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Last updated: Acute Gastroenteritis (incl C Diff)
on December 16, 2014

Thirty Top Tips

Ten Top Top Tips

1. Asking for help is probably the most important thing a junior doctor must learn
2. If the patient looks unwell, do an ABG
3. Finish the job
4. An incorrect initial diagnosis may be copied
5. Be nice and have the odd break
6. DRUGS & ALLERGIES and DRUGS & ALLERGIES 
7. Take a proper social history
8. Completed referrals clinch diagnoses
9. "Listen to the patient, he is telling you the diagnosis"
10. Quick brief effective communication is a skill
 

PS have you looked at the observations?


1. Ask a senior, don't be afraid. You would not ask a junior co-pilot to land a Jumbo in a snowstorm. So, why should a junior doctor be expected to be able to handle a seriously ill complicated patient, in their first 1-2 years? As a general rule, if in doubt, ask. Make it clear early in the conversation with a senior, what you want (eg telephone advice, or actually to see the patient, and over what time frame). And don''t be afraid to ask that senior back, if you are still concerned. Good senior doctors often ask more senior colleagues for advice. If you are still not happy, don''t be afraid to ask that senior to arrange a second opinion. There is no shame in any of this; no one will laugh at you. It''s better than making a big error, especially in your first 1-2 years of medical life. There are NICE (2007) guidelines concerning acutely ill patients in hospital. Asking for help is probably the most important thing a junior doctor must learn

 

How do you know that you do not know? This may seem a stupid question. But sometimes you are not sure whether you know or do not. This state is not good enough for the public. Ask yourself whether you can explain the diagnosis to the patient. No? Well you do not know enough, so ask. Or .. 

 

 

 Albert Einstein (1879 - 1955)

 

 

“I do not like to state an opinion on a matter unless I know the precise facts.”
Albert Einstein. Quoted in an interview, New York Times, August 12, 1945.

 


2. Do an ABG.
If the patient looks unwell (or might be), do an ABG, especially if you do not know the diagnosis. This will often give you a clue as to the diagnosis. If it does not, it may give you information that will alert a senior to review the patient. There are very few serious acute illnesses, that do not lead to some degree of acid-base balance disturbance, or blood gas disturbance, or electrolyte disturbance or a high lactate. A raised lactate (>1.0 mmol/L) is a concern. A high lactate (>2.0 mmol/L) is bad.
Some think that a normal CRP is a similar screening test. We disagree. You can have an acute MI, or severe asthma, with a normal CRP. Also, the frail elderly often do not mount a good immune response to infection. So, they can be infected with a normal CRP

 

3.  FTJ. Finish the job. An investigation is not an investigation until it is written in the notes, signed, and acted upon. So, if you are going home, it is a good idea to pass it on to a colleague - face-to-face - all the patients that you have assessed. Ask them to: 

           1. follow up all tests you have done, if the result is not yet known;
           2. chase any referrals you have made but not completed;
           3. go back and see any patient you are worried about
           4. check drugs (esp important ones) are given, esp if the patient leaves the ED.

In one study, 20% of drugs written up were not given by the nurses, usually because the drug is not available on that ward. You will not necessarily be told that a drug is not being given. So, check the drugs cards every day 
Write the name of the doctor you have asked to do these things for you, clearly, in the notes.  With the improvement in junior doctors hours, and more shift working, there is now a greater medicolegal onus to handover properly. All of this is hard, as you are now expected to look after large numbers of ill patients, with the clock on, and targets chasing you. Try to put targets to the back of your brain, just focus on the patient in front of you. Leave the targets to the bosses

 

Your colleagues will not believe you with such explanations. Tell the truth. If you have not finished the job, or do not intend to, tell someone and record who you have asked to FTJ for you - that is, if they agree. If they do not, it's still your job 

 

4.  Why are you admitting the patient? This may seem an obvious question and answer (''they are ill and this is a hospital, where ill people go''). But are they best managed in a hospital? The frail elderly may be better off being treated in their own home, or nursing home; away from the risk of ''superbugs'', and unnecesary investigations. Even the non-frail elderly, if they are mobile, may be better managed as an outpatient.  Many hospitals have outpatient care pathways for minor PE, DVT, GI bleed, angina, suspected cancer. They may see the right senior doctor quicker that way, and have the key investigation done before they see that doctor; eg a CT abdomen/chest can be done before they see a consultant in the ''two-week cancer wait system''. This process can be accessed by GPs not you. Find out how to access those clinics, and use them. Remember, the three reasons for admission are:

           1. Patient ill, and best managed as an inpatient;
           2. Social (you can die of social isolation);
           3. You have no idea what is wrong with them

In this latter situation, something deep down may tell you it might be serious. And/or you think admission will lead to a quicker senior opinion, or specialist test than outpatient management. That is fine. Be careful

