The practice of Medicine
This is just to let you all know that I have decided to suspend physical appointments in my office for the foreseeable future. These will be replaced, where possible, with video and telephone consultations which have been in place for the last week, and are working well.
I will still be available to provide emergency, in person care, where necessary.
As the spread of the Corona virus in the community deepens, so does the likelihood of being exposed to the virus, particularly to those carrying the virus, who have not yet developed symptoms. This makes it very difficult to identify those at risk of spreading infection.
I have made this difficult decision to to protect all of those under my care, my staff, and myself from unnecessary exposure to the virus, and to assist public health efforts to slow its spread through social distancing.
I also have a duty of care to provide on-going care to existing patients, and I will continue to provide support using video consultations and the phone.
I am also asking all patients with non urgent problems to postpone their visits for the moment. All non-urgent new patient appointments will also be postponed.
This situation will remain in place until April 19th 2020 in the first place. Please check back here for updates.
Where patients need to attend in person, additional special precautions will be taken to protect patients and staff.
Infusion therapies will continue as scheduled but extra precautions are in place. If there is any change to this situation the infusion centre will contact you.
I have a scheduled appointment. Do I need to contact the office?
No. My office will contact you directly to arrange a video or phone appointment, or to reschedule.
I don’t have an appointment but need one. What do I do?
Rest assured the office team are all still working and contactable. The best way to contact the office at the moment is by email on email@example.com (not GDPR compliant but I’ll leave that up to you). The phone has been particularly busy this week so it currently the easiest way to get in touch.
Thanks for your patience and understanding at this difficult time. Stay safe.
Dr. Ronan Kavanagh MD FRCPI
It’s 10pm on a Sunday night and all of my family and I are watching and laughing at Gogglebox on Channel 4. Except for my teenage son, who is upstairs in his bedroom. He is studying hard because he has decided that he wants to be a doctor. He’s started his vocation early — he’s only 14.
I reassure him that he is only in second year and there is still plenty of time. But he has already decided that to do well, certain sacrifices (eg, Gogglebox) need to be made to get him over the line.
It is not like those who choose medicine are the only ones studying hard, but I’m already beginning to notice in him something that I hadn’t noticed about my own life in medicine: how a life in medicine marks us out as different from early on and how it can shape and define us from then.
The competitiveness for places in university is high, which demands a degree of focus, obsessiveness and perfectionism early on in those intent on making it. Those sacrifices will serve my son well but will need to continue throughout university training and post-graduate life if he is going to succeed.
After a few years of being surrounded by other over-achievers, he will probably assume that this is the norm.
His medical school training and life as a junior doctor will shape him further.
Like a novice entering a seminary, he will quickly become accustomed to the costumes, props and rituals that define it. He will be exposed to sleepless nights, illness and death in a way that few of his non-medical friends are, but medical training will encourage in him a degree of objective remove from his patients to help him survive. But he won’t notice because most of his friends will also be doctors.
He will also discover early on that society confers a special value on doctors and aspiring medics. Medical students are celebrated in families and society in a way that novice priests might have been in the past — ‘he’s going to be a doctor, you know’. It is well recognised that even the primitive tribal medicine man (who was also often a priest) was released from the obligation of procuring food for his tribe.
Society needs doctors to be different, and placing us on a pedestal is probably an expression of its need to bestow a kind of magic and infallibility on us. It is part of the way they acquire the necessary trust to surrender themselves to our care. Whereas it might help us get a table in our local restaurant (‘What time would you like to eat, doctor?’), that perceived specialness demands a price.
Doctors are seen by some of their flock, not as the flawed, vulnerable human beings that they are, but as separate, dehumanised, almost God-like versions of themselves. It makes certain people (especially those we have met professionally) behave awkwardly with us socially.
We become a bit like those lonely priests who are greeted exclusively by their title of ‘Father’ — as if they had no name or identity of their own.
Those who embrace their role too seriously (priests and doctors) have to give up part of themselves and will be set up for the inevitable and painful fall from grace when they (and their flock) realise that they’re not as God-like as they thought they were.
