Blogging Revision

Ok, so I'm not supposed to be blogging because I'm supposed to be revising but I had a wonderful thought - what if I combined the two?

What better way to revise ethics and consent than to discuss it. It's a grey area without a yes or no answer. It is more a matter of common sense and opinion so I'm asking for your opinions on the following scenarios:

1) You are the SHO on an upper GI surgery firm, you are told to explain a diagnosis of gastric cancer and start to consent a schizophrenic patient for surgery.

2) You are a new GP partner in a GP surgery seeing a woman who is going in for a elective operation, and she doesn't want the people in the hospital to know about her Hep C status... it turns out that she thinks if the hospital knows about her Hep C status, her social worker would find out and not let her to see her daughter.

3) A husband slept with prostitute in Thailand on business trip. Wife is unaware but attends GP with sore throat & demands to know what’s wrong with husband & wants same treatment.

So, how might you approach the above situations, go on, leave a comment and help with my revision.

A Lesson in Ethics

Today's communication skills session was on ethics, it was a useful session and brought up some interesting discussion. Its also a potential OSCE station for finals so it was useful in that respect too. The session was based around simulated consultations and I thought I'd share some of the cases with you to get your thoughts and opinions.

1) You are an FY2 in GP practice, an elderly patient's relative comes to see you. They are concerned that their elderly relative is unfit to drive. They would like you to contact the DVLA.
The elderly patient does not see that he has a problem despite arguments with his relatives and is reluctant to come and see you.

What do you do?

2) Last week a pregnant young woman came to see Dr Pickles at your practice with PV bleeding. Today, her sister has come to see you to complain that Dr Pickles did an internal examination on the pregnant woman without informing her that he would do so and without having a chaperone. The sister is also concerned that this internal examination may have led to the patient having a miscarriage later that day.

What do you do?

3) You are an F1 on the ward, a patient comes to you and reports that she just saw a more senior doctor "sniffing a white substance". She is reluctant to make a written statement or to follow-up the complaint, although she is very concerned.

What do you do?

4) You are an F1 on the ward. A social worker has asked to see you about Miss 'Caine, unfortunately Miss Caine discharged herself earlier that day and her whereabouts are unknown, you hope her GP will persuade her to return. Miss Caine was an IV drug abuser who has Hepatitis B. The GPs referral letter mentions that Miss Caine's 13yr old son, Tom, has Hepatitis B. As far as you know, Miss Caine, and her son, may or may not be aware of this diagnosis. Tom is currently in social services care, he is in a house with 2 other children and has been known to bite in the past. The social worker wants to know about Miss Caine's care and about Tom. She needs to know if he has Hep B and is a danger to those around him.

What do you do?


I ended up having number 4, which was apparently the hardest, fortunately the argumentative simulated patient was away today. I'll post what I said in the comments later.

Answers on a £10 note to the usual address.

Communication Skills

This afternoon we have 4 hours of communication skills, we tend to have 3 or 4 communication sessions scattered througout each clinical year. The sessions do tend to drag a bit but they're certainly not entirely useless. Sessions in the past have included; breaking bad news and dealing with angry patients. They use actors as simulated patients and we each take it in turns to practice situations. This is very useful as it doesn't matter if you make any mistakes or mess up telling someone they're going to die, of course they're not actually going to die as they are actors. But it means that if and when the time comes for you do it for real, you'll at least have some experience of the situation. The dealing with angry patients sessions last year was interesting, the actors are very good and do tend to get quite into their character so it can be quite realistic.

This afternoon's session is on ethics, I suspect this should be quite useful as we don't do ethics at any other time really.

Buy Your Tickets Here

For the post code lottery,

I recently read this post on the Guardian by a medical student. Mr Thomas (a pseudonym) raises some interesting points but he does so with an exceptionally poor attitude. Judging by some of the other things he has written for the Guardian his attitude isn't a one off. Honestly I wonder how some of these people get into medical school in the first place, I've heard a number of stories recently at various medical schools of students with awful attitudes, in some cases directly towards patients on clinical placements. I wonder how far they have to go before they get kicked out! I know I can have an attitude at times but NEVER towards patients, it is my view that all patients are as important as each other and they should all be be important to me, or you, as a doctor. Mr Thomas however, makes a point that he doesn't care about so-and-so receiving expensive treatment as long as he gets to go home early. It might be fine as student to be able to go home early but once qualified, it should be his patients that come first, not his desire for an early finish.

Anyway, now I'm done ranting I can talk about the actual article: "Expensive Drugs On The NHS Are Not A Right"

Fundamentally Mr Thomas makes a good point, that there is only a finite budget available for the NHS and this must be distributed sensibly and fairly. At the end of the day, things like this always come down to money and as we all know the NHS isn't founded on an orchard of money trees. There always has to be a line and unfortunately some people are always going to be on the wrong side of this line. The important thing is who defines this line and how do they do it?

Basically it comes down to assessing how much quality of life, and how much an extra year of life are worth. This is impossible to accurately quantify, not only does each person differ, but it is morally impossible to put a value on life. Nevertheless this is the way things must be done and is the way they are done when deciding if treatments are worthwhile. The people that fall on the wrong side of these decisions are always going to have a case for challenging that decision. But at what cost? They take the NHS to court (rightfully or wrongly, you decide) which probably costs thousands of pounds. If they win, they get their treatment but at the expense of someone else, the NHS having spent money defending their case which could have otherwise been spent on patient care. If they don't get their treatment they are left feeling hard-done by and the NHS is still out of pocket. There can be no winners in a situation like this!

An important factor which makes this story a media favourite is the fact that regulations often differ depending on your post code. One person living in one town might be entitled to the £10,000 treatment which might improve the patients quality of life. Just down the road in another town, a similar patient might not be. Now this isn't fair, if there is going to be a line then that line should be the same for all patients throughout the country, this might be difficult sometimes as each patient is different but it is morally wrong to discriminate based on post-code. This is the reason we often read about patients going to court seeking their treatment and perhaps they are right to do so. Guidelines need to be standardised before we can defend the decision to withhold a treatment due to cost.

What do I think about these expensive treatments? I don't know enough about them to comment. I would imagine each patient has their own case. It is hard to decide who gets the treatment and who doesn't but unless the NHS finds a way to print its own money, these decisions are always going to have to be made. Is there a solution? I don't know.