Cases that changed me - why you should ask about the beetroot (26 May 2025)

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Dr Kat Ralston (KR): Hi, welcome to this episode of Clinical Conversations brought to you by the Royal College of Physicians of Edinburgh Trini and Members Committee. My name's Kat Ralston. I am a member of the T&MC and a geriatric medicine registrar in Edinburgh. And we're going to do something a little bit different today on the podcast and I'm really excited to introduce this mini-series which is all about cases that changed me. And I think we all have cases in our past that have stayed with us. For me, it's often when things have gone wrong, or I'm worried I've made a mistake. I think it can also be when a case has posed particular challenge or when there's been a difficult interaction particularly between professionals And I'd argue that these difficult moments we encounter are not only inevitable, but they're essential to how we learn and develop in medicine. So, in this series we'll have the privilege of hearing from experienced consultants about how they've navigated and reflected on these challenging times that have gone on to shape their practice and their career. Today, I'm really delighted to be joined by Dr. Chris Tiplady, who's a consultant haematologist in Northumbria, as well as a clinical lecturer and programme lead for the Master's in Medical Education at Sunderland University. Welcome, Chris.

Dr Chris Tiplady (CT): Thank you. That's very kind of you. And thank you for asking me to be here.

(KR): Thanks so much for coming on the podcast. And I can't wait to hear about your case and what you're going to talk about. So, I think we should just get into it if that's okay.

