Whereas I am long past the point where I have realised I can’t know everything, I like to think I’m good at keeping up to date. I keep abreast of the medical literature, attend conferences and tick all of the necessary CME boxes to keep the Medical Council happy. And yet, as I pass the mid point in my professional career, I have a sense that I may have reached a plateau.
I was reassured to read that I’m in good company. Atul Gawande, surgeon and well-known author of the The Checklist Manifesto, seemed to reach a similar peak in his mid-40s. Writing about it in The New Yorker, he describes a levelling-off of what had been steady improvement in his surgical outcomes for years.
Noting the transformative effect that an hour with a tennis coach had on his tennis game, he began to wonder why doctors didn’t use coaches to ‘up their game’ in a medical setting. Top-class athletes and opera singers don’t assume that they have achieved perfection once they finish their initial training, he observed. They are constantly reassessing, tweaking, and improving with the aid of a second pair of eyes and ears. If a tennis player like Rafael Nadal could benefit from a coach, then why couldn’t a doctor?
So Gawande decided to get himself one. He invited a retired general surgeon under whom he had trained to come and spend a morning observing him and coaching him in theatre. The effect was transformative. The 20-minute feedback discussion they had at the end of his operating list gave Gawande “more to consider and work on” than he’d had in the previous five years.
If it’s good enough for Gawande, I thought…
So last month I persuaded a colleague and long-time mentor to come and coach me. Hoping that he would tell me that I had already reached perfection (but also deep down fearing that I would be exposed as an out-of-date charlatan), I invited him to observe me for a morning in clinic. A full morning load was scheduled and the patients were notified in advance that another doctor would be present. There would be no specific agenda — he would give me feedback on anything he thought worthwhile throughout the course of the day.
He sat, much like a school cigire, at the back of the consulting room and remained largely silent, taking notes, occasionally approaching the examination couch to watch as I examined and performed procedures on my patients. This was the first time I had been observed in this way since I was a medical student. A little daunting, but after a while I largely forgot that he was there.
After lunch, he gave some feedback.
His most interesting observations related to my consultation style and the pace of the interaction. I have become very skilled (like many of us) at ‘keeping things moving’. As a result, I tend to leave almost no time for pause or reflection. Pauses, we agreed, allow us time to step back into ourselves, to try to re-gather a degree of objectivity after periods of more intense engagement during a consultation. Pauses also, of course, allow our patients time to gather their own thoughts and formulate questions. Missed opportunities to do so included the potentially quiet moments while a patient dressed or undressed, during a physical exam, or while washing my hands.
Additionally, whereas I always review patient notes immediately before I see them, this can be a slightly rushed affair when running behind. This results in an air of distractedness as I alternate my attention between my patient and the computerised medical record to double-check information. A suggestion to read through the notes of all patients before the clinic starts was made, allowing a more thorough assessment and freeing-up some time during the consultation.
I also received feedback on my examination technique, on my use of imaging (a tendency to over-rely on imaging findings in making certain diagnoses), my injection technique (“less stabbing, more distraction”), and the language I use to reassure patients (some patients require more of a ‘you will be fine’ approach than a ‘you’ll probably be okay’ one). We also discussed work-life balance, the redemptive powers of hard work, debt, death (ours) and planning for retirement.
It was hugely rewarding and fulfilling, a unique opportunity to get feedback from a peer and I’d be happy to recommend it.
Although at this stage of my career I’m not in this to win any competitions, it is still nice to aspire to an occasional personal best.
Anyone for tennis?
Note: Thanks to the ever-wise Dr Maurice Barry, Consultant Rheumatologist, Connolly Hospital, Blanchardstown, for his time and counsel.
This article originally appeared in The Medical Independent
Sheridan’s cheesemongers is one of my favourite places to visit on a Saturday morning. It’s a beautiful shop in the market area of Galway city, with an impressive selection from the best cheese makers from Ireland and Europe. In cheese terms, the possibilities of Sheridan’s are almost boundless.
I have been a visitor to the shop on many occasions over the years, and, with Seamus Sheridan’s help, have extended my cheese knowledge beyond the Babybels and Easy Singles of my childhood.
All the same, the feeling of excitement I get on entering the shop is often accompanied by a level of anxiety as I approach the counter. We’re having some people round for dinner and I have to select something for after the meal. What’s the name of the cheese I had the last time? Is it meant to smell like that? Is it ok just to just get some Cheddar? Will I choose that Gubeen cheese or a Milleens from Cork, a Manchego from Spain, an Azeitão from Portugal or one of the many other dozens of cheese on display? It’s hard not to be overwhelmed.
Sometimes, I wish someone would make my mind up for me.
What would you say is the most commonly missed fracture? You would be forgiven (even as an orthopaedic surgeon) for getting the answer wrong. It is not, as you might have speculated, a missed scaphoid fracture, vertebral fracture or even a Greenstick fracture.
