Tuesday, May 1, 2018
World Class Hospital Medicine: Pride, Hope & Faith!
Pride:US Hong Kong
Why?
We provided World Class Medicine without trying. We did!
A quote from a fellow blogger, Dr. No.
What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.
Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. Others are now unable to diagnose the most basic of emergencies such as appendicitis and what hope is there that they will diagnose meningitis?
Can we continue to practise World Class Medicine even if we wanted to?
Here is a reprint:
Tuesday, May 24, 2011
It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.
Patients or their relatives are used to trust the judgment of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.
David Cameron is no different and he has stated so on record.
I am not here to analyse his faith.
I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978
The Mayo of the United Kingdom
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.
Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom
Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.
The unusual cases:
As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.
Pride:
Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US Hong Kong
Why?
We provided World Class Medicine without trying. We did!
A quote from a fellow blogger, Dr. No.
What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.
Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. Others are now unable to diagnose the most basic of emergencies such as appendicitis and what hope is there that they will diagnose meningitis?
Can we continue to practise World Class Medicine even if we wanted to?
Here is a reprint:
Tuesday, May 24, 2011
It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.
Patients or their relatives are used to trust the judgment of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.
David Cameron is no different and he has stated so on record.
I am not here to analyse his faith.
I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978
The Mayo of the
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.
Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom
Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.
We used to practice real, good and economical medicine.
The unusual cases:
Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.
As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.
Supermarket:
Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.
But supermarkets can get things wrong too. In Spain after the Christmas of 2009 there were 4 million unsold hams.
©Am Ang Zhang 2010
Back to the patient:
Would my patient be dealt with in the same way in 2011?
GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
Paediatrician to me: ? Psychosis or even Catatonia.
Seen same day and admitted to Paediatric Ward, DGH.
Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
Radiologist (Hospital & no India
Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
Patient unconscious and transferred to GOS on same day. Seen by various Professors.
Patient later transferred to Queen’s Square (National Hospital
Seen by more Professors.
Regained consciousness after 23 days.
Eventually transferred back to local Hospital.
None of the Doctor to Doctor decisions need to be referred to managers.
We did not have Admission Avoidance then.
How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.
The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.
Not to mention the operation etc. and the transfer to the Centres of excellence.
“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."
The final answer to her PRAYERS:
But perhaps God works through his people in his own way. Discoveries in Medicine should therefore enhance our faith rather than the other way round.
It took nearly 30 years for the real answer to her prayers to really emerge.
©2012 Am Ang Zhang
The Bright Young Doctor now:
I was staying at our resort in Boquete and was having dinner with three friends all of them with medical connections. One was in hospital administration and one a nurse. The husband of the nurse was a pharmacist. Somehow the conversation drifted into medical topics and knowing that I am a Child Psychiatrist the pharmacist started talking about his nephew who was nearly sent to a mental institution as he suffers from catatonia and doctors eventually diagnosed schizophrenia and put him on antipsychotics. Luckily the catatonic symptom probably saved him as some bright young thing just read the book Brain On Fire and gave him the Clock Test. That led to the NMDAR antibody testing that proved positive. He responded well to the treatment regime that has been developed and is off all antipsychotic medication.
My Teratoma patient was lucky as she belong to that group that improved without further treatment once the Teratoma was removed. She eventually had a baby.
The Power of Prayers & Teratoma: Brain & NMDA!
.jpg)
Anti-NMDA Receptor Encephalitis
NEW ORLEANS — A mysterious, difficult-to-diagnose, and potentially deadly disease that was only recently discovered can be controlled most effectively if treatment is started within the first month that symptoms occur, according to a new report by researchers from the Perelman School of Medicine at the University of Pennsylvania. The researchers analyzed 565 cases of this recently discovered paraneoplastic condition, called Anti-NMDA Receptor Encephalitis, and determined that if initial treatments fail, second-line therapy significantly improves outcomes compared with repeating treatments or no additional treatments (76 percent versus 55 percent). The research is being presented at the American Academy of Neurology's 64th Annual Meeting in New Orleans
565 cases! Not so rare!
The condition occurs most frequently in women (81 percent of cases), and predominately in younger people (36 percent of cases occurring in people under 18 years of age, the average age is 19). Symptoms range from psychiatric symptoms, memory issues, speech disorders, seizures, involuntary movements, to decreased levels of consciousness and breathing. Within the first month, movement disorders were more frequent in children, while memory problems and decreased breathing predominated in adults.
