Category: Blog

Before reading this, take a moment to go and browse through your Facebook. Don’t be looking for what happened last Friday or what your ex is up to now, but instead, visit the profile of friends who have gone overseas for placements or volunteering and look at their photos. Once you’ve done that, come back and allow me to tell you about the day I met Emmanuel.

A few months after the 2010 Haitian earthquake, I found myself volunteering in Léogâne, a city of around 100,000 people. The city was near the epicenter of the earthquake and as many as 30,000 were killed here in the disaster. Due to the earthquake, not only were homes and businesses of many people destroyed but the health facilities in the city were decimated as well. Because of this destruction of local health facilities, residents were forced to seek care at foreign-run temporary replacements such as the field hospital where I volunteered. This is how I met Emmanuel.

Emmanuel was a 28 year old labourer who was brought in by friends while experiencing an asthma exacerbation. He had a long history of asthma, which was often made worse by the dust that he worked amongst. He initially appeared to be experiencing his typical asthma attack that usually resolved with salbutamol. The small oxygen concentrator used to provide him with nebulized salbutamol seemed to be providing some relief. However, after a few minutes of improvement, his condition suddenly deteriorated. Emmanuel began to display the unnerving appearance of someone who has reached the point of complete exhaustion from breathing. The only monitoring equipment available was an old pulse oximeter, but even this told an alarming story. The oxygen saturation dropped from a high of around 95% to 89% and his heart rate plummeted from 110 to 45 beats per minute. Emmanuel was close to death. Adrenaline was administered and repeated in hopes stopping this deterioration. After a few very tense minutes, Emmanuel’s condition improved and it became evident that there would be a happy ending to this story.

But this story is not really about what happened to Emmanuel during the worst of his exacerbation but rather is about what happened immediately after. At this point when things were calming down, one of the foreign volunteer nurses, who had been contributing to his care, took a picture of Emmanuel. He did agree to this but he certainly wasn’t in a position to truly give informed consent for this. In your Facebook friends’ photo albums you will likely find pictures of their Emmanuels.

The desire to capture a lasting image of someone whose care you have helped with overseas is understandable. For some reason, it even seems to be socially acceptable. None of us would ever take a picture of a patient on the wards. How is it that we don’t frown upon pictures of patients taken overseas?

Enjoy your overseas volunteering or placements. Take lots of pictures when touring around the country. When at the hospital though, patients deserve the same respect as they get here in Australia.

It’s not an uncommon scenario: The medical team arrives at the patient’s bedside for the daily round. A phone rings and the registrar excuses herself from the bedside to answer it. Meanwhile, the intern checks the dosage of the medication being prescribed online. One of the medical students is looking up one of the patient’s diagnosis whilst the other replies to a personal text. During the time spent with the patient, most of the team has used their smartphone.

The use of smartphones by medical staff and students in the clinical environment has increased dramatically in recent years. Purported advantages include ease of access to information, use as clinical learning tools and improved communication with other medical staff. [1-3]

Smartphone use amongst medical students is already high, with a recent Australian study showing that the majority of medical students own a smartphone and 72% of these use their phones to access medical apps. [4]  Given this, medical schools in Australia are investigating the role that formalised introduction of mobile phone technology into curricula could play in medical education. [4,5] In the United States, some medical schools already require that students have access to a smartphone or other handheld device during their clinical years. [6,7]

The implications of increased smartphone use in the clinical environment may not be entirely positive. Medical students and staff report potential disadvantages of smartphone use to include spending less time with patients, [8] challenges navigating personal/professional boundaries [2] and potential for distraction from clinical tasks. [2,8] The risk of distraction from clinical tasks is not insubstantial. In a recent study performed in the United States, 57% of junior medical staff self-reported using smartphones during rounds, with 37% admitting to using them to access personal texts or emails. [9] As a consequence of smartphone use, 19% further reported that they had missed important patient information during rounds. [9]

The use of smartphones in clinical settings, whether for personal or professional purposes, may also have implications for doctor-patient communication. One report has suggested that junior medical staff frequently interrupt clinical encounters to answer phone calls and that this behaviour was sometimes perceived as unprofessional by other staff. [10] The impact of the digital device on non-verbal aspects of communication [11] and patients understanding of the doctors’ reasons to use a smartphone [12] are other potential ways that this communication could be negatively affected. There is, however, little research that directly examines patients’ perceptions of smartphone use by clinicians.