It is the SECOND fracture.
The tendency to ‘call off the search’ (in medicine and in procedural cop shows alike) after you have already found what you were looking for, leads to a common error of cognition called ‘premature closure’. Cognitive errors of this type play a part in up to 75 per cent of medical misdiagnoses and are largely due to either faulty data gathering or faulty information processing. Errors due to deficiencies in medical knowledge are a much less common cause of misdiagnosis. The problem it seems is not a case of ‘not knowing’, but of ‘not seeing’.
Read the rest at the Medical Independent
“All of humanity’s problems stem from man’s inability to sit quietly in a room alone”.
So said Blaise Pascal way back in the sixteen hundreds.
Last month, to the great amusement of some of my surgical colleagues, I attended a meditation workshop at the Royal College of Physicians of Ireland. It was delivered by Brother Laurence Freeman, a Benedictine monk and world leader in the practice of meditation.
Left to themselves, our minds tend to wander, continually reminiscing and ruminating about the past, anticipating and planning thefuture. When moments present themselves where we might have the opportunity to pause, there are now almost infinite ways of distracting ourselves using new technologies. The net result is that the present moment tends to get squeezed out. Therefore we tend to live in a state, Brother Freeman describes, of imperceptible disconnectedness. This lack of situational awareness may even lead to medical errors – one of the reasons that the “art of paying attention” is receiving so much attention in medical quality and safety circles.
Despite the fact that herbal cannabis is being used by many patients for arthritis symptom relief, and although the medical use of cannabis has been legalised in certain countries, most doctors (including me) know very little about the subject.
This years American College of Rheumatology meeting included an excellent and timely update which could be summarised as follows;
Lab based research
There is some evidence to suggest that cannabis derived substances (cannabinoids) may alter certain types of pain response, and reduce some of the immune response, in animal models of arthritis. Altering the processing of ‘endocannabinoids’ (substances which are made naturally in response to pain) may also alter the response to pain in this setting.
Despite this promising evidence from the laboratory, no good quality research (a randomised controlled trial) has yet been performed using herbal cannabis in humans. There have been a couple of small, uncontrolled studies which have suggested possible improvements in certain arthritis symptoms (pain and sleep for example) but with significant side effects (see below).
Part of the problem is that herbal cannabis contains over 60 cannabinoids (and hundreds of other compounds) and it is not yet certain which of these might be effective. Also, the strength of these components varies widely between products and their absorption varies considerably from person to person. Thus far, it hasn’t been possible to separate the analgesic properties from the psycho-active ones.
A more targeted approach has involved the use of certain subtypes of synthetic cannabinoids.
Rheumatoid arthritis and Fibromyalgia
Studies performed using these compounds in rheumatoid arthritis (an oral spray called Nabiximols – containing the cannabinoids, THC and cannabidiol) and in fibromyalgia (an oral preparation known as Nabilone) resulted in some improvement in pain and sleep but were still associated with significant side effects – especially drowsiness. These formulations are not licensed for the treatment of arthritis pain but are available in certain countries for the treatment of other conditions (such as MS and neuropathic pain).
Whereas there is a common perception that smoking or ingesting cannabis is relatively safe, information presented at the meeting suggests that regular use can result in significant side effects which are listed below.
Cannabis results drowsiness, reduced short term memory, selective attention and reduced reaction times for up to 5 hours after using. Whereas this may not be perceived as a problem for recreational users, it may pose significant problems for those using cannabis regularly for pain relief who want to drive. Use of cannabis doubles the risk of dying in a road traffic accident, and is the most commonly used drug in up to 7.6% of people seriously injured in motor accidents.
Smoked or ingested cannabis can cause hypotension (low blood pressure) and increases the risk of having a myocardial infarction by a factor of five. For those who already have angina, it reduces exercise capacity by 50%. There is evidence suggest that regular cannabis smoking doubles the risk of lung cancer and may damage the lungs over time (especially regular use begins earlier in life).
Whereas cannabis can reduce the symptoms of anxiety in some, it can cause anxiety or depression in others. This is particularly true in those with either a personal history or family history of mental illness.
The Bottom line
Evidence suggests that manipulating the cannabinoid system may be a useful approach for the relief of certain symptoms in rheumatic disease but the session concluded that more research should be done to clarify the mechanisms of these effects.
This risk benefit profile of inhaled herbal cannabis indicates that it should not be recommended for the treatment of pain arising from arthritis.
Where used, cannabinoids should be reserved for patients with pain refractory to standard medical treatment.
Pharmacologic preparations are more desirable than largely uncontrolled herbal use.
Who should avoid cannabinoids?
