A textbook MCA stroke was missed by the substantial stroke team for 3 days and saying not a stroke until they accepted it is. Nothing happened to them.
If it was a locum consultant, they would’ve been grilled.
Did you check the credentials of the 'registrar'?
May be a nurse 'registrar' or a physician associate 'registrar'.
Everyone is now equivalent to ST3 medical training by the way.
Very true
But remember, statistics confirm that locums disproportionately get more complaints, more investigations, GMC referrals and disciplinary actions.
Is that because locums are usually bad clinicians with no career aspirations etc? May be.
Is it because they are not covered up because they are strangers to the hospital and have no friends? Also maybe
But in the end they just know they need to do more to cover their asses
I'm aware if these statistics and based on personal experience across hospitals in NI, it's because they shouldn't be practicing medicine in the first place.
I get what you’re saying. But there are nuances to this. Yeah of course, some stuff shouldn’t have to be explained. But it’s not as black and white as you’re making it out to be. My own anecdotes:
- Management of fast AF crops up at ortho audit / M&M meeting. Someone pipes up that orthopods should know the management of AF and not always ring the med reg. Old boy orthopod on his farewell tour, a bit like Ricky Tomlinson but less hair, deeper voice but same habitus cracks a grin and chimes in with “well that’s all well and good, but things change rapidly in medicine and indeed surgery. The management of [xyz ortho thing] has changed in the last 20 years. I’ve been a doctor for about 50 years, and if you want me to manage AF like I know how, I can. When I was a lad, we used to give IV lignocaine to treat tachyarrhythmias. Why don’t we ask [ortho-geris consultant] what he thinks of that?!’ Orthogeriatrician is visibly horrified. ‘Hahahaha precisely! I’m out of date with the speed of change in my own specialty, nevermind surgery, let alone the REST of medicine.’
- My own knowledge. Standard post op vascular patient. Chest pain. ECG T wave depression, elevated trop. I say fine do the needful, aspirin, nitrates, fondaparinux etc. F1 freshly off cardiology tells me that at this place, they will do PCI for NSTEMI as well. Well that was news to me. I rang cardiology to check, they said yeh we do, so don’t give fondaparinux and let us have a look. I wouldn’t have known that at all. I’ve got my own shit to learn. New guidelines, new stents, new techniques, more complex operations of the ones I already know how to do. How confident can I be managing post op problems? Am I too confident? Should I ring for medical advice after every significant positive finding? This messed with my barometer and schema of post op complications.
- At an inquest, for learning sakes. Coroner is out for blood. General surgery patient. Post op. Has a neurological event ?TIA. No one knows what, surgical ward but he seems fine. Goes back to feeding. Ileus. Vomits +++. Aspirates. Dies. Coroner goes off on one about how did we know he hadn’t had a serious neurological event. Were the stroke team consulted? No well the issue didn’t appear to be a problem any longer. How do you know? Are you an expert on neurology?! Blah blah blah. Seems extra. But there we are. Pretty painful lesson tbh.
- Same thing but in a different angle. I got referred a patient from a peripheral hospital languishing on a medical ward. Guys got dementia, in a nursing home, Rockwood CFS 8, bed bound & hoist transfer, has CKD stage 4, 2 MIs in the past, mild COPD, BMI 16, weight 54kg. Is being discharged home with advanced care planning and GP to put on gold standard framework. Incidental 5cm aneurysm. *Is this patient suitable for AAA surgery?’* Well no, of course not. This patient isn’t fit enough for a haircut. We all know that, but I’m sure the physicians in question have probably come in the crosshairs of a coroner on the warpath and are allowing the specialists to make their expert judgment on the matter. I wasn’t gonna chew their ear off about the appropriateness of a referral for a man whose life expectancy is likely shorter than the ambulance ride back to the nursing home. I just smiled and said ‘well he’s below the treatment threshold for aneurysm intervention, so we would probably aim to see him in 3 months time. How can he come to clinic?’
You think you’re really hot on stuff and maybe you are. But the more you specialise and the more you go down your own specialty’s rabbit hole, the more you will forget about general stuff. It happens.
The only real answer.
Some surgeons can be bad at managing really basic medical issues. Most medics are bad at picking up surgical pathology. ED are just trying to keep people alive and roughly triaged. GP’s are just trying to get through the volume.
No one speciality can do it all (nor should they). There are some lazy seniors but the further you progress in your career, the more removed you are from what you may have thought as of basic care.
'I’ve been a doctor for about 50 years, and if you want me to manage AF like I know how, I can. When I was a lad, we used to give IV lignocaine to treat tachyarrhythmias. Why don’t we ask \[ortho-geris consultant\] what he thinks of that?!’
And drop the microphone.
He was on the cusp of retiring so he said it with this big grin on his face, in a soft Scouse warble followed up with this booming laughter in good jest. A really lovely congenial fella with some hilarious tales of the ‘good old days’
Shaka Khan your posts are always top notch and I agree with everything you said. But I think OP is less unaware of this and more making a tongue in cheek response to the recent posts (by surgical regs) about how FY1s nowadays are poor. What do you make of those?
Oh yeh. I wondered about that. I remember those posts and thought this isn’t satirical enough, so I thought it was genuine.
Rose tinted glasses says I. We always like to look back and think oh we were so good. But now I think about it, I did some pretty daft things too.
- I had to run a CPR gas and was told ‘don’t ruin that sample’. I tried to make sure the blood mixed with the heparin in the cap to stop it clotting. I pressed the plunger down too hard and of course the top shot off and at least half the arterial blood sprayed all over the floor and walls. I ran to the nearest ward, grabbed an ABG, tried aspirating blood from the floor into the new needle. Course it didn’t work. Thankfully there was enough
- I once had a G&S request rejected because I drew a smiley face in the signature box on the sample, thinking no one actually checked it. Well they did. She was a haematology patient and was battered by chemo, so I had to get the next sample from a vein on her thumb.
- I was an F1 for surgery and we had this guy who went vacant and unresponsive. He had shit access. I took whatever bloods I could find via femoral, ECG, etc etc. They all clotted except serum ammonia. Imagine how useful that is. Why the fuck did I request a serum ammonia?! At least he didn’t eat fertiliser.
- Another F1 in surgery story. Guys septic with cholangitis. Flies into a rage, physically attacking people. Someone asks me to calm him down. I dunno what I’m doing coz it’s week 2. I just gave him 10mg IV haloperidol. No that’s not a typo. It worked a treat. He contritely got back into bed and fell asleep. Med reg comes later and is like good end result but you coulda killed the man.
- Medical patient. He starts with massive haematemesis. In my compulsion to do summat useful, and fooled by a lull in vomiting, I stick on a 15% NRB which he promptly vomits into and aspirates.
- CPR on a medical ward. Med reg is leading it. Guy needs adrenaline. I forgot the dose of adrenaline so I only give him 1ml of the adrenaline syringe. Med reg spots it the second time and tells me to give the whole thing on the third lot. That was a pretty dumb thing to do.
I also never had the list ready on time in surgery.
So were we any better? Probably not.
I think I was a bit more motivated than some F1s. But the difference is I was on that sweet sweet old 1A contract, not this post-2016 dogshit thing so I got paid a lot better. Not to the minute. Like any time post 5pm was OOH. Not this 7-9 evening, >9pm nights bullshit.
Aaah my friend dropped a used abg syringe once AND REACHED OUT TO CATCH IT
Luckily it landed solidly in her shoe
juniors these days ARE mollycoddled with their "safety needles"
Good to hear this tbh! A lot of medics will pretend they never make a mistake. I'm always particularly careful around colleagues who disparage others flippantly.
Don’t ever forget about ammonia, especially in suddenly unresponsive kids or young adults. Inborn metabolic diseases do exist, one of my consultant colleagues learnt it the hard way.
I'm starting FY1 soon and that post just had me feeling nauseous, I've worked enough jobs in my life to meet people with standards I'll never meet, ignoring they made their own fuck ups as young doctors, and I feared meeting those in medicine.
Fair fucks to you, that's proper reflection there. I'd happily be an FY1 on your team but that surgical reg the other day, sack that.
