Spring Cleaning

Judging by my desk, I think it is safe to say that everything needs to be tidied up once in a while, if only to restore function. It was high time that this blog was sharpened up, and put into some semblence of focus.

And in a more appropriate way of reorganising something, that means to start from the ground up again; most of the posts were horrendous, trite wafflings of an over stressed, naive, student. Some of them were useful, and so remain. Things that weren't wholly relevant to a running commentary on the state of play in medical education in this country have been deleted, in a vague attempt to get back to some sort of message.

The three posts that remain, post-purge, are useful as a reminder for those that follow after. A dutuful reader would remember that the OSCEs usually change some things around, but in the early clinical years - at least - they aren't going to throw in the huge surprise. Patients are stable, with clear signs. Actors are simply that - and have a script. Just jump through the hoops and you should be set.

Whether or not this becomes a Dr Rant-esque site, or attempts to bridge the divide between the vehement and the reasoned, remains to be seen. Given the way my medical school - as an entity - continues to be one of the more poorly organised groups of professionals, it is only a matter of time, one feels, before this site is overtaken by the vitriolic and the desperate.

Having said all of that, it must countered by the fact that this is an opportunity to refresh one's outlook on the future.

OSCE (2)

Neurology, Orthopaedics, & Psychiatry:

• Lower Limb Exam
• Lower Limb Present &Viva
• Antidepressants discussion with patient
• X-ray - OA hip.
• Alcohol Hx
• Alcohol Presentation and Viva
• Shoulder Exam
• History Lower back pain
• Present Histroy Lower back Pain
• Ethics of homicidal patient
• Hand exam
• Panic Disorder Viva
• Psychotic symptoms Viva
• ???

A weekend at work

Lets call the man Bob.

Bob is 68 years old, and has been going to my church since before I moved to the area. I haven't really spent any time talking to him before today. Bob collapsed today in church, during the sermon.

My church is lucky, in the way that it has a resident GP, and a Sister as well. So when Bob collapsed during the sermon (one of the minister's more entertaining ones, in all honesty), there was a team of people to look after him.

I wasn't the first up to help, though when I did, the doctor took a step back, and basically let me run the first aid. Bob was talking, probably suffering from his "funny do's, doc, going to hospital tomorrow". He just keeled over, pale and clammy, and very quickly recovered. The fact that he was talking immediately made me jump through the ABC, and I started to feel more in control of the situation. Having a senior partner at a GP surgery as back up is obviously a nice safety net to have as a med student, starting to get more confidence in treating a new casualty.

After we got him sorted out, he had a second funny turn, and from sitting and talking to me (Pulse 60, Cap refill <2sec),> like a vaso-vagal episode, which Bob was due for testing for in the Cardiology department the next day.

Looks like Bob is getting his tests early, this time as an inpatient.

Politics anyone?

One of my friends is a Conservative.

Gone are the days where one would commiserate the fact, and share a sad glance, preparing a political intervention in order to save them from a life of solitude and ridicule. Indeed no.

In my "West Wing" addiction, I have seen art imitate life (Santos based on Obama), and life imitate art (my friend making a political mistake on a blog that caused some strife). Labour have had 11 years to turn around the Post-Thatcher quagmire, to build steadily in an economically plush environment. The Blair years seemed, to me, as a child growing up with no other interest in the world than whether Lancashire would finally win the County Championship.

However, many blogs are highlighting the mess that the NHS is in, from GPs to hospital staff. With that in mind, I searched the Parties websites, looking for a manifesto, or some basis for the changes that have been foisted on healthcare in the UK.

The Conservatives didn't have a "The Manifesto" page, but various "trendy" areas of a site designed to look good. Who knows if there is substance to their NHYes campaign, or whether it is purely a PR stunt. Given the catchy quote from the website:

Labour's financial mismanagement has encouraged a culture of profligacy and waste within the NHS. The number of managers in the NHS is increasing almost three times as fast as the number of doctors and nurses. There are now 264,012 administrators in the NHS, compared to 175,646 beds. In the last year alone, 5,000 more administrators than nurses were recruited. By 2004-05 the extra cost of employing NHS administrators was almost £1.6 billion a year more in real terms than it was in 1999-2000.

Its hard to say what is more shocking - that the Conservatives, those well known champions of socialised healthcare, would be supporting the NHS; or that the NHS has more managers than Beds. Soon enough it won't have enough trained consultants, but thats another matter. What do these administrators do? The new computer system for clinicians should not be accessed by these people, so what will they administer? Letters? Appointments? NHS Direct? Or is it as I have seen on the wards, where the administrators have little ability to do anything without a protocol - even taking a referral to put it onto the computer system (that they, as aforementioned, aren't supposed to be able to access).

