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Think the life of a doctor is dull? Think again! In a previous post, I recommended ten books by medical men which all doctors should read. Today, it’s the turn of medical movies. By focusing on the extremes of human life – birth, death, suffering, illness, and health – such films provide insight into the human condition and the part that we as doctors play in this never-ending theatre.

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Doctors in the UK are striking for the first time in over 40 years. This comes after months of failed talks between the government and the British Medical Association (BMA) regarding the controversial new junior doctor contract. We do so with a heavy heart, as it goes against the very ethos of our vocation. Yet the fact that more than 98% of us voted to do so, speaks volumes about the current impasse.

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Advance Reader Copy supplied by the publisher.  Final version subject to changes.


Mateo travels with his mother every summer to visit his relatives on the Hill of Dust in Oaxaca, Mexico.  This year, his grandfather Teo says that he needs young Mateo's help;  he begins to tell Mateo a fascinating story of his youth,

     As he speaks, his words somehow beam light onto an imagined screen, flooding the room with people and places from long, long ago.  "Mijo, you are about to embark on a journey of marvels.  Of impossible fortunes.  Of a lost duck, three-legged skunk, and a blind goa - all bravely loyal.  Of a girl who gathered power from storms and sang back the dead.  Of an enchanted friendship that lifted souls above brutality.
     He pauses, tilts his head, "Perhaps there will even be an itermission or two.  But as of yet, there is no end.  That, mijo, will be up to you."  He winks, clears his throat, and begins.
     "There once was a girl called the Queen of Lightning ..."

The story then retreats to the Oaxaca of the mid-1900s, a time when Mexico's indigenous Mixteco people crossed paths with the mysterious Roma in the hills outside Oaxaca.

Grandfather put his hand on my shoulder and said, "They are like us, outsiders in Mexico.  Both our people have little voice in the government.  City folk consider us backward.  We live on the fringes, the wilds of our country.  So it is with the Rom." 

...

I looked at Esma and her grandparents, who were admiring the sawdust mosaic of the flowered caravan.  And I wondered if the key to her people surviving had been separating themselves from outsiders -  gadjés. Maybe that's what bonded them together as they danced around their bonfires, night after night for hundreds of years.

     As was foretold by the fortune teller and against impossible odds, young Teo becomes "friends for life" with Esma, the young Romani singer.  It is as if they are bound to each other by magic and music and the power of lightning - their destinies tied inexplicably to one another.

Teo reminisces to his grandson Mateo,

She could work magic.  One moment, I'd felt hurt and angry.  The next honored that she'd confided in me.  And now, inspired, as though anything were possible, if I believed it enough.
     She climbed onto the rock, raised her arms. "If you believe you're weak, you'll be weak.  You're cursing yourself.  Yet if you believe you're strong, you'll be strong.  Give yourself a fortune and make it come true."

   
There is definitely magic between Teo and Esma, the indio boy and the Roma girl, and there is magic in the pages of The Lightning Queen.

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Nurses play a huge role in hospitals, clinics, and various care facilities throughout the world. However, there are widespread misconceptions about what responsibilities nurses have. Nurses are saving lives and making a difference every day in health care with little recognition from the media or the world at large. Test your knowledge and see how much you really know about what exactly goes into the job of being a nurse.

Featured Image: USMC – 07790 by Ryan R. Jackson. Public Domain via  WikiCommons

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By Kenneth M. Ludmerer

“Don’t get sick in July.”

So the old adage goes. For generations medical educators have uttered this exhortation, based on a perceived increase in the incidence of medical and surgical errors and complications occurring at this time of year, owing to the influx of new medical graduates (interns) into residency programs at teaching hospitals. This phenomenon is known as the “July effect.”

The existence of a July effect is highly plausible. In late June and early July of each year, all interns and residents (physicians in training beyond the internship) are at their most inexperienced. Interns—newly minted MDs fresh out of medical school—have nascent clinical skills. Most interns also have to learn how a new hospital system operates since most of them enter residency programs at hospitals other than the ones they trained at as medical students. At the same time the previous year’s interns and residents take a step up on the training ladder, assuming new duties and responsibilities. Every trainee is in a position of new and increased responsibilities. The widespread concern that these circumstances lead to mistakes is understandable.

Yet, despite considerable consternation, evidence that there is a July effect is surprisingly hard to come by. Numerous studies of medical and surgical trainees have demonstrated no increase in errors or complications in July compared with other times of the year. Many commentators have declared the July effect a myth, or at least highly exaggerated. A few studies have shown the existence of a July effect, but only a slight one—for instance, on the sickest group of heart patients, where even a slight, seemingly inconsequential mistake can have grave consequences. Even here, however, the magnitude of the effect does not appear large, and the studies are highly flawed. Certainly, there is no reason for individuals to avoid seeking medical care in July should they become ill.