Because of these risks (and others) the presenters suggested that these compounds should be especially avoided in the following;
Young people, especially those under the age of 25 (who are particularly at risk of dependance)
Anyone with a history of psychiatric illness or substance abuse (or those taking another psycho-active drug)
Those with history of cardiac disease or liver disease
Every year around this time, I begin to get excited about travelling to the annual scientific meeting for my specialty in the US. The schoolboy in me sees the journey as a kind of adventure, a grown-up’s version of a school trip abroad. I always pack my bag a little earlier than is necessary, make sure I have got something to read on the trip, and even worry a little about who I will get to sit beside on the plane.
What is not to like? With the blessing of our loved ones, we get to spend a few days alone in a nice hotel in one of America’s better cities and get to catch up with old friends and colleagues. Even better, it is all from the safe moral high ground of medical education. But do we really learn?
Galway hosted Irelands’ first Performing Arts Medicine Conference in October of this year.
The theme of our inaugural conference was the health of musicians. Our panel of speakers included health care practitioners from diverse specialty backgrounds such as Neurology, Psychiatry, Rheumatology, Primary care, Psychology, Anatomy, Occupational Medicine, Occupational therapy, Osteopathy and of course, our patient experts.
I have included a selection of those presentations from the day which focused on the musicians hand.
I hope you enjoy them.
Dr. Fiona Molloy, Consultant Neurophysiologist (Beaumont Hospital) speaks about Hand Dystonia in Musicians.
Katherine Butler, Hand therapist (London Hand Therapy Clinic) speaks about rehabilitation of the musicians hand (with some emphasis on hand dystonia).
Mr Ian Winspur, Consultant Hand surgeon (London) talks about his 25 years experience of surgical aspects of managing the Musicians Hand
Here’s the panel discussion with all 3 experts, chaired by Dr. Juliet Bressan, Director of the Dublin Performing Arts Centre.
Are you a health care professional who has a commerical idea involving technology that could improve health but don’t know where to start ?
Undoubtedly inspired by the enthusiasm (and success) of the entrepreneurs presenting, this was one of the hot topics of discussion at the .Med medical innovation meeting in Dublin this month. Here’s a few of the suggestions that were made by our panel of speakers and from the audience that might help you bring your idea to fruition.
Healthfounders is a a company founded by the inimitable Australian Dr. Johnny Walker. Johnny is a radiologist and successful medical entrepreneur who has built and sold a successful global diagnostics company. He wants to leverage Health Informatics to create compelling personalised digital and mobile solutions for the stakeholders of the wider Healthcare ecosystem. Johnny wants to ‘pour petrol’ on the ideas of medical and health entrepreneurs and ignite their energies.
If you have an idea for a technology that disrupts health, you could do a lot worse than go and have a cup of coffee with Johnny in the Hermitage Clinic.
HealthXL is an accelerator program specifically designed for helping people with ideas for disrupting health with breakthrough technology. They bring people with ideas together with the people who have the necessary expertise to help them ‘accelerate’ those ideas to a point where they are likely to attract investors and customers. The whole programme takes three months.
This program is run by experienced entrepreneurs and backed by leading global health investors, medical professionals and corporates.
I was lucky enough to act as a mentor on the first HealthXL ‘checkup’ weekend where a variety of people (including health care professionals, expert patients, technology startup companies) came along and pitched their ‘raw’ idea to the group. HealthXL is like a combination between the Xfactor (with more nurturing than humiliation although some ‘tough love’ is dispensed) and Dragons den (except the Dragons are nicer). They also serve beer.
HealthXL is funded by a number of sponsors which means that its free of charge to participate in the programme which is based in Trinity development campus.
i360medical is a new, Dublin based, healthcare solutions and medical device innovation company. The principle behind i360medical is to act as an international and national innovation enabler and hub that has the expertise necessary to take new healthcare ideas and medical technologies to market. The company, led by CEO Derek Young, will act as a conduit between healthcare, academic and business, to develop and commercialise new ideas and solutions.
Dr. Philip Gardiner who is a rheumatologist based in Derry was one our speakers. He spoke of how he developed his data glove for rheumatoid arthritis with the assistance of the local translational medicine unit in his local hospital (Altnagelvin Hospital).
Philip says of C-Tric; ‘They are specifically designed to ‘kick-start’ good ideas with funding, facilities and/or to help organise research assistants. They provided some kick start funding to buy our first dataglove (the application for this was really straightforward) – and they have provided advisory support to get us through the various ethics applications. The computing team at UU (Magee) have invested 2 years of PhD work on the project so far which has proved very productive.’ If you have an idea, perhaps one which may require significant clinical research, as well as technological know how and funding, your local translational medicine department may be a good place to start.
If you have an idea for a health related app which could be used by health care professionals, you should speak to Professor Declan Lyons, clinician and founder of Doctot, a technology company which develops ‘mobile tools for health care professionals’. Declan’s company have developed 18 different applications, ranging from tools which allow rapid scoring of clinical outcomes in the clinic. Doctot are very happy to speak to any one working within health who has an idea for mobile health app development.