Friday, 24 July 2015

I'm A Paeds FY1... Get Me Out of Here!

With the much anticipated first Wednesday in August (for non-UK/non-hospital based folks, that's when all the junior doctors change jobs and our shiny new colleagues start their first roles as qualified doctors) fast approaching, I'm breaking from the EBM theme to write a #tipsfornewdocs type post for those who will be starting out in the crazy, scary, exciting world of paediatrics. I never actually did a paediatric rotation in FY1 but over the past year or so I've worked with numerous FY1 colleagues, some of them excellent and some of them a little less so. This is basically a list of the things I think really make the difference between the good ones and the rest.

If you're starting your first job as a doctor on paediatrics, lucky you! Whilst a lot of people are naturally anxious about working with children (yes, some of them are quite small, and they can be sticky and noisy, and worse than that, they come with parents attached!) you'll be working in a very well-supported environment with, on the whole, a very approachable group of senior colleagues. No one will expect you to be cannulating neonates or taking bloods from chunky toddlers on your first day! You also have the benefit, if you start in August, of working in a specialty with quite marked seasonal variation in admissions, so over the summer it should be relatively quiet on the wards and you'll have time to get your head around how things work before the winter chaos commences!

Paediatrics is a lovely, varied specialty with lots to learn. How much you do in terms of venepuncture, cannulation etc is largely up to you - if you aren't comfortable, no one will make you do it, but if you're keen then the SHOs and registrars will be more than happy to teach you. There should be lots of opportunity for getting involved in audit, if that's your sort of thing, and there's usually some kind of research going on if that's what interests you. So what makes a great paediatric FY1?

Be organised. This goes for every FY1 job out there, to be honest. If you know who your patients are, what's going on with them and when they might get home, you'll probably not go far wrong. If you know a patient might go home, get started on their discharge paperwork early. This is great for your patients, as it means they have less of a wait between being told they're fit for discharge and actually getting to go home. It also keeps the nurses happy, and frankly keeping the nurses on your side is one of the biggest things you can do to help yourself survive as a junior doctor!

Be interested. I get it, not everyone is keen on kids. For some of you, paediatrics will probably be your worst nightmare. We all do at least one job during our training we are not remotely keen on (FY1 general surgery, in my case), but these jobs still have plenty to teach you. The majority of you will end up having some contact with children during your future training, and even if you have your heart set on geriatrics from day one, there's a lot of opportunity for embracing multi-disciplinary working and improving your communication skills, which will be useful in any future career. You don't have to love it, but please don't treat your rotation as some kind of sentence which must be served.

Be able to spot a sick child. This is the biggest "clinical" thing expected of you if you're going to be involved in assessing children. Hopefully you'll get a chance to see new admissions to the unit and clerk them, as that's probably the best learning opportunity. No one will expect you to correctly diagnose everything you see, but it's important that you can recognise those children who look unwell and need senior review sooner rather than later. There is a really useful website called Spotting the Sick Child, which has elearning modules and videos of what to look out for and is worth doing if you aren't clear what a sick child looks like (you also get a certificate of completion which you can stick in your ePortfolio...). If in doubt, ask. Children can deteriorate quickly so if you aren't comfortable and feel something is wrong, get help sooner rather than later. Management priorities for someone acutely unwell follow the ABC approach, but you should never be in a situation where you're dealing with this by yourself. The DEFG (don't ever forget glucose) is particularly important in young children as they're prone to hypoglycaemia and it can have serious consequences.

Be friendly. Engaging well with a child can make a huge difference. Not everyone is naturally comfortable with children, but if you can chat about something that interests them, that's a great start. Knowing which characters frequently appear on t-shirts and pyjamas is useful, as clothes are a great starting point for conversation ("oh wow, that's Peppa Pig on your top, is she your favourite?"), as are toys and characters around the room. Frozen and Minions are particularly popular at present. If you can distract a child talking about whether they like Anna or Elsa best or how funny it is when the naughty Minions turn purple, you're much more likely to work out whether they have genuine abdominal tenderness, for example. Hi-fives after finishing an examination or procedure go down well, and if there are bravery certificates and stickers on the ward these tend to be good bargaining tools if you need to do something the child perceives as unpleasant (including looking at the throat; you would be amazed at just how much kids hate opening their mouths when you ask them to do it!).