Gogglebox is nearly over and I’m tired and want to get to bed early — I have a busy clinic and a couple of important meetings tomorrow. But my wife reminds me that I still have important work to do tonight — tomorrow is bin day.
I call upstairs for my son.
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
The hedonistic lifestyles of certain musicians will be familiar to many readers, but the unexpected dangers of playing a musical instrument may not.
Aware that I have an interest in musicians’ health, last week a medical colleague alerted my attention on Twitter to an interesting article in the October 2013 edition of Der Hautarzt (German dermatology journal), describing a condition I hadn’t heard before of called ‘fiddler’s neck’.
Fiddler’s neck is a condition where the afflicted violin (or viola) player develops an unsightly mark on the neck — just beneath the angle of the jaw. Although not that well recognised among dermatologists, it is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition (of quite different aetiology) seen in teenagers. The abnormality is due to an area hyperpigmentation and lichenification of the skin due to the rubbing of the instrument on the neck (erythema, scaling, cyst formation, scarring and inflammatory papules or pustules also occur). The article describes the development of a ‘violin hickey’ in (an undoubtedly embarrassed) 72-year-old lady.
Reading about this curious affliction prompted a ‘knight’s move’ wander through the literature on instrument-specific afflictions — and there’s lots to choose from.
Violinists who succumb to violinist’s hickey are also, presumably, susceptible to a condition known as ‘fiddler’s jaw’ (a condition akin to temporomandibular joint disorder, which comes about because of the way the violin is ‘clamped’ between the angle of the jaw and the shoulder), ‘fiddler’s finger’ (Garrod’s pads of the dorsal interphalangeal joints of the left index and middle fingers) and ‘pizzicato paronychia’ (infection in the nail-fold in string players secondary to pizzicato playing). A similar condition can also develop in pianists.
‘Fiddler’s neck’ is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition seen in teenagers
Jazz aficionados will immediately recognise the ballooned-cheeked appearance of ‘Satchmo’s syndrome’ in trumpet player ‘Dizzy’ Gillespie. The condition, originally named after Louis ’satchel mouth’ Armstrong, occurs in trumpet players, trombonists and French horn players comes about as a result of rupture of the orbicularis oris muscle (due to high pressures generated while playing high notes). Pressing the hard metal mouthpiece hard against the soft tissues of the lips without warming up can also cause injury; Freddie Hubbard, the well known jazz trumpeter, allegedly tore his lip during an “ill-advised high-note cutting contest” with another trumpeter, according to the Jazz Times in 2009.
Other hidden dangers of playing wind instruments include ‘flautist’s chin’ — a dermatological condition brought about by irritation from saliva and possibly nickel allergy, and ‘clarinetist’s cheilitis’ (perhaps explaining the ubiquity of the ‘jazz goatee’ in certain musicians). The spread of herpes, HPV and hepatitis have also been described due to the use of instruments that have not been cleaned properly (again, much like ‘violin hickey’, other aetiologies may need to be considered).
Both ‘guitarist groin’ (lower-limb DVT due to the pressure of a guitar held in the classical posture for long periods on the flexed thigh) and ‘guitar nipple’ have also been described. The latter is a form of ‘traumatic mastitis’ and was originally described in a letter to the BMJ in 1973. The case series describes a series of younger female guitarists, who all developed a cystic swelling about the base of the nipple. The cause, it seems, was the playing of full-sized guitars (by younger musicians) and direct trauma to the nipple area by the instrument.
Shortly after the ‘guitar nipple’ report was published, the BMJ published a letter describing an intriguing condition known as ‘cello scrotum’. The eight-line letter, published in 1974, describes the case of a professional cellist who developed an inflamed scrotum which, the author suggested, came about as a result of playing the cello for several hours a day.
Whereas the accuracy of the report was later questioned by other commentators (one suggesting that scrotal friction against the supporting chair was more likely to be responsible than direct cello trauma, per se), it was frequently cited in the literature over the years until the original author finally wrote to the BMJ in 2008, admitting that the case had been fabricated. The original letter had actually been signed and submitted by the Chairman of a brewery in Suffolk (the husband of a doctor) as a practical joke — never expecting that it might be published.