(CT): That's fine by me. It's been really interesting since you asked me about this. I have thought of dozens of cases of people, of stories, and I've wondered which direction to take it. And just like you've said, I think my heart was telling me to go down the mistakes, the regrets, the interactions, the shouting, the telephone calls. I might accidentally talk about some of those things as well. And there's a few people who've stuck in my mind over the years that really have changed me. And some of those will be quite random things about beetroot. I hope I get onto that story. There's a lovely story about beetroot. So, you have to remind me. But there are things I wish I'd done, but also on the flip side, things I wish I hadn't done and doing things by error of commission and error of omission is something that bugs me a lot. And I've waxed and I've waned, and I've thought about all sorts of different things to talk about. And I was even writing them down this morning and I've got lots of things in front of me, all of the options that I was thinking about telling you. And it makes me feel old. It makes me feel grey because there's so many people, patients, cases, all sorts of things. And then... It leapt into my head the one patient that's probably caused more of a ruction than any other in my practice over the last ten years. And it's probably nearly ten years ago that this man came into my head. I've been practicing as a consultant since 2001. That's more than ten years. I was still a hard-edged consultant by that stage. And this is a random story, perhaps. And it's actually a patient I've never actually met. And I hope I can explain because this was in the days before the medical examiner situation. A lot of people listening will remember the part two CREM form and the process of that is that when we are talking about confirmation of cause of death. That's two clinicians were involved, you know, one who knows the patient very well and one who has to just review notes and go through things. And I was that second clinician reviewing and confirming a cause of death. And I was called to the office where the notes were, and I had a name, and I'd set aside some time to go and review the notes and spend a bit of time doing this. As you should do. And it was a very big, thick set of notes. We've gone electronic now. I don't know what it would feel like or look like now, but there was that Big slightly falling apart notes that are fraying at the edges. They've been used so much. The cardboard is starting to give. There are bits of paper that fall out. Yeah, but these notes are kind of get a bit ungainly when they've been used so many years. And I picked them up and a piece of paper fell out. And it was the piece of paper that fell out that hit me instantly. It was a very carefully worded Escalation plan that that man had mentioned and had agreed, which was never to be admitted to hospital. And I knew because I was doing this part two cremation certificate that he had been admitted to hospital. So, I'm thinking instantly, what's gone wrong here? Why is this man in hospital and why am I doing this? And it didn't take me long to find other bits of paper tucked in in between notes and things that showed that this was a man who had quite advanced malignancy. He'd been in and out of hospital a number of times. He had a period of in hospital, not that many weeks before where it became clear what the diagnosis was doing. And he'd had a full discussion to try and never come back to hospital again. It was clear that he did not want that. So, I'm thinking, why the heck has this man been in hospital? And I start to look through the notes. His family had phoned the ambulance. The ambulance crew had arrived. The ambulance crew had assessed him, and I think there was a little bit of pressure from family. I'm not quite sure. That's a little bit harder to distinguish from notes like this, but he ended up being brought into emergency care because he was breathless. And I think that was a predominant thing. There's that management of his breathlessness because he had an advanced lung cancer. And. This is where it started to upset me as I went through the notes. He's admitted to ED, and he's therefore seen instantly by a team of people who've never met him. They went into full ED mode. I think that's the best way I can describe this. Full ED, full emergency department mode. And I don't blame them for this. They didn't know. They didn't have notes. They didn't have this paperwork. They have the family there clustering around what's going to happen here. And they went into full ED mode. And what I remember is reading through what was done. And first of all, there was the Venflon. The usual panel of blood tests, which probably included D-dimers. And then there was the chest x-ray. You know, we're not too far into things here. But then there was the blood gases. And I remember that was the line that I felt had been crossed. In terms of doing something to somebody who didn't want things doing, there was also blood cultures, and there was IV antibiotics, there was IV fluids, and then there was an admission, and he deteriorated within hours and died. And I sort of just thought there's no worries here about the cause of death. You know, it was very, very clear. He had advanced metastatic cancer and the thing that we'd failed in was Respecting his wishes. And I don't know if that was family. I don't know if that was automatic pilot from everybody had been involved, but this really kind of upset me. I remember this quite distinctly. And I think what this translated to me over the coming months and years, apart from a bit of a campaign and a bit of a begrudging nudge to a lot of people about these kinds of things. Was my own sort of regrets in not making it clear when patients that I was looking after when they were in their last six months of life and it's so easy to miss those things. And I think we have to make it really clear to people when they're in their last six months of life. To enable the conversations, to have proper conversations about these things and to make sure everybody knows what's going on. So I. I started doing a bit of work around this just for my own benefit. You know, was I part of this problem where patients weren't having their end of life been recognized? What were the issues around that that meant people went into automatic pilot and did everything? Because that's our default, I think, as doctors. Do everything. Dive. Do. Test. Stick needles in. And it's turned into so many different thoughts I've had over the years about stepping back, giving time, don't rush, have conversations. And I think distilling down to me is that ability to recognize when people are in their last six months of life. And I know that as a haematologist, we're often accused of failing to recognize that. We all know all the jokes. There's some very, very horrible sort of dark jokes about things like this, but you know, there's a truth there because it's sometimes extremely difficult to spot when people are in those last six months. When you've known someone for years, when you've looked after them for twenty years, you've kind of gone grey together. You're treating the sixth relapse of their cancer or whatever it may be. And it's sometimes really difficult to spot that line where someone Process into that last six months. So my learning from this man is something about conversations. That those conversations need to be recorded, documented, and absolutely clear. That other people around you need to know about those conversations. So that's where the documentation goes. And I think the other aspects for me is a wider piece of work about recognizing life-limiting disease, about recognizing that last six months. And I would say it's probably the hardest thing in the world to recognize. I think I may have given myself a bit of a reputation trying to work out that last six months. It's almost impossible, but I've had a few sort of Clues and ideas over the years about what helps me. And as I've talked more about this to other people, you come across other people who've got that kind of ability to recognize six months. And there's a few clues that people kind of give us patience with. Signs, things that go wrong, whether it's bed ulcers or whatever. And I've had conversations where other people have started saying the same thing. And really that's what I've learned. This is from a man who I never met and it genuinely upset me when it happened. And it's definitely changed how I address a lot of things. Whether that's just conversations, taking a bit more time, not rushing into things, trying not to make mistakes. And I've got lots of ideas in my head that I hope you'll ask me about.