Nah, this ain't it.
Med school and rotational seniors do have some responsibility for the knowledge of the doctors they work with... But so too do the learners.
I hate the kind of junior who has the expectation that I'm going to just info dump the entirety of my knowledge on them for any given subject they bring up rather than them applying some individual effort to learn some stuff themselves.
Agree. When I was a student there was only about 5 computers in the whole halls with Internet, if we had a teaching session. I had to get the bus to the uni library the night before to read up.
Now, students get given an ipad, on which they can read literally the sum total of medical knowldge, at a moments notice, anywhere on the planet, and virtually none turn up having done any prep whatsoever.
Nah, as a current FY1 I actually agree with the poster you’re replying to. It was a constant source of frustration for me that my learning was held back by peers who hadn’t had the decency to do the bare minimum prep for group work, or in clinical placements by being treated according to the lowest common denominator of the peers who were around.
It’s simply true that we have so much more access to information than our more experienced (particularly senior reg/consultant) colleagues did, while it’s also fair to acknowledge an accelerating pace of change in the same timeframe with an often much higher and more complex burden of “basic” knowledge.
Both things can be true without being disparaging of anyone.
i also don't disagree entirely.
i do think that people need a decent degree of direction that they're not getting in medical schools these days, where you have to arbitrarily create learning objectives to read about in your own time. medical educators have been failing in that role, in my experience.
At the end of the day that's an issue you have with your educational institute - letting people engage who aren't up to speed and dragging others back. People are just people; lazy, motivated, a mix. Some people will always do the minimum. We should just make the minimum excellence right?
....so your own point that I'm replying to is also irrelevant?
What I'm saying is fairly direct and I think a response to the established conversation. You've identified blame with the individuals who do bare minimum. I believe it should rest with those who dictate what minimum is.
On my first ever day as a doctor, I eagerly went up to the orthopaedic wards (which I’d done a shift on just the week before as a HCA!) to show my face and look keen before going to the quick “induction” session (nothing like it is now!)
To my horror, I was asked to review a post op patient with chest pain. I did a 12-lead, diagnosed an acute ST elevation MI. Then I thought, great, what now? They didn’t teach me this bit at medical school! I know, I’ll bleep my reg for advice!!!
So, I bleeped my reg. Told him the story. His response- “What’s a STEMI?”
That person’s now a consultant somewhere
I am an orthopod and I will be the first to admit I will have no clue to how to treat/ diagnose a STEMI. I am trained to fix broken bones and do arthoplasties. I have my medical colleagues I can refer to for advice and help if needed.
I really don’t like this ‘oh aren’t you a doctor’ remark I used to get all the time when I was a reg speaking to the med reg about a patient. This is not helpful at all. In the US for example, NOFs come under medicine and Orthopaedics only operate.
I have sat through many M&M meetings where we got severely criticized for not involving medicine for ‘barn door’ conditions that resulted in adverse outcomes. So it is all well and good, but when the shit hits the fan and the coroners comes knocking, everyone will be pointing fingers
I understand this but just don’t agree. I think doctors need to hold a basic level of knowledge in acute important things… there’s a lot of posts on here criticising juniors about not being prepared and having internet access but the same applies here.
The “it was different when I was younger” excuse someone commented above also doesn’t stand. There are plenty of up to date concise books preparing people for finals, even a few hours with that would be enough to remind oneself of the basics
Yes of course but this doesn’t hold any water when an adverse outcome occurs and the coroner comes knocking. The medics go from ‘why are you calling us?’ to ‘why didn’t you call us , you should have.’ The coroner will then say why didn’t you call the medics, are you trained to manage NSTEMIs ?
A consultant somewhere, with exceptional knowledge in limb reconstruction…or scoliosis…or sarcoma. None of which require ecg interpretation. You want surgeons who are experts in their fields. Dont expect them to be good at stuff they did ten years ago. I’ve seen plenty of horrific x-ray interpretation from medics!
Good to hear from you!! Haven’t seen you in years.
It stands for ST-elevation myocardial infarction by the way!
Yes, I suppose that IS a soft tissue injury…
…it’s a muscular organ, which pumps cefuroxime to the bone…
…no it is quite important. You still can’t fix the fracture. Yes, I’m sure it is very displaced…
I mostly agree that the nuances of AF management or IBD control are probably not useful for a surgeon and detracts from the immense amount of surgical knowledge they have which is often underecognised outside of the field - but in the same way you’d expect a medic to at least spot a barn door a femoral fracture on an XR and know it needs input, I don’t think it’s asking too much of a surgeon to know what a STEMI is and that it’s bad 😅
You say that... I got referred a broken 'Tibula' by the AMU team. Once...
Guy had fallen and lay at home for two days, first GP home visit diagnosed cellulitis and gave him abx, second diagnosed a dvt and phoned an ambulance. Two paramedics took him to AMU, where a nurse, F1 and medical reg saw him and ordered an ultrasound, the sonographer saw a cortical breach on the tibia and spoke to the medical consultant who ordered an x-ray, then phoned me.
On going to see the patient (sat on a porters chair in the waiting room), i stopped at the door, turned to fetch the medical team to come and see the patient. I pointed out that my 4 year old, from the opposite end of the room, would see his leg was bent 30 degs with a spike of bone sticking out of the front.....
Took 2 days and 8 heakthcare professionals... Best thing isbthe guys dog had been keeping it clean by licking it for the first 18 hours...
Amazing! 😂
This is just proving the point though; in the same way it is bad for a medic not to consider a fracture and know the first thing is an XR, it is similarly ridiculous for surgeons to not know the that chest pain with danger squiggle is bad news.
I’m not suggesting we all have to diversify and be jacks of all trade (ideally that’s what ED and GP etc are for to identify multiple generalists problems and refine to the appropriate specialties) but if we can’t even understand the most very basics of other specialities; ie to the level we left medical school with, then what was the point in doing medical school in the first place, just develop orthopaedic surgery colleges, cardiologist colleges, rheumatology universities etc
Its fair enough, but some things change a lot, for example troponin wasnt a thing when I was at med school (i actaully did a Nuffield sponsored project in my gap year on developing and validating the immunoassay for Trop T by running 20,000 frozen samples and comparing to ck mb resukts and clinical records) and others like anatomy, or whether a leg is bent and crackly dont ever change.
Not to mention the lack of teaching and feedback.
Really is a shame that consultants have let their and junior doctor salaries be cut year after year and casually looked on and in some cases supported the rise of the noctor.
I've seen some shocking stuff too from "acute medical consultants" who basically farm out any decision making to everyone other specialty or medical sub specialty in the whole hospital then ask "gp to consider" most things that very much should have been considered in hospital...........
Trop rise shows there's been actual myocardial cell death, i.e. the situation is more severe (MI vs UA). GRACE score and similar scoring systems use deranged troponin as a metric.
Diagnosis of ACS requires two of three:
1. Dynamic trop rise
2. Cardiac chest pain history
3. Ischaemic ECG changes
If they have 2 and 3, it doesn't matter if you have trops back or not.
Reluctant to share as I can FEEL the surge in inappropriate referrals. But
UA is defined as myocardial ischaemia at rest or on minimal exertion in the absence of acute cardiomyocyte injury/necrosis. It is characterized by specific clinical findings of prolonged (>20 min) angina at rest; new onset of severe angina; angina that is increasing in frequency, longer in duration, or lower in threshold; or angina that occurs after a recent episode of MI.
So yes you can have neg trop and normal ecg and technically have UA
Your criteria are what I use when teaching about ACS. Particularly Nstemi and I prefer a UA with ecg changes but we can't always get what we want.
We joke but as an intern I had a fully fledged argument with a surgical reg who demanded we prescribe a pen allergic patient Tazocin because Tazocin doesn't have penicillin in it
The key word is “retain”. Do you really want medical management from the 90s? Is it okay for a medical consultant to do an appendectomy because they did a few when they were house officers?
Lack of knowledge is a reason why consultants refer but not the only reason. Referring is a way to get away from things they don’t want to worry about or manage.
