Another Professionalism Debate

Professionalism is something that I personally reflect on a lot. I want nothing more in my medical career than to do no harm and to be professional so that I provide the best for my patients.
At medical school I always seem to be coming across situations in which I question the professionalism of the doctor/healthcare professional I am working with. I understand that in stressful situations when there is a lot to do and think about sometimes common courtesies get missed, but there are times when I see things that make me question professionalism and how we come across as medical professionals.

The case that got me thinking about this issue again this time was on our hospital placement. Each fortnight we go around the wards and practice on unsuspecting patients our history taking and examination skills. For patients this must be a really daunting prospect anyway. Our hospital tutor goes to the patients and asks them if they would be willing to talk to, and get prodded by the medical students in advance of our session and  if they say yes in we go. There are six of us and you can see the shock and mild panic at the number of students on every patients face as we file into the bay and crowd round them, hemmed in by the curtain. And then our hospital tutor introduces them and we take a history/do our examination. The poor patient has to sit there whilst 6 of us go through the motions one after the other. Nothing we are subjecting them to is painful and I think some of them enjoy it as a way to pass the time but there are occasions when we go in and it is clear that the patient wants to go back on their previous ‘yes’ to being a guinea pig. For example there are occasions in which the patients family are there and they clearly want to spend this time talking to their family member and not to us.
In this situation though what is the right thing to do? Should we be quick (this is often the option that our hospital tutor goes for, allowing only a couple of us to do the examination or taking a rapid fire history himself) or should we recognise that the patient doesn’t want to be examined right now and leave them be. I personally would prefer the latter. Whilst it is important for us to be able to practise examinations, none of these patients actually have signs, we are more just looking at normal at the minute so we can practice on ourselves. I don’t see that there is any need to disturb them when they clearly don’t want to be disturbed. I wonder how we come across if we don’t pick up on these signs and act accordingly and I worry that we come across as rude to the patient.

There was a specific situation during our hospital placement that made me particularly uncomfortable and after discussing it with my colleagues it was clear that they felt the same. There was a patient on the neurology ward who we went to see to practice respiratory examinations. When we entered his bay it as clear that it would be difficult to take the respiratory examination as he had his arm in a sling and a neck brace on and we were informed that we shouldn’t sit him forward. He also had external fixation on one of his legs and it was difficult to get in close to him. I was expecting our hospital tutor to leave him be and not let us examine him because none of use wanted to risk hurting him but he pressed on and let one of my colleagues have a go. As soon as we entered the bay it was clear that the patient wanted to chat, he was talking in confused sentences but appeared to believe wholly that he was getting his point across. What made me uncomfortable was that our consultant completely ignored him and talked only to us. All the time that he was talking the patient was trying to get his attention to tell him his story, from what I could gather, but our consultant continued to ignore him.

This made me uncomfortable. Understandably though we were rushed for time and I know he was trying to get the best for us from an educational point of view. I would have felt much more at ease if our consultant had spoken to him a little, even just said yes at the end of a few of his sentences to appear as though he was listening. This type of thing makes me question how we come across. In my mind that made him less professional but the patient, who was admittedly very confused, didn’t seem hugely fazed. Our consultant redeemed himself by talking to the patient very well after my colleague had finished her examination but it still grated on me that he had ignored him until that point.

It also makes me wonder about a larger problem. The NHS and medical care in general is supposed to put patients first and yet we as trainee doctors are constantly doing procedures which our seniors could perform better than us. How is that putting patients first? It is putting our medical education first surely? Of course new doctors have to be trained for the future well-being of patients and I suppose that finding the balance is the key.

Anyway enough reflection. I need my bed to have a productive day of revision tomorrow!

The Theory of Everything

There was no better way to see in the New Year today than by watching the wonderful movie that is ‘The Theory of Everything’. For those of you unsure, this is the new film about the life of Steven Hawking and his progressive journey through life with Motor Neuron disease. He was given approximately two years to live but he is still with us today. As a future medic I found this film extremely thought provoking. One line particularly caught my attention,

‘Your thoughts won’t change, it is just that soon people won’t know about them’. 