If you do send the patient home, write a good letter (TTA) to the patient''s GP. If necessary, add a handwritten note, and ask patient to take that to the GP

And, if you are admitting them, why is the patient not on a low molecular weight heparin (LMWH)?  If in doubt, start the patient on a LMWH. This means all hospital inpatients, not just surgical. Recent research has highlighted the number of preventable deaths from pulmonary embolism.  Few patients being admitted walk around a lot. That is why they are coming into the hospital

5.  Be polite but firm, especially with colleagues. The whole ethos of Acute Medicine, is to bring the same standard of clinical excellence that you observe given to patients with rare and/or serious diseases (acute leukaemia, ARF, MI), to more common diseases (COPD, pneumonia, confusion). This does not happen by trusting the system. You need to push your patient forward, by being polite but firm with colleagues eg "Yes, i know she is 88 yrs old, but i would like a CT head at 10pm on Sun night, PLEASE" .. and .. chase chase chase. But. Even though medicine seems hierachial (and it is), its important to respect your colleagues, junior and senior. Listen to them, they may be right. And even if they are not right, embarrassing them or bullying them, is destructive. How will it help them, you, or the next patient? If you have to slag someone off, have the courage to do it to their face. Or don''t do it. Don''t put any negative comments re a colleague in writing, unless the issue is very serious. If you do, be prepared to face them in court. Writing things down racks it up, and can have serious consequences for you

6. What is it all about? The Team
In an ''all action'' Emergency Department, or Medical Admission Ward, there are often more patients than you can cope with; and your work is making your life is a misery. Alternatively, when it is quiet, it is easy to think that the whole process that you are involved with, is designed to make you happy, interest you or make you a better doctor. But busy, or quiet, it is not about you. It is about that old-fashioned value called service. As the theologian and physician Albert Schweitzer (1875-1965) observed “I don't know what your destiny will be but one thing I know. The only ones among you who will be really happy are those who have sought and found how to serve.”

 

So, who is it service to? 1. The patient. 2 The team = the ED/Acute Medicine team, and the whole hospital mega-team. The team is much stronger than the individual. So. Despite the pressures, spare a moment for THIS patient. Be confident. Be nice, give hope, explain the high likelihood that the team will make them better.  But be careful what you say, eg you may have a high index of suspicion that the underlying condition is very serious. But do not tell the patient or family (unless you are sure that they are likely to die today or tomorrow). This is not your role, and you may be wrong. Saying someone ''might have cancer'' is about the worse thing you can say. Wait for the tissue, and the pathologist

 

Even if you do not buy this 'fancy stuff' re Schweitzer etc, something that most doctors would agree with .. is the importance of teamwork. One cannot provide top quality emergency care on your own. You need a radiographer, radiologist, lab people, senior doctors, nurses, cleaners, porters etc etc.  So, if you are not naturally a team player, have a think about it. How can I become one? At least at work, for my patients 

 

7. Explain what is happening. It may be obvious to you, but it is not to them. For example, try to give them a predicted length of stay, and where they will end up, and how they will get there. They do not understand how a hospital works. Try to explain ward movements; and where they are in the process. A baseball diamond is a good analogy: first base = ED; second = admission ward; third = final (specialist) ward; fourth - discharge lounge

 

 Some blood tests need explaining carefully

 

 Some xrays too

 

8. Nine crimes of non-thinking and/or arrogance  ..

i. The crime of believing everything you are told. With the large number of health professionals being involved in emergency care, clinical information is being passed from one to another all the time. But it is easy for false information to be recorded then copied and copied again, until it becomes gospel. Whatever the ''rank'' of the person before you, check the data yourself. Do you agree with the diagnosis? .. then check and check again. Eg, Does the patient really have dementia or cancer? If so, how advanced are either condition? As soon as you record the ''D''  or ''C'' words, minds close, and treatment goals change. You can call it ''mild or early dementia'' or ''cancer of X (not active problem)'' to diminish the impact, if that is true

 

It is temptingIt is tempting just to copy what the previous person has written. Don''t

 

ii. The crime of Rationalism vs Empericism. Rationalism and empericism are two contrary philosophical views about the sources of knowledge. Rationalists (like Descartes, as in Cartesian Philosophy) think that knowledge must be absolutely certain and that it comes from reason. If there is no reason to think there is an elephant outside the room, then there isn''t one there. Empericists (like Locke) think that all knowledge comes from sense perception and ''inner perceptions'' (ie feelings/judgements) of the mind itself. If you have reason to believe that there may be an elephant outside the room (you can smell something strange and the building keeps rocking) then it probably is there. Why does all this airy-fairy stuff matter for a junior doctor? An example is the over-belief in tests as a source of knowledge, with disasterous consequences for the patient. This is particularly important in the modern age when ''game-breaker'' tests come back quickly, perhaps too quickly. Its easier to believe the test, than go back and retake the history or re-examine the patient