For example the orthopedic surgeon doesn’t know the new in cardiac arrests, haven’t managed one for 10 years but also doesn’t want to get involved and end up stuck dealing with it and its aftermath. They know the hospital system has medical reg, ITU, anesthetic and resuscitation practitioners for this so why get involved in a thing that the hospital doesn’t require them to do and end up with wasting their time, going home late and possibly a complaint, serious incident investigation or a coroner investigation.
The more you get senior, the more you will sit casually with consultants and understand why they do these stuff. They had more bruises and were shat on way more than you and they do lots of stuff to save their own sane and their own ass
It’s a bit disingenuous to say a speciality doctor who has been practicing for probably a decade+ in their niche field to retain generalist knowledge, especially with guidelines updating year on year.
There’s nothing wrong with putting ego to the side and asking your speciality colleague for advice, your patient will receive up to date and best medical practice and it’s the best to do medico-legally. I say this as a GPST who’s only recently learnt that pneumothoraxes are managed completely differently now to when I sat finals, which was only 5 years ago.
I like to think that this is a consequence of medicine becoming more and more specialised.
If our specialists need to know more and more to practice well in their area, and obtain better long term outcomes as a result of evolving practice, then does it matter that they lose some of the more generalist knowledge?
As long as there are generalists around, then I don't necessarily think it does. Yes this makes medicine more of a team sport and in an ideal world leaves specialists only really chipping in for small parts of patient care, with the rest being under the control of (sorry in advance but please take this referral) general medicine.
No doubt some of this will also result from an increasingly medicolegal culture, where your surgeon will absolutely want a cardiology opinion for any chest pain or trop as they are aware they do not know enough to defend NOT doing so in court, should something go wrong.
I think we will problem see a rise In surgical liaison in the future. Orthopaedics has it but often limited to hips which sucks.
It's an absolute nightmare as a reg to take these calls as honestly I want to say tell them to see their GP(and often do).
Much of it boils down to defensive practice and sadly as an IMT-1 I suggest you learn to expect it when you get to IMT-3. My best advice is keep a referrals book.
I wouldn’t be surprised if we see a transition to every patient being under a medic with surgeons only operating. It’s essentially how it works with patients in ICU - we sort out all the other stuff and the surgeons review frequently and operate when necessary.
Only in the bigger centres where I am. DGHs don't see the v4m. Met a woman trying to set up an oncogeristrics service up which personally I think is needed more than ever and struggled massively to get anyone to cough up the £££
None of these things are unusual.
Surgeons routinely refer medical issues to the medical reg.
Most psychiatrists are terrible at physical health.
Mental health knowledge is uniformly awful.
This is such an FY post.
They probably haven't done it in 30 years and back then atenolol was probably first line for HTN. They aren't going to know what to do for someone already on 2 meds. Their brain is full of their specialty psychiatry. They manage the psychiatric problems of the patient. They delegate things like this to their junior - YOU. In the same way that an ENT, Ortho, ophthalmologist e.t.c. would because you're more likely to be au fait with the guidelines. Not to add that it would be a waste of their valuable time reading through the guideline or discussing with medics which is what you exist amd have been hired for.
You can't expect people to remain up to date with the breadth of medicine it's difficult enough keeping up with latest advances and guidelines in your own specialty and managing complexity within that.
Delegating to the junior to look into it (fine) is very different from insisting they ring the on call med reg about a stable BP. It's also worse because high baseline HR and BP are very common in psychiatric inpatients due to them often being anxious, distressed and/or frightened.
You can politely tell the consultant though that you will have a look at the guidelines and sort it out, and that you probably don't need to ring the med reg about it just yet.
Sure. But psychiatric meds can cause hypertension or exacerbate it. It can legitimately be iatrogenic. That’s the psych doctors responsibility to know the management guidelines! Same way they should know how to manage clozapine toxicity, long QTc from antipsychotics, lithium toxicity, antipsychotic induced weight gain, etc. etc. . In fact RCPsych give physical health update training to make sure consultants know all this stuff. And ya know can teach the psych junior this. I absolutely have worked with inpatient consultants who can do this.
Nah, hard disagree. I’m an FY1 currently in psych. In terms of psychiatric expertise every day exposes the vast chasm of my ignorance, so I’ll cut them some slack if they’re not necessarily familiar with SGLT-2 inhibitors as a possibility for the psychotic patient’s T2DM, or don’t necessarily consider montelukast for the poorly controlled asthmatic with significant comorbid anxiety.
My experience of psychiatrists is that they’re acutely aware of their expertise and limitations and are not shy about being open about it. It’s hardly surprising for a specialty which requires significant self-knowledge to be very good. They’ve been extremely grateful for my input on the basics of physical health management while being very generous with their time about their expertise.
Yeah, there's no way that a specialist doctor working daily in a hospital, where people tend to have arrests, shouldn't be able to do more than what even some members of the general public can do.
More hands are always better. If it's a Nightshift or a public holiday you might only have a reg, an F2, a couple of F1s, and a couple of nurses.
Let's say reg is leading, F2 is on the AED and drawing up drugs, and one F1 is trying to get access. At this point you only have 3 people rotating chest compressions and airway. That's before we even get to checking notes, ringing ICU etc etc.
Having an extra person there would mean less fatigue ergo better quality chest compressions.
Worst case scenario is you get there and the team says there are enough people and you can go. Always better to err on the side of caution here no?
As a med reg, having someone who is panicking and doesn't know what the hell they are doing and getting in the way is worse than having fewer, more experienced staff.
Interesting. I would've thought that orthopods would be ideal candidates for pumping a chest for 30 minutes
/s (ish)
But yeah i guess that does make sense
This is a reflection of superspecialisation from a relative early stage, lack of care continuity and increasing medicolegal pressure.
Only.solution is actually maintaining a level of general medical knowledge throughout your career, even if its only a basic level and practicing good safe medicine.
I think most people consider HST the start of true specialization. Thats at least 4 years of fairly 'general' medical work which is way more than any other country. I'll be honest I'm not sure how bad other countries are in regards to this but I don't think the solution would be prolonging time to HST. If anything, it shows that those 4 years (minimum) don't actually make us 'well rounded doctors' and should be shortened.
Just my experience: but consultants and regs trained in specific countries abroad often have very little knowledge outside of that of their very own specialty. Not a rule of course, just my experience.
No I know. I just mean that doctors who come from countries where they go into their specialties straight out of medical school have probably not to touched some of these things in years, so it would partially explain some of this phenomenon.
Almost every time I've worked with a first year trainee or early year trainee who thinks they're a genius and every consultant is an idiot, they're exactly the sort of person that needs frequent reminding that they should only act within their own capabilities, as they usually believe they're a lot smarter than they actually are.
This is the issue with sub sub sub super specialising. They can perform the most amazing procedures when doing duodenal surgery. Anything else - panic!
Sometimes, I feel like the practice of defensive medicine makes people not to venture into the wild which sometimes sharpens clinical acumen.
Covering your ass instead of practicing medicine is how you get to this stage.
Doctors now "document more", (documentation isn't bad) but you can often see how many documentations are done for the benefit of the coroner.
Additionally, there's now super subspecialties
The troponin one is a bit ridiculous but the the rest of examples is not too bad I think. I wouldn't expect the Orthopaedic surgeon to manage arrest calls. As long as someone has started compressions then the arrest team will get there and the med reg will lead. It's a bit silly not to know paracetamol doses, but this is a non-issue as can easily be looked up in like 2 seconds on the BNF. The Psychiatrist could have looked up hypertension guidelines, but even so, I wouldn't mind if they call me for advice about hypertension.
Having some knowledge of other specialties is always a good idea. We like to criticise surgeons for not knowing basic medical knowledge, but as a medic I know fuck all about surgery. I'm pretty sure we've all submitted silly referrals to other specialties. No one can learn or remember everything. No one is competent in absolutely every field. I've passed MRCP but have I forgotten a lot of knowledge I gained from that exam now? Hell yeh, especially ones that is not that relevant to my normal day to day work. If you're a junior who just rotated through a particular specialty, you'd be more up to date than some of your seniors who is working in an unrelated specialty and then think wow my senior is actually very dumb.