My patient was under 18 and presented with catatonia symptoms. She later lose consciousness and was ventilated.
"Our study establishes the first treatment guidelines for NMDA-receptor encephalitis, based on data from a large group of patients, experience using different types of treatment, and extensive long-term follow-up," said lead author Maarten Titulaer , MD , PhD, clinical research fellow in Neuro-oncology and Immunology in the Perelman School of Medicine at the University of Pennsylvania
The disease was first characterized by Penn's Josep Dalmau, MD, PhD, adjunct professor of Neurology, and David R. Lynch, MD, PhD, associate professor of Neurology and Pediatrics, in Annals of Neurology in 2007. One year later, the same investigators in collaboration with Rita Balice-Gordon, PhD, professor of Neuroscience, characterized the main syndrome and provided preliminary evidence that the antibodies have a pathogenic effect on the NR1 subunit of the NMDA receptor in the Lancet Neurology in December 2008. The disease can be diagnosed using a test developed at the University of Pennsylvania
Teratoma: finally!
In earlier reports, 59 percent of patients had tumors, most commonly ovarian teratoma, but in the latest update, 54 percent of women over 12 years had tumors, and only six percent of girls under 12 years old had ovarian teratomas. In addition, relapses were noted in 13 percent of patients, 78 percent of the relapses occurred in patients without teratomas.
As Anti-NMDA Receptor Encephalitis, the most common and best characterized antibody-mediated encephalitis, becomes better understood, quicker diagnosis and early treatment can improve outcomes for this severe disease.
The study was presented in a plenary session on Wednesday, April 25, 2012 ET at 9:35 AM at the American Academy of Neurology's annual meeting.
[PL01.001] Clinical Features, Treatment, and Outcome of 500 Patients with Anti-NMDA Receptor Encephalitis
Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies
Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.
Related paper:
>>>>>>The full Chapter: Chapter 29 The Power of Prayers
David Cameron, if it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.
Just like Mayo Clinic:
“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”
But it is probably too late:
Just like Mayo Clinic:
“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”
But it is probably too late:
Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.
King’s Fund: Million £ GP.
Sir Roger Boyle: 'It is horrific that the NHS's future is threatened'
NHS : Andrew Lansley, his Doctors and MPs.
NHS : Andrew Lansley, his Doctors and MPs.
See also:
Comments:
- Dr No said...
- Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
Sunday, April 29, 2018
Flat Earth & Miracles: Professor! Professor! 3 month? !
It is not my intention, either as an individual or as a scientist, to express an opinion on religious visions and miracles. Science has generally failed to understand these phenomena and many religions on the whole have tended to ignore scientific explanations.
For the religious amongst us, a close study of the history of religion would have seen deliberate attempts a couple of millennia ago to trick people into believing certain things supernatural. In a recent visit to Ephesus
When the Western World was in the tight grip of the Catholic Church, the Jesuits were generally regarded as the greatest scholars. They brought Western culture and religion to the East. They must have had a glimpse of the Chinese understanding of the universe and the world. Yet for so long the religious view of Flat Earth held true. Did the Jesuit scholars know the truth or did they pretend not to in order to avoid persecution and possible death? We shall never know.
Many “visions” have proved to be the work of errant brain waves due either to epilepsy or brain tumours. Yet the Church continued to celebrate these phenomena.
© 2012 Am Ang Zhang
From my book The Cockroach Catcher, Chapter 15: Miracles:
First Miracle
When Professor MacFadzean first arrived in Hong Kong many years ago, he was consulted on a middle-aged Chinese man, a fisherman who had a huge lymph node under his left arm pit. Investigations showed that it was a secondary from a primary in the lung.
The man asked him, “How long?”
“Three months. Maximum six.”
Two year later as the Professor was crossing the harbour on Star Ferry, a man came up to him. It was not difficult to spot him anywhere in Hong Kong as he was at least a head taller than most, with a bright red face that Scots seem to acquire in Hong Kong .
“Professor. Professor. Remember me?”
The man pointed to his armpit.
No mass.
“Three months. Remember?”
It turned out the man sought the advice of his fortune teller in Shatin on the third day of Chinese New Year, and he had a good “fortune” telling him about an illness disappearing.
“Now it has disappeared!”
What a miracle! Fortune telling has been a major growth industry in Hong Kong . Recently, the richest Chinese business woman left all to her fortune teller.
“Never be definite about prognosis, especially if it is a bad one. Spontaneous cures have been recorded regularly, especially with lung cancer.”