KR: Thanks so much, Chris, for sharing that. Really, really important case and definitely resonates with me as something I've seen lots and reflected lots about in terms of that doing everything when actually that might not be the right thing for that person. And I guess it's maybe the type of person you are that you were just reviewing this as a part two clinician and immediately thought, am I part of the problem? Shows us how important that reflection is and thinking about our own practice when we're seeing cases. Because a lot of people could have just been like, yep, cause of death, fine. Move on to the next one. So I think that's really important for people to see that. And think about their own practice when they're seeing things like that. I mean, there's lots to talk about. And we've just finished on thinking about spotting that last six months And maybe we'll pick up on that first because I think that people do find that challenging and people are worried about getting it wrong and that's probably a bit of a barrier as well as not wanting to be the person that's talking about You know, doom and gloom and death when actually that patient and that family might be sitting there thinking quietly I think this is what's happening to me but no one wants to speak about it. So, the question I often ask myself Is, would I be surprised if this person died in the next six months? And I find that quite helpful. I wonder... What you've picked up over your years of practice in terms of trying to spot these patients that can really benefit from having these what matters to me conversations, which I think is what we're talking about ultimately.

CT: Absolutely. Yeah. And I think I'd love to apply some science, and I know there are some tools, there's some apps and things that you can do to try and do that. I don't know if that's something that we would routinely do, you know, on a monthly visit when a patient's seeing us, hang on, I'll just see what your risk is. And there is something about that feeling, but I've tried to quantify that feeling into something and. There's lots of different ways I've looked at this. There is something about an anger. I hope that doesn't come across badly. Sometimes when patients aren't responding to treatment. Things are becoming frustrating. You almost feel yourself getting angry. What's going wrong here? Why aren't things working? And I've learned to kind of highlight that one. That could be because I've made a mistake. I'm on the wrong diagnostic tree here. But sometimes that feeling of hang on, things aren't going right is a little flight to me and that I've learned that one to watch out for. I think the other thing that came out for me was reviewing how many people die after admission to hospital. It's as simple as that one. You know, if you just take a lock stock. Entire proportion of people who are admitted to hospital. It's something like nearly 30% of people who've been admitted to hospital will be dead within a year. You know, that's a huge clue just being admitted to hospital. And clearly, we can distinguish the difference between me falling off my bike and hurting my arm and had been admitted to hospital to the person who's admitted to hospital for medical reasons. I remember having this conversation with a group of physicians and one of that team had done an analysis of people who'd had peg tubes fitted. And guess what? There's about thirty maybe 50% of people who have a peg tube fitted will be dead within a year. And you kind of start thinking, hang on, where's this going? And then there's another group of people. Yes, we've reviewed everybody who's ever had a bed sore. Or a pressure sore skin has fallen to pieces over pressure area. Guess what? These are all people who had given us clues. And I wish I could remember who taught me this one. I suspect it was probably a Twitter thing. But there was, I hope it doesn't come across as callous in any way, but it was described as the four horsemen of the apocalypse. And there's kind of four clues that are there. And you do see these four things spread out amongst various risk scores. And number one is the presence of a life-limiting disease. It's ill-defined that whether that's cancer, heart failure, respiratory, whatever it is, the idea there is a disease here. And then the other risk factor on top of that, weight loss, unexplained, persistent, ongoing weight loss. Then the next one was immobility, not getting out of the house anymore, staying in bed too much. Not getting out in the morning. And then the fourth one was these recurrent admissions to hospital. And if you start looking at the people who are in and out of hospital and you spot those other things, so they're also losing weight. They're also getting out of their house less and less, and they've got these illnesses. You're into actually the territories of maybe sixty or 70% of people with those kind of things are probably going to be dying. And it's not your fault. It happens. This is what happens. I remember other things I've noticed. There's a really good paper about people who are transfused for medical reasons, not because they've had their leg operated on, they've lost a lot of blood. So, transfusion, you know, we know a huge proportion of blood transfusions go to people who are in their last year of life. The clues are there. They're screaming out at us. And you've got to recognise these, and you've then got to have those conversations because you owe it to people. When you or I have six months, I'm pretty sure I want to know. I'm off to Marks and Spencer's to buy ready meals and eat rubbish. I want to go traveling. I want to do things. And if someone hadn't told me that I may be in my last six months, I'd probably be very, very angry. Yeah, I think we owe it to patients and families I think is a really good way to think about it because if they don't have the information, they cannot make the decisions on what's important to them in that time. And it just made me think, there's a really nice video, The Last 1000 Days, that was made, I think it was NHS England, and it's around that thought of actually, when people are admitted, they're probably in their last 1000 days of life. And what is important to them in that time is really important and it's not a prolonged hospital admission in most cases. And I guess A challenge I just thought is that, I mean, do people need to be in their last six months of lives to even be having these conversations, you know? Or should we really be thinking about it in a wider sense? I do like that, and I think I pick the patients where that's easily done versus the ones where it's much harder to do. There are some really hard-edged folks around here and it's very easy to talk about those things with some people. We sometimes have that conversation with people about what would happen if we did nothing. And I think that's a nice way into that where, you know, if we don't treat this cancer, if we don't operate on this lump, if we do do these things, and that can be a gateway into a conversation like that. Thank you. I can't say I talk about death with everybody. There are some people who you can clearly tell would run out of the building screaming if you mentioned those kinds of things. And there's other people who are almost fishing for the conversation and you have to take it as you go. One thing's for us, you know, it should be me doing this. You know, someone under my care, it shouldn't be the person in ED. It shouldn't be the person on the evening ward shift who's never met them before. It should be something that happens over a period of time rather than it being on a trolley down a dark corridor. And that will be my other learning from this. That's my personal take on this. Don't expect other people to have these conversations for you.