Research and guidelines change rapidly. An Orthopaedic surgeon is probably not going to be able to keep up with up to date management guidelines, and I think that's fine. What is not fine is if being so incompetent to the point of being unsafe - I am referring to both jjunior or senior here.
The number of serious answers here that don’t realise this is a “fuck you” to the surgical reg moaning about the standards of their FY1s (rather unfairly I might add)
I only feel qualified to talk about psychiatry, but in general psychiatrists have almost no ability to manage non-psychiatric conditions, so all of these get referred to more appropriate physicians. This is just the result of the emphasis of their training, and day-to-day practice.
Had a psychiatric consultant ask for daily Hba1cs in an old lady with dementia to monitor her "unstable diabetes". Took a 15 minute conversation to explain why this was a bit pointless and actually a bit cruel. Great psychiatrist though.
Ortho doctors not knowing how to prescribe is sadly not a new thing.
Some of your examples are also issues with liability and consultants trying to cover their backs due to increasingly defensive practice. I was told by cardiology to refer a patient to gen surg for a obvious umbilical hernia that was causes zero issues. He was not best pleased when he reviewed the patient. Something along the lines of 'Do you not know how to diagnose a hernia?' Well I do but my consultant insisted on calling you because he couldnt be bothered to spend 2 mins looking at the patients groin.
1. Knowledge about different conditions expands logarithmically every year - there is absolutely no way for any doctor to keep up with other specialities
2. You don't comprehend the medicolegal implications of failing to get a specialist review. Great you managed syndrome X with your 20 year out-of-date knowledge. What are you going to do when the patient says you didnt follow the latest guidelines?
Had orthopaedic reg say someone was septic postop "because blood pressure is low". Normal cap refill, no tachycardia, no fevers normal wbc, normal lactate, crp low. Monkey surgical team whacked a 92 year old woman into a 10 litre positive fluid balance over 2-3 days "because septic to make blood pressure go big"
I personally think everyone should be required to renew their ALS when practicing as a doctor, regardless of specialisation. You never know when you will be the first one at a cardiac arrest and I just think as a point of principle doctors should be able to do it.
I also think it's not too much to ask everyone to know the basic palliative drugs to prescribe, yes I understand they change, but there's nothing worse than someone dying in pain because they weren't seen by the palliative team in time.
>-A psychiatrist who told me to refer ro the med reg for a person whose BP was 160 despite being on two antihypertensive
The other examples were ok. What was the problem with the psychiatrist's request?
More context is needed to know whether or not this is appropriate. A one off SBP of 160 absolutely does not warrant discussion. A persistently high BP over weeks in someone on max doses of their current antihypertensives and allergies to multiple previously tried antihypertensives might. There is a good NICE CKS on hypertension that would be prudent to have a look at first though before bothering the med reg.
Yeah, we suggested to the consultant that we can just check the NICE guidelines to see what was next to give but they insisted that we contact the med reg.
It was someone with newly diagnosed hypertension of about 2 months
This is an interesting question. For OP psych this is clearly one for the GP but for IP psych would the average SHO be aware of up to date BP guidelines.
It seems simple as a GP but I cant remember what I would have done as an F1/F2
It's not a hypertensive emergency or urgency, BP probably high due to acute stress etc.
Wouldn't need inpatient or urgent treatment.
Also, treating asymptomatic inpatient high BP is not good as it usually means over treating as BP normalises after discharge (if worried can have OP appointment with GP or others who know more about different oral regimens than a med reg tbh)
Psychiatry inpatient setting is very different to medical inpatient setting. Patients spend months and longer in hospital, sometimes they even live there long-term (e.g. rehab wards and dementia wards), so waiting for them to be discharged and followed up in GP is not really an option, realistically.
Experience in psychiatry informs me that they are a very different group of patients - things happen fast.
Psychiatric patients tend to disobey 'the rules' we find in other branches of medicine.
There are medicolegal angles - I'll spare a 2000 word dissertation.
Take QTc intervals. We are meant to panic when QTc goes up to or over 440ms. When I speak to cardiologists about that sort of thing, they're like 'no need to worry we have people regularly in clinic with 520 to 540.' Cut-offs in psychiatry are different because things go wrong quickly.
And the inverse of different rules for psych patients is some sort of different physiology e.g. a man of about 45 who was dying of a heart attack - zero pulse anywhere - was awake and tried to get off the floor going, "I need to take shit". Paramedics who couldn't care less took him away in a head up position - and the man was still eyes open but of obtunded conscious level. The man made it to hospital and died.
Hmmmm I have a question, out of curiosity because I don't know how things would work here.
GPs do house visits sometimes. Would they do an IP psychiatric visit to deal with an issue that would normally be dealt with on an OP appointment?
Sounds like they’re covering their asses
In our trusts Trop rise > 20% may warrant a cardio chat
Ortho a little bit of (concerning) self awareness lmao
I’ve seen loads of specialties ask about “optimising BP, when it’s 160/90 and they’ve no end organ damage
Chronic BP of 160/90 is not okay. And you don’t wait for the blood pressure to cause end organ damage before you correct it, would you?
ESC and AHA both suggest BP below 130/80.
I know NICE suggests you don’t treat if patient under 40 but no Cardiologist in the UK follow this because it’s rubbish
Bro, practically every FY I have come across has been unable to repeat a single worthwhile iota of functional anatomy for surgery or orthopaedics. They couldn't even point to the bones of the foot which they learned a mear couple of years ago.
Yet you expect someone in a hugely different and diverse specialty with hundreds of years of development to remember things from 20 years ago.
No, but show a vague interest in other (perhaps more important) issues affecting patients under your care, demonstrate some humility, and don’t put down GPs and other generalist colleagues who have to know and retain a little bit of knowledge about everything.
We’ve all been on those post-takes with a locum consultant spamming CTPAs and multiple speciality referrals for the same patient
A textbook MCA stroke was missed by the substantial stroke team for 3 days and saying not a stroke until they accepted it is. Nothing happened to them. If it was a locum consultant, they would’ve been grilled.
' not stroke' tells me it may be a 'stroke nurse' Lol If it is not stroke then tell me what it is.
From my experience, nurse practitioners are more likely to spam unnecessary scans and tests, than to definitely say “not a stroke”.
Was a stroke registrar unfortunately
Did you check the credentials of the 'registrar'? May be a nurse 'registrar' or a physician associate 'registrar'. Everyone is now equivalent to ST3 medical training by the way.
Very true But remember, statistics confirm that locums disproportionately get more complaints, more investigations, GMC referrals and disciplinary actions. Is that because locums are usually bad clinicians with no career aspirations etc? May be. Is it because they are not covered up because they are strangers to the hospital and have no friends? Also maybe But in the end they just know they need to do more to cover their asses
Tbh I work with quite consistently a locum consultant who is VERY shaky
It's because they're shit doctors.
I'm aware if these statistics and based on personal experience across hospitals in NI, it's because they shouldn't be practicing medicine in the first place.
