminsky, Scribe Publications 2010.

I recently received this book as a graduation present from some old friends, and just on reading the cover jacket I was pleasantly surprised to see such an exciting collection of authors, ranging from the multi-award winning Atul Gawande (surgeon and writer for the New Yorker), through household name neurologist Oliver Sacks (author of Awakenings, Seeing Voices, and many other books) to our very own poet Peter Goldsworthy (who received an Order of Australia in 2010 for his services to literature).

Alongside these heavyweight authors there are another 12 highly respected authors whose medical practice varies from General Practice to ENT Surgery, including the editor Leah Kaminsky.

In this collection Kaminsky has divided the writing into fiction and non-fiction categories and starts with Gawande’s essay from The New Yorker “The Checklist”. This essay formed the starting point for his current novel (and New York Times Bestseller) The Checklist Manifesto. As an entry into this collection, which seeks to “look behind the doctor’s mask”, it is a treatise on innovation that looks at the barriers of arrogance and traditional reliance on “expert audacity” in medical practice. Through stories about his own patients and reflections on research both within and outside of medicine, he explores the increasing complexity and responsibilities doctors are dealing with and the difficulty in making systematic changes that are clearly in the best interests of patients.

Other pieces in the non-fiction category give pause for consideration and reflection. For those of us entering the profession Sandeep Jauhar describes the issues faced as an Intern, and Perri Klass encounters the guilt of being responsible for spreading pertussis while continuing to work through sickness. Danielle Ofri writes of her experiences in ICU, probing the pointlessness and waste of resources that can occur with some treatment, while ultimately driving towards the struggles that can overwhelm doctors, with the saddest and most hopeless of consequences.

The non-fiction section gives a human insight into the practice of medicine; of the fallibility, the passion, the hierarchy, the commitment and discipline, and the demands and rewards of being a doctor. It also gives just a small taste of each of the different authors. This is both a strength and a weakness - at times I felt disappointed at the brevity of the texts, yet I was also pleased to be introduced to so many new (to me) authors. Many of the pieces were extracts from longer text, which gave the effect of being slightly out of context. In one, The Nazi Doctors by Robert Jay Lifton, there is such extreme editing and lack of detail that the power of the concepts is lost almost completely.

In contrast, the fiction stories seem to be able to stand well on their own - and most are short, well-formed, complete stories in their own right. These stories forge headstrong into the complexities of the human condition. Dealing with concepts of ageing and sickness, obsession and experimentation, loss and grieving, absurdity and horror, this section of the collection I found emotionally moving numerous times. There is variance in the quality of the writing - all of it is of a high standard, but not all of it communicates with the same strength and clarity. The short format though, is ideal for teasing out an idea and allowing a reader to ponder further about the characters involved. Unlike the non-fiction section, I didn’t find myself wanting more from the fiction stories.

This collection is startling for the high quality authorship, the honesty, the diverse topics, and the insight it provides into the experiences of doctors across a range of fields. It is likely to find an audience in both medical professionals and the general public alike. Indeed, it deserves a wide readership. Personally, I would recommend it to doctors to read as a reminder of the impact of the responsibility they carry each and every day, and of emotional quotient present in every interaction with a patient. There is also the possibility for inspiration, of thinking about better ways to practice and better ways to live. And finally, if nothing else, it may introduce you to a new author whose work resonates with your own thinking.

into the body

i’ve just been playing with google’s new body browser.

head over to http://bodybrowser.googlelabs.com/ to have a play yourself. you need a recent browser that supports WebGL and the first page will let you know of some options. i downloaded the Chrome beta as i figured it’d be optimised to work with another google product.

after a relatively short loading time you’re presented with a female body in anatomical position. you then have the ability to rotate in 3D and zoom in or out - the interface is similar to Google Earth and plenty of other 3D apps. you can then use a slider to remove the layers - from skin down through muscle, organs and bones, all the way to nerves. in fact, it was a nice little touch to have the nerve roots on the spinal cord be made up of individual nerve bunches.