Hopefully there’s no practical jokers among the authors of the reports of the other conditions described.
This article was originally published in The Medical Independent
When’s the last time you read a comic?
As a boy I loved reading The Beano and later, like lots of other adolescent boys, immersed myself in the more violent worlds of Action and 2000AD. As a medical student, I became attracted to the subversive allure of Fat Freddy’s Cat, The Fabulous Furry Freak Brothers and then, in my late 20s, to Viz magazine. Then I stopped. Whatever role comics might have played in my childhood and young adulthood, it was time to move on. So why do I find myself, in my early 50s, back reading comics again?
Because of GP and cartoonist called Ian Williams. Williams is responsible for coining the term ‘Graphic Medicine’ which describes, according to the graphicmedicine.org site that he helps run, “the role that comics can play in study and delivery of healthcare”. Williams has also produced a wonderful new semi-autobiographical graphic novel, entitled The Bad Doctor — “a darkly humorous tale of medicine, cycling, obsessive-compulsive disorder and heavy metal”. The book details the life of the flawed (in his own eyes), yet deeply human, Dr Iwan James. This wonderful meditation on medicine, humanity and healing is a great reason to start reading comics all over again.
As soon as the book starts, we are drawn into Dr Iwan’s world and sympathise with him as he hilariously navigates the daily grind of heartsink patients, difficult colleagues, middle age, baldness and self-doubt. It is particularly touching where it deals with his experience of growing up, trying to maintain relationships and work, all while suffering from OCD.
In a scene depicting his childhood, it describes the early development of an exaggerated sense of responsibility for the health of those around him (something many of us will identify with). He even demonstrates how his unique experience of living with an illness can help him to help his patients. In another touching scene in the book, he breaks the usually unspoken boundaries of the doctor-patient relationship by sharing the details of his own illness with a patient struggling to cope with OCD — and in doing so, helps his patient.
Writing comics, and bearing witness to his own problems may also have had a cathartic effect for its author. Writing in The Independent, Williams describes how comics gave him a means to talk about an area of his life he hadn’t, as a doctor, felt able to share before.
“In fact, I almost never discussed them with anyone before finding my voice through the medium of comics, in which I found a way to articulate my own earlier struggle with mental illness.”
The book also details the attitude of his professional colleagues to his mental health problems. When he confides with his practice partner that he has fantasised, throughout his life, about killing himself (“Wouldn’t act on it, though… don’t worry. It’s only a mental habit. I don’t own a gun or a guillotine”), his partner’s primary concern is that this might invalidate the practice insurance.
I read the book three times in 24 hours (although it runs to just over 200 pages, it can be read in 30-to-40 minutes). There is something unique about the reading experience of being pulled along by the combination of the framed pictures, the text and the gaps in between. Using cartoons, he manages to describe Dr Iwan’s world in a way that would have been impossible in the form of an essay or through fiction.
With great bravery, wit and technical skill, Williams has managed pull off a number of impressive feats simultaneously. By digging under the surface of a doctor’s working life in the context of his day-to-day existence, he gives an insight into how the theory of medicine is so different from its practice. He also demonstrates what it is like to live life with a mental health illness, while simultaneously showing an excellent doctor practising good medicine, despite it. All the while keeping us laughing and entertained.
This funny, sometimes sad and courageous book will, I hope, go some way to help non-medical readers to understand the challenges of practicing medicine and show that doctors, like them, are human and suffer.
It might even help a few doctors to think a little differently about mental illness amongst their own.
This article was originally published in The Medical Independent
Last weekend I was rear ended and my sturdy 2006 Volvo V-70, which I had planned on driving for another few years, was written off. As I got out of the car, I became aware that my neck was painful but naturally declined an onlooker’s offer of calling for an ambulance. The embarrassing prospect of being placed in a cervical collar and being presented to an emergency department colleague on a stretcher did not appeal to me. Besides, I had to drop my daughter to a party.