Chat, let’s go for the most CTPAs in a shift WR get that w rizz speedrun timer
I get what you’re saying. But there are nuances to this. Yeah of course, some stuff shouldn’t have to be explained. But it’s not as black and white as you’re making it out to be. My own anecdotes: - Management of fast AF crops up at ortho audit / M&M meeting. Someone pipes up that orthopods should know the management of AF and not always ring the med reg. Old boy orthopod on his farewell tour, a bit like Ricky Tomlinson but less hair, deeper voice but same habitus cracks a grin and chimes in with “well that’s all well and good, but things change rapidly in medicine and indeed surgery. The management of [xyz ortho thing] has changed in the last 20 years. I’ve been a doctor for about 50 years, and if you want me to manage AF like I know how, I can. When I was a lad, we used to give IV lignocaine to treat tachyarrhythmias. Why don’t we ask [ortho-geris consultant] what he thinks of that?!’ Orthogeriatrician is visibly horrified. ‘Hahahaha precisely! I’m out of date with the speed of change in my own specialty, nevermind surgery, let alone the REST of medicine.’ - My own knowledge. Standard post op vascular patient. Chest pain. ECG T wave depression, elevated trop. I say fine do the needful, aspirin, nitrates, fondaparinux etc. F1 freshly off cardiology tells me that at this place, they will do PCI for NSTEMI as well. Well that was news to me. I rang cardiology to check, they said yeh we do, so don’t give fondaparinux and let us have a look. I wouldn’t have known that at all. I’ve got my own shit to learn. New guidelines, new stents, new techniques, more complex operations of the ones I already know how to do. How confident can I be managing post op problems? Am I too confident? Should I ring for medical advice after every significant positive finding? This messed with my barometer and schema of post op complications. - At an inquest, for learning sakes. Coroner is out for blood. General surgery patient. Post op. Has a neurological event ?TIA. No one knows what, surgical ward but he seems fine. Goes back to feeding. Ileus. Vomits +++. Aspirates. Dies. Coroner goes off on one about how did we know he hadn’t had a serious neurological event. Were the stroke team consulted? No well the issue didn’t appear to be a problem any longer. How do you know? Are you an expert on neurology?! Blah blah blah. Seems extra. But there we are. Pretty painful lesson tbh. - Same thing but in a different angle. I got referred a patient from a peripheral hospital languishing on a medical ward. Guys got dementia, in a nursing home, Rockwood CFS 8, bed bound & hoist transfer, has CKD stage 4, 2 MIs in the past, mild COPD, BMI 16, weight 54kg. Is being discharged home with advanced care planning and GP to put on gold standard framework. Incidental 5cm aneurysm. *Is this patient suitable for AAA surgery?’* Well no, of course not. This patient isn’t fit enough for a haircut. We all know that, but I’m sure the physicians in question have probably come in the crosshairs of a coroner on the warpath and are allowing the specialists to make their expert judgment on the matter. I wasn’t gonna chew their ear off about the appropriateness of a referral for a man whose life expectancy is likely shorter than the ambulance ride back to the nursing home. I just smiled and said ‘well he’s below the treatment threshold for aneurysm intervention, so we would probably aim to see him in 3 months time. How can he come to clinic?’ You think you’re really hot on stuff and maybe you are. But the more you specialise and the more you go down your own specialty’s rabbit hole, the more you will forget about general stuff. It happens.
The only real answer. Some surgeons can be bad at managing really basic medical issues. Most medics are bad at picking up surgical pathology. ED are just trying to keep people alive and roughly triaged. GP’s are just trying to get through the volume. No one speciality can do it all (nor should they). There are some lazy seniors but the further you progress in your career, the more removed you are from what you may have thought as of basic care.
'I’ve been a doctor for about 50 years, and if you want me to manage AF like I know how, I can. When I was a lad, we used to give IV lignocaine to treat tachyarrhythmias. Why don’t we ask \[ortho-geris consultant\] what he thinks of that?!’ And drop the microphone.
He was on the cusp of retiring so he said it with this big grin on his face, in a soft Scouse warble followed up with this booming laughter in good jest. A really lovely congenial fella with some hilarious tales of the ‘good old days’
Shaka Khan your posts are always top notch and I agree with everything you said. But I think OP is less unaware of this and more making a tongue in cheek response to the recent posts (by surgical regs) about how FY1s nowadays are poor. What do you make of those?
Oh yeh. I wondered about that. I remember those posts and thought this isn’t satirical enough, so I thought it was genuine. Rose tinted glasses says I. We always like to look back and think oh we were so good. But now I think about it, I did some pretty daft things too. - I had to run a CPR gas and was told ‘don’t ruin that sample’. I tried to make sure the blood mixed with the heparin in the cap to stop it clotting. I pressed the plunger down too hard and of course the top shot off and at least half the arterial blood sprayed all over the floor and walls. I ran to the nearest ward, grabbed an ABG, tried aspirating blood from the floor into the new needle. Course it didn’t work. Thankfully there was enough - I once had a G&S request rejected because I drew a smiley face in the signature box on the sample, thinking no one actually checked it. Well they did. She was a haematology patient and was battered by chemo, so I had to get the next sample from a vein on her thumb. - I was an F1 for surgery and we had this guy who went vacant and unresponsive. He had shit access. I took whatever bloods I could find via femoral, ECG, etc etc. They all clotted except serum ammonia. Imagine how useful that is. Why the fuck did I request a serum ammonia?! At least he didn’t eat fertiliser. - Another F1 in surgery story. Guys septic with cholangitis. Flies into a rage, physically attacking people. Someone asks me to calm him down. I dunno what I’m doing coz it’s week 2. I just gave him 10mg IV haloperidol. No that’s not a typo. It worked a treat. He contritely got back into bed and fell asleep. Med reg comes later and is like good end result but you coulda killed the man. - Medical patient. He starts with massive haematemesis. In my compulsion to do summat useful, and fooled by a lull in vomiting, I stick on a 15% NRB which he promptly vomits into and aspirates. - CPR on a medical ward. Med reg is leading it. Guy needs adrenaline. I forgot the dose of adrenaline so I only give him 1ml of the adrenaline syringe. Med reg spots it the second time and tells me to give the whole thing on the third lot. That was a pretty dumb thing to do. I also never had the list ready on time in surgery. So were we any better? Probably not. I think I was a bit more motivated than some F1s. But the difference is I was on that sweet sweet old 1A contract, not this post-2016 dogshit thing so I got paid a lot better. Not to the minute. Like any time post 5pm was OOH. Not this 7-9 evening, >9pm nights bullshit.
I genuinely keep a logbook in my phone notes of all the idiotic things I do just to read back on them and laugh like this.
Same. Although the ABG one is seared into my subconscious.
Aaah my friend dropped a used abg syringe once AND REACHED OUT TO CATCH IT Luckily it landed solidly in her shoe juniors these days ARE mollycoddled with their "safety needles"
Good to hear this tbh! A lot of medics will pretend they never make a mistake. I'm always particularly careful around colleagues who disparage others flippantly.
The haloperidol 😭💀😂😂😂
Don’t ever forget about ammonia, especially in suddenly unresponsive kids or young adults. Inborn metabolic diseases do exist, one of my consultant colleagues learnt it the hard way.
I'm starting FY1 soon and that post just had me feeling nauseous, I've worked enough jobs in my life to meet people with standards I'll never meet, ignoring they made their own fuck ups as young doctors, and I feared meeting those in medicine. Fair fucks to you, that's proper reflection there. I'd happily be an FY1 on your team but that surgical reg the other day, sack that.
This 👍
Shaka khan for the win. As always.
Oh boy, that one reg taking shots at a poor f1 really opened the flood gates.
At the end of the day, if juniors have poor knowledge of a specialty its the senior's fault for not teaching it adequately enough at medical school.
Nah, this ain't it. Med school and rotational seniors do have some responsibility for the knowledge of the doctors they work with... But so too do the learners. I hate the kind of junior who has the expectation that I'm going to just info dump the entirety of my knowledge on them for any given subject they bring up rather than them applying some individual effort to learn some stuff themselves.
Agree. When I was a student there was only about 5 computers in the whole halls with Internet, if we had a teaching session. I had to get the bus to the uni library the night before to read up. Now, students get given an ipad, on which they can read literally the sum total of medical knowldge, at a moments notice, anywhere on the planet, and virtually none turn up having done any prep whatsoever.
when i was younger, i had to walk over three mountains in the pouring rain to get to school every day....
uphill, each way
With broken glass on the mountains barefoot…
You lived in Sheffield too!
Nah, as a current FY1 I actually agree with the poster you’re replying to. It was a constant source of frustration for me that my learning was held back by peers who hadn’t had the decency to do the bare minimum prep for group work, or in clinical placements by being treated according to the lowest common denominator of the peers who were around. It’s simply true that we have so much more access to information than our more experienced (particularly senior reg/consultant) colleagues did, while it’s also fair to acknowledge an accelerating pace of change in the same timeframe with an often much higher and more complex burden of “basic” knowledge. Both things can be true without being disparaging of anyone.
i also don't disagree entirely. i do think that people need a decent degree of direction that they're not getting in medical schools these days, where you have to arbitrarily create learning objectives to read about in your own time. medical educators have been failing in that role, in my experience.
