Bad Medicine: Why the doctors are striking.

This is a cross post from my Huffington Post column. Feel free to read it there instead…

I am a big believer in Good Medicine.

Notice the capital “M”? We all know about “medicine”, which often takes the form of tablets that help you to get better. But Medicine is the art of getting people better. Learning Good Medicine is a process of skilled training that takes doctors decades of experience, practice, mistakes and reflection.

Good evidence = Good Medicine

GoodmedicineScience means “using evidence to prove a theory”. Applying science to Medicine means that all our actions need to be based on reliable, good quality evidence.

It is impossible to practice Good Medicine without evidence – a fact that is drummed into us at medical school. Science is the reason doctors don’t try to cure impotence with electrocution, cure migraines by drilling holes in people’s skulls, and never encourage people to drink their own urine.

Look at some of these examples, to see how important evidence is:

Why do we ask Mrs Jones to take tablets for blood pressure?
Because the evidence shows that it reduces her risks of strokes, heart attacks, heart failure, kidney failure, and lots of other nasty things.

Why do we use paracetamol when little Timmy is burning up with his sore throat?
Because the evidence shows us that it relieves distress in children with raised temperatures.

Why does Mr William’s GP always ask him about smoking?
Because evidence shows that simple advice from a GP nearly doubles the chance that Mr William will quit in the following year.

Being a good doctor means practising Good Medicine. If we are going to take risks with people’s lives, we need to be sure that what we are doing is helpful; I’m sure you agree.

The government doesn’t have good evidence

Unfortunately, there is a problem. The NHS isn’t run by nurses, and doctors, and pharmacists, and radiologists, and dieticians, and the many, many other professionals who understand that evidence is the most important underpinning of everything we do together.

David_Cameron_(28_January_2011)The NHS is run by politicians. Politicians like David Cameron, and Jeremy Hunt. Politicians who don’t seem to understand that Medicine without evidence is Bad Medicine. We, the doctors, are terribly concerned, that the politicians are in a hurry.

We want a 7 day NHS. Oh yes! We want a better health service, no doubt about it. But “7 day health service” is a buzzword. On its own, it doesn’t mean anything. Even if Jeremy Hunt sits on the toilet one morning, and has a brilliant idea, its very important that we test his idea.

Many of you will remember the incident in 2006 in London when a new drug, TGN1412, was given to 6 men, all of whom nearly died, with multiple organ failure. Ultimately, there was several problems with that trial, but a fact point is: aren’t you glad they didn’t try that drug on thousands of people at once?

The government isn’t proposed untested drugs, but it does want to roll out a junior doctor contract across the country, without testing it first. The junior doctors are concerned that it runs the risk of making problems much worse. Why is there such a hurry to take action without getting more evidence first?

What evidence we do have doesn’t support the government’s claims

Mr Hunt claims he has evidence that 11,000 people die each year due to weekend staffing. But let me read you a line from the conclusion of the very report he is quoting:“It is not possible to ascertain the extent to which these excess deaths may be preventable; to assume that they are avoidable would be rash and misleading.” In other words, he is claiming the study as strong evidence to support his actions: but the report makes it very clear that it is absolutely not.

Mr Cameron wants us to “become the first country in the world to deliver a truly 7-day NHS“. But he talks about 24/7 GP practices, despite the initial evidence we have not supporting this in practice. The Public Accounts committee grilled policy advisers on what their cost-benefit analysis evidence was, to discover that they haven’t done any. They asked a key question: “If you don’t know in broad terms what the answer is, how can you be doing the policy?”.

We would agree, strongly. If the government doesn’t know its changes will save lives, how can they be implementing them?

Why the junior doctors are striking

The government has said they are going to force a new contract onto doctors. But they don’t have any evidence that the new contract will save lives. We, the doctors, are very concerned that it will cost lives, and we keep saying it, but the government isn’t listening to us.

Knee jerk decisions?
That’s Bad Medicine.

Actions without evidence?
That’s Bad Medicine.

Changing the NHS that 53 million people rely on without trialling to see if the changes are harmful?
That’s Bad Medicine.

