Tag Archives: medicine

Can we find the spirit of ’45 in 2013?

Today marks a defining moment in the history of Britain, but looking around you wouldn’t believe it. Today, April 1st 2013, sees the The Health and Social Care Act (HSCA) come into force.

The death certificate of the NHS, issued by the National Health Action Party

The death certificate of the NHS, issued by the National Health Action Party

Some still believe that those opposed to the HSCA are over-dramatic, reactionary or naive. They will probably dismiss the National Health Action Party as extreme and publicity-seeking as it has issued a death certificate for the NHS, citing the cause of death as the HSCA 2013, with contributing causes including Thatcherism and the failure of New Labour. But it is difficult to see how anything but extreme statements and gestures can capture the attention of the public. Our generation is standing by as the NHS is quietly privatised and I for one am ashamed.

In 1948 the Attlee Labour government founded the NHS “the greatest gift a nation ever gave itself.” Since then it has been gradually eroded and dismantled. The King’s Fund’s infographic depressingly visualises various points of attack by multiple governments, starting with the creation of the internal market in 1989 when Margaret Thatcher signed the paper “Working for patients”. New Labour also have a lot to answer for; their PFI legacy crippling many Trusts today. But no previous government has actually tried to privatise the NHS, knowing that there would be a public outcry. Cameron and Clegg have privatised by stealth; clouding their agenda in a language of ‘choice’ ‘clinician power’ and ‘patient centredness,’ and ensuring that the reform documents were so long and complex that no-one, including most Ministers, understood them. The British media failed to report the warnings of individual doctors, nurses and other healthcare workers, and the demands of traditionally silent bodies such as the Royal College of Physicians to drop the Bill.

Screen Shot 2013-04-01 at 18.33.01

The most worrying aspect of the reforms that come into force today are the Section 75 regulations, which state that all NHS services must be put out to competitive tender. This is not just allowing privatisation, it is mandating it. And all these profit-motivated private firms will be operating under the ‘brand’ of the NHS, so patients may not even know. Until the inevitable problems start to surface and it is too late.

Screen Shot 2013-04-01 at 18.34.44As I watched the welfare state being dismantled around me this week, I went to see Ken Loach’s film The Spirit of ’45 at The Barbican Cinema. It was a poignant reminder of a time full of hope and promise, and was a stark contrast to what I see today. In 1945 there seemed to be a collective vision of a society that could pull together for the benefit of all, with at least some people from all social classes believing that the State was a force for good, and that it had a responsibility to provide and protect the simple things most of us spend life striving for: purpose, dignity in work, family, safety, health, wellbeing, shelter, and comfort. 

Particularly powerful were interviews with doctors and patients who remembered a time before the NHS, when healthcare was only for the rich. In The Spirit of ’45 Dr Jacky Davis and Dr Jonathan Tomlinson, doctors working in the NHS today, talk eloquently about the doctor-patient relationship and about their fears about the future. Marketisation and competition change the relationship of doctors and patients to salesmen and consumers. I am no salesman and never will be.

The day after I saw The Spirit of ’45 I was on call in hospital. I was asked to speak to a patient about her medications before she went home, and quickly scanned through her notes before going to speak to her. She had had a tough few weeks, having been diagnosed with incurable (but treatable) lung cancer – only two weeks from having a chest x-ray revealing an unexpected abnormality to tissue diagnosis and treatment plan. This rapid diagnosis and treatment was an example of what happens every day in the NHS, and is a great example of the efficiency of our healthcare system, but it had left her little time to process the news. She was anxious about her medications prior to discharge so I spent a few minutes clarifying them and reassuring her.

As we ended the conversation she said thanks, and then hugged me tightly. It was nhs logoan unexpected level of physical contact and gratitude for a conversation that could only have lasted ten minutes. But it made me think. She wasn’t really thanking me. She was thanking the NHS: there for her from cradle to grave; at the most difficult time of her life; no questions asked; free at the point of need. Patients in the NHS are taken under the wing of an institution and cared for under an ideology. Today that ideology has suffered a fatal wound. Health is not a commodity, and markets will not make our NHS more efficient, more equitable or of higher quality.

Nye Bevan said “The NHS will last as long as there are folk left with the faith to fight for it”. As Owen Jones says “It is with huge regret that I must say that – however much faith we have – we did not fight to save it. The question now is – do we have enough faith to bring it back to life?”

As I look around the political landscape I fail to be inspired or energised by what I see. Attlee had vision, drive and a belief in the people.

I am looking for the Spirit of ’45 in 2013. Let me know if you find it.

What’s in a name?

At work recently I felt like a broken record. “What’s their name?” I said again and again with increasing frustration as I received calls about patients who were referred to as “bed 3,” “side room 1,” and “bed 9.”

