What has you here today?    work history (html) about me tajik bookmarks

RCEM Learning Podcast. 6th of December, 2018 ANTE·MERIDIEM 12:35

I worked as an SHO in the Mater Emergency Department in Dublin from July 2014 when Andy Neill was a registrar there, and my thinking then was ‘this man is clearly great as a doctor, I am glad of any input from him on almost any presentation, my one concern is not to overload him with questions, I’d prefer him not to burn out while I’m here.’

The Irish secondary care system is, let me phrase this diplomatically, uneven, and when I was working as an SHO in non-central-Dublin hospitals the guidance from registrars was of limited benefit to the patient or to either of the doctors. There was no whisper of this situation from Andy, and from most of the registrars in MMUH.

The correct specialty (in terms of benefit to patients and long-term quality of life for the doctor) for most of the doctors most of the time in the Republic is General Practice. And so I applied for the training scheme, and have been in Donegal since July of 2015; I thoroughly recommend the Donegal Specialist Training Scheme in General Practice, I have spoken at length with trainees across the Republic and the North about their schemes, and in terms of almost anything objective, the Donegal scheme comes out best.

But; the first specialty I worked in post-intern-year, early 2013, was Emergency Medicine. And, well, I really enjoyed it. I enjoyed how general it was, I enjoyed randomly having to deal with an Afghan refugee where my Persian was of some use, knowing that نقرس is gout was of actual help to the patient, I enjoyed managing patients well through French without issue when the triage nurse in Blanchardstown (closest hospital to the airport!) was worried about the need for an interpreter but hadn’t actually organised an interpreter on triage. I even enjoyed that anyone who had put up with the fourteen hour wait was actually sick enough to need to be in hospital, and so I knew how to manage them from my intern year! I didn’t know much about sprained ankles or migraines, but I did manage to learn it.

And I still like it. Five years later, I am still consistently seeing ED patients a proportion of the week and enjoying it, there is no prospect of me stopping ED work in the medium term. I’m not doing it in Dublin, but that is mainly a constraint of my registration rather than an explicit choice.

Which is a roundabout way of saying I listen to the RCEM Learning podcast because I enjoy it and it is relevant to my day-to-day work. I write this post today because I now contend that it is a high point of human learning.

I attended some local teaching in Donegal yesterday from a medical specialist, about one of her areas of interest and the appropriate management and approach to referral; and it reminded me of how bad medical teaching can be. She used data from the US population that differed importantly from the Irish population to make decisions; she appeared to have no insight into the day-to-day pattern of presentations to GPs in general and how her recommendations would impact on her clinic numbers, when making a presentation to GPs in large part advertising her service; practicality and pragmatism were at no point involved in the presentation. It was as bad an experience as any of the bad presentations involved in my experience of Computer Science lecturers, and those fellows had the theory of mind of a four-year-old Sheldon Cooper.

Nothing like the above ever happens with the RCEM Learning podcast, of which Andy is the backbone. Doctors’ weaknesses of understanding are usually with formal statistics; the RCEM Learning podcast gets this right consistently. Practicality and pragmatism are front and centre. The variation in speakers, from the UK to ourselves to Australia, a little bit the US (certainly not a massive cultural variation, but a big variation in how health care systems are funded and how the associated incentives play out), mean that the decision-making cul-de-sacs that give bad outcomes for economic reasons are mentioned as avoidable.

I listen to lots of North American podcasts relevant to Emergency Medicine, and they’re great, much better than our medical specialist above. RCEM Learning still edges in front of all of those I listen to. If you are a doctor who drives and has anything to do with Emergency Medicine (whether working in it, taking referrals from it, or making referrals to it), make your car handle podcasts in some way, and listen to the RCEM Learning. podcast when it comes out. You will make better decisions, you will have a better understanding of the decisions made when you refer, and you may incidentally start rhyming ‘now’ with the French word for ‘eye’, which will be entertaining for everyone.