KR: Yeah, because I think the timing of these conversations in a lot of cases is in a crisis and that, as you say, it's just not really what we should be aiming for. And people take a lot of information and guidance from the notes and from your clinic letters and your clinic letters and your clinic appointments are the times when these conversations are ideal to be happening in times of stability. So, I think your point about making sure that these conversations are both happening and documented carefully so that the person at 3am knows what you're thinking and what conversations have been had already is so important. And I'm interested to know in the case that you talked about, I know you weren't involved, but I wondered, did you have any inkling of what kind of conversations were had? Because I guess in my mind, the patient knew what was happening. The patient had written very clearly that they didn't want to move to the hospital, but the family seemed to not be quite on the same page. And I think that's the other interesting point is that you need to bring the whole team along, not just the patient. If you're wanting to Maintain someone's wishes because if it's only the patient who's had that conversation, you'll have the family in the background wanting everything done and not having a good understanding of what's important to them. Yeah, I think there was an assumption in ED that a change of mind had been had because the patient arrived in ED. Therefore, he was having regrets or his second guest or the family, you know, dynamic had changed or there was some symptom that perhaps they hadn't anticipated that led to that. But it felt like it was a binary. It wasn't sort of do a little bit. It was the full ED experience. I think you're right though, that clinic letters are really important, and it can just be a few lines documenting a conversation that can be phenomenally helpful for someone making a decision. In the dark hours about whether it's intensive care, whether you go for surgery, whether you intervene with something, hard conversations that you shouldn't duck away from. And in a busy clinic, especially on a Friday afternoon. It's much easier to duck away from those conversations. They aren't nice to have, and you need to learn how to do them and find a way in. Do you have any tips on how to navigate these conversations?

CT: Yeah, it's so nuanced and it's really about getting to know people and maybe I can mention the beetroot. I've got beetroot written down here because I want to mention the beetroot. That's been one of my ways into people is finding something that you share that's common. And it means you need to be good at the small talk. I hate small talk. You put me in a room with people outside of medicine. I'd rather sit in the corner and just not talk to anyone, but. When you're at work, the small talk's helpful. What makes people tick? And I've discovered people's interest in trains, in history, in travel. You mentioned Mallorca or something and people might tell you about that and you just get a little insight. And one of the common things I ask people about is food. I love food. I eat lots. People eat lots, but you can nearly always find something to share. And I can't remember how we did it, but there was such a lovely lady, I would love to remember her as we're talking, who we somehow got onto talking about pickled beetroot. I remember I saw her in hospital. It was one of those admissions. She was somebody with lymphoma. She was having recurrent admissions. And I went to see her on the ward that she was in and there was a big jar of pickled beetroot on her bedside table. And take the clues that are in front of you. You know, tell me about the pickled beetroot. And we got on to talk about pickled beetroot. I love pickled beetroot in case you hadn't guessed. She loved pickled beetroot. We talked about food because she was obviously in her last few months and the family were finding the food that worked, that she fancied, and she needed that sharp astringent bitterness of the beetroot. For the taste. And we talked about how it went really well in sandwiches. And we talked about the red dye that it makes your bread turn. And the nice way it goes with cheese and things like that. And we just talked and talked. And it was just a little glimpse into what made her happy and you start talking and it goes from there. What I remember really nicely was she bought me a jar of pickled beetroot. A big jar appeared and I remember taking this home because I cycled to work and I was thinking, if I fall off my bike on the way home, it's going to be a very gnarly mess on the street that would be difficult to explain. But it was just the loveliest thing. And it was probably the cheapest gift. It was, I think, a pound from Safeway’s down the road. But it was just the loveliest thing to get from someone was a jar of pickled beetroot. And she sticks in my mind hugely because the family was so, so caring for her. They were spread around the world as well. And I remember having to have conversations with people in the south of this country and in the south of another country. And we arranged the timing so we could have these conversations. Teams was just kicking off and it was a great way of having those conversations. And it often started about beetroot and food. And it was a lovely way of getting to know her, getting to know what mattered and helping manage her time. I'll remember her forever. A lovely lady.

