Friday, 23 November 2007

Medical Residency System In The UK

Dear Bloggers

It may well be known how the USA medical residency system works by Japanese residents because of the wide-spread American influence in Japan. However, I am certain that little is know about the UK medical residency system which I will endeavour to unveil in this article.

It may be best to explain the infrastructure of the system to see how it related to the residency system.

Basically, in a usual district hospital there are 10 medical teams which are usually Cardiology, Respiratory, Gastroenterology, Diabetes and Elderly Care medicine who although have their own speciality, they also practise General Internal Medicine and therefore see all medical problems.

Each respective team will usually have a first year doctor, and more senior doctor who may be anywhere from a second year to a fourth year doctor. There will also be a Registrar doctor who will be sometimes assigned to two teams within the same speciality thereby covering four doctors below him/her. These days, the number of Registrar level doctors has increased and therefore, it is likely that a Registrar will cover only one team. Each team has its own consultant who will also have a respective speciality and who also practises general medicine.

Each team will look after around 20-30 patients and the work will be split between the first year doctor and more senior doctor or they will see all the patients together. This thereby allows all the patients to be seen usually in a morning and all the jobs are carried out by the afternoon. If a patient gets sick then one doctor is available, usually the senior, to sort it out whilst the junior continues to see the other ward patients.

The Registrar is a more Senior doctor who is in training to become a Specialist consultant. The Registrars are usually engaged in a combination of Outpatient clinics and Ward work and hence, if patients are sick they are usually called upon to resolve matters especially if the less senior or junior doctors cannot solve the problem.

If all else fails, the Registrar may defer to the team consultant who has responsibility to try and resolve the problems.

Hence, there is an upward chain of command whereby the ultimate responsibility for all the patients lies with the consultant of the team. It is therefore in the consultant's best interest to know what is going on with the inpatients and this is done by twice weekly ward rounds in most cases.

The UK ward rounds involve the whole team seeing all the inpatients whereby the consultant can be updated on recent tests and blood results, but more importantly new history and physical changes. This is a great opportunity to learn as all the junior members of the team (everyone else lower than consultant level) have a chance to learn if they have been doing things correctly and get feedback from the consultant. This is also a safety mechanism for the patient as they will be seen by an experienced physician who will take more history and examine them and review drugs, interactions and start or stop such drugs. They will also make further plans and decide on discharge. Such an interaction between junior doctors, the consultant and the patient is a great opportunity for learning about history taking and physical examination but it also provides skills on how to manage inpatient problems, multi-organ system problems and how to decide on when to call the more senior doctor and when to discharge the patient.

Doctors do not stay in the hospital after 5:00pm if their work is finished. They are able to go home and rest--- or study !

If they are on-call, as a team, they will also admit ALL new medical patients referred from community GPs, other hospitals (transfers) and the outpatient clinic plus Emergency Room (Accident and Emergency [A&E]). Thus, all patients are admitted under the care of a single consultant on-call and that may be anywhere from 10 to 30 or 40 patients in a 24 hour period.

The on-call team work from 9am to 9pm and then go home. A night team who work for a week of nights take over from 9pm to 9am.

On the morning of the next day, the team do a Post-Take ward round to see all the new patients. Again, history and physical are reviewed by the consultant providing a great learning opportunity for the Residents. This is a legal requirement for all patients to be seen within 24 hours by a consultant when admitted to the hospital. This provides great training in emergency medicine.

On-call varies and may be once in a week or may involve a week of nights or a whole weekend, but no on-call session lasts more than 12 hours.

Why is this important? Well a fatigued doctor makes mistakes. A recent lecture given by Dr Landrigan in August 2007 at the National Institute of Health gives an indepth explanation of fatigue in doctors and increased chances of making medical errors and driving accidents after doing long on-calls and with sleep deprivation [ ]

Hence, the UK system having implemented the famous Working Time Directive has stopped most doctors working more than 56 hours per week.

I for one who worked under this system felt fatigued working 12 hours straight when on-call and was relieved to be able to get a good night [or day] sleep after on-call. I also worked under the old system which meant a full 24 hours on call or 72 hour weekend (Friday, Saturday and Sunday) without much sleep and hence, I know the acute differences that the Working Time Directive implemented and I am sure that it caused a reduction in the frequency of mistakes within the hospitals throughout the UK.

In the USA, some hospitals are trying hard to reduce doctors hours but they are by no means in line with the standards currently employed in the UK system.

In summary, the UK system has many doctors per team with a chain of command upwards when a less experienced doctor does not know what to do, which incorporates multiple checks and balances for the patient to try and avoid accidents and misdiagnoses. The consultant has a responsibility to see all new patients and all the inpatients, the latter, several times during a working week. Residents never work more than 12 hours at a time unless under exceptional circumstances and hence, it is hoped that this will reduce mistakes by doctors.