Smartphones are undoubtedly useful clinical tools and uptake by clinicians and medical students reflects this. As smartphones become a permanent fixture on the ward round, we need to think about how our use of smartphones affects communication and care of patients.

1.         Kajewski CM. The iPhone: Is it an indispensable tool for medical students? Australian Medical Student Journal 2010;1(1):61-2.

2.         Wallace S, Clark M, White J. ‘It’s on my iPhone’: attitudes to the use of mobile computing devices in medical education, a mixed-methods study. BMJ open 2012;2(4).

3.         Wu RC, Morra D, Quan S, Lai S, Zanjani S, Abrams H, et al. The use of smartphones for clinical communication on internal medicine wards. Journal of Hospital Medicine 2010;5(9):553-9.

4.         Koehler N, Yao K, Vujovic O, McMenamin C. Medical Students’ Use of and Attitudes Towards Medical Applications. Journal of Mobile Technology in Medicine 2012;1(4):16-21.

5.         Luanrattana R, Win KT, Fulcher J, Iverson D. Adoption of mobile technology in a problem-based learning approach to medical education. International Journal of Mobile Learning and Organisation 2010;4(3):294-316.

6.         Stanford School of Medicine: eStudent [cited 2013 April 30]; Available from: http://med.stanford.edu/estudent/.

7.         Georgetown University School of Medicine: Handheld computing requirement [cited 2013 April 30]; Available from: http://som.georgetown.edu/studentservices/informatics/about/HandheldComputing/.

8.         Robinson T, Cronin T, Ibrahim H, Jinks M, Molitor T, Newman J, et al. Smartphone Use and Acceptability Among Clinical Medical Students: A Questionnaire-Based Study. Journal of Medical Systems 2013;37(3):1-7.

9.         Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. Smartphone use during inpatient attending rounds: Prevalence, patterns and potential for distraction. Journal of Hospital Medicine 2012;7(8):595-9.

10.       Wu R, Rossos P, Quan S, Reeves S, Lo V, Wong B, et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study. Journal of medical Internet research 2011;13(3):e59.

11.       Alsos OA, Das A, Svanaes D. Mobile health IT: the effect of user interface and form factor on doctor-patient communication. International journal of medical informatics 2012;81(1):12-28.

12.       Miller KH, Ziegler C, Greenberg R, Patel PD, Carter MB. Why Physicians Should Share PDA/Smartphone Findings With Their Patients: A Brief Report. Journal of Health Communication 2012;17(sup1):54-61.

“What? Margaret Thatcher is dead!” exclaimed the first medical student.

“Um…Who is Margerie Tha-that-sure?” replied the second with a blank expression. I could not help myself overhearing this conversation and my jaw nearly hit the ground.

As medical students, we are constantly being reminded of the expectation that we, as future practitioners, will eventually step into leadership roles within our communities. This often puts doctors in positions to shape government policies. Indeed, it is almost impossible to separate modern medicine from politics. Therefore, adding a political element to our curriculum would provide medical students with an ideal opportunity to prepare for these responsibilities.

Political studies would not only keep us informed regarding current policies, it would enlighten us to the process through which new policies are formed and existing policies are altered, replaced or removed. Individuals involved in this process must often maintain a broad knowledge of multiple disciplines including, but not limited to, cultural studies, religion, sociology, business studies, science, and technology. Therefore, it is important for medical schools to emphasise the importance of non-medical knowledge amongst medical students. This will equip our future clinicians with the insight to effectively fill leadership roles within society, and also provide holistic care to the wide array of patients that live in Australia.

Without such political knowledge, it is difficult to understand how scientific breakthroughs come to be applied to patients. The United Kingdom (UK) needle exchange programme, which provides clean needles for drug users, was introduced by Margaret Thatcher’s government in response to the then emerging knowledge of patterns of HIV transmission. This contrasts with the Australian needle exchange programme, which was born from civil disobedience but also inarguably effective. Despite remaining contentious within our society, this programme paved the way for the current stance of harm minimisation in Australian drug policy. A broad knowledge of social issues and an understanding of the actions of both doctors and politicians are required to appreciate how these politically controversial decisions were made.