 

An example. The rationalist assesses a cachectic patient with pleuritic pain and finds the d-dimer very high. He orders a V/Q scan which is negative and sends a patient home with a bronchial carcinonoma. An empericist recognises the falability of the d-dimer test, and ''feels'' (because of the weight loss) that there is ''something odd'' going on, so despite a negative V/Q scan, keeps the patient in, for further investigation and a senior opinion. The senior has seen this trap before and makes the diagnosis. So a good doctor has the logical skills of a rationalist, but knows when to ''flip into empericist'', and break the rules (eg not believe a test); trusting his/her sense perception when he/she feels the diagnosis is not what the tests suggest. They will go on a calculated hunchs. As a junior doctor you may not have developed the ''empericist inside you'' yet. You need time and experience to develop empericism. It''s part of what makes us human. You need to start your journey sometime. Why not start to think laterally, and start to find ''your emperical brain'' today?

You are the living descendent of two philosophical giants (Descartes and Locke). Respect them both, continue both great traditions

Want to read more? Try the Stanford Encyclopedia of Philosophy or Internet Encyclopedia of Philosophy 

 

iii. The crime of doing unnecessary tests (''going fishing''). There are many tests at your fingertips. Try to avoid blitzing the patient with every test you can think of, as many have a significant false positive rate. A ''positive'' test can then lead to more (perhaps) dangerous tests. More tests can be added tomorrow. Blindly doing a Troponin T, or D-Dimer in anyone with chest pain, or Tumour Markers in someone with weight loss, is bad medicine. On the other hand, remember that the ED doctor will have a different view of tests to the Physician. He/she has to decide whether the person needs to come into hospital, you have to decide what''s wrong with them. Eg, blood cultures rarely change management on day one (and never affect the admission decision) but they do affect treatment on Day 2 or 3. So, if they have not done them (quite reasonably), you do them. And don''t criticise them for not doing them. Also, if you do a test, do it properly. You will get a much better report from a radiologist if you fill in the patient''s clinical information properly; eg ''Pleuritic chest pain ?cause, D-dimer = X, on OC pill, examination normal'' will get a better report than ''Collapse ?cause'' 

 

iv. The crime of 'Dr Google' ie lack of deep understanding. What is the point of going to medical school? Some would say that we teach you to ask the W ('Why?') and H ('How') questions. But, the easy and rapid access to high quality IT is affecting us all, and inhibiting these questions, and deep understanding. Or, "Learning just enough and learning just in time will increasingly trump understanding a subject deeply" (Technology, knowing and learning. Gorry GA, 2009).

 

It is possible to be a good doctor, especially in emergency or acute medicine, and have little understanding of why you are treating a patient. An example. You diagnose and treat a patient with Acute Coronary Syndrome correctly. You are  looking after him/her with the best of intentions, to the best of your ability, in their interests, maybe to a high satndard. So, whats wrong with that? You don't have to own an incubator to be an expert on chickens, as they say. Another example. You prescribe a statin for a patient with risk factors, and a raised cholesterol. But what is a statin? What is the evidence that they can affect mortality (almost none, actually)? Do you know? Do you know how to find out?

 

Dr Google undoubtedly saves lives all over the world, every day. But there are dangers too. The main danger of the Dr Google mentality is that we all become increasingly dependent on copied, compiled and compressed electronic information, guidelines, care pathways .. and websites like this one. But the patients deserve more. They deserve that you understand why you are making your decisions. So why did you make that decision on this patient today?

 


v. The crime of making (judgemental) assumptions,or preaching to patients. ''The nun is as likely to have syphilis as the prostitute''. Though not entirely true, it is a good saying to remind you not to be judgemental. So be careful about making (or excluding) diagnoses, based on how the patient (or family) talk, look, or behave. Doctors like a drink too. This is not only true for sexually transmitted and alcohol/drug-related diseases. The fit looking young patient may have had a myocardial infarction or dissecting aneurysm

 

Alot of us do bad things, including doctors. The middle class may buy their claret from Waitrose, but is drinking alot of it any better or worse than a patient who has had a difficult life, buying cheap cider at a corner shop? Some would say skiing or playing rugby is just as stupid as eating too much or taking recreational drugs. BUT. The real danger of judging the patient is that you will either over-investigate for a lifestyle associated disease if you think the patient is ''high risk'', or worse under-investigate if you think they are ''low-risk''

 

Healthy livingDon''t preach or judge the patient. It''s not your role

 

vi. The crime of (over) diagnostic certainty (ie arrogance). An incorrect initial diagnosis may be copied. As you are often the first person to see the patient, there is a big danger that if you make an incorrect diagnosis, colleagues down the line, will merely copy it. A diagnosis of 'Urosepsis' and 'Collapse?TIA' is almost always wrong. More importantly, they can be diagnoses to pass on, as it is always easier to agree with the previous diagnosis, than challenge it. Most of us tend to come to a diagnosis quite quickly; often using pattern recognition, ''pigeon holing'' the patient into a syndrome we have seen many times before (UTI, dementia, exacerbation COPD). Then we stick to that diagnosis, whatever later information comes through. This is dangerous. Sure, if you really are certain of a diagnosis, state it and act on it. Take the glory. But if you are not, keep your differential wide, ''cover your bases'' (ie initiate treatment for your second most likely disease, and third, in some cases). Make sure your diagnosis introduces some uncertainty for the next reader (eg Acute confusional state, Cause uncertain, Probable sepsis, Possible UTI'' is better than ''?UTI''. Leading on from this ..