Bad Medicine kills people. Support your junior doctors, and tell the Government we want a safe, evidence based NHS, and we are willing to take the time to do it properly. #notsafenotfair

I’ve cross posted this on my personal site, If you feel strongly, please post it on your site too. Feel free to contact me me on twitter as @bigonroad. Thanks for reading!

Day Six: Aspects of mission work

The following is part of a series of posts about the Developing Health Course 2012 run by CMF.

I cycled today! 14 miles on my dad’s mountain bike. Excellent practice for a potential 26 mile cycle to Skegness on my next rotation. I decided that this exertion deserved a reward with a croissant, before the morning session began…

Caring for the carers

Not Supposed To Feel Like This book coverMary Hopper has lived and worked in Rhodesia/Zimbabwe and South Africa for many years, and also runs a counselling and trauma workshop for those working in resource poor settings.

Elijah was afraid and ran for his life. When he came to Beersheba in Judah, he left his servant there, while he himself went a day’s journey into the wilderness.

He came to a broom bush, sat down under it and prayed that he might die. “I have had enough, Lord,” he said. “Take my life”.
1 Kings 19 

Following this, God strengthened Elijah, takes him to a quiet place, given a word of encouragement: and then gives him another difficult job to do.

The passage from Kings is a word to those who have grown wearing in well doing. Also a word to those who think that this will never happen to them. Huge list of people who have shown stress in history: Jeremiah, David, Charles Spurgeon, Martin Luther


Both acute and chronic stress have physiological effects. Its a common problem in the field of world mission. 20% have taken anti-depressants since becoming missionaries.

46% of missionaries suffer psychological problems (mainly depression) – their home organisations only knew of about 7.5%.

What can cause stress and burnout in resource poor settings?

  • Frustration
  • Feelings of inadequacy
  • Busyness and tiredness
  • Conflict within teams
  • Cultural differences
  • Language barriers
  • Distance from local church – no fellowship
  • Sad spouse, stuck at home
  • Personal healthcare issues

Greenhouse effect: a plant in a greenhouse in the UK won’t grow out of control. Pop it into the Congo jungle, and it will grow out of control. Social conventions in the UK can reign back behaviours: drinking too much, driving, marriage problems. etc – without that control, it can worsen abroad.

Children especially can find returning home to the very civilised culture in the UK very difficult. No one at school will understand the freedom of running around barefoot under the sun. Studies show that children struggle with moves most, especially when they have to leave friends behind.

Single women can have problems: cultural expectations are often that must be prostitutes.

Further problems

  • Questioning the meaning of life
  • Loss of purpose
  • Loss of hope
  • Changes in beliefs
  • Doubts
  • Giving up faith
  • Anger
  • Feeling far from God

“I felt as if my life had ended; I just had to do things for other people; I couldn’t do enough for them.”

It is normal to feel low/disorientated when adjusting to a new culture. People who accept this is normal, and seek support, soon start to feel normal.

What is our theology of suffering and poverty?

When surrounded by dying and suffereing, how do you respond to “How can there be a God, if all this is happening?!”

When working in a relief programme and witnessing a lot of death, poverty and suffering, I found my spiritual beliefs gave me a lot of comfort, and helped me “lay it all to rest” in my head.

“Are you tired? Worn out? Burned out on religion? Come to me. Get away with me and you’ll recover your life. I’ll show you how to take a real rest. Walk with me and work with me—watch how I do it. Learn the unforced rhythms of grace. I won’t lay anything heavy or ill-fitting on you. Keep company with me and you’ll learn to live freely and lightly.”
Matthew 11:28-30

Helping yourself: Prevention

  • Take a day off every week.
  • The Sabbath principle
  • Don’t overwork – do a Bible study on when Jesus said “no”, or didn’t meet needs”
  • Do things you enjoy
  • Have an attitude of gratitude

Helping yourself: Responding when you feel low

  • Allow yourself to cry or scream if you want to.
  • Write about your feelings in a journal, letter, email, blog…
  • Ask people to pray for you.
  • Do things you enjoy: have a bath, go for a walk.
  • Set SMART goals: specific, measurable, achievable, relevant, time-bound.
  • Use CBT websites, such as Living Life To The Full

Savour the culture!