The fact that I might have injured my neck caused some concern (and some mirth) amongst family members, who could still clearly recall my first whiplash injury — almost 40 years earlier. Having sustained what was, in retrospect, a minor neck strain (following a jump from a wall), I awoke the following day with such severe neck pain that my parents were unable to persuade me to get out of bed. The local GP was called, strong painkillers, muscle relaxants and a neck collar were prescribed and over the next few days my home bedroom was gradually converted, my younger brother recalls, into a temporary intensive care unit.
My physical and considerable emotional needs were carefully attended to by my attentive parents, my fluid balance restored with MiWadi infused through a bendy straw and my nutrition maintained with jelly and ice cream. After a time, and once I felt well enough to lift my head from the pillow, I was transferred to a lower-dependency unit located in the family TV room. After a further, lengthy period of rehabilitation, it was considered safe to allow me to return to school. My neck pain continued and over next few years, I would travel around the country see the best physiotherapists, orthopaedic surgeons and rheumatologists in the land. The advice I received from more than one specialist was that I needed to be very careful with my neck, pay extra attention to my posture and avoid contact sport at all costs.
Despite medical interventions (and perhaps precisely because they had stopped), my neck pain eventually settled. The experience, however, has given me a unique insight into my own low threshold for unpleasantness, some understanding of the non-medical dynamics of chronic pain and how completely unaware most of us are of them as sufferers.
It therefore came as a pleasant surprise that my most recent whiplash injury settled down within a few days. Could I have toughened up?
A quick Google search alerted me to a possible explanation for my speedy recovery: Doctors, it appears, are relatively immune to the long-term effects of neck injuries following rear-end collisions. A study by Ferrari published in 2001 examined the effects of whiplash injury in doctors compared to a control population. Doctors developed acute symptoms less frequently than non-doctors and injured doctors settled down more quickly than controls. They were also quicker to return to work after an injury.
The author’s proposal was that the development of chronic neck pain after a road traffic accident is largely culturally and geographically determined and that these factors are much more important than the mechanism and severity of the initial injury. Where there isn’t an expectation of the development of chronic neck pain after an accident, he argued, then it is much less likely to occur.
In ordinary circumstances, Ferrari detailed in his book The Whiplash Encyclopaedia — The Facts and Myths of Whiplash, the often frightening circumstances surrounding the initial management of a neck injury (paramedics, collars, stretchers and EDs) tend to create the impression than the injury is not benign.
The initial lack of response to treatment by various therapists and specialists (where attention is repeatedly drawn to the symptoms), and subsequent frequent misattribution of symptoms to abnormalities seen on imaging, all tend to further amplify and reinforce the apparent seriousness of the injury. The additional influence of compensation, he argued (the MiWadi, jelly and ice cream of my own experience) can lead to worse outcomes. He pointed out that in countries where ‘no-fault compensation’ has been introduced (and where financial compensation for continued suffering was removed), the incidence and severity of chronic symptoms in this setting has improved.
Most people injured in this setting will be oblivious, as I was, to the influence that all of these factors will have on perpetuation of their symptoms.
It makes sense, though, that doctors are less likely, by the nature of their training and knowledge, to be susceptible to these influences, or to be fortunate enough to avoid exposure to them in the first place. Ferrari has also published similar positive and early recovery outcomes in rodeo riders who have been involved in road traffic accidents — another group with an expectation, based on personal experience, that neck sprains are pretty common and will usually settle down.
As I write, I feel a twinge of pain in my neck. Maybe I should have an MRI scan…
This article was originally published in The Medical Independent
In the 1999 movie The Matrix, the story’s hero Neo, played by Keanu Reeves, learns how to slow down time. With special training, our hero’s perception and reflexes become so highly attuned to his environment that he is able to anticipate and dodge bullets, blows and kicks — while remaining unflinchingly calm.
There are days in medicine where we all wish we could be like Neo.
