Post 10 Life; a lottery for patients and staff


Late one night, a couple of weeks ago, the Lancashire police received reports that a car was being driven east bound at speed on the west bound carriageway of the M62 trans-Pennine motorway.   Regrettably before they were able to intercept the vehicle, it was involved in a ‘head-on’ collision and two people were killed.   The police later reported that the driver of the car was arrested on suspicion of driving under the influence of alcohol.   The two people who died so tragically were of course, completely innocent – it was simply their misfortune to be in the wrong place at the wrong time.   Had they started their journey five minutes earlier or five minutes later they would still be alive.

Another police report that caught my eye recently stated that the monthly murder rate in London exceeded that of New York in both February and March this year.  The population of the two cities is similar.   The recent increase in the London homicide rate is largely due to knife crime.  I’m not involved in emergency medicine these days but when I was, I realised how much the outcome of any individual assault depended on luck.   If someone was punched and knocked to the ground in a minor altercation outside a pub on a Saturday night, nine times out of ten they would simply get up and dust themselves down.  They would have no ill effects other than a couple of bruises, a torn jacket and wounded pride.   However if, as they fell, they chanced to hit their head on a kerb stone the outcome could be very different, indeed fatal.
The same is true of knife crime. The heart and lungs are protected by the rib cage, so a blow to the chest with a knife may merely glance off a rib resulting in a small cut that needs no more than a couple of skin stitches. Equally the knife may chance to slip between the ribs and penetrate the heart resulting in sudden death, a murder charge and a long period of detention at Her Majesty’s pleasure!  The assailant when striking the blow has no idea what the result will be.   In practice though, he is putting himself entirely in the hands of Lady Luck.


Most doctors and nurses will admit that luck has also played a significant part in their lives.  It certainly has in mine; no more so than when I faced the exam which would determine whether I qualified as a doctor. Having taken the written papers, I had to prove my competence in a clinical assessment at the bedside.  It was a question of chance which of several examiners would interrogate me, which patient I would have to examine and what questions I would be asked.  I received no favours from Lady Luck that day; instead she smiled benignly on a fellow student friend of mine!
My assessment started when I was given a sample of urine to test.  The sample was red and it was no surprise that it tested positive for blood.  So far so good!  I now had 15 minutes to wait before meeting my examiner.  It was obvious that the initial questions would centre on the causes of blood in the urine so I began to classify them in my mind.

There were the general abnormalities of blood clotting, such as haemophilia and anticoagulant therapy.  Then there were local problems of the various parts of the waterworks system; problems in the kidneys such as stones and tumours; abnormalities of the ureters, bladder, prostate and urethra.  I thought of them all. Then I considered how each of these problems would be investigated and treated.
Soon I had the perfect answer organised in my mind.   I was confident.   I would dazzle the examiner, not just with my knowledge but with the structured way in which I presented the facts.
‘Good morning, Sir,’ I said when introduced to the examiner, a dour looking Professor of Surgery from a London teaching hospital.  I looked him straight in the eye determined to impress.
 ‘Have you examined the urine sample that you were given?’ he asked.
‘Yes, Sir, I have.’
‘What did you find?’
‘The presence of blood, Sir.’
‘That’s quite right.  Not too difficult I suppose, given that the urine was red!’ His voice was quiet and held just a hint of sarcasm.
I was ready for him – my prepared answer on the tip of my tongue.
The examiner allowed a small humourless smile to cross his face.
‘Tell me young man, about the causes of blood in the stool?’
In a confident voice, I began to answer.
‘There are many causes of blood in the urine, Sir,’ I said, ‘and we can start by dividing them into general causes and local....’ 
‘No,’ he interrupted, the sarcasm now more pronounced than before.  ‘Didn’t you hear? I said blood in the stool.’
‘In the stool Sir?





‘Yes, Lambert, in the stool.’  The voice was now mocking in tone.

The bored expression had vanished; his smile now a satisfied beam.
The bastard!   I thought, wondering how often he had pulled this particular trick on other unsuspecting students.
Having carefully prepared a list of all the causes of blood in the urine, I was completely thrown to be asked for the causes of blood in the stool.  My confidence evaporated, my mind became a complete void.
I was angry with myself for making an assumption about the question I would be asked and furious with the examiner for the trick he had played on me.  I became hot, I started to sweat and still my brain ceased to junction. ‘Blood in the stool’, he had said, ‘blood in the stool’.  Slowly my mind cleared but it was only after a good deal of prompting that I managed to stutter and stammer some sort of answer to the question.
                                                                               ---------------------------

The experience of one of my fellow student (whom for the purposes of this story we will call Graeme Boswell) was strikingly different.
During his medical school days he had spent some time on an ENT unit and the consultant, Miss Peterson (another pseudonym), at the time the only female surgeon in the hospital, a pleasant quietly spoken grey haired fifty year old, was supervising while the students looked up each other’s noses with a nasal speculum.  
Graeme had no difficulty looking up other students’ noses, but no-one was able to catch even a glimpse inside Graeme’s nose. Miss Peterson came to see what the problem was!
She examined his nose and saw that it was blocked due to an old injury.

‘Can you breathe through that?’ She asked.

‘No’ was the reply. ‘I can only breathe through my mouth and everyone says I snore as well.’
‘You need a submucous resection. It’s not a major operation. Go to my secretary and book a date. Tell her that I’ve said you can pick a date to fit in with your studies.’
Graeme duly had his surgery in the Easter vacation.
                                                                            -----------------------------

Fast forward 12 months to the medical final examination when who should Graeme find as his examiner but Miss Peterson who immediately recognised him. She looked as his nose.

‘Can you breathe through that?’ she asked, not for the first time!

‘No, I’m afraid I can’t!’

She had a quick look at it. ‘Hmm. I’ve not done a very good job there, have I’ she said. ‘Off you go! I don’t think I ought to ask you any questions.’

The next stage of the assessment was for Graeme to be observed whilst examining a patient. He feared the worst when he learned he was to meet the ferocious external examiner who had examined me and was known to have failed numerous candidates the previous year.

‘Examine this neck.’  The instruction was curt, the voice severe.

Graeme looked at the patient’s neck from the front and saw a goitre – a swelling of the thyroid gland. He was just stepping behind the patient to palpate it when the examiner interrupted him


‘You have a cauliflower ear,’ he exclaimed. ‘How did you do that?’

‘Lots of bumps and bruises, Sir. I bit of boxing and a lot of rugby!’

‘And what’s your name young man?’

‘Boswell Sir, Graeme Boswell.’

‘That rings a bell. Didn`t you play for the United Provincial hospitals?’

‘Yes, Sir’

‘Excellent, excellent! It’s good to see you again, Boswell. I’ve no further questions for you. You may go!’

So Graeme, lucky fellow, passed both assessments without being asked a single medical question!!


Comment

With the realisation that using different patients and diverse examiners did not allow a fair assessment of a candidate’s ability, most medical practical exams now take the form of an OSCE - Objective Structured Clinical Examination.
All students face the same questions by rotating round a series of ‘stations’. Stations might include patients with physical signs, interpretation of x-rays or blood tests, or questions on prescribing.  
There are usually two examiners for each station and strict marking criteria, so the assessment is far more objective than it was ‘in my day’.


 Quotation of the day
1)    In examinations, those who do not wish to know, ask questions of those who cannot tell.                                                                                                                                                                        Walter Raleigh 1861-1922

2)    "Luck Be a Lady"  Song written by Frank Loesser in 1950 and first performed by Robert Alda. The song was featured in the musical Guys and Dolls and became the signature tune of Frank Sinatra.

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