Mary has learnt far more from the people culturally in her area than she’s ever taught them. Coming home can be difficult because we have changed. She is no longer English – she is Shonglish: Shona and English. You come back, and you bring both cultures with you. One story she told us was very revealing:

“When I first went to Rhodesia, I still liked men to allow me to walk through doors first. There was one paramedic who seemed very rude – sometimes he would push me out of the way! One day, I confronted him, ‘Why are you so rude?’.

He explained, ‘In this land, I am the man, I must be first through the door. If I am first through the door, it is me who will be shot, it is me who will be blown up by the landmine.’

This rather turned my theology of manners upside down!”

Sabbath living

It is good to try to live out a Sabbath principle, even if we can’t necessarily have a set day each week.

God has called us to be a living sacrifice, so there will be times where we do have to work very hard, at the same time there are periods where he takes us behind still waters, times to get up on the mountain out of the crowds.

God has also called us to be members of a body – teamwork is an integral part of sharing a workload, jointly serving.

Managing teams across cultures

Joyce Banda Malawi PresidentStanding barefoot in the sun for 20 minutes made me feel ready to sleep in the sun, but before that, we had Jane Bates heading up our final session for the weekend.

Cultural intelligence is a valuable skill, since our personal cultural situation so affecst the way we think, live and relate to one another. Jane shared some of the insight she has to this as a half Indian woman, raised in the UK by an English mother, and currently working in Malawi.

A simple model of different culture: our Prime Minister is the leader of our country, in Malawi, the President Joyce Banda is called the Mother of the Nation.

  • How do people greet each other?
  • How do people behave when they disagree with each other?
  • How do people behave when they disagree with you?
  • Do people publicly question/teach one another?
“A fish only discovers its need for water when it is no longer in it.”

We all have our own culture, but we may not recognise it until we are out of it.

Going beneath the surface

There are different layers of culture: “tip of the iceberg” culture is anything you can perceive with your five senses. Such as clothing, temperature, geography, smells. But its the deeper things that will affect your relationships more:

  • opinions, viewpoints & attitudes
  • philosophies & values
  • convictions
  • rules about relationships
  • attitudes to time
  • how the individual fits into society
  • role of the family
  • different role expectations
  • fear of losing face
  • attitudes to money & corruption

Case studies

What is your response, and what cultural issues may you need to consider?

You are part of a team of a team about to set out for a community visit and are waiting for team members to arrive. The last member of the team is over an hour late and gives no excuse on arrival.

  • “Initially I found this very frustrating, but as time passed, I settled into their culture and became more late myself. Important meetings, I would tell them an hour earlier than I actually wanted them there.”

As team leader your office manager is one week overdue in submitting a report for donor funds. The donors are hassling you for the report.

  • “Frustration”
  • Cultural clash from donor expectation

The hospital you work at has run out of oral liquid morphine. Last week your staff went to the pharmacy to get distilled water, and you contacted the pharmacy warning them of this impending shortage.

  • Frustration, understanding of problems with electricity.
  • Increase your stocks – create buffers.
  • Perhaps the pharmacist is not aware of pain being caused.

Overseas donors question why you have failed to extend the contacts of one of your staff members who they found ‘warm and personable’ on their recent visit.

  • Everyone can have several different faces.
  • Discussing problems, differences in living and working with people rather than seeing them on a visit.
  • Important to have knowledge local labour laws and local contracts.

A visiting foreign doctor in the department of which you are head has one month left on his contract. He disappears and emails a week later saying that he has “decided to get some experience in accident and emergency before he leaves”.

  • Considering his own advancement over his responsibilities. 
  • Need to look at the contract.
  • “?He is avoiding anyone losing face: if he came to me to ask for more experience, and I couldn’t provide it, then I’d be losing face”.

Your team refuse to go into the field unless you provide money a cold drink and a daily allowance.

  • Assess the normal amounts and behaviour.
  • Definitely provide a drink.
  • Bargain 

Patient on the ward is the wife of one of your staff team. She has tested positive for HIV but only you are aware of this result.