 

 

Just because it looks like a zebra, it does not mean it is. For the record, these are. In fact they are the now extinct Burchell''s Zebra. The last one died in the London Zoo in 1910.

 

vii. The crime of not putting the effort in for an easy diagnosis. Even at a junior stage it can be a bit easy. You have been a doctor for a year, you know the patient has lobar pneumonia, you have seen 20 before. You have seen the CXR before you see the patient, to save time. You cut corners. You don't check the antibiotics you have prescribed are given. You don''t check for allergies. You forget to pass on a crucial bit of information (eg previous episode same part of same lung; raising possibility of a foreign body). Things go wrong with an easy case too. Concentrate on the easy cases too, they may not be as easy as they seem. Or as Heraclitus of Ephesus (535–475 BC) put it, "You could not step twice into the same river"

 

viii. The crime of being a poor prescriber (and ADRs). All good doctors are good clinical pharmacologists; physicians, surgeons, psychiatrists, GPs, the lot. Are you? 5% of medical admissions are partly due to poor prescribing. But before you criticise the poor prescribing before the patient comes into hospital, have a look at your own. Is yours perfect? You should write up all drugs in CAPITALS, generic names, correctly written units, clear signature, date, month and year. Don't be lazy, and just copy others with illegible dangerous prescribing. Remember the nurses will, by and large, give out what you have written (or what they think you have written), but it is not their fault primarily if there has been a mistake. It's yours. Junior doctors that make serious errors (especially in their first two years) may end up suspended or even in front of the GMC. This would not be a good start to your career. The usual reasons are prescribing and/or communication

 

Adverse drug reactions (ADRs) cause 5% of medical admissions. The five commonest causes of ADRs are: antibiotics, anticoagulants (esp warfarin), NSAIDs (including aspirin), anti-arrthymics, and diuretics. Look out for these five groups. Pirmohamed M et al, published a very good review in the BMJ in 2004

 

If you have spotted an ADR, have you done everything you can to stop it happening again? There are 4 things you should do: 1. inform patient; 2. inform GP (in writing); 3. report it to your hospitals ADR system, if they have one (most do not); and, 4. send off a yellow form. This can be in paper form (and give to a pharmacist) which you tear off from the back of a BNF, or in e-form via the MRHA website

 

This website is very useful, especially for its section called Drug Safety Alert. This gives up to date analysis of ADRs that have ever been reported for all drugs

 

 

ix. Respect .. and the crime of not being nice. This may sound the most 'pink and fluffy' crime. If you are not nice, you can still give 'technically good' (ie correct) care. But what about respect? They are individuals not numbers. It is not enough to make the diagnosis, you need to show the patients' that you care about them, are kind, are interested in them, and respect them

 

Slow down for a bit and be nice to a patient. Western Medicine isn''t that great is it, really? Being nice may be good medicine too. Introduce yourself properly, and social niceities are important ..

 

 

Also. If you are nice to them, they will be nice to you (eg may give you a better history). Remember, they are scared, in an uncomfortable and unfamiliar environment. They will give more back, if they are relaxed, which in turn may help them


9. Have a break. Doctors are human (ish). We need breaks, have a quick coffee after every 4 patients, think about them; rethink your diagnosis; go back and make changes. Have a proper 30 minute+ lunch, dinner, or meal in the night, every 4 hours. Maybe text your partner, or parent. Tell them how much you love them, and are grateful for their support. Have you snapped at anyone today? If so, go back say ''sorry i snapped at your earlier, i feel under pressure because of X, i will try not to do it again''. Little apologies help in the hurly burly of ED life. When you are away, think about cleanliness. It may not seem that important to you, but it is to patients and families - ie wash your hands more than once in a shift

 

 

No spitting .. and wash your hands occasionally


10. ''Gerifix''. Especially at night, when there are less seniors around, and you are not sure of the diagnosis, if the patient is very ill, it is not wrong to 'treat the lot' - buying some time, to find out what is wrong with the patient. So, prescribing ''gerifix'' (nebulisers, steroids, antibiotics, furosemide, enoxaparin) is not wrong, at least in the short-term. IV aminophylline is good for both CCF and COPD/asthma. Remember the frail elderly (and smokers) can have more than one disease; especially as smoking is a risk factor for IHD (and therefore CCF), CVD, and COPD