Of course, at times it is convenient and even desirable to omit a patient’s name in a conversation. It was suggested on Twitter that it may be better to overhear what ‘bed 9’ needs rather than ‘John Doe is ready for his haemorrhoidectomy,’ and in this case I agree! My worry is that in most cases there is no explicit intent to maintain confidentiality. Instead the convenience of referring to people by their bed number slips into routine communication. I have certainly been guilty of this myself. I worry that this is not merely disrespectful, but that it contributes to the dehumanising experience of being a patient, and negatively impacts on the doctor-patient relationship.

There are many factors that contribute to dehumanisation in hospitals. It is often not the fault of individuals, and I would certainly not suggest any of the nurses I work with are uncaring. Instead the environment and structures inherent in the way we work create an “us and them” divide where healthcare workers and patients are in different tribes. This extends to factors as simple as the clothes we wear, an example of “deindividuation.” I am always amazed by the dramatic transformation when a patient puts on their own clothes as they get ready to leave hospital, having previously only worn a generic hospital gown. They miraculously turn into a “person” rather than a “patient.”

Image from: http://healthland.time.com/2010/02/09/designing-a-glamorous-hospital-gown/

The design of hospital gowns is practical but does not enhance dignity

A recent paper by Haque and Waytz “Dehumanisation in medicine: causes, solutions and functions” explores this idea further, identifying a number of contributing factors, considering simple solutions, and also exploring examples of necessary and unnecessary dehumanisation. An example of necessary dehumanisation is that it reduces physician burnout: if I felt the same intensity of empathy for every patient undergoing a blood test as a typical non-healthcare worker would, I would be overwhelmed and unable to do my job. But there are many examples of unnecessary dehumanisation that we should identify, expose and address to ensure they do not affect how we think of, and care for, our patients.

Although as individuals we may aspire to a partnership model with our patients, our structures rarely facilitate this, and there is a danger that we see patients not as individuals but as tasks to be ticked off. I am much less personally interested that “bed 9 needs a cannula,” than I am that “Eve’s cannula has tissued again and she really needs her iv fluids.” And when I think about constructing a management plan, I am much less likely to take the time to explain my clinical reasoning and involve the patient in decision making if I think of him as “the PE in bed 3″ rather than “Bob, the lovely history teacher who has a PE.”

If and when I become a patient I want my medical team to treat my as an individual, consider my personal context and experience of illness, and integrate this into their decision-making process. I do not want to be referred to as “bed 2.” I realise that as a Medical Reg I would embody ‘the nightmare patient’, but something approaching this true partnership model should be what we aspire to for every patient, not just those (like me) who explicitly demand it. Many things need to change to achieve this ideal including; better data sharing with, and ownership by patients; better public and patient education allowing valuable discussion about trial data and the value and limits of evidence-based medicine; and a dramatic change in our IT structures such that they enhance rather than impede communication across arbitrary boundaries of primary, secondary  and tertiary care.

We should work to achieve system changes, but they will take time to implement. We can take immediate personal responsibility for our own actions and our own role in dehumanisation in healthcare.

A statement in Haque and Waytz’ paper that particularly hit home was:

“Medical education and training should also incorporate practices that allow physicians to emphasize the common humanity they share with their patients, specifically their shared mortality; illness narratives; and vulnerability to disability, suffering, personal loss, and other forms of uncertainty”

I am a passionate advocate for a strong educational focus on our common humanity, and for the power in sharing personal narratives, thoughts and uncertainties as professionals with the aim of demystifying and disempowering the role of “the health professional.”  I suppose that is one aspect of what this blog has tried to achieve. By sharing my personal experiences and exposing my doubts and flaws I hope to show the human side of my role as a doctor.

I have been inspired by NHS Change Day to consider what small changes I can make in my own practice that will improve the lives of my patients. I will be pledging to re-humanise my personal practice of medicine, by always using patients names as a constant reminder of their individuality. I hope that hearing  “bed 9 wants to see you” will become the exception rather than the rule. You can make this happen. Pledge with me

NHS Change Day

When the lights go out

Most people I know have never watched a person die. Even those that have been to funerals and therefore have seen and been in physical proximity to a body, have rarely been present at the moment of death. The moment when in the eyes of the dying person the lights go out.

I have been there, in the moment, a number of times and remember every time with eerie clarity. Sometimes I have known the patient well; other times I have only met them in their last minutes or seconds. Sometimes it has been almost ethereally peaceful. Other times it has been frantic, chaotic or distressing despite our best efforts to treat end of life symptoms. Most often it has just happened.

Jean* had been admitted from her nursing home with end-stage dementia and multi-organ failure and was clearly in the last hours of life when she arrived in the emergency department. I admitted her in the morning and was passing through the medical assessment unit a few hours later and felt the need to pop in and make sure she was comfortable. There was a stillness in her room that felt anticipatory. I offered to stay whilst the healthcare assistant went to attend to another patient and so happened to be sat by Jean’s bed when she died. She was calm and comfortable. When the moment came it felt like the world paused for a moment and held its breath, while she held hers, then exhaled as she breathed her last breath.

And then the world continued on, with one less person in it.