You get back from two weeks leave to find that only two home visits have been done instead of the usual 8-10.

You are planning to do an HIV awareness campaign in a local community. Your staff workers return from their day’s visit saying they failed to do the activity as religious leaders “refused permission”.

Your staff team are regularly seeing and treating relatives of staff with general health issues regularly during time for your palliative care clinic.

Within your team, rumours have reached you (from a senior team member) that another staff member is having a sexual relationship with one of her immediate juniors. The junior staff member is about to come up for his appraisal.

Keys for managing a team:

Lead by example

Teach forward planning


Transparent process of recruitment and selection

Train those starting work

Fixing salaraies and offering incentives

Seek opportunities for professional development

Team building get togethers

Day Two: Medicine

The following is part of a series of posts about the Developing Health Course 2012 run by CMF.

I left a little earlier today so that I could skip the traffic. This was successful to some extent, saving me about 15 minutes. Unfortunately, failing to get a swipecard yesterday meant I spent around 15 minutes waiting outside until someone let me in. Eventually though, I managed to get a cup of coffee before the first session began…

Mental Health

Photo of Mental Health patient wearing chains.Maureen Wilkinson (who spoke yesterday) started us with another picture:  “I’d like you to come with me to the edge of the Sahara. You are visiting an old lady, in a cut, nearing the point of death. On the vast horizon, a dust cloud appears, and it become clear that its a group of Arabs on horses. The riders are wearing bright blue robes. The constrast in vitality between their life and the dying lady is vast. Africa is a land of many contrasts. 

A few hundred miles away, there is a hospital. A shiny clean new building, with new wards. It is a pleasant place to be. However, a few hundred metres away there is a shack with blacked out windows. Patients are chained to the wall and fed once a day. This is the Mental Health Unit. Africa is a land of contrasts, and few none are as stark as those between the physically and mentally ill“.

Is there any other group in history that have been so set apart, forced to live in exclusion, ostracised? Lepers. And how did Jesus deal with lepers? He touched them. We need to touch those with mental health disorders. Looking at which disorders cause lost years of life due to disability, psychiatric illness leads the pack more than threefold over the next area. It causes 15% of the global burden of disease, but gets less than 1% of health spending worldwide.

On first visiting Mission Hospitals in the 70s, Maureen would ask “How do you treat those with mental illness”. They often replied “We don’t”.

Worldwide challenges include: disruption to community, absence of social welfare net, adverse social dynamics; gender inequality, women & children vulnerability. Traditional practices can cause a problem: some hospitals have established referral pathways from traditional healers – you can’t stop people using them, but if they don’t have success, encourage them to send people to the hospital. This was tried in Malawi, which led to children with burns due to epileptic fits coming into hospitals for the first time, and numbers of burns falling… African Man Drinking Maize Beer

Drugs and alcohol are a major problem in the developing world, especially Africa. Causes chronic ill health, risk taking behaviour, spousal abuse, RTAs. Community solutions and local awareness and leadership engagement can impact this.

One great story is where a group in Uganda got together with the hospital, local leaders, government and churches, and held a large community meeting. Different people stood up, asking people to stop using cannabis, influential leaders and community members each trying to engage with the youth. Finally, the local government minister stood up and said “You must all stop using it, I believe very strongly in this!”. However, someone at the back of the crowd shouted “You! You grow this evil weed, and I know where your field is!”

Catatonic schizophrenia is much more common in developing countries, and is rarely treated in the way it needs to be – thought to be evil spirits or “madness”. Commonly seen with waxy flexability and auto-obedience. Older drugs calm down patients, but it is the newer drugs which are really effective at treating the disease. Depot preparations are often more easily usable in a developing world context. Chlorpromazine, Haloperidol and Fluphenazine are common and cheap options.

There are high levels of post-natal depression, especially if a girl is born, since cultural expectations are often for male babies. Mother-in-laws are a worldwide problem!