Be professional. There's a fine balance between being child-friendly and being silly. Yes, parents want someone who's good with their child and knows how to communicate with them, but they also want a doctor. Being daft when you're examining and chatting to a kid is fine, but make sure when explaining finds and communicating plans to parents that you come across as the knowledgeable professional you are. This also goes for speaking with teenagers, who will be wholly unimpressed if you treat them like children.

Common things are common. Have a basic grasp of the common presentations and how to manage them. A lot of paediatrics is about simple things, done well. Wheeze and fever are probably the 2 most common presentations, so know your local investigation and management guidelines for these. You'll also probably see a a lot of jaundiced babies, rashes and gastroenteritis. If you can take a decent history, examine and work out which kids are the really poorly ones (see earlier point) you won't go far wrong.

Enjoy it! Paediatrics is fun and children are interesting. Plus, where else can you get baby cuddles, play with bubbles and watch cartoons whilst at work?!

Good luck!

Monday, 13 July 2015

Potential Pitfalls in Evidence Based Medicine

In my last post, I talked a bit about why we need to use evidence in medicine. However, much as I support using evidence wherever possible, I can also see that there are a number of things that can go wrong when using EBM approach. Most of these are not due, per se, to EBM, but are down to issues with its implementation. Nonetheless, I think they're worth discussing.

One of the biggest issues with evidence is knowing how to apply it. A study may say something that sound potentially interesting, but it's important to work out whether the result actually applies to the patient sat in front of you before changing your practise. Was the study you're reading carried out exclusively in 50 year old men with high blood pressure but no other co morbidity? That doesn't mean that the 65 year old diabetic women in front of you won't benefit from the intervention studied, but it does mean that the evidence is less applicable to her and you should think carefully about applying it to her case. Lots of studies look at extremely specific groups. This is to reduce the likelihood of "confounding variables" - things other than the intervention which may result in a difference in outcome between study groups. However, the flip side is that the study result may not apply to those who differ from the specific group looked at in the study. It's therefore well worth having a good look at the inclusion criteria for participants in trials and bearing in mind that the results might not automatically apply to all of the patients you see.

A related issue arises when we look at guidelines. Clinical guidelines are available for many, many conditions now, and provide advice on interventions, investigations, referrals etc. In the UK, most of these are issued by The National Institute for Health and Care Excellence and, in Scotland, the Scottish Intercollegiate Guidelines Network. Guidelines are usually devised by a group of professionals appraising the available evidence - basically, they've done the hard work for you and read through all the evidence to determine what the best thing to do is in a number of situations. They will usually reference the evidence they used, should you wish to read it for yourself, and also tell you how strong the evidence is behind each recommendation. However, they are not hard and fast rules, they don't replace clinical decision making and they certainly don't cover every eventuality. Use them, just don't do so without thinking.

An issue it's also worth talking about is the difference between clinically significant and statistically significant. Statistical significance in most medical (and other) science) is usually taken to mean p <0.05. This means that there is less than a 1 in 20 chance that the result occurred by chance; in other words, it's likely that any difference in outcome between groups was down to differences in intervention rather than just being coincidental. Statistical significance is important because it's how we know that our interventions have actually done something. However, this has no reflection on whether the difference in outcome will make any kind of difference to a patients health, well being or long-term risks. This is another important thing to bear in mind before advising or prescribing an intervention based on evidence; will the outcome matter to my patient? An example where this becomes important is when thinking about statins, a group of drugs which lower cholesterol. There is good evidence that (a particular group of) patients who take statins are significantly less likely to suffer a stroke or heart attack within 20 years than those who don't. This sounds great, but if you have an octogenarian sat in front of you, does this really matter? They are unlikely to live another 20 years, so is it worth adding to their drug burden, with all the risks of side effects and drug interactions this brings? I'm not saying don't, just that you should be realistic about what the benefits of this will be to your patient. Maybe discuss the risks and benefits with them and see what they think.

There are other important factors to think about too when looking at a paper/trial/study. Rather than go through all of them, it makes more sense to hand over to the experts at this point. There are really useful study appraisal checklists available on the CASP (Critical Appraisal Skills Programme) website, which guide you through the things you should ask yourself when you're considering the value of a piece of research.