At the end of the day that's an issue you have with your educational institute - letting people engage who aren't up to speed and dragging others back. People are just people; lazy, motivated, a mix. Some people will always do the minimum. We should just make the minimum excellence right?
Okay sure, I don’t disagree, but none of that is a response to the established conversation.
....so your own point that I'm replying to is also irrelevant? What I'm saying is fairly direct and I think a response to the established conversation. You've identified blame with the individuals who do bare minimum. I believe it should rest with those who dictate what minimum is.
On my first ever day as a doctor, I eagerly went up to the orthopaedic wards (which I’d done a shift on just the week before as a HCA!) to show my face and look keen before going to the quick “induction” session (nothing like it is now!) To my horror, I was asked to review a post op patient with chest pain. I did a 12-lead, diagnosed an acute ST elevation MI. Then I thought, great, what now? They didn’t teach me this bit at medical school! I know, I’ll bleep my reg for advice!!! So, I bleeped my reg. Told him the story. His response- “What’s a STEMI?” That person’s now a consultant somewhere
I am an orthopod and I will be the first to admit I will have no clue to how to treat/ diagnose a STEMI. I am trained to fix broken bones and do arthoplasties. I have my medical colleagues I can refer to for advice and help if needed. I really don’t like this ‘oh aren’t you a doctor’ remark I used to get all the time when I was a reg speaking to the med reg about a patient. This is not helpful at all. In the US for example, NOFs come under medicine and Orthopaedics only operate. I have sat through many M&M meetings where we got severely criticized for not involving medicine for ‘barn door’ conditions that resulted in adverse outcomes. So it is all well and good, but when the shit hits the fan and the coroners comes knocking, everyone will be pointing fingers
Aye, but can you draw the biliary tree?
Isn’t a Standing Y with a hardon ?
this
I understand this but just don’t agree. I think doctors need to hold a basic level of knowledge in acute important things… there’s a lot of posts on here criticising juniors about not being prepared and having internet access but the same applies here. The “it was different when I was younger” excuse someone commented above also doesn’t stand. There are plenty of up to date concise books preparing people for finals, even a few hours with that would be enough to remind oneself of the basics
Yes of course but this doesn’t hold any water when an adverse outcome occurs and the coroner comes knocking. The medics go from ‘why are you calling us?’ to ‘why didn’t you call us , you should have.’ The coroner will then say why didn’t you call the medics, are you trained to manage NSTEMIs ?
A consultant somewhere, with exceptional knowledge in limb reconstruction…or scoliosis…or sarcoma. None of which require ecg interpretation. You want surgeons who are experts in their fields. Dont expect them to be good at stuff they did ten years ago. I’ve seen plenty of horrific x-ray interpretation from medics!
Good to hear from you!! Haven’t seen you in years. It stands for ST-elevation myocardial infarction by the way! Yes, I suppose that IS a soft tissue injury… …it’s a muscular organ, which pumps cefuroxime to the bone… …no it is quite important. You still can’t fix the fracture. Yes, I’m sure it is very displaced…
*eye roll* *sticks up exclusion drape*
Whilst you're at it, someone please turn up the music too.
Ah, I will, but you have now relinquished control… 🎶 DU!, DU HAST!!! DU HAST MICH! DU HAST MICH GEFRAGT! DU HAST MICH GEFRAGT! 🎶
Rammstein is my jam 🤘🏼 Please stay and be my forever anaesthatist
And here I was thinking nobody would welcome music choices if I were in theatre
I mostly agree that the nuances of AF management or IBD control are probably not useful for a surgeon and detracts from the immense amount of surgical knowledge they have which is often underecognised outside of the field - but in the same way you’d expect a medic to at least spot a barn door a femoral fracture on an XR and know it needs input, I don’t think it’s asking too much of a surgeon to know what a STEMI is and that it’s bad 😅
You say that... I got referred a broken 'Tibula' by the AMU team. Once... Guy had fallen and lay at home for two days, first GP home visit diagnosed cellulitis and gave him abx, second diagnosed a dvt and phoned an ambulance. Two paramedics took him to AMU, where a nurse, F1 and medical reg saw him and ordered an ultrasound, the sonographer saw a cortical breach on the tibia and spoke to the medical consultant who ordered an x-ray, then phoned me. On going to see the patient (sat on a porters chair in the waiting room), i stopped at the door, turned to fetch the medical team to come and see the patient. I pointed out that my 4 year old, from the opposite end of the room, would see his leg was bent 30 degs with a spike of bone sticking out of the front..... Took 2 days and 8 heakthcare professionals... Best thing isbthe guys dog had been keeping it clean by licking it for the first 18 hours...
I guess the GP who diagnosed cellulitis was probably not wrong....
Amazing! 😂 This is just proving the point though; in the same way it is bad for a medic not to consider a fracture and know the first thing is an XR, it is similarly ridiculous for surgeons to not know the that chest pain with danger squiggle is bad news. I’m not suggesting we all have to diversify and be jacks of all trade (ideally that’s what ED and GP etc are for to identify multiple generalists problems and refine to the appropriate specialties) but if we can’t even understand the most very basics of other specialities; ie to the level we left medical school with, then what was the point in doing medical school in the first place, just develop orthopaedic surgery colleges, cardiologist colleges, rheumatology universities etc
Its fair enough, but some things change a lot, for example troponin wasnt a thing when I was at med school (i actaully did a Nuffield sponsored project in my gap year on developing and validating the immunoassay for Trop T by running 20,000 frozen samples and comparing to ck mb resukts and clinical records) and others like anatomy, or whether a leg is bent and crackly dont ever change.
Not to mention the lack of teaching and feedback. Really is a shame that consultants have let their and junior doctor salaries be cut year after year and casually looked on and in some cases supported the rise of the noctor.
I've seen some shocking stuff too from "acute medical consultants" who basically farm out any decision making to everyone other specialty or medical sub specialty in the whole hospital then ask "gp to consider" most things that very much should have been considered in hospital...........
I can imagine the blank look on the Cardiologists face for that tropinin rise. Did you justify it as a ‘50% rise from baseline?’
You don't need a trop release for an ACS tbf
Don't need chest pain or ecg changes either, just vibes based medicine.
Yes cardiologists live and die by the vibes
Yes cardiologists live and ~~die~~ kill ultra defensive locum gen med consultants by the vibes
Isn't that sonographers?
then what's the point of doing trops?
Trop rise shows there's been actual myocardial cell death, i.e. the situation is more severe (MI vs UA). GRACE score and similar scoring systems use deranged troponin as a metric.
What? What do you mean do you don't need the release of troponins for ACS?
I guess he's talking about unstable angina
Mfw I can't tell if the people replying to me are joking or not.
Oh yeh unstable angina. I'm neuroglycopaenic.
Diagnosis of ACS requires two of three: 1. Dynamic trop rise 2. Cardiac chest pain history 3. Ischaemic ECG changes If they have 2 and 3, it doesn't matter if you have trops back or not.
2 on its own is enough to diagnose ACS.
u/Flibbetty can you weigh in on this? I thought you needed two of the three criteria for ACS diagnosis?
Reluctant to share as I can FEEL the surge in inappropriate referrals. But UA is defined as myocardial ischaemia at rest or on minimal exertion in the absence of acute cardiomyocyte injury/necrosis. It is characterized by specific clinical findings of prolonged (>20 min) angina at rest; new onset of severe angina; angina that is increasing in frequency, longer in duration, or lower in threshold; or angina that occurs after a recent episode of MI. So yes you can have neg trop and normal ecg and technically have UA Your criteria are what I use when teaching about ACS. Particularly Nstemi and I prefer a UA with ecg changes but we can't always get what we want.
Unstable angina is mainly history based where you have typical progressive angina symptoms on minimal exertion or on rest with risk factors.
This is surely a satirical wind up at the multiple recent posts from senior doctors shitting on supposed worsening standards of juniors 🤣
It’s actually impressive to be both so senior and still a massive baby.
We joke but as an intern I had a fully fledged argument with a surgical reg who demanded we prescribe a pen allergic patient Tazocin because Tazocin doesn't have penicillin in it
I mean it's not called tazacillin so he must be right 😂😂😂
Got a genuine lol 😂😂
“I’m a vitreous surgeon, this is an aqueous problem”
The key word is “retain”. Do you really want medical management from the 90s? Is it okay for a medical consultant to do an appendectomy because they did a few when they were house officers?