To the patient, it was old ways triumphing over modern medicine. It was his “miracle”.
To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:
First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.
Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?
Flat Earth & Miracles: Duping & Human Kindness!
Saturday, April 28, 2018
Flat Earth & Miracles: He will never learn to speak!
It is reassuring that there are still people that were kind enough to risk everything in order to help others in desperate need. It became more upsetting when you realised that the kind-hearted person has been duped. But then even government has been duped into paying millions of our money to so called charitable organizations we can hardly blame any individual except of course the individual is not losing other people’s money but their own.
Photoshop Miracle:
Black Currant Miracles © 2012 Am Ang Zhang
It is not my intention, either as an individual or as a scientist, to express an opinion on religious visions and miracles. Science has generally failed to understand these phenomena and many religions on the whole have tended to ignore scientific explanations.
For the religious amongst us, a close study of the history of religion would have seen deliberate attempts a couple of millennia ago to trick people into believing certain things supernatural. In a recent visit to Ephesus
When the Western World was in the tight grip of the Catholic Church, the Jesuits were generally regarded as the greatest scholars. They brought Western culture and religion to the East. They must have had a glimpse of the Chinese understanding of the universe and the world. Yet for so long the religious view of Flat Earth held true. Did the Jesuit scholars know the truth or did they pretend not to in order to avoid persecution and possible death? We shall never know.
Many “visions” have proved to be the work of errant brain waves due either to epilepsy or brain tumours. Yet the Church continued to celebrate these phenomena.
The first picture is the original: the rest miracles!
From my book The Cockroach Catcher, Chapter 15: Miracles:
Second Miracle
The second “miracle” I am going to recount was again not experienced by myself but occurred none other than where most miracles happened.
And in the 20th Century.
I heard about it at a World Congress on Infant Psychiatry held in Chicago
Generally the big plenary sessions at nine in the morning were reserved for the big presentations. Given that it was an Infant Psychiatry Congress, one was surprised to be having a presentation of a case of an older child.
Yet this was a presentation by one of the most respected professorial units in Jerusalem
The professor was himself on stage. He was already rather old, but when he spoke he did so with authority and a certain air of natural arrogance. It was the kind of arrogance that came as a matter of course to one who had made a discovery of some kind that none of us in the hall, except his team, had heard of. Perhaps pride is a better word to describe it, but no matter. Something big.
His presentation involved the showing of some film clips, one of which was from the BBC archives.
This boy suffered from severe epilepsy from a very early age and was on four different medications. He never acquired speech, ever.
He had a younger brother, bright and very advanced, who was reading well before the age of three, not unusual for Jewish boys you might say, but unusual given his brother could not speak.
His mother sought help for him over the years, and by the time he was twelve, most specialists she consulted told her there was a critical period after which a child would never acquire speech.
She had said her fair share of prayers at the Synagogue.
One day, unbeknownst to her, her genius toddler took an overdose of his brother’s medications. He was found in time and his life was not threatened. For four full days after he came out of intensive care, he stopped talking altogether.
It suddenly occurred to her that it could be the medication that was holding her son back.
She immediately secured a consultation at a top hospital and the consultant said that it was possible to use other methods to control the epilepsy.
But it would be drastic, as it involved removing nearly half of his brain.
“Without medication would he learn to speak?”
Now this was where the BBC film cut to a big picture of the lady consultant who said, “Never. He is beyond the critical age. He will never learn to speak. Never ever.”
The Professor in a very solemn voice said from the podium, “She is not one of ours.”
The boy had the operation. He was now free from epilepsy and free from any medication.
Mother decided to emigrate to Israel
“What a wise move.” The Professor interjected again.
The boy now came under the Professor’s care, and a big team of different therapists started working on him.
And mother’s prayers were at last answered.
The boy now spoke fluent Hebrew and reasonable English. Not one but two languages.
I remembered what one Rabbi said to me at our friend’s son’s Bar Mitzvah, “You know our God will give, but we must work hard.”
And Old Mac: Never say never.
Flat Earth & Miracles: Duping & Human Kindness!
To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:
First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.
Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:
First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.
Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?
Friday, April 27, 2018
Photoshop Fun: Charcoal Rendition!
Close up, Eucalyptus © Am Ang Zhang 2013
The Original: Original photograph taken with Nikon D70 and ED180/2.8 lens: still amazing after all these years.
High End Photography & Wine
Photography: Tasmania & Bokeh!