Resident educational is somewhat informal as it takes place during ward rounds and post-take ward rounds, but there are also educational sessions carried out by all the consultants on an ongoing rota once a week to teach specific topics. Moreover, the Registrars also do training sessions for the junior doctors and medical students.

Grand rounds take place weekly as do journal clubs. Other training for higher exams the doctors usually do Self-Directed Learning and they may also go on training courses. Registrars also go on specific training courses. For advanced exams (MRCP) the consultants and Registrars will usually rotate on a training scheme whereby they will take the senior doctors to a patient and ask them to examine a body system. They will then provide their advice and constructive criticism on how the doctor can improve their examination skills in order to pass this high-level exam.

The MRCP exam concentrates on history and physical examination with little emphasis on scans such as CT or MRI.

All training sessions take place at lunchtime in most hospitals with food provided.

Moreover, I have never seen a UK doctor fall asleep in any meeting.

In summary, I think that the UK system is comfortable for working in but also for having free time as well; the so-called Work-Life Separation. Doctors do not need to remain in the hospital out of hours as any problem is handled by the on-call team for that time, and that includes speaking with relatives.

There is an upward chain of responsibility by every member of the team and a very good but informal way of training the junior doctors on frequent wards rounds at the bedside plus formal teaching sessions.
Training focuses on the patient and not on interpreting radiological scans.

This is a different system to that found in Japan and such a system may be somewhat of a surprise to you.

Have a nice holiday :-)

Tuesday, 20 November 2007

Professor Tierney, Dr Aoki and Some Great Cases

Dear Bloggers

Today Professor Tierney visited our institution for just two hours, but it was two hours of brilliance.

The first cases consisted of a patient with pharyngitis, fever and shoulder pain. This was presented by our fourth year resident Dr Fukuda. Professor Tierney lectured on the quality of information about platelets and how you can predict either marrow failure or consumption just by observing the change in absolute numbers. The result of the case was meningococcal septicaemia with infiltration into the CSF without laboratory data indicating meningitis.

Professor Tierney and Dr Aoki were lecturing on how they had seen previous cases of meningitis without cells in the CSF; rare but still possible ! Never say Never.

However, during Dr Fukuda's presentation, he was being called to say his wife had just given birth to their second child--a daughter. Looks like Professor Tierney is a Lucky Charm too.

The second case presented by Dr Ban, was a very interesting case of a young female with a previous diagnosis of Diffuse PanBronchiolisis (DPB) and Immune Thrombocytopenic Purpura (ITP). The patient had been admitted with recurrent respiratory problems and there was a concern that the original diagnosis was in doubt.

The patient also had hypogammaglobulinemia.

Professor Tierney went through this case methodically and came up with differentials such a Histiocytosis X, Immotile Cilia Syndrome, Kartagener's Syndrome and potentially, Cystic Fibrosis.

However, pulling all the elements together, he considered that the initial diagnosis of DPB, made some 10 years before, was wrong and in fact, he considered it to be a congenital condition called Common Variable Hypogammaglobulinemia otherwise known as Common Variable ImmunoDeficiency (CVID).

I had also been consulted on this very same case a week before and my opinion was also CVID and it is good that two minds can think alike.

The disorder is rare and Prof Tierney admitted only ever seeing 2 previous cases in his whole career and this made his third.

UpToDate 15.3 covers CVID in some detail although I am sure any good medical textbook will detail this condition.

The two hours flew by and it was a shame that it had to end. Anyhow, there is always next year ! :)

Lastly, Congratulations to Dr Fukuda and his Wife on the Birth of their Second Child.

Hypoglycaemia masquerading as Hyperglycaemia !

A recent case at another hospital is a caveat for a common problem-- hypoglycaemia.

A female patient with a history of type 2 diabetes was admitted following several episodes of unconsciousness lasting up to 12 hours each time. The patient eventually presented to the hospital because of concern as to the cause.

On the first episode, the patient had collapsed to her right side with no associated seizures or incontinence. She awoke some 12 hours later.

The second episode, she collapsed whilst eating and again, this lasted some 12 hours. At that time, she was noted to be disorientated and could not remember how to cook or wash up dishes. She was also found to have some cerebellar dysfunction. These symptoms spontaneously resolved.

When she presented in the outpatient clinic, her blood sugar was high, approx 200mg/dl.

It was initially considered by the admitting doctors that it was an unusual neurological problem although the subsequent MRI was normal.