This quote, I think,  profoundly sums up the suffering of those with motor neuron disease. To be totally aware of your decline, to have your thoughts as intact as they were from the days when you can still walk to the days where you require constant assistance must be torturous.

This movie has captured that struggle immensely well and I cannot commend Eddie Redmayne enough for his highly considered performance. I am so glad I watched this film as I think I understand this suffering to a greater level now.

I have a new found respect for Steven Hawking and the incredible hurdles he has overcome, both personal and professional. He is one of the greatest minds of our time and he has not let his MND sway him from his work. He is an inspiration.

I’ll leave you with this quote which contains a mentality I wish to adopt for the New Year:

‘However difficult life may seem, there is always something you can do and succeed at.’

Thank you, and Happy New Year!

Professionalism

It’s a funny word.

A word that is completely drilled into us over and over at medical school. Even before we get here we are told that from now on we must behave in a professional manner, not do anything that could compromise our fitness to practice and stay on the straight and narrow.

Yet there isn’t actually an accepted definition.

It’s a very difficult word to define because it means different things to different people and relies heavily on context.

I generally judge professionalism by looking back on things that I or others have done and to think if there was a way to do that that would have respected the dignity of the patient more, that would have been less painful for the patient or that would have been easier on my colleagues?

But still it’s hard to know if I’m hitting at the right ball park. For example last week when I was on my HCA shift – this is a thing that the medical school are making us do at the weekends now, it’s an annoying amount of time to lose from studying and other stuff that I want to be doing but I think I’m learning, though how relevant that learning is, is another matter.
So anyway, I was on my HCA shift on an elderly care ward. I love this ward because although a lot of the patients are confused there are patients with some wonderful stories who’ve been in hospital for a while and want nothing better than to sit there and recount all their travels to you – it’s lovely. I was in a bay this time with a few distressed and sometimes aggressive patients I had been warned.

I had another HCA and a staff nurse working with me. One of the patients was on a mattress on the floor as they had no more low profile beds and he was a falls risk. He was due to be moved but I also questioned that – is it better for him to be on the floor, what about infection risk? Or do we risk putting him in a normal bed and him falling? What’s the right thing to do here? In light of the following events I’m glad he was in a mattress on the floor but I remember questioning it at the time. We got on with the morning work and at one stage I was in the bay alone. This man had been distressed all morning and tossing and turning trying to get up and out of bed despite being unable to stand. I turned my back for a minute and heard him cry out. I spun round and he was half way across the bay on his front with blood all down the front of his hospital gown. Turns out he had pulled his catheter out and was running away in the only way he knew how because he was disorientated and felt like he wasn’t safe. I yelled for help and got down beside him to reassure him and calm him down. I took his hand, looked him in the face and spoke to him calmly and he did begin to calm down. However then the nurse and HCA arrived and he riled up again.
Both this nurse and HCA were incredibly professional all morning, maintaining brilliant dignity when bed bathing patients and talking to them well but I think the nurse at this stage was frustrated with this patient. He had been distressed all morning and we had kept going back to calm him down. He had already pulled out cannulae and catheters before all of which had to be replaced and by this point I think the nurse was done being calm with him. THe nurse didn’t snap but was quite short with the patient and was just generally portraying a frustrated exterior – now this meant that calming the patient down took a lot longer because he picked up on the frustration and amplified it in himself.

Was the nurse being un-professional to outwardly direct his frustrations at the patient?

I don’t know, I know it didn’t sit right with me and I preferred to personally take the calm exterior approach however frustrated I was internally. But I can understand the reason for his frustration. The patient eventually calmed down, the catheter was re-fitted and he was calm for the rest of my shift even as he was hoisted and moved to a low profile bed. So the nurse getting frustrated had no repercussions – so was it unprofessional?

I can’t give you the answer and I don’t think most people can either, its more down to personal opinion. Professionalism is subjective and the most important opinion on whether or not you are being professional is that surely of your patients and your colleagues. If they perceive to be professional then you are, aren’t you? Even if not so much in your personal life?