I've hopefully discussed the main issues that occur when trying to implement evidence. In my next post, I plan to talk more about what we actually mean by "evidence" and how we can decide whether one piece of evidence is more or less worth using than another.

Thursday, 9 July 2015

Why We Need Evidence in Medicine

I’m a self-confessed geek. I like learning. I like working things out. I like science. I did a science degree before going to medical school and I spend my spare time on such fun activities as post graduate certificates and systematic reviews. This doesn’t mean that I think of medicine as a science – I think there is definitely an art to lots of what I do – but I do think that it’s important for doctors to have a good understanding of scientific methodology so that they can interpret the vast amount of evidence they are presented with when making clinical decisions.
This is the first in a series of posts about evidence-based medicine. It's deliberately simplistic so that those outside of the medical field can understand it, but I hope it doesn't come across as patronising. The premise of this post is to explain why we need evidence in medicine. In later posts, I'll go on to talk about what constitutes evidence, problems we face in evidence-based medicine and ways in which we can use it to benefit patients.
I’ve heard numerous colleagues tell me that they “aren’t convinced by this evidence based medicine lark”. Their arguments usually centre around the fact that they have seen interventions work before and therefore are happy to use them again. On the surface, this is a reasonable argument. Someone is poorly. You give them some tablets. They get better. Next time you see someone who is poorly in the same way, you give them the same tablets. They get better too. The problem is, how do you know that they wouldn’t have got better anyway?
Let’s take a common example – a cold. If you have a cold and you take a course of antibiotics, you’ll probably feel better within 2-3 days. However, if you don’t take the antibiotics, you’ll also feel better in the same amount of time. That’s just how long it takes for a cold to get better, but if you gave every patient with a cold some antibiotics, you’d be forgiven for thinking you had found an excellent treatment. Observations like this are very useful in medicine. They’re the basis of a lot of important discoveries. They just aren’t the be all and end all.
So, how do you work out whether your treatment actually makes a difference? This is where trials come in. In very simple terms, if you want to know whether or not your treatment works, you need to randomly give it to half the people you see with a particular condition and not give it to the other half. If the half who get the treatment get better more quickly than those who don’t, that’s a good indicator that your treatment probably does make a difference. Of course it’s more complicated than that, but that’s the basic premise.
You might ask why I really care about evidence at this stage. After all, in the examples I’ve been giving, the patients all get better. There are two issues that we need to address here. The first one is side effects. No medication is risk free, so before choosing to give it to your patient, you want to be comfortable that the benefits of using it outweigh the risks. If you’d stopped at the first, observational stage, you wouldn’t know that your treatment didn’t offer any benefit over not treating, so you’d be subjecting all your patients to the risk of a treatment that might not actually make them any better. Remember, “first, do no harm”.
The next issue is about multiple treatment options. What happens when two people think their treatment works? We owe it to our patients to give them the best possible treatment, so we need to use trials and evidence to work out which option is “best”. This needs to take into account multiple factors, such as which treatments make more people better, which ones get people better more quickly and which ones have fewest side effects.
This has been a very brief run-down of why we need evidence. Without proper trials etc, we are left guessing whether or not things work and which things work best, and who wants medicine based on guess-work?

Monday, 6 July 2015

Survival Tips For Medical Students

Tonight I noticed a tweet asking for top self-care tips for medical students, and (unsurprisingly) I felt I had too much to say to fit it into 140 characters, so I thought it might be worth a blogpost. Being a medical student is an amazing experience, but it can also be incredibly difficult for lots of reasons. This post isn't supposed to be in any way comprehensive. I'm not an expert, by any stretch. This is just a collection of suggestions and ideas based upon my own experiences and those of people I know.

Work hard.
Medicine is hard work. Most of it isn't intellectually particularly stretching, but there's a vast amount of stuff to learn and the majority of people will have to do a reasonable amount of work to keep on top of it. I'm not advocating becoming a hermit, but going to most of your lectures, showing up on the wards and keeping up with reading will mean exam season is far less stressful. If you have to actually learn everything from scratch, rather than just revise it, you'll be giving yourself a far more difficult task than is necessary.