However, another doctor suggested examining the daily drugs that the patient took to see if these phenomena were drug-induced. Sure enough, the patient was taking metformin and glimepiride 1mg-- diabetes drugs !

One junior doctor suggested that this could not be hypoglycaemia because the admission blood sugar was normal-high and that the patient had no warning signs of hypoglycaemia. This reasoning was not correct for the following reasons:

1) Most cases of hypoglycaemia are drug induced e.g. sulphonylureas / alcohol / insulin and as a consequence, they can cause a decline in blood glucose levels. The reflex reponse of hypoglycaemia is the output of Growth Hormone, Adrenaline, Glucagon in additon to Cortisol, whereby there is glycogenolysis and gluconeogenesis. Of course, this mechanism then over shoots and causes hyperglycaemia. This is the Sygomni Effect and is often seen in the early morning e.g. 3am when the patient wakens with sweats or wakes up on the floor with a headache having had a nocturnal seizure ! Some patients don't get symptoms of hypoglycaemia. Either this is because of beta-blocker use and hence, the adrenergic response to hypoglycaemia is blunted or the patient has been having recurrent hypoglycaemia which is associated with reduced warning signs.

2) Hypoglycaemia can therefore self-correct through the correcting mechanisms described above and when the patient is admitted to hospital may have a low, normal or high glucose level. The latter two scenarios DO NOT EXCLUDE an episode of hypoglycaemia.

However, some patients blood sugar can go extremely low and they may experience neuroglycopaenia and subsequent brain damage and hence, hypoglycaemia must always be treated.

With such a history of prolonged unconsciousness with periods of normality punctuating such episodes in a patient with diabetes on hypoglycaemic agents, one must allows consider this to be drug induced until proven otherwise.

The glimerpiride drug is a once daily dosing 3rd generation sulphonylurea. Because of its long period of activity, it can induce hypoglycaemia. Metformin rarely causes hypoglycaemia by itself.

Hypoglycaemia should always be considered in diabetic patients who have an HbA1c <7% (DCCT-aligned) who take insulin or an SU drug. This was demonstrated in the DCCT study when the more intensive the diabetes was treated, and hence the lower the HbA1c towards to the population normal range, the higher the recorded refequency of hypoglycaemic events. In this case, the patient had an HbA1c of 6.8% (non-DCCT aligned) and hence, it is difficult to say exactly what the DCCT aligned HbA1c was without the appropriate adjustment to DCCT.

Patients with suspected drug induced hypoglycaemia should receive iv glucose infusion (50ml 50% glucose) and the diabetes medications should be halved in dose or in some cases stopped and changed to a shorter acting agent e.g. glibenclamide changed to gliclazide.

In this case, the glimepiride was stopped. It is better to allow the DM control to run slightly high for several weeks so as to allow the mechanisms for hypoglycaemia to auto-correct before trying to attain tight control again. Hence, earlier warning for hypoglycaemia can hopefully be restored.

Finally, patients with hypoglycaemia have to got through several steps to correct their hypoglycaemia 1) They have to have warning signs 2) They have to recognise those warning signs 3) They have to consider how to correct the problem e.g. decide to eat some food 4) They have to put the thought into motion e.g. eat some food.

Anywhere along the way, such patients can have a failure to correctly manage a step, resulting in hypoglycaemia being uncorrected. For example, a patient may have warning signs and recognise them but fail congitively to consider how to correct the problem or fail to eat food despite wanting to.

Remember: Patients with hypoglycaemia can present as unconscious, confusion, aggression, appear drunk, appear with hemiparesis or seizure etc.... CT / MRI are nice tests for making nice pictures, but never forget to check a blood sugar and check the drugs as something simple as 50% 50ml Glucose can correct the problem in seconds and save a life, and save embarrassment for you too.....

Please consider ! :)

Monday, 19 November 2007

Prof Tierney Back in Town

Dear Bloggers

Professor Tierney is back in Town. Today he began his 3-day whirl wind lecture tour at C.

There were three morning sessions organised, two of which Professor Tierney presented his own cases acquired from other hospitals in Japan. The middle session involved a case presented by the C residents to put Professor Tierney to the test.

In view that Prof Tierney may be presenting his other cases at his future hospitals in Japan, I will not reveal their contents. It is a surprise !

However, the C case involved a female who presented with an intermittent nocturnal non-productive cough, fever and hypoxaemia. The diagnosis was made from history and physical examination and later inferred by chest roentogen / CT, which was extrinsic allergic alveolitis. This was a simple diagnosis for this Professor of Medicine :)

One odd thing was the request of a resident to have Professor Tierney to sign his wallet!!! Perhaps the strangest request he has ever had !