Thran. 23rd of October, 2018 POST·MERIDIEM 11:53

Thran /θræn/ (th of thin, rest of the word as in ‘ran’) is a word used in this part of the world to mean “stubborn, obstinate.” This little vignette on Reddit, about the roads I drive to do my grocery shopping, prompted me to look it up. To my surprise it’s not in the second edition of the OED, but from the Scots dictionaries it is likely the same word as ‘thra,’ which is. For your edification, here is the OED2 entry.

thro, thra, a.¹ (adv.) Obs. Forms: 3­4 Þra, (5­7 Sc.) thra, 4­5 Þro, thro, throo (5 throe).
[ME. a. ON. Þrá-r ‘stubborn, obstinate, unyielding, refractory, persistent, zealous, eager, keen’, adj. cognate with Þrá n.: see prec.]
1. Stubborn, obstinate, persistent; reluctant to give way, or accede to a request.
(The spelling throw in quot. c 1500 is app. due to confusion with other words.)
a1300 Cursor M. 5803 (Cott.) King pharaon..es ful thra [Trin. Þro], Lath sal him think to let Þam ga.
13.. Ibid. 28092 (Cott.) Vn-buxum haf i bene, and thra A-gayn my gastly fader al-sa.
c1400 Destr. Troy 5246 þat were Þro men in threpe, & thre-tyms mo.
?a1500 Chester Pl. (Shaks. Soc.) II. 11 In this place, be you never so throe, Shall you no longer dwell.
c1500 Smyth & his Dame 317 in Hazl. E.P.P. III. 213 Be thov neuer so throw, I shal amende the sonne, I trow.
c1560 A. Scott Poems (S.T.S.) xiii. 31 Than be not thra ȝour scherwand to confort.
1603 Philotus xl, Scho is sa ackwart and sa thra, That with refuse I come hir fra.
b. Of a corpse: Stiff, rigid.
a1400­50 Alexander 4452 Graffis garnyscht of gold & gilten tombis Thurghis to thrawyn in quen ȝe Þraa worthe.
2. Stubborn in fight, sturdy, bold; fierce. Also fig.
c1320 Sir Tristr. 777 þei Þou be Þro, Lat mo men wiÞ Þe ride On rowe.
?a1400 Morte Arth. 3757 They..thristis to Þe erthe Of the thraeste mene thre hundrethe.
c1400 Ywaine & Gaw. 3570 Thir wordes herd the knyghtes twa, It made tham forto be mor thra.
c1400 Destr. Troy 6422 Merion..With Þre thousaund Þro men Þrong hym vnto.
Ibid. 6446, 6462, etc.
c1470 Henry Wallace ix. 846 Wallace with him had fourty archarys thra.
1513 Douglas Æneis viii. xii. 128 And Gelones, thai pepill of Sithya, In archery the quhilk ar wonder thra.
1535 Stewart Cron. Scot. (Rolls) I. 250 The Albionis, thocht tha war neuir sa thra, Out of the feild on force wer maid to ga.
3. Angry, wroth, furious, violent.
13.. E.E. Allit. P. A. 344 Anger gaynez Þe not a cresse, Who nedez schal Þole be not so Þro.
c1375 Sc. Leg. Saints ii. (Paulus) 504 As he, Þat firste wes cristis fa, And in thra will his men can sla.
c1380 Sir Ferumb. 3968 Wan Þay come to Þe dupe Ryuer, þat wilde was & thro, Entrye Þanne ne darst hy noȝt.
c1400 Destr. Troy 147 He bethought hym full thicke in his throo hert.
c1440 Bone Flor. 2075 Sche dyd me oonys an evyll dede, My harte was wondur throo.
c1475 Sqr. Lowe Degre 1017 With egre mode, and herte full throwe, The stewardes throte he cut in two.
4. Keen, eager, zealous, earnest.
a1300 Cursor M. 14392 (Cott.) Ful deueli war Þai Iuus thra þair blisced lauerd for to sla.
c1320 Sir Tristr. 615 Rohand was ful Þra Of tristrem for to frain.
c1350 Will Palerne 3264 þre M. of men Þat Þro were to fiȝt.
1400 Destr. Troy 470 Mony thoughtes full thro thrange in hir brest.
c1425 Wyntoun Cron. v. vi. 1198 Sancte Gregor..Made special and thra oryson Þat God walde grant his saule to be..fre.
?a1500 Chester Pl. (E.E.T.S.) 451 Falsehed to further he was euer throe.
[1775 John Watson Hist. Halifax 547 A person is said to be thro about any thing, who is very keen or intent about it.]
b. fig. Of a thing: Ready, apt, disposed.
a1425 Cursor M. 16560 (Trin.) þei..cut Þis tre in two..What Þei wolde Þerof shape: þerto hit was ful Þro.
B. adv. Obstinately; vigorously; boldly.
a1425 Cursor M. 5997 (Trin.) ȝitt Þe kyng hem helde ful Þro For wolde he not lete hem go.
c1450 St. Cuthbert (Surtees) 6032 Oxen twenty and twa War drawand Þis bell full thra.
c1470 Golagros & Gaw. 60 The berne bovnit to the burgh..and thrang in full thra.