11. Grey case thinking ('What it's not thinking'). Sir Arthur Conan Doyle wrote "It is an old maxim of mine that when you have excluded the impossible, whatever remains, however improbable, must be the truth". How does this idea apply to medicine? Well, the impossible is often quite easy to exclude, leaving you with many probabilities and improbabilities. But, which is the truth? Whether the patient is frail and elderly like the patient above or not, and the senior review also does not come up with a clear diagnosis, it is best to rethink the patient as a 'grey case'. In other words, become a detective, pursue different lines of enquiry. And when it comes to treatment (again) 'cover your bases'. Eg rather than thinking what is the diagnosis and treatment, ask yourself why is A or B not the diagnosis? And why are you not treating it with X or Y? And if there is no reason not to give treatment X or Y, give it


12. DRUGS DRUGS DRUGS are important causes of '3C''s = collapse, confusion and coma. So, take a proper drug history, including recent changes; especially antibiotics (C difficile).
5-7% of preventable acute medical admissions are due to prescribing errors (Howard RL et al, Br J Clin Pharmacol; 63(2): 136–147, 2007). Prescribing is a factor in a much higher percentage of admissions. 50% of ''prescribing error admissions'' are due to four drugs: antiplatelets, diuretics, NSAIDs and anticoagulants.  In one study, it was estimated that the number of patients admitted at any one time in the UK with an adverse drug reaction, amounts to seven (yes seven) 800-bedded hospitals; and costs the NHS about £466m per year, at 2004 prices (Pirmohamed M et al. BMJ; 329: 15-19, 2004).  So it is illogical not to take an accurate drug history, especially if you are the ''first clerker''. If the patient cannot give you one, contact the family, GP or nursing home. Look at the ambulanceman''s report. Oh yes, do not continue antibiotics that the GP has precribed that are clearly not working

 

13. Take a proper allergy and social history. Not doing so, is extremely dangerous. Writing ''NKDA'' is not a drug history. It probably means that you have not asked the question, or the patient does not know. So, write ''PENICILLIN'' (if that is the case), ''Nil'' or ''Uncertain''. It is what it says on the tin. The social history is important too. In terms of bed management and the discharge process, the social history is vital. It is that, that determines when (and how) you can discharge the patient later in the admission. For example, if the patient has come from a nursing home, discharge may be a lot easier than if they are just coping in the community, with little social support. Also, do not forget to write down all important conversations with the patient or family, especially related to the seriousness of the diagnosis and prognosis

 

14. What you look like. Even though there is a tendency for doctors to dress casually (eg bare below the elbows), it does not mean that patient or relative is not interested (or worried by) your appearance or attitude. So, for example, entering their room with a coffee in your hand, no badge, not introducing yourself, slouching on a bench, not looking at the patient, then taking a text from your girlfriend is not professional. If you behave like this, the patient will have less confidence in you, your diagnosis, treatment and the team. Have you introduced yourself properly?

 

This may be a safe outfit for a doctor, though not patient-friendly

 

Posture Whatever your dress, think about your posture

 

 

 

The Army ''Parade Rest'' is a good professional look: the classic ''ward round position''


15. Referrals clinch diagnoses. 
It is just as important to chase a senior or specialist referral than to chase the biochemistry. For example, if the specialist is not in your hospital, find the nearest one. Ring the consultant oncall at 2am; they may be grumpy but most prefer to be contacted than not contacted. They care about the patients too. That''s why they became doctors


16.  Simple information: 
note the presenting complaint, look at the basic observations and read the ambulanceman's report. Quite often in the ED, no none knows what is going on. If this is the case, go back to the simplest information. This includes the presenting complaint. Often the clue to the diagnosis is there. And believe them. If they say they are SOB, they are SOB. Few patients lie. Also, the presenting complaint should have a profound effect on the admission decision

Next. Look at the observations. The nurses go to great efforts to take observations. So it is ignorant not to look at them. Pay particular attention to pyrexia/hypothermia, hypotension (<100/70), tachyopnoea (>30 RPM) low O2 saturation (<95%) and tachycardia (>100 BPM) and the BM (10 mmol/L). As a general rule, a tachycardia indicates a significant acute illness. So be careful about sending that patient home; and if you do admit them, where is the safest environment? A fever means they are infected today. It may not be the underlying problem, but it needs attention. Sometimes when none of this helps, no one (including the patient) knows why they are here, or what is wrong with them, the answer lies often in the ambulancemans' report


17. Oxygen is a drug, and should be prescribed.
It can be beneficial, even life-saving; but can also make the patient worse (especially removing the hypoxic drive in COPD). Even though O2 has a placebo effect, there is no point in prescribing it, if the patient is not hypoxic (Saturation <95%; or BTS guidelines on O2 therapy (2008)