Despite this, the lack of political knowledge among many medical students is startlingly obvious as illustrated by the “Thatcher conversation” above. I am currently in the fourth year of my studies, and apart from a few lectures which I have encountered in public health regarding health policies, the curriculum is lacking in political studies. The importance of a broad non-medical knowledge and understanding of policy-making has not been impressed upon students. While dedicated and ambitious students may find time to fill these holes themselves, it may be beneficial for medical curricula to touch on these important issues.

There are several ways in which political studies can be integrated into our curriculum. One way is to introduce a series of lectures complemented with tutorial discussions; another way is to implement a policy to mandate the selection of at least one general education subject related to politics in medicine. Such approaches would help students to appreciate the importance of political knowledge in the medical field. After all, how can medical students become the leaders of tomorrow if we don’t have the knowledge to do so?

I recently heard that one of my friends – a medical resident, had developed pneumonia and had to be admitted to hospital for a week of intravenous antibiotics. She had been working long hours on a stressful rotation and as a result had not been sleeping or eating particularly well. She began to notice a pain in her chest, shortness of breath and hot and cold flushes, but chose to ignore the symptoms. It was only when she had a near collapse that she sought help.

Her story did not surprise me. I myself waited almost ten days before booking an appointment to see a GP for extreme lethargy, progressively worsening moist cough and shortness of breath. When I finally had the appointment, I realized how uncomfortable I felt being the person sitting in the patient’s chair. I did not like waiting 40 minutes in the waiting room for my appointment. I particularly disliked the examination process and having someone else auscultate my chest. The whole experience felt strange and somehow ‘not-quite-right’. I was not used to being in this position. On talking to other medical staff – it was the same. Doctors do not like being patients.

The British Journal of General Practice in 2008 performed a systematic review investigating doctors’ access to health care and the barriers they faced. One of the key barriers to accessing healthcare was: ‘embarrassment’. Davidson and Schattner found that 71% of doctors described themselves as embarrassed when seeing another doctor. While ‘embarrassment’ is a broad term, the studies reviewed described this as:

• general discomfort with the patient role
• concern that the treating doctors might think they were over-reacting to a trivial illness
• concern (embarrassment) that they should not impose upon another doctor’s time, especially if the illness was a trivial one
• discomfort in exposing self to peers personally and emotionally
• feeling like a failure as should be able to cope
• mental health issues

Other barriers listed included lack of time to see a doctor, costs involved, trying to find the ‘right’ doctor to see, confidentiality, fear of loss of control, self-treatment, and inside knowledge into the limitations of the health system. While much needs to be done to overcome many of these barriers, it is reassuring to know that there is now greater awareness about these issues. Health promotion is being taught at the university level to medical students with the emphasis on looking after one’s own physical and mental health and not falling into the thinking patterns listed above – i.e. feeling ‘embarrased’ to seek help. At the hospital level, systems are being established for providing support to stressed and ill doctors. On a national level, programs such as the Beyond Blue Doctor’s mental health program and the General Practice Registrars Australia helpline are now available. It may also be worthwhile establishing a GP database listing GP’s that are willing to care for doctors as patients. With greater awareness of these issues and better support services in place, hopefully doctors can become more comfortable assuming the patient role and taking care of their own health.

 

References:
Kay M, Clavarino A, Doust J. Doctors as patients: a systematic review of doctors’ health access and the barriers they experience. Br J Gen Pract. 2008 July 1; 58(552): 501–508.

In a world where sleep deprivation is the new normal, there are medical students.

Most of us spend a third of our lives in this state of suspended consciousness and yet we still understand very little about what sleep really is. This ambiguity has led many to conclude that sleep may be wasted time. Society values output, efficiency and, by implication, sleeplessness. But what are we really sacrificing before the mighty altar of productivity?

Sleep has been linked to better mental health, cognitive function, and general wellbeing, and its absence has been correlated with a number of pathologies, including depression and hypertension. [1] It follows then that by cutting sleep in our quest for more time, we could end up sicker, sadder and stupider.

There is considerable evidence emerging in the form of both animal and human studies for the role of sleep in consolidating memory and learning, particularly procedural learning. [2,3,4,5,6] It is thought that learning tags neural pathways, which can then be reactivated and consolidated during the following period of sleep. [7]

But what about those times when we simply can’t make a full night of sleep?