Each time I have had this experience I have felt the same incredulity at the enormity of the moment. Whether I apply a philosophical or a religious framework, I struggle to grasp what happens when everything that makes up the person; their memories, actions, impact, emotions, beliefs are suddenly gone. The contrast between the significance of the event, and the undramatic way it often occurs, never fails to astound me.

When I know that one of my patients is dying I always feel an urge to check on them rather more often than is clinically necessary. Somehow I feel a responsibility to make sure they are not alone for the final moment. I know that many nurses share this feeling, but I sometimes wonder who we are really there for. Are we fulfilling an unwritten societal contract that means we must ensure no individual has to face the abyss alone; or are we, the living, reasserting our own vitality by forcing ourselves into close proximity with death?  I know many nurses who, whether religious or not, still insist on opening the window after a patient has died to “let the soul out,” as part of a ritual ingrained in them during their training. Even the confirmation of death by a doctor, which mandates checking pupil reactions, palpating for the pulse, and listening for heart and breath sounds, feels part of the ritual. In a busy shift this necessary pause feels appropriate to mark the fact that the world has lost another individual. The need for ritual at the end of live is pervasive across ages and cultures, but in an era of high expectations of healthcare we seem to struggle more with the inevitable than ever before.

“For the love of God,” Damian Hirst

We need a greater acceptance of the body’s physical frailty and a more realistic view of the limits of medical intervention. We need to find a more tangible connection with all stages of the circle of life, despite our sanitised and secularised society. We need to embrace the fact that the inevitability of our own mortality sets us free to live in the moment. As Wittgenstein noted “eternal life belongs to those who live in the present.”

I intend to make every day I have left count, before the lights go out.

How to die: CPR and the concept of futility

I recently cared for Ernest,* an 87 year old gentleman who spent around two weeks on my ward. Prior to admission his health was poor. He was bed-bound due to the late stages of a degenerative neurological disease, and had associated cognitive impairment. He had several other health complaints, and had been in hospital multiple times in the previous year with infections. He had always responded to antibiotics but his condition and level of interaction with the world had declined with each admission. On arrival to our ward I noticed that he did not have a DNAR order and, since he was not able to discuss his wishes, I looked to the family for information and to broach this subject. I was surprised to find that several vocal family members were adamantly against a DNAR. I had lengthy discussions explaining my reasons for believing that attempts at resuscitation would be futile and that setting limits of care was important to ensure we pursued quality, not just quantity of life. They listened, seemed to understand, and themselves identified his frailty, deterioration over the last year, and decline in his quality of life. However they strongly objected to us making him “not for attempted resuscitation.” As the end of the week approached I felt uncomfortable about the lack of a DNAR order, and about the possibility of this frail gentleman suffering a brutal and undignified exit to the world should his heart stop. I tried to communicate my personal discomfort to the family, and the reasons for it in the context of my experience of the realities of CPR attempts in those with poor underlying health. I also made it clear we were not asking for them to make this decision, but wanted to integrate their views into the medical decision-making process. I was aware of the potential to be seen as being coercive and paternalistic, but felt a duty to act in what I believed to be the best interests of my patient. We treated him with escalating regimes of iv antibiotics, iv fluids and nutritional supplements with no improvement, and by the end of the first week the family reluctantly withdrew their objections to a DNAR. Unfortunately he did not respond to treatment, his organs began to shut down and he drifted into a state of unconsciousness. At the end of the second week the Consultant and I had further difficult conversations with his family members about the withdrawal of antibiotics, fluids and nutrition. He died; peacefully and comfortably with his family present.

I thought a lot about Ernest and his family at the time and in the weeks since. I was taken aback by the strong objection to a DNAR order and, not for the first time, wondered about the expectations of the public of medical interventions. I also wondered what I could and should have done differently; where the line is between professional advice and personal opinion; and to what degree families’ wishes should be followed in the face of futility.

An article in the NEJM addressed the question “Is it always wrong to perform futile CPR?” and suggested that there are some circumstances in which it may beThe "Father of Modern Medicine" right to proceed with futile treatments at the end of life for the sake of the family: for those left behind. I recognise this argument, but my personal beliefs align more with those who contend that this is never right, as it treats the patient as a means to an end, rather than an end in themselves (see Kant), and causes harm to the patient. The Hippocratic Oath is very clear on the duty not to do harm and  to recognise one’s limits.

This quote from a 1988 letter to the editor of NEJM seems even more appropriate today, as the options for what can be done grow, whilst what should be done, is not always considered :

“It seems we have lost sight of the difference between patients who die because their hearts stop and patients whose hearts stop because they are dying.”

Conversations about the limits of medical intervention, the inevitability of death, and the need for priorities other than duration of life are not broached often enough or openly enough. The aim of talking more openly is not to remove hope, but to give patients the space to exercise true choice and autonomy, to define their own priorities, and to live out the time they have left in the way they choose. It also releases the medical team to do all we can with total conviction, comforted by appropriate limits. We live in an ageing society. More people now die from chronic conditions after a long period of declining health, or from a combination of factors best defined as frailty. Atul Gawande, Professor of Surgery at Harvard Medical School, when asked by a family member whether one of his patients was dying admits to struggling to know how to answer:

“I wasn’t even sure what the word “dying” meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.”