Depression often present with somatization. There is poor cultural awareness of mental health disorders – some languages do not even have words for depression.  It can present with total body pain, crawling over body, or other non-specific symptoms. In some countries, sadness is thought to be caused in the heart, and so presents with palpitations and abdominal pain. Once you get behind the story, you can often find common biological and cognitive symptoms of depression, that the patient might not have been aware of. Amitriptyline and Fluoxetine are good drugs to use: advise asking pharmacy if they can stock SSRIs, since they are cheap now, and safer in overdose. Remember to ask for risk of self harm/suicide, and be aware of increased risk at start of treatment as energy levels rise, but mood stays low.

Always think in consultations:

  1. Is this person physically ill?
  2. Are they under influence of drugs or alcohol?
  3. Then… could they have mental illness?

 General Medicine

PyjamasOur second morning session was a joint effort from Malcolm Molyneux & John Day. We were given case studies to read and then discuss points about medicine in resource-limited settings.

The fundamentals of clinical practice and disease are the same everywhere. Pneumonia, Hypertension, Diabetes, Gastroenteritis and many other conditions remain common. Whilst there are changes – less IHD, more HIV/AIDS, increased endemic infection, etc – the underlying science of treatment and diagnosis remains static.

Expectations of patients remain unpredictable. The man who’s life we saved, but then complained that we had lost his pajama bottoms is an example of this.

It’s important to find locally who can advise and teach you, and also nationally: maybe try to make it to a grand round one a month? Try to run a regular weekly teaching session, or join an online group. We did a straw poll amongst us: In a group of 35 doctors with an interest in developing world medicine, only two won’t have access to internet. It’s becoming a highly accessible tool worldwide. Key observations:

  1. Fundamentals of good clinical practice are the same everywhere.
  2. But there are important differences in practice.
  3. Acquire local recommendations / guidelines.
  4. Learn who can help.
  5. Devise ways to confer regularly with staff and colleagues.
  6. Maximise and appreciate what you CAN do, rather than bemoan what you can’t.
  7. Promote other cadres to do things well.
  8. Note first impressions of what’s good/bad.
  9. Re-visit your recorded first-impressions a few months later.
  10. Write: record events, ideas, progress: for publication, for your own records.

Case studies:

36 year old male in rural India. Severe breathlessness since this morning, no cough/haemoptysis. Has had increasing abdominal swelling over past 3 weeks. No vomiting. EXAM: very dyspnoeic. Chest and heart normal, Abdo: ascites ++, ?hepatic mass. No peripheral oedema.

  • TB Pericarditis – Common cause of ascites and hepatomegaly after R heart failure. Feel for pulsus paradoxis. Could be an acute presentation, even though usually chronic.
  • ?Hep B malignancy – Most cases of Hep B are caused due to transmission in infancy. Commonly leads to hepatocellular carcinoma.

40 year old mother of 6. Vomitedx3 this morning, and had one loose stool. Then began coughing and seemed breathless. 2 hours ago had a seizure, and has been restless but not responsive since then. EXAM: GCS 8/15. Making restless, purposeless movement of all limbs. BP 110/70, pulse regular 60/min, T 36C. Breathing noisily – ?secretions ++. Chest: widespread crackles.

  • Ingested toxin: organophosphates. Small pupils, floppy patient. Fasciculations. Treat with atropine.
  • ?Ingested toxin: chloroquine.
  • ?Hypo/hyperglycaemia.

49 year old policeman been more drowsy over last 24 hours. Now talking, but not sensibly, and can’t walk since this morning. He has complained frequently of headache during the past 2 weeks. EXAM: GCS 7/15. BP 140/100, pulse 56. T 53.3C. R pupil larger than left. R pupil does not constrict to light shone into either pupil. L pupil constricts to light shone into either pupil. Makes some movements of all limbs – seems to move right limbs more than left.

  • Cerebral TB.
  • ?HIV Cryptococcal/Toxoplasmosis.
  • ?Sub-dural haematoma.

General Medicine Part 2

I used the lunch break to run home and pick up my wife, who was being driven slightly mentally unwell by her entrapment in a home with a child and 3 dogs. After gulping down some creamed spinach, we started again, with a brief talk from myself about Social Media and the #cmfdevhealth hashtag, before moving on to Part 2 with Malcolm & John again.