Obstetrics and gynaecology and politics of the sexes. 23rd of October, 2018 ANTE·MERIDIEM 01:28

Professor Chris Fitzpatrick of the Coombe (one of the major Dublin maternity hospitals) just had a piece published by the Irish Times on the energetic condemnation of men involved in the CervicalCheck scandal and his discomfort with it, as a male obstetrician and gynaecologist. It’s a cry from his heart, not particularly well-sourced, and that’s fine, he’s not publishing an academic paper, he’s trying to change hearts more than minds.

I posted some of the below on the comments on the Irish Times site and prefer to re-post it here: of course, it’s not in the interest of women to have the male half of medical students rule out obstetrics and gynaecology as a career choice, especially when female doctors and medical students already disproportionately choose those specialties with a good work/life balance. Obstetrics and gynaecology is not, and can never be, absent a 90% elective Caesarean section rate, a specialty with a good work/life balance, particularly in the training years. The ideal thing for women in general would be to have all medical students and junior doctors interested in general surgery (which equally has a terrible work/life balance) conflicted about that vs. obstetrics and gynaecology, something very different from how things are now.

To be clear, I have no issue with doctors choosing speciality based on work-life balance; someone has to do the more agreeable jobs, and that generally leaves plenty of work for the rest of us, and I like my job, I get paid well for it.

Most working doctors won’t particularly disagree with me on sex and speciality choice with regard to work-life balance, but for any lay readers, let me support my comment with data. The Canadian figures on speciality by sex (I don’t see any Irish figures published, but there’s no particular reason to think there would be a massive proportional difference) are oriented by proportion of doctors working; it is more useful for my purposes to break them down by percentage of each sex working. The below is calculated from a subset of the table, ordered roughly by best work/life balance to worst work/life balance.

Speciality% of working female doctors in that specialty% of working male doctors in that specialtyRelative likelihood of a female doctor working in that speciality vs. a male doctor working in that specialty Comments
Medical Genetics0.1%0.008%2.3809:00–17:00, Monday to Friday
Rheumatology0.7%0.4%1.64One very rare wake-me-up-in-the-middle-of-the-night emergency
Dermatology0.8%0.6%1.39Almost no emergencies
Haematology0.6%0.5%1.29 Emergencies almost always handled over the phone
Urology0.2%0.9%0.23A really undervalued specialty when it comes to work/life balance
General practice56%48%1.17As I understand Canada versus .ie, these figures would underestimate how agreeable GP is here in its work/life balance.
Cardiothoracic surgery0.03%0.2%0.17Actually more comparable to urology in work/life balance, but the path to get there involves general surgery, which see
Emergency Medicine0.8%1.3%0.6
General Surgery1.4%2.8%0.51Loads of competition, ridiculous hours while training, minimal opportunity at the end (general medicine is eating the specialty’s lunch from one end, interventional radiology from the other)
Obstetrics and Gynaecology3.5%1.7%2.04This figure is very very different from General Surgery, see above.

I have excluded anything paediatric from the table, because, well, a) the paediatrics specialities throw off the correlation massively and b) it is super-routine to come across doctors of either sex who went into the speciality because they liked children, when the speciality involves in massive part sticking needles into various parts of children who are really not on-board with the idea, and in lesser part WATCHING CHILDREN [you can’t cure] DIE, which is something you should not volunteer for if you like children. I have also excluded the laboratory medicine specialists, because I know nothing constructive about their work/life balance, beyond assuming it’s good.