For patients in the late stages of chronic health conditions such as heart failure and COPD the week or month of their death is not predictable, but the fact that their lifespan is limited is fact. Starting these conversations is difficult, and communicating the concept of futility can be a huge challenge. What does futility really mean? What % survival from CPR does the public think is achievable and what would they define as futile? Is this the same definition as doctors? It is no wonder that we struggle to find the words, but this is no excuse. The medical profession must not collude in the conspiracy of eternal life, and the  perception of death as failure.

So how do we move forward? A recent JAMA article has suggested a standardised approach to determining DNAR status. Reading the conclusions, the most striking thing is that they sound like simple common sense: “Whenever there is a reasonable chance that the benefits of CPR might outweigh its harms, CPR should be the default option. However, in imminently dying patients….The default option in this situation should be an order to not attempt CPR.” The problem is that life is rarely so black and white, and many patients arrive at hospital with a potentially life-threatening illness but are not imminent dying. It is these patients who still need appropriate limits of care setting, but this is not built into our day to day practice.

The conclusions of the NCEPOD report “Cardiac Arrest Procedures: Time to Intervene?” have been widely reported but often with a negative spin, painting doctors as the enemy of patients “fighting for life.” This is an emotive subject and the media are rarely helpful, fuelling fears of patients having decisions made for them and being abandoned at the end. The Daily Mail can always be relied upon to deal as insensitively as possible with these complex subjects (see here and here, where they conflate the question of the appropriateness of DNARs with communication issues and accusations of neglect, making it difficult for the public to consider the issue in isolation.) The Chair of the NCEPOD report has identified the fact the we all need to recognise and accept the limits of what medicine can achieve. But who does he mean by “all?” This is a societal issue, and discussions need to leave the hospital ward and GPs’ surgery and find their way into people’s homes.

Reflecting on my interactions with Ernest’s family, I was heartened by this quote from Atul Gawande in The New Yorker:

“People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come…”

I will continue to have these hard discussions, but hope that in time they will be made easier by a greater awareness and preparedness from the public. Death is a part of life and our continued silence only makes it more deafening when it arrives.

See The Health Culture blog: “Actions surrounding the moment of death are highly symbolic,MedicalEthicsandMe‘s thoughts, and lots of posts on the Medical Futility blog for further insightful discussion.

* names changed to maintain confidentiality

A Grief Encounter

Last week was particularly stressful; marked by staff shortages, anguished relatives, conflict over complex discharge processes, and pressure to create beds. The amount of time I spent with each patient on my ward rounds was less that what I, or they, would have wanted but despite coming in early and leaving late there are only so many hours in a day. In weeks like these I often feel guilty as I leave work that I am unable to give more time to those patients and relatives facing the end of life.

More than many other people I know, I am acutely aware of the fragility of life.

Modern medicine is amazing and can achieve results and outcomes that continue to astound me. The satisfaction of discharging a patient with a smile on their face after an admission for respiratory failure that looked like it might be their last; or being able to tell a patient that their cancer is curable, is difficult to describe. But even more difficult to articulate is the sense that the days in which I have the greatest impact, the days that are most rewarding are those in which I’ve had to break really terrible news, and have done it well. Such conversations require patience, time, compassion and, I used to think, empathy. I have seen grief, and its many varying manifestations. But being close to grief is not the same as understanding it and I am often aware of the vast distance between myself and a patient’s relative as we sit side by side in a quiet room after I have delivered bad news. What do I really offer in this situation? I try to communicate the medical facts clearly and sensitively, and give patients and families a sense of what will happen next. I feel sympathy, but am unsure whether I can truly say that I empathise. I have limited life experience and, thankfully, very little personal experience of death, and I find it difficult to imagine what grief feels like.

I recently read a powerful blog from a woman who had seen friends, and acquaintances experience grief, helped them through it and thought she understood. Until her father died. “That night I fought off a panicked dream of the earth falling away under my feet. I realized then, that until that moment, I had never had the right to speak.”  This acknowledgement that there is a gulf of emotion between seeing and experiencing grief is something others have identified, including physicians.

I hope that I can continue to find the time, compassion and words to help patients and their families through the most difficult times in their lives. But, selfishly, I hope that for as long as possible I maintain a degree of distance and lack of understanding and that I continue to sympathise but not empathise.

“No one ever told me that grief felt so like fear.” C. S. Lewis (1898 – 1963)

The Dangers of DIY Diagnosis

I spend all day talking to patients about their health and disease, explaining the rationale for tests and discussing the possible outcomes of different treatment strategies. This is often difficult and complex. I struggle to articulate risk, uncertainty, and the art of medicine; the shades of grey that are a day to day reality, and which medical school does not necessarily prepare you for.  I was therefore outraged when, on my way home after a hard day at work, I saw this advert on the Tube:

An advert on London Underground for an over the counter blood test.