you can also select to run each of the major groups in differing opacities - so you can highlight just the bones and vessels for instance.

while browsing the body you can also select any object to bring up a label of the name of that part. there is plenty of detail for a medical student level - for gross anatomy at least. i was a bit disappointed that i couldn’t get a good inferior view of the brainstem and base of the brain or of the circle of willis (although to be fair at least you could get labels for the component parts - see the image).

the other really excellent feature is the search bar. you can simply type in any part of the body and it will create a list (if your spelling is not quite right) and zoom you to the location. sadly it didn’t recognise the Great Vein of Galen, or the clitoris - in fact no parts of the external genitalia are included. not even the vulva gets a mention. perhaps they’re hoping to discourage the more prurient users… (as an aside, this wouldn’t be the first time that female genital anatomy got revised)

but really, all in all the bodybrowser is quite remarkable - and being in beta means there’s still more to come.

at this stage it’s an excellent resource for patient education and for students to have another tool for reinforcing their gross anatomy.

christmas pause

it’s not quite the end of the year.

but i’m sitting here, in a reflective mode, thinking about the last four years.

studying medicine has been a bit of an endurance test. i’m wondering if practicing it will be the same. i’m not expecting it all to be, but i am wary of the bureaucracy of hospital systems and the glacial speed in which change occurs in such settings. i’m sure some resilience and capacity for enduring will be necessary.

the majority of the content of medical school is not particularly intellectual - some areas are of course, but most medical schools aim to produce safe and competent interns, not exceptionally intellectually gifted doctors. and this is a good thing. the difficult part of medical school is really to do with the amount of material that has to be studied. if you can pass an undergrad degree (any degree really) and can be diligent in your studies, you can get through medical school. accepting that there’s a limitless amount of information out there, and knowing where your own limits are in terms of knowledge are both important aspects to becoming a doctor.

recently i was speaking with the partner of a first year registrar about graduating (although he was not in health, he has some perspective on studying medicine through his partner) and the mix of art and science in medicine. he was very firmly of the belief that the main approach as a doctor comes from a rigid scientific algorithmic type of model - where the absolutes of knowledge are drawn to bear on the specific patient you’re dealing with. he said this in response to my claim of the benefits of having a generalist arts degree in being able to communicate well and to be able to deal with ambiguity - and that medicine had far more shades of grey than it is thought to have.

of course, it’s vitally important to have understanding of scientific principles and concrete (or as concrete as possible) understandings of pathophysiology and the mechanism behind treatment, yet this all fails to be of much benefit if there is no engagement with the more unknown/subtler/qualitative aspects of the patient and their disease or condition. this is partly because the science is still not finished.

pharmacogenomics is a burgeoning field that will change many treatment options in the decades to come - but right now, there are drugs we use that don’t work in certain people because of their genes - or have a reduced effect. tamoxifen (used in treatment for specific types of hormone receptor positive breast cancer) is converted to endoxifen (the active substance) in the body by a particular enzyme. the gene that is responsible for this enzyme can have a single nucleotide polymorphism that reduces the metabolism of tamoxifen to endoxifen - thus limiting the efficacy of the treatment and increasing the risk of recurrence. it’s now possible to test for the gene responsible (although the evidence doesn’t suggest this is best practice) and thereby determine if that treatment is worth using or not. this has only come to light in the last few years. imagine how many other drugs may not be functioning as we expect because of yet to be discovered/understood gene interactions.

there was a study recently that examined placebo - but did so by letting the patients know that they were taking a placebo - and still found a significant benefit to using placebo (and yes, it was a small study, but this just indicated the need for more research). alongside this are studies showing the importance of the doctor patient relationship in outcomes.

and then i think of the choices people come to - being able to help a patient decide about pursuing treatment (with all the associated side-effects) or allowing the natural progression of their disease to follow through. the sorts of skills to deal with these issues are not found in didactic and rote learning or rigid algorithmic models. these require the ability to listen, to discuss, to question and to allow time to understand what people need.

i hope the next few years will see me finding a path that straddles the art and science, and allows me to develop my skills and knowledge in both areas.