Well that’s another debate right there. I’ll leave you with this thought:

‘Medicine is, in essence, a moral enterprise, and its professional associations should
therefore be built on ethically sound foundations. At the very least, when physicians
form associations, such occasions should promote the interests of those they serve.
This, sadly, has not always been the case, when economic, commercial, and political
agendas so often take precedence over ethical obligations. The history of professional
medical associations reflects a constant tension between self-interest and ethical ideals
that has never been resolved’

Thank you.

An interesting case…

Fortnightly we at our medical school take the afternoon to go to a local GP surgery and get some teaching from current GP’s and meet a few patients.

We’ve been going for a few weeks now and I must say our GP is a fantastic teacher, one of those highly enthusiastic people who is ready to tell you absolutely everything he knows about a topic.

Back in our first week we were learning initially about general end-of-bed observations and taking an examination of the hands and face. We learnt first and then to practice what we had learnt on a few patients who had some interesting signs.

One of the patients had psoriasis which on examination of her hands was hardly noticeable but then she rolled up her sleeves and we saw that she was covered. From this I learnt not to just take the surface of things, to dig a little deeper and you might uncover something that you’d otherwise have missed. This would obviously have come out in the history but as we just examining the patient today we could have easily missed it.

By far the more interesting case for me, however, was her husband who just came in the capacity of taxi to bring her into the surgery. He had however had a pretty obvious and extremely interesting operation that I had never seen before or knew existed.

Before he even entered the room we could hear him chatting to our GP in a gravelly, very hoarse voice which at first I just thought was his voice until he walked into the room. It was immediately obvious that he was talking through a valve in the middle of his neck which he pressed in order to make sound and let go of to breath. I had truly never seen anything like it.

He told us that he had had a tumour of his true vocal cords and that in order to be cured he had, had to have a total laryngectomy (surgical removal of the larynx (voice box)). This obviously removed his power of speech however surgery can provide a solution to this. He had, had what is known as a tracheo-oesophageal puncture performed and then a prosthetic valve placed in to allow him to regain a form of speech known as oesophageal speech.

Apparently his degree of speech is very good in comparison to the normal outcome for these patients and I must say that apart from the gravelly tone of his voice his speech was entirely normal. He has learnt to use the valve very well.

The principal of the operation, from my understanding, is that a patient who has had a complete laryngectomy needs to breathe permanently through their neck. A hole (fistula) is made between the trachea and the oesophagus and the voice prosthesis is inserted which does not allow food down the trachea but does allow air into the oesophagus.
Air in these patients enters and leaves through the valve in their neck but when the patient occludes the valve and prevents air escape by this pathway air enters the voice prosthesis and enter the oesophagus and escapes through the mouth. As the air passes through the upper tissues of the oesophagus it vibrates replacing the vibrations previously produced by the vocal cords.

This is what it looks like in the flesh:

Oesophageal speech, I’ve been told, is hard to master especially initially but there are clinics for these patients to go to where they can learn to speak well using these prostheses and the result is truly astonishing.

There are of course implications on this man’s life, he will never be considered in the same way and there will be a prejudice that comes from the sound of his voice. He said himself that children are scared of him now and he does resent that, but for him the ability to still communicate close to how he used to succeeds that and once people get to know him they understand and there is no judgement.

It amazes me everyday the things that modern medicine can achieve and this man and his surgery reminded me why I decided medicine was the career for me in the first place.
Very cool!

Just to show those of you who haven’t seen this – here is a patients story:

https://www.youtube.com/watch?v=SaREnCLP3RM

Care, Compassion and Commitment…

To me these are the things that make up a good medical student and a good doctor.And of course you need to have a little bit of charisma and personality as I hope to demonstrate with this frankly glorious photo if I do say so myself.
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This is me, little bit exuberant at times but I like to think that I possess the qualities to become a good doctor. My name is Lydia Edge and I’m just starting my second year of medical school in the UK. Having just completed first year and finding that the more I progress through medical school the more I need somewhere to share the experience I’ve decided to start a blog where I can do just that.
Expect to find posts not just about medical school but about university life in general, about my summers and how I’m spending my time away from studying. I’m still learning about myself as well as about medicine so there will be an element of reflection about decisions I’ve made, paths I’ve taken. Let’s see how it goes!

Ask questions, get involved, I would love to hear from all of you!