18.  End-of-life care, and Advance Decisions to Refuse Treatment.
Good end-of-life (EoL) care is good medicine. Many doctors now use the Liverpool Care Pathway (2004) (pdf), of local variants of it and www.palliativedrugs.com 

It is essential, as many such patients are handled in the Emergency Department, or Medical Admission Ward, and do not make it to specialist wards. Remember you are free to exercise your own professional judgement. In other words, just because a patient comes in with a label of ''Ca something, with mets'', it does not mean it is time to institute an end-of-life pathway. This decision should NOT be made by a junior doctor. It is a consultant decision and he/she may well want to have a discussion with the patient''s GP and/or specialist consultant first (either of whom may have more idea of the patient''s prognosis). Read all the letters you can, before you speak to anyone. Equally, if an EoL Pathway is instituted, you need to know how to do it; and how to get the patient home quickly, if that is what they (and their family) want

You should understand what is meant by Advanced Directives, as the law has changed in this area recently: the 2005 Mental Capacity Act (Advance decisions to refuse treatment: A Guide for Health and Social Care Professionals, 2008 (pdf))

So. It is OK for a patient to die of ''old age'' or a ''fatal disease'' where the best therapy has been attempted. You will feel sad, but if you have delivered excellent EoL Care, that is ''good medicine'' and you should be proud


19. Bed management and nursing time.
Good bed management can be as or more important than good medical management. Why? Well, we all know that if your patient, ends up on an inappropriate ward, under a less than interested team, they may die - and that death may have been preventable. So. Find out how the bed management process works in your hospital. Then, when you have decided that your patient needs to come in, try to start the process of getting them to the right ward (see motto of website above ie ''right patient right place right time'')

The right bit of the right ward is important too; eg, it is not good to put a patient with an NSTEMI on an ordinary cardiac ward. They need CCU, or an observed bit of a medical admission ward, with a cardiac monitor (and nurses aware of the diagnosis) for the first 24h at least. Think about weekends and Bank Holidays, and nursing numbers and time; eg, if you have no HDU, ITU is full, is it good idea to put a patient with meningitis on the ''correct ward'' (neurology) on a Friday night, when you know nursing numbers are not adequate through the weekend? Alternatively, even if nursing time is adequate, does that specialist ward have senior ward rounds at weekends, and Bank Holidays? Find out 


20. "Listen to the patient, he is telling you the diagnosis" Sir William Osler (1849-1919).
Most mistakes in medicine are made not because the physician is not a good diagnostician, or the surgeon, a good operator; but because we don''t listen. Doctors like talking, but are not always good at listening. On a busy medical take, it is hard to find time to let the patient talk. Try, or you may miss the diagnosis, or treat inappropriately. You don''t need to know all of the eponymous signs of aortic regurgitation (for the record there are 12 .. Eponyms and the Diagnosis of Aortic Regurgitation: What Says the Evidence? Babu AN et al. Ann Intern Med; 138: 736-742, 2003). But, you do need to know how to listen

 

  
William Osler (1849-1919); Osler principle (a constellation of symptoms is caused by one disease process) is usually true; but not necessarily in the elderly

Changing from a talker to a listener is hard. Doctors like to talk. But, you can do it. You can change. Then you can make progress, or as Bertrand Russell (1872-1970) said "Change is one thing, progress is another" 


21. Doing nothing.
This is a skill. You can just watch. Some say that ''masterly inactivity'' (or ''MI'', which does not mean myocardial infarction or mitral incompetence) is the most important skill of a doctor. You can shut up. Silence can be assertive. Good doctors (physicians, surgeons, GPs, the lot) have it, and bad doctors don't. In terms of acute medicine, the skill has many uses. Examples include not admitting a frail elderly person from a nursing home, so the hospital can give her C diff, if a return to her home is appropriate. Another would be not writing up an ACS protocol on everyone that comes through the ED with chest pain (it will harm a proportion). An extension to the ''MI'' phrase is ''MICLO'' (masterly inactivity, with cat-like observation)

 

 Action You dont always have to ''do something''. Observation is OK. 17th-century drawing “The operator excises the breast with the tenaculum helvetianum”. Or, as the Roman poet, Publius Ovidius Naso (43 BC – 17 or 18 AD), known as Ovid, put it: "Time is the best doctor" 


22. Presentation (in five sentences)
 

"Since brevity is the soul of wit .. I will be brief". Shakespeare''s Hamlet, 1603