That the July effect is so difficult to demonstrate is a tribute to our country’s system of graduate medical education. Every house officer (the generic term for intern and resident) is supervised in his or her work by someone more experienced, even if only a year or two farther along. Faculty members commonly provide more intense supervision in July than at other times of the year. Recent changes in residency training, such as shortening the work hours of house officers and providing them more help with chores, may also help make residency training safer for patients—in July, and throughout the year.

Uncertainty is intrinsic to medical practice. Medical and surgical care, no matter how skillfully executed, inevitably involves risks. It would not be surprising if a small July effect at teaching hospitals does occur, particularly in certain subgroups of critically ill or vulnerable patients, given that house officers are the least experienced. However, the fact that this effect, if present, is small and difficult to measure provides testimony to the strength of graduate medical education in the United States. Indeed, the quality of care at teaching hospitals has consistently been shown to be better than at hospitals without interns and residents. Patients may be assured that their interests will be served at teaching hospitals—in July, and throughout the year.

Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, and Learning to Heal: The Development of American Medical Education.

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Image credit: Multiracial medical students wearing lab coats studying in classroom. Photo by goldenKB, iStockphoto.

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My first experience with Dr. P was a week after we discovered our surprise forth pregnancy. I found myself seated uncomfortably on the metal table being interrogated by a very contemplative man half my height, but with an IQ obviously twice mine. He spoke with a fairly thick accent and seemed dubious of my procedure of choice.

Dr. P, “Missa Myers, you seem very young. How old are you?”

Me, “I’m thirty-four.”

Dr. P, “How old your wife?”

Me, “She’s thirty-three.”

Dr. P, “Oh, that very young. You sure you want this?”

Me, “Yes Doctor, I’m sure.”

Dr. P, “You know, this permanent. You might want reversal, but it maybe not work.”

Me, “I know. I’m sure.”

Dr. P, “Your wife sure? She know?”

Me, “Yes, she knows.”

Dr. P, “Okay, you sure. Just one more time I ask, because you maybe not go back?”

Me, “Dr. P, we just found out we were pregnant with our fourth child.”

Momentary pause for contemplation.

Dr. P, “Oh. In that case, why you not come see me sooner?”

He checked a box on his form and left. The procedure came a few weeks later. I’ll mention no specifics except to say that once I was prepped and ready, the quiet, secluded corner room seemed to turn into Grand Central Station. Nurses, accountants, inspectors, magazine vendors, interns, dog walkers, board certifiers, and I think a few pharmaceutical sales reps all of the sudden had important business in my room. Finally the good doctor came and did his work. I left hoping to never see Dr. P again. No offense, but I thought seeing him again meant a fifth bundle of joy. I was wrong.

My second trip to see him came after experiencing some discomfort during a long run. Until then, I had no idea that Urologists did everything! When I went back to the very same room, there sat my friend, Dr. P. who remembered me distinctly.

“How your baby?” Dr. P asked.

Me, “She’s doing great. Six years old now.”

Dr. P, “How old are you?”

Me, “I just turned forty.”

Dr. P, “You know, Missa Myers, we start thinking about prostate health at this age…”

 

I’ll leave the rest to the imagination. Based on my experience with Dr. P, I have some advice for men.

First, when your Urologist asks you your age, consider consider the ramifications of the question.

Second, when you are greeted by your friendly Urologist, remember that his hands have been places that my dog’s nose only dreams about.

 

 

I poke fun at my interaction with Dr. P, but men’s health issues are not a laughing matter. Fortunately, I only had a couple of kidney stones that were easily blasted out. Get checked when it is time to get checked, men. Others are counting on you!

 

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By Heidi Moawad

As a medical student, you are the future of health care. Despite the persistent negativity about the state of health care and the seemingly never-ending health care crisis, you have astutely perceived the benefits of becoming a physician. There is no doubt that health care delivery is unreasonably complex for everyone involved and, as much as political party loyalists insist that this is the fault of the ‘other’ party, the bureaucracy and inefficiencies have endured despite the back-and-forth changing hands of responsibility.