I should sue Myrios for emotional distress: I almost fell onto the tracks. What shocked me was the cynical, and cheerful, exploitation of people’s worries about their health.

On their website Myrios say “with all conditions, preventative medicine is key, so it is important to check your health and well-being periodically.” I have no objection to this statement and wholeheartedly endorse the “prevention is better than cure” message. But to suggest that this can be achieved by having a random panel of blood tests is outrageous.

The advert offers testing for a number of ailments, ranging from anaemia to syphilis. Below I offer my initial reaction to each of these, and a reason why you should not buy the test (I suggest you spend your hard-earned money on a giant Easter egg, lunch and an exhibition at the Tate Modern, a subscription to the LRB, or a nice bottle of red).

What concerns me about this advert, and others like it, are the ethics of marketing to vulnerable individuals and the validity of consent to the tests.

I imagined I was one of the patients I often see in clinic and typed “do I have lung cancer?” into Google. The top hit (if you don’t have the wonderful Adblock installed) is Insight Medical offering “peace of mind” from a CT scan of the Chest. This test could indeed reveal a Lung Cancer, and if detected early the outlook is better. But the test involves exposure to radiation, and should only be offered to those with the right risk factors and symptoms or signs to make sure the potential benefit outweighs the known harm. In this context, the test will be offered by a Respiratory Physician, for free on the NHS.

An example of a particularly advanced CT scanner, capable of producing amazing images in seconds

Research is ongoing for an effective lung cancer screening programme for asymptomatic individuals, and progress has been made in the use of CT for screening (a low dose protocol). I hope that in my lifetime we create an effective programme to find early cancers, amenable to aggressive curative treatment. But disappointingly there is currently insufficient evidence that CT screening makes a difference to outcomes, even in carefully selected high risk populations, which is why it is not offered as an NHS screening programme, which are subject to rigorous controls and quality assurance.

I could go on for pages about the complexities of screening; about the need to evaluate the sensitivity and specificity of a test and to know the prevalence in the population you’re testing to have a good idea of false positive and false negative rates; about the need to have a good knowledge of the natural history of the disease you’re screening for and consider lead time; about the need for precise protocols on patient selection, frequency of screening; about  how important it is to know what the intervention will be if an abnormality is detected; about the need to have systems set up to manage and perform these interventions, with appropriate after-care. I recommend The Pod Delusion Episode 129 for a great discussion with GP Dr Margaret McCartney on this subject, and also her BMJ article.

What is not often talked about is the difficulty in dealing with incidental and indeterminate findings.  What if you go for a CT Chest looking for “complete peace of mind” and it identifies a small nodule? It doesn’t look like cancer, the rest of the scan is normal and you are otherwise well. But it’s there. And you’re “high risk” as you’re a smoker. It’s too small to biopsy and your doctor recommends “watching it” with a repeat scan in 6 months (which you pay for and have.) The nodule is unchanged and your doctor recommends a further scan at 12 months. It is again unchanged so, as per guidelines,  she recommends one further check CT at 24 months. The nodule is still unchanged so she says there is no need to watch it anymore. What started as a desire for “peace of mind” has resulted in 2 years of repeat scans (with the associated cost and radiation exposure) and the unquantifiable psychological cost of knowing there is something there. Even at the end of this period you may feel uneasy that this nodule exists and there may be longterm anxiety about it. I wonder whether a scenario like this is discussed in the consent process for the initial CT. I also wonder how many patients switch to NHS care after the initial scan, leaving the NHS to pick up the bill for ongoing care and tests. As always private companies want all the profit, none of the responsibility.

I absolutely encourage you to be an empowered patient, to take control of your health, to research your condition (from evidence-based and peer-reviewed sources) and to practice preventative medicine yourself. I encourage you to talk to your doctor about your concerns. In this model of healthcare delivery there is a partnership between the patient and physician; the physician providing the expertise necessary to evaluate and contextualise the evidence, in order to advise patients on their options. Admittedly not all doctors will respond well to this, and many are still uncomfortable with the “medical Googler” but as healthcare providers we need to get better at this – our duty of care extends to protecting patients from exploitation and worry. I expect to have more and more conversations that centre around critical analysis of evidence found on the Internet. I expect to be challenged and educated by my patients in the future, and hope to steer them far away from exploitation and harm.

Don’t be taken in by cynical marketing. If you are ill or are worried about your health see your doctor. The NHS is a wonderful system and, for now, remains free at the point of need. If you need it, use it, and save your money for enjoying life.

Below are the specific tests offered by Myrios and reasons why not to buy them. 

1. Anaemia. This is a condition in which the Haemoglobin (Hb) level is low. Hb carries oxygen from the lungs to the tissues and if it is low you may feel tired or breathless. Your GP would routinely do this test (for free) if you had these symptoms. There are many, many reasons for anaemia that would require your doctor to talk to you and examine you, in order to decide on subsequent tests.