Brevity. Soul. Wit  Mug

Quick brief effective communication is a skill
, especially when you are busy, and patients are ill. Try not to 'tell a story' (ie just represent waht the patient has said). Try to present in five sentences (remember the human brain can only hold seven facts in its STM). One. "This 108y old astronaut presents with 6h of central chest pain" (how patients come into hospital is not normally relevant). Two. "The pain came on rapidly and was associated with nausea and sweating". Three. "PMH is unremarkable". Four. "There was nothing to find on examination". Five. "The diagnosis is an acute anterolateral STEMI, and I have initiated thrombolysis". No relevant negatives. Don''t add social or drug history unless relevant; and, if you do, try to slip that into first sentence, eg "This 108 yr old astronaut who lives in a nursing home .. " etc. Also think about who you are presenting to and why, ie if you have not got a question for your colleague, don''t ask one. If you have, add it as sixth sentence - only if necessary. Six. "Im not sure whether to ring the cardiology registrar, what do you think?". The listener will ask something anyway. A good presentation can be remembered and re-presented with a 90% ''handover'' of knowledge, in a hours time. A bad one cannot

 
23. Relationships with Colleagues (some say the hardest part of being a doctor!). Mm. Try to get on with colleagues. Don''t play professional games. It''s not a competition and it''s not about you. Bite your lip. Be straight and be fair. Show respect to colleagues, at whatever level; and they might be the same with you. All of this is true for your relationship with nurses (and porters, cleaners, everyone). It''s not just a doctor-doctor issue. If you don''t get the job, say "thank you for being interested in me and I respect your decision. My colleague is clearly more appropriate for the job". Do not take it personally. Move on. Medicine is a small world, don''t burn your bridges. If you annoy that colleague today, they may remember this when you meet next time, and he/she is interviewing you, for the job you really want. Reputations stick 


24. Being a doctor. It is not a job.
It is a vocation. You are the healer, shamen, wise man in the tribe. So, you need to behave like one. Do religious leaders moan about their hours, pay or working conditions? No. So, you should not too. The day you think of it as a job, is the day you stop yourself from being an outstanding doctor one day. At best you can be adequate. Who wants to to adequate?

There is another view of course. What is a 'good' doctor? and is it  'OK' to be a 'good enough' doctor? Think about what a 'good' doctor is, before you say someone is a 'bad one'. There are bound to be colleagues that you like more than others, are cleverer than others, or think are 'better' doctors than others, at a technical level 


But being a doctor (Latin for 'teacher') is not just about technical skills (ie getting diagnosis and treatment right)
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It's also about caring, teaching and loads of other stuff. At the end of your career, what do you want people to say about you: "Oh yes, he/she was quite a good doc, but a bastard"?, or "He/she was a great doc, and achieved a great deal for the people of X, over a long career"? 


So, is good enough OK? Lets begin near the beginning. Why did you want to be a doctor? Was it because you strive for perfection, and you wanted perfection for the patients? Do you spend hours obsessing over the tiniest details of your life until they’re exactly right? Do you feel uncomfortable when everything in your life isn’t 'just so'? Are you prepared for every eventuality, even the most unlikely? In short, are you a perfectionist? Alternatively, most of the time, will 'good enough' do? 


There’s a point where it takes more and more energy to achieve smaller and smaller gains — where you’re putting in as much effort as you’ve spent on a project (eg this patient) so far to get a tiny 1% or 2% improvement. When you are a 1st or 2nd year doctor, you cannot be perfect. You do not have enough experience. What you can do is strive for the best you can do, for this patient, imagining that he/she is your relative.That is probably a better concept for a doctor than the 'good enough' idea, or striving for perfection all the time. As you get more senior, the goal changes, and you should strive for perfection. It is rarely obtained of course 


At some point in this journey, you will feel like a doctor. Having a 'Dr' in front of your name is only the start 


25. Targets (4h especially).
We are all now well aware of the ''4h A&E Target'' = the Government has stipulated that >95% (previously 98%; reduced by Coalition Government on 22.6.10) of patients entering every ED in the UK, are discharged home, or admitted into a bed, in 4 hrs of arrival. From your perspective as an F1/2, this target is irritating, and an unnecessary ''tick-boxing exercise''; when you are trying to focus primarily on patient safety and clinical care. You don''t want to make any mistakes, especially in your first 2 years of clinical practice. This is understandable. But, whatever you think about the targets, they are leading to improved and quicker care in all Trusts; as, to hit them, there needs to be more senior involvement at the coalface. So, try not to moan about them, just get on with it, and try to do your bit to hit it, with your patient(s) today. Lying on trolleys in corridors for 24h was an inhumane way of looking after the elderly. Let''s not go there again 


26. What is the diagnosis? ie the down side of a target and protocol driven ''send em all home'' mentality.
Do i need to follow them up? Targets, by and large, have led to major clinical gain. But there is collateral damage - and that may be your relative next time. Acute coronary syndrome is a good example. The (false) belief that a myocardial infarction can only be diagnosed 12 hrs after the onset of pain, is partly driven by the need to exclude the diagnosis of MI, so the patient can be sent home ASAP, to make the target; rather than to include the diagnosis, and treat accordingly. For example, you CAN measure Trop I, or Trop T BEFORE 6 hrs and 12 hrs respectively (ie against protocol), as the enzymes might be rising