In fact, sleep may not need to follow the traditional eight-hour block pattern to exert its benefit. A recent study showed that the natural deterioration in performance during repeated practice of a repetitive technical task was reversed by a thirty-minute daytime nap. [8] In the same study, subjects who napped for an additional thirty minutes actually experienced improved performance compared to their original ability, demonstrating the learning effect of sleep. The researchers went on to show that naps of sixty to ninety minutes can yield performance improvements equivalent to a normal night of sleep. [9]

The idea that a single afternoon nap can refresh the mind and enhance learning is particularly enticing to medical students and doctors, to whom the concept of an eight-hour sleep is often little more than a childhood memory. Such findings suggest that a biphasic sleep pattern (one sleep, one nap) may improve overall brain function, particularly if you need to maintain concentration and memory retention later into the evening. This siesta model is widely practiced in tropical climates to remedy the natural afternoon spike in sleepiness, and the phenomenon of power-napping has already entrenched itself in the vocabulary of the working public.

Of course, there are always those who insist on taking things further, which brings me to the vastly less scientifically validated portion of this article. Polyphasic sleep is a relatively new arrival on the scene, although its adherents cite the supposed sleeping habits of historical figures like Thomas Edison and Leonardo Da Vinci as early pioneers. It operates on the principle that much of our conventional eight hour sleeps are spent fluctuating through transitional states of semi-consciousness and low-grade rest and are thus wasted.

Building on the siesta model, by introducing more and more naps, the core sleep can be progressively whittled away, eventually culminating in the ultimate expression of polyphasic sleep, the aptly titled Uberman Cycle: a twenty-minute nap every four hours, indefinitely. That’s a total of two hours sleep per day!

While there are adherents posting on the internet who claim to have maintained rigid sleep diets like this for months and years at a time (i.e. Steve Pavlina), there is a notable absence of validated evidence for such minimalist sleeping patterns or their effects on wider health and cognition. Given the growing body of research asserting the importance of sleep for learning, performance and general wellbeing, I can’t in good conscience recommend such extreme sleep diets, no matter how appealing the idea of a twenty-two hour waking day might be.

What does all this come down to, aside from a thinly veiled excuse to live a Mediterranean siesta lifestyle? Firstly: sleep matters, and we medics are particularly prone to missing out on it. If you find yourself in a period of your life where adequate sleep is impossible (read “internship”), don’t underestimate the potential benefits of naps. Secondly: it could well be that sleeping is the easiest way to study that science has discovered so far. So next time you see me face down and snoring on my Talley & O’Connor’s, please don’t wake me or shake your head in disappointment–I‘m studying.

What are your sleeping patterns like?

References:

1. Skalski, M. (2010) Sleep Medicine. Overview of Medicine [Przeglad Lekarski], 67(9):721-5.

2. Ellenbogen, J.M., Hu, P.T., Payne, J.D., Titone, D. & Walker, M.P. (2007) Human relational memory requires time and sleep. Proceedings of the National Academy of Sciences, 104(18), 7723-7728.

3. Fischer, S., Hallschmid, M., Elsner, A.L., & Born, J. (2002) Sleep forms memory for finger skills. Proceedings of the National Academy of Sciences, 99(18) 11987-11991.

4. Rasch, B., Born, J. (2013) About Sleep’s Role in Memory. Physiological Review, 93(2), 681-766.

5. Wagner, U., Gais, S., Haider, H., Verleger, R., & Born, J. (2003) Sleep inspires insight. Nature, 427(6972), 352-355.

6. Walker, M.P., Brakefield, T., Morgan, A., Hobson, J.A., Stickgold, R. (2002) Practice with Sleep Makes Perfect: Sleep-Dependent Motor Skill Learning. Neuron. 35(1), 205-211.

7. Walker, M. P., & Stickgold, R. (2006). Sleep, memory, and plasticity. Annu. Rev. Psychol., 57, 139-166.

8. Mednick, S.C., Nakayama, K., Cantero, J.L., Atienza, M., Levin, A.A., Pathak, N., & Stickgold, R. (2002) The restorative effect of naps on perceptual deterioration. Nature Neuroscience, 5, 677-681.

9. Mednick, S., Nakayama, K., & Stickgold, R. (2003) Sleep-dependent learning: a nap is as good as a night. Nature Neuroscience, 6, 697-698.

10. Nishida, M. & Walker, M.P. (2007) Daytime Naps, Motor Memory Consolidation and Regionally Specific Sleep Spindles. PLoS ONE 2(4) 341.