2. Cholesterol. An important and necessary component of cell membranes, but high circulating levels of some forms of cholesterol (LDL) and relatively low levels of other forms (HDL) promote atherosclerosis and so are linked to cardiovascular disease (heart attacks, strokes). This test is offered for free in NHS Health Check schemes to everyone aged 40-74, and is part of a comprehensive assessment taking into consideration personal and family history, lifestyle factors and other risk factors.

3. Diabetes. A diabetes assessment forms part of the free NHS Health Check, and  is not just an isolated blood glucose test but takes into consideration other risk factors. An isolated single test of high blood sugar does not diagnose diabetes, so further tests such as an oral glucose tolerance test might be needed, in addition to lifestyle advice and support.

4. Glandular fever. This is a viral infection caused by Epstein Barr Virus, also known as infectious mononucleosis. It often affects young adults and is contagious. Common symptoms include fever, sore throat and swollen glands/lymph nodes. For most people this condition is unpleasant but not dangerous and they get better in a few weeks. There is no reason at all for a healthy person to be tested for this disease. A doctor can advise on when the test could be helpful (including when a simple monospot is appropriate, and when other antibody tests may be needed), as part of an overall assessment of a patients’ signs and symptoms. Available for free on the NHS.

5. Gout. A condition in which patients suffer from recurrent inflammatory arthritis. They have attacks of hot, swollen, painful, red joints; often the joint at the base of the big toe, but other joints can also be affected. It is caused by elevated uric acid levels in the blood, which crystallise in joints and cause inflammation. Unfortunately a blood test for uric acid levels is very inaccurate in the diagnosis of gout. High levels are not always associated with a patient suffering from gout, and low levels do not rule out gout. In fact in an acute attack the patient may have low levels as the crystals leave the blood and enter the tissue. A hot, swollen, painful joint needs assessment by a doctor as it may have many possible causes, requiring different tests and treatments. This is available for free on the NHS.

6. Hepatitis B and C. These are viruses which are transmitted through bodily fluids, including blood and sexual contact. They may cause chronic liver disease, which puts patients at risk of cirrhosis and liver cancer. There are vaccines available to help prevent transmission. If you think you are at risk of Hepatitis B or C you need a comprehensive assessment, taking into consideration risk factors, travel and sexual history, signs and symptoms. You may need tests for other blood-borne and sexually transmitted infections such as HIV. You may need further liver tests such as an ultrasound. All for free on the NHS.

7. Hypothroidism. This refers to an underactive thyroid gland. It has many causes ranging from iodine deficiency (rare in the Western world), autoimmune diseases, to pituitary disease. Symptoms are often vague and include tiredness, cold intolerance, weight gain, constipation and depression. These symptoms also have many other possible causes. If you think you may have hypothyroidism you need to see your doctor so that they can consider other possible explanations for your symptoms, and arrange the appropriate tests. For free on the NHS.

8. Iron, Vitamin B12 and Folic acid. These are all substances needed for many functions, but specifically as part of the process producing red blood cells that carry oxygen to the tissues. If they are low you may become anaemic. There are many reasons why your iron, B12 or folic acid level may be low, ranging from dietary deficiencies, to stomach and bowel diseases, so you need to be seen by your doctor to evaluate what the most likely cause is in your case, and they can then suggest relevant further tests. For free on the NHS.

9. Menopause. This is a normal stage in the reproductive life of a woman, when menstruation stops. During the transition some women experience symptoms for which they seek help, such as hot flushes, sleep disturbance, vaginal and urinary symptoms. There is no definitive test for the menopause, although changes in hormone levels may be detectable. There is no reason to check hormone levels in most cases. If you are having distressing symptoms your GP would want to see you to talk and support you through them. For free on the NHS.

10. Stomach ulcer. A stomach ulcer (which can actually be in the stomach or first part of the small bowel, the duodenum) may lead to abdominal pain, nausea, bloating and blood in the vomit. It has a number of causes, but by far the most common is infection with Helicobacter pylori. A small minority are caused by gastric cancer. If you have symptoms you need to see your GP to assess you and consider whether a blood test (for H pylori serology) will be helpful, whether you would benefit from a trial of treatment, or whether you should have further tests such as an endoscopy. All this is available for free on the NHS.

11. Syphilis. This is a sexually transmitted infection caused by a spirochete, Treponema pallidum. The initial stage of infection stage presents with a single “chancre” a firm, painless, non-itchy skin ulceration. Syphilis is very easily cured with antibiotics. If left untreated it can eventually spread to other areas of the body, including the central nervous system, and cause serious illness. If you think you are at risk of having contracted syphilis you need to be tested for other sexually transmitted diseases and need to be seen at a GU Medicine or Sexual Health clinic. For free on the NHS.