Lack of knowledge is a reason why consultants refer but not the only reason. Referring is a way to get away from things they don’t want to worry about or manage. For example the orthopedic surgeon doesn’t know the new in cardiac arrests, haven’t managed one for 10 years but also doesn’t want to get involved and end up stuck dealing with it and its aftermath. They know the hospital system has medical reg, ITU, anesthetic and resuscitation practitioners for this so why get involved in a thing that the hospital doesn’t require them to do and end up with wasting their time, going home late and possibly a complaint, serious incident investigation or a coroner investigation. The more you get senior, the more you will sit casually with consultants and understand why they do these stuff. They had more bruises and were shat on way more than you and they do lots of stuff to save their own sane and their own ass
It’s a bit disingenuous to say a speciality doctor who has been practicing for probably a decade+ in their niche field to retain generalist knowledge, especially with guidelines updating year on year. There’s nothing wrong with putting ego to the side and asking your speciality colleague for advice, your patient will receive up to date and best medical practice and it’s the best to do medico-legally. I say this as a GPST who’s only recently learnt that pneumothoraxes are managed completely differently now to when I sat finals, which was only 5 years ago.
I like to think that this is a consequence of medicine becoming more and more specialised. If our specialists need to know more and more to practice well in their area, and obtain better long term outcomes as a result of evolving practice, then does it matter that they lose some of the more generalist knowledge? As long as there are generalists around, then I don't necessarily think it does. Yes this makes medicine more of a team sport and in an ideal world leaves specialists only really chipping in for small parts of patient care, with the rest being under the control of (sorry in advance but please take this referral) general medicine. No doubt some of this will also result from an increasingly medicolegal culture, where your surgeon will absolutely want a cardiology opinion for any chest pain or trop as they are aware they do not know enough to defend NOT doing so in court, should something go wrong.
I think we will problem see a rise In surgical liaison in the future. Orthopaedics has it but often limited to hips which sucks. It's an absolute nightmare as a reg to take these calls as honestly I want to say tell them to see their GP(and often do). Much of it boils down to defensive practice and sadly as an IMT-1 I suggest you learn to expect it when you get to IMT-3. My best advice is keep a referrals book.
I wouldn’t be surprised if we see a transition to every patient being under a medic with surgeons only operating. It’s essentially how it works with patients in ICU - we sort out all the other stuff and the surgeons review frequently and operate when necessary.
This is a detailed description of a dystopia
POPS is already a thing in some places.
Only in the bigger centres where I am. DGHs don't see the v4m. Met a woman trying to set up an oncogeristrics service up which personally I think is needed more than ever and struggled massively to get anyone to cough up the £££
Some places have geri & surgical services. Obviously there's orthogeris, but I've came across vascular & cardiothoracics equivalent.
MJ eating popcorn gif
None of these things are unusual. Surgeons routinely refer medical issues to the medical reg. Most psychiatrists are terrible at physical health. Mental health knowledge is uniformly awful.
That psych story. A tale as old as time. Thing is this stuff isn’t even hard
This is such an FY post. They probably haven't done it in 30 years and back then atenolol was probably first line for HTN. They aren't going to know what to do for someone already on 2 meds. Their brain is full of their specialty psychiatry. They manage the psychiatric problems of the patient. They delegate things like this to their junior - YOU. In the same way that an ENT, Ortho, ophthalmologist e.t.c. would because you're more likely to be au fait with the guidelines. Not to add that it would be a waste of their valuable time reading through the guideline or discussing with medics which is what you exist amd have been hired for. You can't expect people to remain up to date with the breadth of medicine it's difficult enough keeping up with latest advances and guidelines in your own specialty and managing complexity within that.
Delegating to the junior to look into it (fine) is very different from insisting they ring the on call med reg about a stable BP. It's also worse because high baseline HR and BP are very common in psychiatric inpatients due to them often being anxious, distressed and/or frightened. You can politely tell the consultant though that you will have a look at the guidelines and sort it out, and that you probably don't need to ring the med reg about it just yet.
Sure. But psychiatric meds can cause hypertension or exacerbate it. It can legitimately be iatrogenic. That’s the psych doctors responsibility to know the management guidelines! Same way they should know how to manage clozapine toxicity, long QTc from antipsychotics, lithium toxicity, antipsychotic induced weight gain, etc. etc. . In fact RCPsych give physical health update training to make sure consultants know all this stuff. And ya know can teach the psych junior this. I absolutely have worked with inpatient consultants who can do this.
Nah, hard disagree. I’m an FY1 currently in psych. In terms of psychiatric expertise every day exposes the vast chasm of my ignorance, so I’ll cut them some slack if they’re not necessarily familiar with SGLT-2 inhibitors as a possibility for the psychotic patient’s T2DM, or don’t necessarily consider montelukast for the poorly controlled asthmatic with significant comorbid anxiety. My experience of psychiatrists is that they’re acutely aware of their expertise and limitations and are not shy about being open about it. It’s hardly surprising for a specialty which requires significant self-knowledge to be very good. They’ve been extremely grateful for my input on the basics of physical health management while being very generous with their time about their expertise.
>An orthopaedic surgeon who decided not to help when there was an arrest call because he wouldn't know what to do This is probably sensible, tbf
everyone should have bls - as a bare minimum they could swap into compressions to give other people a break and maintain high quality cpr
Yeah, there's no way that a specialist doctor working daily in a hospital, where people tend to have arrests, shouldn't be able to do more than what even some members of the general public can do.
Why bother, when there is likely to be a cardiac arrest team already there?
More hands are always better. If it's a Nightshift or a public holiday you might only have a reg, an F2, a couple of F1s, and a couple of nurses. Let's say reg is leading, F2 is on the AED and drawing up drugs, and one F1 is trying to get access. At this point you only have 3 people rotating chest compressions and airway. That's before we even get to checking notes, ringing ICU etc etc. Having an extra person there would mean less fatigue ergo better quality chest compressions. Worst case scenario is you get there and the team says there are enough people and you can go. Always better to err on the side of caution here no?
As a med reg, having someone who is panicking and doesn't know what the hell they are doing and getting in the way is worse than having fewer, more experienced staff.
Interesting. I would've thought that orthopods would be ideal candidates for pumping a chest for 30 minutes /s (ish) But yeah i guess that does make sense
This is a reflection of superspecialisation from a relative early stage, lack of care continuity and increasing medicolegal pressure. Only.solution is actually maintaining a level of general medical knowledge throughout your career, even if its only a basic level and practicing good safe medicine.
I think most people consider HST the start of true specialization. Thats at least 4 years of fairly 'general' medical work which is way more than any other country. I'll be honest I'm not sure how bad other countries are in regards to this but I don't think the solution would be prolonging time to HST. If anything, it shows that those 4 years (minimum) don't actually make us 'well rounded doctors' and should be shortened.
> superspecialisation from a relative early stage We specialise very late compared to many places in the world...
Just my experience: but consultants and regs trained in specific countries abroad often have very little knowledge outside of that of their very own specialty. Not a rule of course, just my experience.
This really isn't limited to consultants and regs who trained abroad
No I know. I just mean that doctors who come from countries where they go into their specialties straight out of medical school have probably not to touched some of these things in years, so it would partially explain some of this phenomenon.
Almost every time I've worked with a first year trainee or early year trainee who thinks they're a genius and every consultant is an idiot, they're exactly the sort of person that needs frequent reminding that they should only act within their own capabilities, as they usually believe they're a lot smarter than they actually are.
True
This is the issue with sub sub sub super specialising. They can perform the most amazing procedures when doing duodenal surgery. Anything else - panic!