I have a friend, he is a paid up Labour member. He has a more lax view of things - accepting that theres many areas that could be improved in the NHS, but lacking clear ideas on how to fix them. Given that he is one of the smartest minds of his generation, like Sam Seaborn, I think we are in trouble.

Ideally, healthcare should be free, and the best care should be given to everyone, with access given to anyone who needs it, when they need it. Unfortunately, doctors and nurses need sleep, so one person wouldn't be enough for the task. That said, those people on the wards, on the shop floor as it were, are the people to organise and deliver that healthcare. Why do they need fifteen levels of middle management before they can get a box of needles for venepuncture? Maybe we should look back to why the NHS was put in place to start with!


Idea - let a Sister organise the wards - heaven knows that they know how to - and leave the doctoring to doctors. Lets save the NHS some money to put towards useful (but expensive) medication by reducing the red tape and hoops that the clinical staff need to get through. Let the NHS be ideal, rather than a quagmire of rushed through half-fixes. Let it be a testament to ability!

The future of the Primary Care?

Its been a few weeks since I've had time to update this blog, but now exams are finished - and almost returned to us 6 weeks after we marked the lottery card that is an MCQ answer sheet - and the next module has started in earnest, I think I need to comment on the current stories surrounding General Practice in the UK; After all, HMG want me to become a GP when I qualify, don't they?

The Furore has long standing roots, with the Governement's previous, accepted, contract proposal finally agreeing payment for the hours that a GP actually works, and limiting the hours too - making a life as a GP more enticing to my colleagues in the medical school system, and making general practice a valid career choice for the future. Sadly, the Government decided that they have given too much away, and now are negotiating with the GPs in a bind - asking for 3 extra hours of service, but suggesting a £1.something per patient payment. The reason - if there is one - is to allow patients to access a GP during current closed time and is a decent goal, in theory. The problem exists when you consider the problems that it would cause.

Longer opening hours means that a GP practice could be open from 0730-2100, increased from 0730-1800. In reality, normal hours run on longer than 1800 anyway - with doctors rightly ignoring the "10 minute consultation" guideline when the case guides them, causing overrunning of the apoointments. On my GP placement last week, the GP was billed to finish at 1730, and I left the building before the last patient went in, at 1830.

The point is to allow follow up appointments when a patient can easily access the surgery, at a time that suits them. If we take hospital outpatients, we do not hear the clamour of "you get paid too much for too little!" - though that, surely, is the next step in this overspinned political farce. Nor do we hear complaints that a patient with a chronic condition had to miss work to have a follow up appointment.

Last time I checked, a Out Patient Department (OPD) employed consultants and juniors; and some of the conditions could be well-managed in the GP practice. Why, then, does the country expect so much leeway from GPs? They see a more senior doctor, more often, than in OPD (where its feasible to see junior doctors (SHOs and SpR) for years before consultant review). How dare the general physician even contemplate having normal working hours for himself?

The danger is that GPs will be forced into this new contract, and find themselves needing to sub-contract the work out to non-specialist, non medically trained pharmacists and nurse practioners working from rigid protocols, and this has already caused problems in patient care.

As a medical student I have had numerous placements in "GP-land" as its lovingly called, and I have seen for myself the dangers of Pharmacists being involved in a clincal decision making capacity.

The incident involved a telephone consultation during a face to face with a different patient (good practice, or just normal? Sadly I think it was incompetent.). The pharmacist then prescribed a dose of benzo's without access to notes or previous prescriptions, leading to a 10x increase of the dose in a weening addict. Two years of work undone by bad clinical practice, right there.

From my portfolio, "Critical incident"

The sad future of medicine is that Medical students are constanty being palmed off onto "associate specialist consultants" - be they nurses, physios, OT, midwives, pharmacists - and not getting the clinical exposure that we need to be able to function on day one as a houseman.

I've seen some medical students speak out against GPs and the current workload - suggesting that GPs do not work for their money - but I heartily disagree, especially when on placement I see doctors working 0800-1800 without pause for lunch or dinner, seeing 20 patients in morning surgery, 5 house visits and conducting the ward round in the local community hospital, followed by a full evening surgery.

In 4 different GP placements I have yet to see a GP resting on his laurels, counting his cash. Instead I have constantly seen professional doctors working tirelessly for their patients, spending as much time as they can with each and every one in a vain effort to convince them that they are not just another person on a conveyor belt in General Practice.