12. Vitamin D. Humans get this from diet and from synthesis in the skin in response to sun exposure. Severe deficiency leads to rickets, a childhood bone disease (almost unheard of now in the Western world) or osteomalacia in adults. Your doctor may test your Vitamin D levels if you have certain bone diseases (for free, on the NHS). There has been recent interest in Vitamin D and its role in multiple health problems including cardiovascular disease, asthma, MS and neurodegenerative diseases. There is a lack of evidence to support Vitamin D supplements unless a patient is severely deficient (uncommon in those with a normal diet who occasionally see the sun), therefore there is little value in testing.

An alternative day: how technology could enhance healthcare

Real day: 

I arrive at work, and quickly check my emails on my phone before I enter the signal black hole that is the hospital where I spend my working life. The SHO is not in yet, so I persuade the ward clerk to briefly give up one of only 3 functional computers on the ward and update the patient list with the details of the 2 new patients, whose names are scrawled onto the whiteboard. I skim through their notes, and cast my eyes over them to make sure nothing urgent is required. I leave a note for the SHO requesting her to arrange some tests, before I go to the secretaries’ office to hunt for a working dictaphone and a spare tape.

I arrive in outpatient clinic 15minutes before the first patient’s appointment and turn on the PC. I find the printed lists of the expected patients and pick up the first set of notes, searching through the years of mis-filing to find the referral letter. I finally find it in between a yellowing letter from Ophthalmology in 1994 and one from General Surgery in 1990 that I’m sure was typed on a typewriter.

This closely resembles my NHS clinic computer

By the time I have read the referral letter the computer has loaded up as far as the login screen. I enter my details, listen to it whir, and watch the egg timer turn over and over. I call in the patient and start the consultation as I wait for the screenprompts to enter separate passwords for the Radiology and Pathology applications. I take a history and perform a physical examination. I finally get access to laboratory tests, but have to filter the results in several different ways to get all the results I need. I can then finally look at some recent imaging, although I can’t compare this to old xrays as they have been archived and I don’t have time to ask the computer system to retrieve them from the data store as this has all taken quite a while and there are many patients waiting in the corridor. I fill in the patients details on multiple separate forms for additional blood tests, a CT Chest, and a further clinic appointment, and fill in a form that I keep to one side to fax to the GP later to advise on new medications. I want to check whether the new medication will interact with one of the patients’ other regular medications but the BNF that should be in the clinic room is missing. I can’t check on my phone as there is no wifi and no 3G signal and I don’t even try the desktop. I run out to the corridor and thankfully the nurse finds me a paper copy and I confirm the new drug is safe.. The patient leaves the room and I dictate a letter. As I rewind to correct a phrase I realise the tape is not working. Thankfully I have learned this lesson the hard way before so have a spare. I feel under pressure as I am already starting to fall behind schedule, grab the next set of notes and call the next patient in.

The morning continues like this, with the Radiology system completely crashing at one point, leaving me unable to review one patients’ latest scan. I therefore have to apologise to them and promise to call them later with the result.

After clinic I return the dictaphone and tape to the secretary and ask her to fax the necessary forms. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them try to look up the recently published guidelines for pleural disease to confirm the latest management advice . The intranet is being difficult and is blocking Google, so I find a patch of signal between the store room and the toilets and resort to reading the guidelines in tiny text on my phone before going to see the patient.

We start the Consultant ward round, pushing the notes trolley around the bays, trying to find the drug charts and observations charts for each patient. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about, but we’re unable to show her the scan as she is bedbound and the “Computer On Wheels” on the ward has not been charged so can’t move from the wall where it’s plugged in.

We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a few months ago, and was investigated at our sister site. She can’t remember what they told her about the results, and we do not have the old notes as they have not arrived from the off site store. We see from the pathology system that some abnormal cells were seen, but without any old letters or notes it’s difficult to know what the clinicians who have been managing her since then have planned. We make a plan that will at least relieve her symptoms in the short term, and hope the notes will arrive before the weekend so we can integrate previous management into our plan.

Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view but social services claim they never received the assessments we faxed and therefore have not put in place the package of care he needs to go home. We apologise to Mr Low for the delay and promise to do our best to get him home before the weekend. The sun is shining and he’d prefer a view of his garden to our car park.

After all the patients have been seen and everything documented, the SHO writes a request form for an urgent xray and walks two floors to drop off the form in the Radiology department. After searching 2 control rooms she finds a Radiographer who accepts the form and promises to make sure the xray is done that evening on call. She then returns to the ward, checks the blood tests and chest xrays that were pending, writes discharge summaries for the patients due to go home the next day, and updates the patient list. Since all these systems are separate it takes a while, but finally it’s done. The medical students she had promised to teach got bored waiting for her to complete all her paperwork and went home. She feels guilty for letting them down.

I have misplaced my patient list, but retrieve it from between 2 sets of notes in the trolley and take it with me to the office. I check the x-rays from the morning clinic and call the patient who’s scan I was unable to see. Thankfully it’s reassuring, so I do not have to break any bad news over the phone (what I was fearing all day). I check and sign the letters typed by the secretaries from a clinic earlier in the week and they are posted out. I write myself a to-do list for the next day, take off my stethoscope and head home, late again.