More case studies:

66 year old former athlete complains of a couple of months of tiredness and weakness, poor appetite and some nausea. A dry cough and slight breathlessness, taking laxatives for constipation and variable left-sided chest pain. EXAM: Alert, Mucosae very pale. Mild oedema of ankles, and face looks puffy. BP 170/115, P52, R24, T34.6C

  • Renal Stones – stream positional? Common in developing countries, ideally needs ultrasound.
  • ?Shistosomiasis.

Homemade Spacer18 year old with episodes of wheezy breathlessness since aged 11. Well between episodes. This year, episodes lasting a few days have recurred 1-3x per month. Has been attending the clinic and is on Ventolin by inhaler. Despite this, has got much worse this week and now can’t go to work. EXAM: R32/min with audible wheeze, BP 105/70, P110 reg, T36. Chest: widespread wheezes only.

  • Asthma. Hugely common in third world. Poor inhaler useage. Could be living in a smoky home, workplace. Poor washing of mites. Pets, etc. Try homemade spacer with plastic bottle. Try an extra steroid inhaler. If not available, use steroid inhalers. Oral ventolin
  • ?Cardiac asthma, retained fluid during period with congenital heart defect.
  • ?Current episode worsened by TB.

A 42 year old woman with polyuria. She has been feeling icnreasingly thirsty recently, and drinks a lot. Thinks she has lost weight. EXAM: Alert. ??slightly dry. BMI 36. BP 150/95, P72, R18, T36.1. Normal physical examination.

  • Diabetes Mellitus – check a BM. Try metformin. Treat BP.
  • ?Diabetes Insipidis – any history of post partum haemorrhage, which could have infarcted the posterior pituitary?

A 19 year old woman from Yorkshire is working in Uganda and has been having joint pains. Feeling feverish for 3 days, with nausea and loss of appetite. Symmetrical pain and stiffness in wrists, arms and hands. Today has noted general itchiness, especially of palms o hands. EXAM: T38C, BP 110/68, R14, P84. No visible skin lesions. Can’t make a fist easily – slight swelling of joints in both hands. Exam otherwise NAD.

  • Hepatitis B.
  • ?Shistosomiasis. Katayama fever – takes 3-6 weeks after exposure. Check raised eosinophilia.
  • ?Reactive arthropathy to a streptococcal infection.

26 year old fisherman sent to you with progressive weakness in both legs – last 2 weeks. Also numbness in feet. UNable to pass urine, catheter inserted as bladder distended. EXAM: T36, P72, BP140/90, R23. Unable to walk, no movement in legs, with reflexes+++, Clonus++ in legs. Arms normal.

  • Endarteritis Obliterans caused by syphilis. Ridiculous.
  • ?Infarction secondary to sickle cell, vasculitis (HIV).
  • ?Shistosomiasis.
  • ?Testicular tumour metastasing.
  • ?Cord compression.
  • ?Pott disease – TB discitis – Hunchback of Notre Dame had this.


Supporative keratitisDavid Yorston gave us our final talk of the day. As ever, I was nearly asleep by this point, despite many excellent cups of tea, but bleary eyed (get it?) I turned my attention to the exciting developing world of optic disease. 

There are two main causes of visual impairment worldwide: Cataracts and Refractive error. This is good, since both of these are resolvable with surgery and glasses, respectively. There are many causes of blindness, some of which are harder to resolve, but Trachoma, Onchocerciasis and Childhood blindness are key areas of attack by the WHO’s Vision 2020 campaign. In great part thanks to Vision 2020, the worldwide picture (get it?) for eye health is improving.

In an Ophthalmology history, you will see (get it?) a few key problems:

  • My eye hurts – Acute Red Eye, Trauma
  • I can’t see – Gradual loss of vision, Sudden loss of vision.
  • I can’t read – Presbyopia.

Acute Red Eye:

David talked about some key red eye conditions. One that stayed with me was Supporative Keratitis, which has a very scary pus line in the anterior chamber (see picture on right), and is the treated by intensive hourly topical antibiotics – no point in giving systemic, has to be given onto the eye.