This might stimulate you to repeat the ECG, that might show that the ST elevation, which was only 1 mm an hour ago, is now 2 mm - and thus indicating the need for thrombolysis or PCI. So, the window of opportunity can be missed, by over devotion to 1. ''Trop T dogma'' (''Trop T will not be done till 12 hrs'' etc); and 2. ''send them home'' medicine (eg ''if Trop T normal, patient can go home''). Bosses happy. But what is the diagnosis? After all, a hospital is where we make diagnoses, and make people better. Similar criticisms can be levelled at a diagnostic strategy that is over-dependent on D-dimer in the diagnosis of thromboembolism. A negative D-dimer has come to be thought of as a ''going home'' test, a bit like an negative Trop T. In both of these syndromes, involve seniors early, and think think think .. and not just about protocols


Remember the patient may have been waiting 30 mins in the queue at the ED reception desk, then 1 hour to see you. They are interested in what is wrong with them, or may be wrong with them, or what they feel is wrong with them. They are not satisfied by the fact that a blood test excludes the diagnosis of something serious. Most patients do not want to be there. They are not nutters. They are there because they are in pain, or uncomfortable, or worried. They deserve an answer. And, there are important diagnoses just below non-serious, eg pericarditis for chest pain, that will benefit the patient. Therefore think about what is the diagnosis? Don''t just give them a ''madeup diagnosis'' eg ''musculoskeletal chest pain''. That may not satisfy them, as well as being not true. Ok, from your perspective, it is a ''good job'' = clear diagnosis in notes, patient has a label. Job done. Job not done. Bad medicine 


Look at the patient, get eye contact, treat them like you would want to be treated - or your relative 


Follow-up is important, very. Just because you do not feel that you need to follow the patient up, it does not mean they thing they shouldn''t have any, or that they don''t want any. Most patients like follow-up, partly to give them some idea of closure. In other words, if you say "diagnosis musculoskeletal chest pain, it will get better, we don't need to see you again", then they are left in limbo, not knowing what will happen next. So, it may be better to say "go to your GP tomorrow, if you are not feeling better, and here is a letter about what we think is wrong with you. But if you are very worried come back here, and we will ''start again'' and have another look at you" 


27. "Pressure is a Messerschmitt up your arse".
Keith Miller MBE (1919 – 2004), Australian Test cricketer and Royal Australian Air Force pilot (WWII). You are knackered, fed up, hate the bosses, hate the targets, problems at home, don't see the point, got exams ahead, don''t know where you are living next year .. ie you feel under pressure. Think about this quote. Yes, its bad. Yes, you are under pressure. But, put it in perspective. Is there a Messerschmitt up you arse? No? It aint that bad really, is it?

Keith Miller 


28. ''A journey of a thousand miles began with a single step'' Lao-tzu, The Way of Lao-tzu, Chinese philosopher (604 BC - 531 BC).
Often, you can feel a very small cog in a very big machine. Not very important. Everyone is ignoring you, and your opinion. Nobody understands. What would happen if you were not there? Not much? Maybe not, but maybe yes. Maybe first your step, albeit small, is the first important step in the patient''s journey. You are part of it, your contribution is important 


29. Why is the patient making you angry?
If this is the emotion you are feeling, there are a two questions you should ask yourself: 1. Is it 'functional'? Psychosomatic disease makes most non-psychiatrists-psychologists angry. There is more about this in the chapter on MUPS; 2. This is not the speciality for you. To stay motivated in a specialty over the years, you need to be genuinely interested in it. So frustration with the system will not extend to anger 


30. At the end of your shift, go home and have a rest. You are a hero.
Follow-up your patients tomorrow. In the hurly burly of emergency work, it is easy to think of yourself as a ''clerking machine'', next patient please. Try not to, prioritise the patient in front of you, make them feel wanted, and find out whether you were right tomorrow 


Oh yes. Keep your sense of humour.
A joke. Real Madrid 2 Surreal Madrid: Fish 

Or, if thats not funny, and you need some inspiration, try this ..


''if'' by Rudyard Kipling (1865-1936)

If you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don''t deal in lies,
Or being hated, don''t give way to hating,
And yet don''t look too good, nor talk too wise: 

If you can dream - and not make dreams your master,
If you can think - and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same;
If you can bear to hear the truth you''ve spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build ''em up with worn-out tools: 

If you can make one heap of all your winnings
And risk it all on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breath a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: "Hold on!" 

If you can talk with crowds and keep your virtue,
Or walk with kings - nor lose the common touch,
If neither foes nor loving friends can hurt you,
If all men count with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds'' worth of distance run,
Yours is the Earth and everything that''s in it,
And - which is more - you''ll be a Man, my son! 


Written in 1896