Imagined day:

I arrive at work. The SHO is not in yet so I grab my personal work iPad from its charging station and login. It opens immediately and I click the app for our patient list to see that the integrated system has automatically updated to feature our 2 new patients, whose names are highlighted in bold. I click on each of them in term and rapidly review their electronic admission notes, imaging and lab results. I have some time before clinic so introduce myself and chat to each of them, checking that each test required has been requested. The system shows an allocated slot for the echocardiogram, which I feedback to the patient. A CT has not yet been requested so I click on this, the system automatically inputting the patient’s details and latest blood results, and input my password to sign off the request. It appears as “pending” in the patient folder so the SHO will not waste time also requesting it if I don’t catch her before I head to clinic.

I arrive in outpatient clinic 15minutes before the first patient’s appointment and login. I pull up the clinic list, and due to the integrated system am able to directly link to all results and previous clinic letters. I read the first patients’ referral letter, check any recent results and review recent chest xrays. I compare to old xrays which is invaluable in this case, revealing a new shadow. I am thankful that old imaging is easily accessible since the hospital solved its data storage problems.

I have a lot of information before I call the patient is, allowing me to take extra time taking a history and performing a physical examination. There is time to explore the patients’ worries and answer questions. With a few clicks I request the additional blood tests, a CT Chest, and a further clinic appointment, and complete a template “urgent GP letter to advise on new medications”. This is automatically saved in my email outbox, with the relevant GP practices email address completed, for me to review and send later.  I click on the BNF app and quickly confirm that the new medication will not interact with one of the patients’ other regular medications. The patient leaves the room and I dictate a letter onto the voice recognition system. I notice a few typos but I elect to save the letter and review at the end of clinic before it is sent.

An example app, developed In London by North East London, North Central London and Essex Health Innovation and Education Cluster (NECLES HIEC) in partnership with Asthma UK, Queen Mary University London, Solar Software.

I am on time, and review the next patients’ recent letters and results before calling them in. I see that they have asthma and have started a new inhaler. I notice that they have been using an app to record their peak flow, which allows the patient, respiratory nurse and me to access the recorded data. I click to view the graph and feel well prepared to have some important discussions on treatment plans with the patient. The morning runs smoothly and I finish clinic with time to grab a coffee on my way up to the ward. I check my twitter feed in the lift and see a link to an article on new evidence on pulmonary fibrosis treatment that I save as a favourite to read later.

I  review and approve the letters from clinic and them and dock the iPad to charge. The letters automatically download and email themselves to the relevant GP practices. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. While I eat I read the article I saved from my Twitter feed and think about a recent patient I saw that I must discuss with my Consultant. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them I look up the recently published guidelines for pleural disease to confirm the latest management advice. I have these guidelines saved as a link in my browser bookmarks so they’re easy to access.

We start the Consultant ward round, entering our comments onto the electronic notes system using our iPads. The drug charts are also electronic, allowing us to make changes at the same time that the nurses are logged in, dispensing drugs from the cupboard. The intelligent prescribing system prompts us to reduce the dose of a patients medication whilst they are on a particular antibiotic. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about but since we’re able to show her the scan on the iPad she is better informed and is able to understand what will happen at the proposed lung biopsy.

We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a year ago, and was investigated at our sister site. She can’t remember what they told her about the results, but we are able to pull up the old notes on the electronic system and can see what decisions were made before, and what the clinicians’ opinions were. We see from the pathology system that some abnormal cells were previously seen, but that after discussion with the patient and her family it was felt inappropriate to further investigate due to her frailty. We therefore make a plan that will relieve her symptoms and are able to start planning a supported discharge with community support.

Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view, and since the relevant forms were sent to social services electronically they logged them on the day they were sent and immediately put in place the package of care he needs to go home. The hospital transport arrives as we are saying goodbye to him and he thanks us for getting him home to enjoy the sunshine in his garden, rather than forcing him to spend any longer staring out at our car park.

After all the patients have been seen and everything documented, the SHO clicks to request an urgent xray and calls the “hot room” where the on call Radiographer is keeping an eye on the urgent referral work stream. He looks at the request on his screen and promises to make sure the xray is done that evening on call. The SHO then checks the outstanding blood tests and chest xrays that were pending, completes the discharge summaries for the patients due to go home the next day (which have results of blood tests and scans auto-populated into them), and updates the patient list. She is then free to do the teaching she promised the medical students, and still finishes on time.

I check the x-rays from the morning clinic and pop in to see my consultant to discuss  a patient I saw earlier in the week. I bring up the new evidence I read at lunchtime and we discuss how this relates to this patient. We complete an assessment on my e-portfolio, and I add an entry to TILT, which I also post on Twitter.

I write myself a to-do list for the next day, take off my stethoscope and head home, on time.