Fortunately, you have seen past the commotion and panic, and steadfastly remained optimistic. There is not a single medical student who ended up where he or she is by accident. The completion of rigorous undergraduate pre-medical prerequisite courses, outstanding grades, and top-notch MCAT scores required for application to medical school only come to those who have a well-thought-out plan, combined with a commitment and perseverance to become physicians. Medical school acceptance is exceedingly competitive, involving a multistep application process starting with preliminary applications, and then progressing to selective invitations for secondary applications and interviews. Academic excellence is the entry point, while interviews serve to distinguish young people who have a passion and a gift for helping humanity. Interviews are granted to few; offers of positions in a medical school class are even fewer.

You have already overcome all of these hurdles and remained focused. You are fortunate to begin your medical education at a time when you can shape the future of the profession. Medical education is becoming more innovative, going beyond traditional approaches to learning. The potential benefits for students are endless. With these advantages, come higher expectations. As a doctor of tomorrow, you will often expect yourself to improve the world around you for your patients.

The direction of health care will certainly improve as your generation of young physicians in training masters the knowledge and proficiencies necessary to become licensed MDs in a few years. The capabilities that will make you a leader are skills that cannot be measured, yet can absolutely be learned. Like many of today’s future doctors, you are likely to find yourself driven to improve the health care options available for patients or to use technology in new ways that have not been thought of before. There has been an increasing trend of physicians playing roles that have not been defined previously.

As a young physician, while you fulfill the requirements for licensing, you may discover that there is more than one way to be a doctor. Some of the ways to be a doctor involve non-clinical work, which typically does not enjoy a well-established path. If you choose to establish experience and find employment in alternative areas besides clinical practice, you will find that you don’t have built in access to guidance and direction. Yet, it is advantageous for you to understand all of the professional opportunities available to you while you embark on the road to becoming physicians. Knowledge is power. Every young doctor ought to appreciate the full array of options after graduation from medical school. This can help set the stage for career satisfaction in the long term. You can attain a career path that is challenging and fulfilling. The results for medicine as a profession will be enhanced when all doctors use their skills and talents in the way that fits best.

Heidi Moawad, MD is neurologist and author of Careers Beyond Clinical Medicine, an instructional book for doctors who are looking for jobs in non-clinical fields. Read her previous blog posts.

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By Rowan Hillson

 
The first time I increased a patient’s insulin dose I lay awake all night worrying that his blood sugar might fall too low.  I was a house officer, and insulin was scary!  The patient slept well and safely.

Diabetes is common, chronic and complicated.  A recent nationwide audit of 12,191 people with diabetes in 206 English acute hospitals found that 15% of beds were occupied by people with diabetes.  Worryingly,  37% of these patients experienced at least one error with their diabetes medications (the full results can be read here).

The National Patient Safety Agency (NPSA) has had over 16,000 reports of insulin incidents.  In 2010 the NPSA  issued an alert requiring action for all health care professionals to improve prescribing and administration of insulin, which was linked to a “Safe use of insulin” e-learning course. 

I trained over 30 years ago.  Are junior doctors more confident now?  Apparently not.  A study of 2149 junior doctors by George et al provides worrying evidence that UK trainees lack confidence in managing diabetes.  Just 27% were fully confident in diagnosing diabetes, 55% in diagnosing and managing dangerous low glucose and 27% in managing intravenous insulin.  Regarding management of diabetes,  24% of respondents would “not often, rarely or never” take the initiative to improve diabetes control. 43% would not adjust insulin in patients with poor glucose control.   

Confidence is a combination of knowing what to do and believing you can do it.  Experience helps.  Also, we all need to know what we don’t know and when to ask for help.   An unconfident doctor may make the patient anxious.  Galen believed that in the 2^nd Century: “Confidence and hope do more good than physic”. 

Trainee doctors receive varying amounts of diabetes training and variable supervised experience of looking after people with diabetes.  With too little training, trainees may rightly be worried about managing diabetes.  Inadequate care of people with diabetes in hospital could worsen virtually every clinical outcome regardless of the main reason for admission. It also worsens patient experience. Diabetes is a common, potentially dangerous but eminently treatable condition. All units in all hospitals should have access to a specialist diabetes team.  And trainee doctors should have training and support in diabetes management until they each feel confident in looking after people with diabetes under their care.

Table from the paper ‘Lack of confidence among trainee doctors in the management of diabetes: the Trainees Own Perception of Delivery of Care (TOPDOC) Diabetes Study’, QJM: An International Medical Journal, Advanced Access, 21 April 2011 

Read on for an excerpt from Dr Hillson’s commentary ’Diabetes – big problem, little confidence’, which is published in QJM: An International Journal of Medicine, Advanced Access, 21 April 2011. You can read the 0 Comments on Diabetes: big problem, little confidence as of 1/1/1900