KR: Yeah, I think it's these small things, isn't it, that stick with you and the way into that what matters to your conversation. It leads me into often a conversation about like, what does a good life look like to you? And that's Being in my garden or being able to pick up my own beach route or, you know, that's really important. And then sort of you can then maybe get onto what wouldn't be acceptable to you. What would a bad quality of life look like? And I think that could be a nice way to frame these conversations because then if you're saying, well, look, if you were so poorly that, you know, this happened, then it's unlikely you'd be able to get back to that and that can kind of help people just navigate some of these conversations and I think focusing on what you can do for people. So instead of what you're not going to do, so say, well, if we did this and this, then this would give you time to do, you know, the things that were important to you. I guess that's kind of how I think about it as well. I agree. And that working out what's important to people is the root of all of this. And it's not always what you think it's going to be. Sometimes it's about spending some time in the garden. Sometimes it's about enjoying sun or a trip down to the cafe or having some ice cream. And, you know, we're obsessed, I think, with survival curves and graphs and charts and things that say this will happen and that'll happen. The reality about all of these things is that you can't very easily predict which bit of that survival curve someone's on and you can really regret doing something to somebody or not doing something to somebody. This is the great dilemma with medicine. That problem. And it's about working out what's important to that person in front of you. And if it's about food and you're about to floor them with some palliative treatment that will put them off food for the last three months of their life, heck, you need to have a bit of a reflect and think about that. Just makes me think, it was a couple of years ago I had a patient who was relatively frail, lived with her daughter, I think, and had come in with a big GI bleed and she'd been transferred down to the ward. Pre-endoscopy, she was on fifteen litres, she'd have loads of blood, blood transfusions, feeling miserable, nil by mouth. And I went to see her at like four o'clock on a Friday and I just sat down and had a chat to her, just getting a sense for who she was. And all she wanted was a glass of milk. That was what she wanted. She had a glass of milk. She liked a particular, I think it was jazz she liked, she liked a particular type of music that she wanted to listen to but she was obsessed with milk and she wanted to go home and we talked a bit about what if we do nothing and we talked about We often talk about brand questions, so benefits of doing something, risks of doing something, alternatives and doing nothing. And after talking through the options, she did not want endidoscopation, she didn't want any more blood tests, she didn't want to be on this horrible mask on her face. Just wanted a glass of milk and to see whether she could get back home again to have her last bit of time at home. And through that we de-escalated everything, got her a lovely glass of milk, got her in a side room and got her a CD set up with the music that she liked and ended up kind of stabilised out and we ended up sort of organising a palliative discharge. I always think back to that case as like, actually, if you had just continued with the plan already, which was for endoscopy, nail by mouth, IV antibiotics, all this stuff, and not had a conversation with her, she wasn't offering that up to me. She was just going along with whatever the doctor said, that paternalistic kind of medicine. And we would have just continued on that trajectory. And it's just, I think about taking the time to sit down and just actually think, what are we actually doing here? And how does that align to what matters to the patient? And yeah, that's just my, one of the many cases I've seen. I reflect on quite a lot.