Acute iritis is almost always idiopathic. Meaning the doctor is an idiot, and the explanation is pathetic.

Trachoma is an eye infection from Chlamydia trachomatis. It used to be a minor cause of blindness in the UK, but was eradicated when we started to wash our faces. You treat it with oral azythromycin. In many developing countries, trials of prophylactic ABx to children are used if prevalence is above 10%. The key is to encourage people to maintain basic facial hygeine.

Ophthalmology neonatorum is the eye infection caused by a mother having gonnococcus, causing pus in the eyes in newborn children. Needs urgent topical antiobitics, otherwise it can cause blindness.

Corneal ulcer – stain all red eyes with fluoroscene – commonly caused by trauma, but the scary causes are generally infection, which will need treatment with antibiotics.

Cannot See:

Blindness is a major cause of morbidity, impacting wealth, health and social circumstances. There is real evidence that Cataract surgery cures poverty. Below are some key preventable/treatable problems.

  • Refractive error – Corrected by pinhole.
  • Cataract – Helped by pinhole, cloudy pupil, reduced red reflex.
  • Glaucoma – Not helped by pinhole, sluggish pupil.
  • Corneal scar – Visible corneal opacity.
  • Diabetes – Diabetic retinal changes, neovascularisation, flame haemorrhages.

A Final Thought:

“He will do even greater things than these, because I am going to the Father.”
John 14:12

This verse has always been a big inspiration to David. Jesus healed many blind people in the gospels, but there are only a handful of documented cases. Through CBM, they are doing nearly half a million cataract operations a year: following in His steps we really are starting to do greater things…

All the livelong night

This weekend, I worked the Freudianly named “graveyard shift” at Chesterfield hospital. Three nights, 9pm until 9am, Friday, Saturday, Sunday.

Whilst a great time to get some real hands-on experience, there is a key problem in working nights. It goes thus:

  1. Most of us are not naturally nocturnal.
  2. Most of us have jobs in the day time.
  3. Night shifts usually only have a day’s grace between day shift and night shift.
  4. It takes more than one day to completely upend your circadian rhythm.
  5. Therefore, you always feel completely, exhaustedly, hungover-jetlagged-coma-after-a-trainwreck tired.

There are two methods for attempting this changover. One is to try and stay up as late as possible the night before, sleep all day, and go to work (hopefully) refreshed. I tried this. The result was that I was so tired on the first shift that I started having visual hallucinations about 4am, attempted to wear a commode around 5, and woke up the next morning completely naked in the middle of the M45.

The other method is to sleep normally the night before, stay up all day, and have a two hour nap before the start of the shift. My SHO used this method. The result was that he became so tired that he began to have paranoid delusional beliefs around 3am, attempted to order the demolition of the hospital library about 6, and woke up the next morning on a ferry to Bergen, with a new tattoo. Of the Queen. On his face.

Obviously there’s a bit of exaggeration there, and neither of us actually developed first rank symptoms of schizophrenia, but we were very tired. Aside from this, the weekend was actually fairly enjoyable. There’s a bit less red tape and paperwork on the night shift, and less distractions.

One highlight was a tired A&E clerking on Friday night from another doctor, who had written “Patient is a resident in a residential home” twice in three paragraphs. Some would say that this is not particularly useful information, even when written twice. The doctor had failed to mention that the woman was profoundly deaf, and severely demented. Which would you rather know?

My most memorable event of the weekend came at about 5:30am Monday morning. I was hungry, so I went to the vending machine to get a packet of crisps.

5:30 I put in my 45p, and selected some Prawn Cocktail Walkers. They fell out of the holder, and got stuck halfway down the machine.

5:31 I got annoyed, and tried to shake the machine. A lot. It didn’t work, the crisps remained stuck.

5:32 Rammed the machine again, and another packet of crisps fell out, Cheese and Onion this time. It also got lodged. Right next to my other packet. Nudged it again, to no avail.

5:34 Tried ringing the vending machine company, asking for a refund of my 45p. Oddly enough, no one there when its barely dawn.

5:36 Decided I *needed* crisps, so used my might again. This time a Capri-Sun fell out.

