Friday, October 30, 2009


One of the facts of life for junior doctors where I work is term assessments.  These go through all the way until adulthood (ie getting your FRACW*), but the prescribed form is different depending on your level.  I've only been in generalist jobs so far so none of this post applies to specialist training jobs.

Part of the process of evalution is trainee self-evaluation.  There is an episode of Scrubs

which highlights the objectives of this.  The NSW assessment form has a range of categories in which trainees can be 

  • clearly below standard
  • borderline
  • at standard
  • clearly above standard

Previously in my assessments I have just ticked myself as being at standard in every category.  As Cox says, I'm not great, I'm just ok.   I've never had anything below "at standard", thankfully, and in most terms my supervisor will pick a couple of categories and put them as "clearly above".  Usually these are the same few topics, and by now I have a clear sense of my strengths and those areas which, while not exactly weaknesses, aren't things areas where I should necessarily be giving tutorials.

This week I was pretty fresh from remembering that patient, so I gave myself a few extra "above standards" for things like clinical knowledge and managing acutely ill patients.   I went to my evaluation...

and my assessor just agreed with me, checkbox for checkbox. 

I wonder if I should have given myself a few more.

* Fellowship of the Royal Australasian College of Whatever.

Thursday, October 29, 2009

hey, remember that patient...

I read about the effects of this phrase on emergency physicians at, but I'd never really seen its effects.  I've been working in emergency while my life in on hold, and I saw one of the attendings from last week in the office, so I said:

"hey, remember that patient from last week?  Jeremy Smith?"

and I could visibly see him work through the algorithm in his head...

"no, remind me again?"

"85 year old, went into resus for hypotension;  from a nursing home, acute on chronic renal failure..."

"oh yeah"

"anyhow, she had a hemicolectomy and is doing well.  A save."

"not just a save, a resurrection!"

Although calling it resurrection may be hyperbole, the dood was ASA 5E, surviving a condition with 50-90% mortality.  and I owe it all to Bongi and one line in that blog post, which made me think of the right diagnosis a year later.

Monday, October 26, 2009

them's fighting words

Auscultation, once thought to be the exclusive province of the physician, is now more important in surgery than it is in medicine. Radiologic examinations, including cardiac catheterization, have relegated auscultation of the heart and lungs to the status of preliminary scanning procedures in medicine. In surgery, however, auscultation of the abdomen and peripheral vessels has become absolutely essential.

The above is from Current Diagnosis and Treatment: Surgery.

Once upon a time, the lovely folks at PagingDr and I had a polite debate about the usefulness of auscultation in the context of how expensive a stethoscope should be purchased.  I still think that auscultation of the heart as part of the daily examination is not particularly useful - the likelihood of developing an abnormality that can be picked up on auscultation is minimal - but I do not believe that auscultation of the lungs is a preliminary scanning procedure;  it is essential in the early diagnosis of fluid overload and pulmonary oedema, much more than the chest radiograph or any other investigation.

Being a ward resident/intern is quite different between medical and surgical teams.  On my medical rotations, I would politely stand and scribe while the registrar examined and dictated.  I would rarely if ever lay hands on the patient;  the ED resident or registrar did the initial examination, and the ward registrar did the daily examination.  On a surgical firm, the ED resident would often not bother documenting a cardiorespiratory exam, and the surgical registrars were never interested in what someone's chest sounded like, front or back.  After the "wave" round at 7am, I would go back between 8-9 and have a listen to the chests (back only).  I would suggest that new interns on surgical teams get into the habit of doing this, and documenting it every day.

I used to listen to the front, but I never picked up a thing.  This may just be a reflection of my (lack of) cardiac auscultation skills.