Play hard.
It's also important to make the most of being a student. Go to toga parties. Play pub golf. Go clubbing whilst dressed as a giant chocolate bar or do garlic and chili body shots from the Med Soc president. Or don't, if you'd rather not. But don't feel like doing an academically demanding degree means you have to  miss out on the student experience. A boss of mine once said "you can resit an exam, but you can't resit a party". I'm not sure that's the most sensible advice, but find a balance that makes you happy. Whether it's partying, music/sports/drama societies, volunteering or just reading novels and watching trashy TV, doing fun stuff is important. Keeping up with friends and enjoying yourself is an essential way of dealing with the stress you will feel from time to time. Speaking of friends, they're really important. Make sure you keep up with those outside of your course, too. Non-medics are brilliant for allowing you to properly relax and giving you a sense of perspective (medic friends are great and can relate to a lot of what you've experienced, but have an awful habit of talking shop so you don't truly escape medicine around them).

But don't forget to sleep.
Seriously, sleep is really important. When you're trying to balance partying and studying, sleep can seem like something you don't have time for, but it's essential. Everything seems worse when you haven't been sleeping well. As a medical student, you've embarked on a pretty awesome journey, but you need to be on top of your game to make the most of it.

Eat well.
OK, so it's boring, but it's another essential. If you're spending long days in lectures and then going out drinking, it can be tempting to sustain yourself on Pot Noodles and Red Bull, but there's no way you'll be at your best if you aren't getting a decent amount of vitamins, minerals, fibre etc. Sorry guys, your Mum is right about this one.

Similar to the above, exercise is useful for both keeping you physically at your peak and helping beat stress. As a naturally lazy person who would rather exercise by lifting a spoon from ice cream tub to mouth than go anywhere near a gym, I totally get that this is not top of some people's agendas, but it's amazing how much more energy you have after a swim or run. Even a brisk walk around the block is better than nothing.

Sometimes you will see things that really resonate with you and upset you. This is absolutely OK. Allow yourself to be upset. Talk to a friend. Have a cry. I still get upset about cases from years ago (such as this one), Remember that if there ever comes a time when sad things don't bother you in the slightest, you probably want to think about a change of career.

Take a break.
OK, so this might go a little against what I said earlier about working hard, but it's important. Sometimes, things will get on top of you (see previous point). You might be unwell. You will have stressors in your life outside of medicine. If you're struggling, give yourself permission to take a sick day. There's no point dragging yourself in when you aren't going to be properly concentrating. Doctors are absolutely terrible for going into work when they're unwell. It does noone any favours. Learn now to spot when you aren't well and sort it out early. Even if you're cruising along fine, don't spend more time working than you have to. If your registrar says you can leave early, do. Don't spend the holidays in the library. Having time off is vital to your emotional and physical well being.

Don't let the b*st*rds grind you down.
There are horrible people everywhere. Some of them will be in your year, some will be your seniors, some will be non-medical colleagues. Giving you a dressing down if you're rude or you really don't know your stuff is fine, but nobody should be bullying you. If they are, report it. Snide remarks, sniggering behind your back, deliberately telling you lies about teaching sessions or criticising your appearance or personality is not acceptable. People who do this are, frankly, arseholes. They're probably covering up their own insecurities by pointing out yours. They may well be jealous of how awesome you are. Either way, it's not cool. Don't let it get to you. (But if you're actually being bullied, tell someone. There is help to stop this kind of thing from happening.)

Be the best you you can, not a second-rate someone else.
This is more general life advice I suppose, but in medical school where you're surrounded by brilliant people it's easy to constantly compare yourself to other people. Try not to. The people who may seem the best at uni are not necessarily the ones who make the best doctors. Focus on your weaknesses, by all means, and work on improving them, but don't assume that anyone who really understands the kidneys or can do a super-slick neuro exam is better than you at everything. Maybe you have a really lovely manner with confused old ladies or perhaps you know intricate details of the coagulation cascade. Whatever it is, you'll have something you're awesome at too. Remember what it is you do well, feel proud of it, and work on improving other stuff so that you become the best doctor you can be, not so that you can beat someone else in an exam.

That's a very brief run-down, but those would be my top "survival" tips. Most of all, remember to enjoy it. You're on your way to doing the best job in the world, and you're going to be awesome at it.