Despite the fact that consultation times have increased over the past few decades, our patients are frequently dissatisfied with the amount of time we spend with them. Increasingly complex and sophisticated medical options and rising patient expectation both dictate that we need more time. But decreased funding and increased pressure to see more patients mean that it’s not always available. The race to keep up has resulted in doctors running faster and faster just to stand still — resulting in what Dr Richard Smith, writing in the BMJ, calls ‘Hamster Healthcare’. It is a style of practice that leads to a reduction in professional (and patient) satisfaction and to burnout.
Whereas one possible solution is to allow enough time for every patient by allocating the necessary resources to do so, this will not be seen as an attractive solution to those paying the bills. An alternative solution to ‘Hamster Healthcare’ will come, according to Smith, from “getting off the wheel, not running faster”. He suggests a fundamental redesign of the practice of medicine to meet the patient needs within the economic constraints that exist. This approach will be music to the ears of those in the Department of Health and health insurers, no doubt.
Technology will help
The creative use of technology in medicine is likely to play a significant role in improving the continuity of care, eg, the use of secure email, text messaging, telemedicine and the use of online communities to share relevant healthcare information and support between visits. By using technology to deal with routine tasks and information-related exchanges, it is hoped that more time can be allocated to more meaningful face-to-face visits, when necessary.
Rethinking the consultation
It has also been suggested that rather than focus on the amount of time spent with patients, we should put some thought into changing how that time is spent. A study of patient satisfaction published in 2002 suggested that a patient preference for “more time” in the consultation correlated with patient dissatisfaction about the “emotional aspects of the consultation”. The study concluded that “a doctor who listens and tries to understand their patient may make the patient feel more satisfied with consultation length and subsequently more motivated to follow any recommendations for change”. This can be a hard task to pull off in 12 minutes, the average duration of a GP visit.
“In our clockwork analogy of the universe, we have an idea of time as something rigid, punctuated and inflexible. This sense of time is reinforced when our care becomes nothing more than a series of tasks.” “But the human experience of time is quite different,” he writes. “In moments of connection, time stands still.”
He also suggests a number of practices which will help us to use our time with patients more effectively; The importance of building a good rapport early in the consultation and of the importance of a good introduction. He advocates the use of mindfulness; the ability to pull our fragmented, distracted selves together to help us pay careful, non-judgemental attention to our patient, and to our reactions to them.
He emphasises the importance of compassion, for ourselves and for our patients, the use of humour and the usefulness of allowing our patients to set their own agenda.
Whereas it is important that we take advantage of whatever technological and metaphysical tricks we can use to maximise the efficiency of our time with our patients, no-one, even Neo, can slow down time.
This article was originally published in The Medical Independent
Sometimes, in an attempt to persuade someone resistant to a particular idea or intervention, the temptation is to push harder.
In medicine, it might be done by addressing any anxieties that our patient might have. When this approach fails, we might even highlight the risks of not taking the advice. Occasionally though, the resistance can’t be overcome.
An alternative approach is to intervene more gently, to stop pushing, or even pull back.
The approach is described in Tao of Leadership, as follows;
“Gentle interventions, if they are clear, overcome rigid resistances. If gentleness fails, try yielding or stepping back altogether. When the leader yields, resistances relax. Generally speaking, the leader’s consciousness sheds more light on what is happening than any number of interventions or explanations. Few leaders realise how much how little will do.”
Doing less to do more. Now there’s an idea.
We can all learn something from Bruce Springsteen.
Even those who aren’t fans of Springsteen’s music will be aware that his live performances, even now that he is in his mid-sixties, are legendary for their duration and for their intensity. He is also extraordinarily articulate and insightful about the psychological process of performance. In an interview with David Remnick for the New Yorker in 2012, he gave some insights into the complex mix of emotions which explain the intensity of his own style of performance;
With all artists, there is a tremendous push toward self-obliteration that occurs onstage. It’s both things: there’s a tremendous finding of the self while also an abandonment of the self at the same time. You are free of yourself for those hours; all the voices in your head are gone. Just gone. There’s no room for them. There’s one voice, the voice you’re speaking in.
Springsteen’s observations about performance will have resonance for those who simultaneously lose and find themselves while caring for others. Healing like music, can act like a drug – with sometimes unintended benefits for the prescriber.