5:39 Having drained the last drop of the Capri-Sun in a contemplative manner, I hit upon an rational plan of action – purchasing the chocolate bar directly above the crisps will cause it to fall, thereby dislodging my crisps!

5:40 The Kit Kat chunky holder turned, and then the chocolate bar twisted out, began to fall and then… got stuck in the mechanism.

5:42 I finished screaming, and decided to whack the machine again.

5:43 Still whacking.

5:44 Another Capri-Sun fell out, but still neither crisp packet nor chocolate bar is released from the vending machine’s iron grip…

5:45 After a final heave, the Kit Kat fell, dislodging both packets, and I left the machine clutching half a newsagent’s in triumph. (Feeling a little guilty at my windfall, I later went to the reception desk in the hospital, who congratulated me on my honesty, but told me to keep the food!)

There ends my summation. At 9:15am Monday I left the hospital after 36 hours of attendance, with mild tooth decay and a mite more experience as recompense. Plus I think I’ll get paid at some point too, but right now I’m more excited about the Capri-Sun.

NB. I am thoroughly committed to being a great doctor, which includes respecting patient confidentiality. All information about patients on my website is anonymised, and often altered drastically so that whilst it still makes a good anecdote, it is unrelated in sex, time, location, age and/or ailment from the original facts.

MedRevise 4.0 is here!

After a month of live beta testing, the time has come to officially launch the new version of to the world at large. To find out the full story, read on…

Nearly five years ago, I arrived at medical school. And I realised I needed to make some notes. But I also wanted to use my computer, and so keeping them in order was important.

And then I realised I could use a wiki. For those of you who don’t know, a wiki is “A collaborative website which can be directly edited using only a web browser, often by anyone with access to it“. So I bought a domain,, which I started to use for my revision.

As time went on, there were more and more notes online, and soon I met my friend Raj, who found that note making on MedRevise was his ideal revision technique too. Over the years the site has grown, and gets quite a lot of visitors: according to our hosting stats, last month (May) we had more than 13,000 visitors, and 112,000 page views. Needless to say, that makes me feel pretty happy!

MedRevise ScreenshotAnyway, this weekend, MedRevise Version 4.0 is launched, notable changes including:

  • Appearance: A new colourful theme. My first foray into Mediawiki theming, which was a pain in the bum, but worth it in the end.
  • About: A sexy new “About” page, and a few tweaks to the front page.
  • Twitter: A link to our twitter feed.
  • Adverts: For the first time, adverts – hopefully to pay some of the costs of the hosting, time maintaining it, etc.
  • See it now, in the screenshot on the right!

So yes, some exciting changes. Find out more for yourself at

Many many plans

So, I have finished my exams. And that leaves me a few short weeks to tackle a variety of projects. Taking inspiration from Lifehacker, I am making a list on here of stuff I am aiming to achieve.

  1. Get healthy: The next 7 weeks, my first hour of each day is exercise. Keep me accountable on this one please!
  2. A new YesIts.Us website: The Lowry Family homepage, in full technicolor. Need to update this, and create a blog for my darling wife.
  3. Install Windows 7 on my PC: I only bought it 5 months ago, and already I feel I should probably install it!
  4. Make A wedding site for my housemate.
  5. Do some more work on Cutting Edge: my large corporate project has been put on hold, but that’s no excuse not to do anything on it.
  6. Finish Let’s get the Crookes homepage up and running for everyone!
  7. A new Everyone’s favourite charity, soon getting a new website. Design by committee – the best way!
  8. Get my server set up: It’s working fine, but its time to get that software running properly, with regular backups, and every PC in the house being served!
  9. Redesign This site is no longer an active portal, so let’s make it a little more fresh and helpful!
  10. Start a peer reviewed journal: Coming soon – The Online Journal of Medicine (also known as OnJoM).
  11. Get tagging: Put post tags on every post on my blog.
  12. Sleep.
  13. Walk the dogs.

Anyone else think this risks burnout? I will take regular breaks, don’t worry! And now I will leave you with what must be the world’s best CV – click the picture below to find out more…