CT: Yeah. I agree. I'm going to give a flip side of an argument in the discussion here because this is the thing that I assume goes through a lot of people's brains and it certainly goes through mind. When you're having these conversations, have I got it wrong? Are they not in their last six months? Are they not dying? And I think that's particularly true in haematology. We have patients who can present in some really dire straits, really tricky situations. You know, a new diagnosis of myeloma, in complete renal failure, needing dialysis, bones broken. With people with twenty-centimetre tumours in their chest, obstructing their oesophagus, compressing their aorta, all sorts of things like that. And they can look like they're dying. And this can happen at relapses as well. And it's really, really difficult. And sometimes you've got to make a very difficult decision. It's just sometimes easier to do everything. It's sometimes easier to do nothing as well. And you've got to be reflective on yourself. Am I doing it for the right reason? Am I doing it because the easiest thing here is to let this person just go. And that little alarm bell has to go in my mind. Hang on. It may also be that we have to do some things to fix it. I find that a very, very hard thing. There's some very obvious situations. Young person fit while coming in with new symptoms and you know what to do. But sometimes young fit person coming in after ten years is the person who's relapsed four or five times and you've got them out of every single crisis over the years and another crisis happens and that's a different end of that. Scale. So, I found this very challenging at times knowing when to do things and when not to do things. It's a slightly different bit of this conversation and the problem is that when you do things to people who've had multiple courses of chemotherapy, you're inevitably going to put them into emergency care at some point. The emergency care physicians will either think you're Over treating or you're doing something to somebody that is causing harm. You wouldn't have done that without considering it in some detail with patients. And that's what I do. You have some very, very detailed conversations with patients. It's hard sometimes to explain risk. It's like the weather forecast. I think I've got a 30% chance of rain tomorrow. So, the weatherman's right. Either way. And that's trouble with data and statistics and chemotherapy and all that kind of stuff. It's very, very hard to predict. And you've got to use experience, you've got to use statistical sort of approaches if you can, give people a fair assessment of risk. But sometimes you don't know what to do. And the only way I've found over the years of resolving that kind of dilemma is just a very, very detailed conversation with a patient. With everybody there, everybody involved, knowing what the risks of doing or not doing are. It's rare that you're in a situation where someone can't talk, but mostly this is about something to have very detailed conversation about.

KR: Yeah, I think that's a really important point and there's some situations that are very straightforward but a lot of situations that aren't and are very difficult to know what is the right thing to do and I think same as you've said, I think it's really just about honesty. with the patient and honesty about uncertainty, which I think is something that we find quite challenging. We want to have answers, and I think being honest and being able to explain uncertainty and understand what is important for that person when you're doing that is really important. It all comes back to this sort of shared decision making, doesn't it? We shouldn't be doing things to people. We should be having a shared conversation to come to a conclusion together about what approach we're going to take. And I think the other point I'm going to just pick up on is that don't know what to do points because I think that people worry about that. I'm about to CCT as a consultant and I worry that what do I do when I don't know what to do? I think as medics or as healthcare professionals, That's something that people are scared of and, you know, you've got the benefit of lots of experience behind you but I think the other thing that I've increasingly learned is that This front of knowing everything all the time as a med reg or whatever is actually a fallacy and we have our colleagues and We have each other to lean on and to ask for help if we're feeling stuck as well as looking at the statistics, the science, using all your experience. So, I think that's the other point that I'm interested in is that actually It's okay to ask for help and that people are asking each other for help all the time.