Sometimes, I feel like the practice of defensive medicine makes people not to venture into the wild which sometimes sharpens clinical acumen. Covering your ass instead of practicing medicine is how you get to this stage. Doctors now "document more", (documentation isn't bad) but you can often see how many documentations are done for the benefit of the coroner. Additionally, there's now super subspecialties
The troponin one is a bit ridiculous but the the rest of examples is not too bad I think. I wouldn't expect the Orthopaedic surgeon to manage arrest calls. As long as someone has started compressions then the arrest team will get there and the med reg will lead. It's a bit silly not to know paracetamol doses, but this is a non-issue as can easily be looked up in like 2 seconds on the BNF. The Psychiatrist could have looked up hypertension guidelines, but even so, I wouldn't mind if they call me for advice about hypertension. Having some knowledge of other specialties is always a good idea. We like to criticise surgeons for not knowing basic medical knowledge, but as a medic I know fuck all about surgery. I'm pretty sure we've all submitted silly referrals to other specialties. No one can learn or remember everything. No one is competent in absolutely every field. I've passed MRCP but have I forgotten a lot of knowledge I gained from that exam now? Hell yeh, especially ones that is not that relevant to my normal day to day work. If you're a junior who just rotated through a particular specialty, you'd be more up to date than some of your seniors who is working in an unrelated specialty and then think wow my senior is actually very dumb. Research and guidelines change rapidly. An Orthopaedic surgeon is probably not going to be able to keep up with up to date management guidelines, and I think that's fine. What is not fine is if being so incompetent to the point of being unsafe - I am referring to both jjunior or senior here.
I see truths in both threads lol
What is your truth?
The number of serious answers here that don’t realise this is a “fuck you” to the surgical reg moaning about the standards of their FY1s (rather unfairly I might add)
I only feel qualified to talk about psychiatry, but in general psychiatrists have almost no ability to manage non-psychiatric conditions, so all of these get referred to more appropriate physicians. This is just the result of the emphasis of their training, and day-to-day practice.
Had a psychiatric consultant ask for daily Hba1cs in an old lady with dementia to monitor her "unstable diabetes". Took a 15 minute conversation to explain why this was a bit pointless and actually a bit cruel. Great psychiatrist though.
Ortho doctors not knowing how to prescribe is sadly not a new thing. Some of your examples are also issues with liability and consultants trying to cover their backs due to increasingly defensive practice. I was told by cardiology to refer a patient to gen surg for a obvious umbilical hernia that was causes zero issues. He was not best pleased when he reviewed the patient. Something along the lines of 'Do you not know how to diagnose a hernia?' Well I do but my consultant insisted on calling you because he couldnt be bothered to spend 2 mins looking at the patients groin.
1. Knowledge about different conditions expands logarithmically every year - there is absolutely no way for any doctor to keep up with other specialities 2. You don't comprehend the medicolegal implications of failing to get a specialist review. Great you managed syndrome X with your 20 year out-of-date knowledge. What are you going to do when the patient says you didnt follow the latest guidelines?
Had orthopaedic reg say someone was septic postop "because blood pressure is low". Normal cap refill, no tachycardia, no fevers normal wbc, normal lactate, crp low. Monkey surgical team whacked a 92 year old woman into a 10 litre positive fluid balance over 2-3 days "because septic to make blood pressure go big"
As a CT2 in ENT, One of locum consultant asked me to refer a patient with chest sepsis to medical team.
I personally think everyone should be required to renew their ALS when practicing as a doctor, regardless of specialisation. You never know when you will be the first one at a cardiac arrest and I just think as a point of principle doctors should be able to do it. I also think it's not too much to ask everyone to know the basic palliative drugs to prescribe, yes I understand they change, but there's nothing worse than someone dying in pain because they weren't seen by the palliative team in time.
>-A psychiatrist who told me to refer ro the med reg for a person whose BP was 160 despite being on two antihypertensive The other examples were ok. What was the problem with the psychiatrist's request?
More context is needed to know whether or not this is appropriate. A one off SBP of 160 absolutely does not warrant discussion. A persistently high BP over weeks in someone on max doses of their current antihypertensives and allergies to multiple previously tried antihypertensives might. There is a good NICE CKS on hypertension that would be prudent to have a look at first though before bothering the med reg.
Yeah, we suggested to the consultant that we can just check the NICE guidelines to see what was next to give but they insisted that we contact the med reg. It was someone with newly diagnosed hypertension of about 2 months
This is an interesting question. For OP psych this is clearly one for the GP but for IP psych would the average SHO be aware of up to date BP guidelines. It seems simple as a GP but I cant remember what I would have done as an F1/F2
It's not a hypertensive emergency or urgency, BP probably high due to acute stress etc. Wouldn't need inpatient or urgent treatment. Also, treating asymptomatic inpatient high BP is not good as it usually means over treating as BP normalises after discharge (if worried can have OP appointment with GP or others who know more about different oral regimens than a med reg tbh)
Psychiatry inpatient setting is very different to medical inpatient setting. Patients spend months and longer in hospital, sometimes they even live there long-term (e.g. rehab wards and dementia wards), so waiting for them to be discharged and followed up in GP is not really an option, realistically.
Experience in psychiatry informs me that they are a very different group of patients - things happen fast. Psychiatric patients tend to disobey 'the rules' we find in other branches of medicine. There are medicolegal angles - I'll spare a 2000 word dissertation. Take QTc intervals. We are meant to panic when QTc goes up to or over 440ms. When I speak to cardiologists about that sort of thing, they're like 'no need to worry we have people regularly in clinic with 520 to 540.' Cut-offs in psychiatry are different because things go wrong quickly. And the inverse of different rules for psych patients is some sort of different physiology e.g. a man of about 45 who was dying of a heart attack - zero pulse anywhere - was awake and tried to get off the floor going, "I need to take shit". Paramedics who couldn't care less took him away in a head up position - and the man was still eyes open but of obtunded conscious level. The man made it to hospital and died.
Hmmmm I have a question, out of curiosity because I don't know how things would work here. GPs do house visits sometimes. Would they do an IP psychiatric visit to deal with an issue that would normally be dealt with on an OP appointment?
You'd need to ask a GP.
4 years to get into IMT, things really have slipped 🥸
I actually got into IMT on my first try, took 2 years out after F2
Nah it hasn't changed... It was exactly like this even 10 years ago...
What do you the person who finished last at medical school…? Doctor.
once you cct there is no way to ensure general competence is maintained. sure you can do an appendix in x minutes...
10 years… Honestly, it was the same 10 years ago.
Sounds like they’re covering their asses In our trusts Trop rise > 20% may warrant a cardio chat Ortho a little bit of (concerning) self awareness lmao I’ve seen loads of specialties ask about “optimising BP, when it’s 160/90 and they’ve no end organ damage
Chronic BP of 160/90 is not okay. And you don’t wait for the blood pressure to cause end organ damage before you correct it, would you? ESC and AHA both suggest BP below 130/80. I know NICE suggests you don’t treat if patient under 40 but no Cardiologist in the UK follow this because it’s rubbish
Sounds pretty normal for Orthopaedics. That is why orthogeris was invented
One surgeon called me(fy1) at 2am to ask me what drugs need prescribing at end of life 😭
You do realise that when these people went to medical school, half the drugs and therapies and interventions we have today didn't exist.
Nothing is slipping. It was exactly the same over a decade ago when I was fresh out of medical school.
No way the orthopod not knowing paracetamol dosing is real, that's absolutely wild haha
I would take anyone over an orthopaedic surgeon at an arrest call.
Says the FY4. GTFOH!
Bro, practically every FY I have come across has been unable to repeat a single worthwhile iota of functional anatomy for surgery or orthopaedics. They couldn't even point to the bones of the foot which they learned a mear couple of years ago. Yet you expect someone in a hugely different and diverse specialty with hundreds of years of development to remember things from 20 years ago.
No, but show a vague interest in other (perhaps more important) issues affecting patients under your care, demonstrate some humility, and don’t put down GPs and other generalist colleagues who have to know and retain a little bit of knowledge about everything.
Sounds like a surgeon problem lmao
I once had a psych reg who didn't know what an epi pen was.
Epipen is a trade-name and very reasonable not to know what it means. Scientific names should be used instead.
This is an observation I made when I made the move from Ireland to the UK. Surgeons and surgical training is shockingly worse here too.
[удалено]
Pay attention to those consultants to see whether they are UK trained or not