CT: Yep. I think you've said all the things that I would have said there and relying on colleagues, having the multidisciplinary team meeting discussion to document it formally, have lots of conversations. Like you said, look at the data if you can, it will get you to a certain point. There's other elements of handling uncertainty, which are hard as well, though it's unsettling. It can cause people to lose sleep. It can cause people to not go home on time anymore because they're looking at the data and what's the latest trial and all this kind of stuff. Sometimes when you've been, I'm feeling old again. You see the latest, greatest trial and a few years later it can be changed, and it can actually be criticized. And what was the right thing to do four years ago is now, you know, way, way the wrong thing. My other reflection on uncertainty and handling it is having the ability to change your mind and feeling comfortable changing your mind and not be embarrassed about changing your mind. If you've got it wrong, say you've got it wrong, don't persist down the wrong route. You know, listen to those clues, that unsettling feeling, that awareness that the patient isn't Doing what you expect them to do if you started antibiotics, you know, the fever isn't going, is there another diagnosis? So be willing to change your mind. Don't be embarrassed. Listen to people, encourage people to tell you that you're wrong. If you're this unassailable front, you're going to make a mess. So, encourage people to tell you what they think. And it is, it's, that hard bit though about handling uncertainty is something you need to expect and embrace, I suppose, is what I'm trying to say. It will happen. There's no way you know what to do every single time. If that is the case, you're probably unaware of something. I think that's reassuring for our listeners is that Yeah, everyone has times all the time when they're not sure what to do. And yeah, if you never encounter that, then there's probably something else going wrong. Great. So, I think we've covered a lot of ground there. I don't know if there's anything else that you wanted to talk about from that case. From the be true person. There's a lot of things I've had going through my mind talking about what I learned from people and the other thing that I haven't mentioned is don't rush. It's a phrase I heard a few years ago, which is rush slowly. And that can be the other thing about making decisions. We're often pressured to making these decisions in one go, in one hour or in one conversation. That's just not life. If you're buying a house, you spend a few months thinking about it sometimes. If you're taking the mortgage out, you'll spend a bit of time and you've given twenty-four hours cooling off time. It's alright to have conversations like this in several chunks. Don't expect to do it all in one go. Don't let other people... I've had some mistakes made in news I've given people who are desperate to know what their biopsy showed or what their scan showed. You sometimes give them provisional information and then at the review, when there's a bit more time, that information changes. So do not rush. And if there's people putting pressure on you to come to a diagnosis or come to a treatment decision, you know, take a breath. If you're not ready to make that decision with the patient, don't be pushed into it. That's definitely a time I've made some mistakes. Just that pressure to do things now. And I've been very, very wary of urgency a lot recently. Too many people telling me everything's urgent. And the reality is, I think we all have very different scales of urgency. Something falling off, that's urgent. Hypercalcemia, that's urgent. But a diagnosis and a treatment plan and a discussion can take time.

KR: Yeah, I think that's a really important point to end on. So, thank you. Thank you so much, Chris. This has been an absolute delight chatting to you, but I guess we better wrap up. So, I think it's always useful just to end with a couple of Learning points that we're both gonna take away. I've got a couple written down so maybe I'll start and I think, I guess I'm looking at it from a frame of just about to go through a career transition as well so I think This is just really helpful for me just to even talk about this stuff but the two ones I have are that concept of being open to being wrong and being honest about that and how we can help speaking up behaviour within our team. And then be a person that is okay to challenge because I think that's really important. And my second point is just the last one you made about don't be rushed. And I guess you're coming at it from a patient point of view, but I often feel a lot of pressure from bed management flow to make decisions and get people out of hospital and actually I think that we need to push back from that pressure when we feel like something's not quite right and Take a bit of time or admit that patient if we need to just be happy in our decisions because I think that's where quite a lot of mistakes can happen. So that's my take-homes and I guess finally I mean, I'm a geriatrician, so this is really an area that I think is so important, but that what matters to me conversation is one of the most important conversations we'll have as doctors in our patient relationship. How about you?

CT: I've got too many notes here of all the things that I've learned. I hope I've given a few of them. Probably at distils down for me is about talking. And being willing to talk and having difficult conversations and learning how to do that. So, you need to get better and better at doing that. And it gets a little bit meta, but you need to talk about talking. You need to check with other people. How did I talk? Did I say the right thing? What did this look like? Because your talking has to be with both the patients and with your colleagues and that openness has to be there. I think I do reflect a lot. I have found writing these sort of things down every now and again has been helpful to me. I find that very, very useful working out why I did things, what I was feeling at the time, why I've gone home unsettled. And you learn how to move on a little bit. These are the big things for me because you have to be able to move on to the next patient as well. You know, you're on a busy on call and it won't just be one patient you have to do this with. You have to be able to do it with lots and lots of people. So, you need to be aware of how you cope, how you manage, how you handle all this. Listen to that inner voice when you think things are going wrong. I think encourage other people to talk to you so that they don't mind telling you when you're wrong. Thank you so much, Chris. That's been excellent. I've really enjoyed chatting and I hope the listeners have as much as me. And thanks so much for listening. I will have a few more episodes on a similar line and I hope you really enjoy them and hope to see you next time. Thank you.

CT: Thank you.